Joseph F. Renzulli, II, MD
Patients who participated in a multidisciplinary care clinic experienced improved outcomes, especially when radium-223 was integrated into an overall treatment program. This is good news because while the advances in molecular oncology and targeted therapies have revolutionized treatment of many solid tumors and hematologic malignancies, improvements in treatment options for men with metastatic castration resistant prostate cancer (mCRPC) have been slower to develop.
However, since 2010 urologists and oncologists have embraced the development of Sipuleucel-T immunotherapy, cabazitaxel chemotherapy, the oral agents abiraterone and enzalutamide, and recently, Radium-223. All of the above agents confer an overall survival advantage in metastatic prostate cancer. However, with these advancements comes questions and controversy regarding optimal treatment sequencing, combination therapy, and appropriate patient selection.
Joseph F. Renzulli II, MD, and researchers, recently described an efficient and cost-effective workflow through a multidisciplinary care (MDC) clinic that relies on the collaboration between urologists, medical oncologists, radiation oncologists, nuclear medicine physicians and ancillary caregivers.
The model is particularly successful when radium-223 is incorporated into the patient’s treatment regimen. Their findings are published in the Journal of Multidisciplinary Healthcare
“Our goal was to demonstrate that radium 223 is an ideal drug to incorporate into the treatment algorithm for mCRPC through a multidisciplinary collaborative effort. We believe more timely and effective utilization or radium 223 results from a multidisciplinary approach. It is the team approach that is important. There is no one specialty that is able to administer radium-223 given that it requires referral to a radiation oncologist or nuclear medicine physician, and that referral typically originates from a urologist or oncologist,” said Renzulli, an assistant professor at the Warren Albert Medical School at Brown University.
The Genitourinary Multidisciplinary Clinic
The Genitourinary Multidisciplinary Clinic, opened in 2007, it incorporates 4 medical disciplines: medical oncology, radiation oncology, urologic oncology, and nuclear medicine physicians, with support from other services to enhance the patient experience and operational efficiency. Psychiatric services are provided for newly diagnosed patients, a licensed nutritionist is available for men receiving hormonal deprivation therapy, a nurse navigator assists in the treatment management process, and a nurse practitioner assists in patient management. The clinic also provides patients to access to a social worker as needed. Patients can be referred to the MDC through a urologist, a primary care physician following a new diagnosis of prostate cancer or for a second opinion. Prior to a new patient visit all outside pathology is reviewed by a dedicated genitourinary pathologist. The initial patient consultation includes reviews of radiologic films and pathology reports with the patient and family members, and an initial treatment plan is developed. The patient receives counseling about quality of life issues, treatment expectations, and patient goals to formulate the best individual treatment plan.
Traditionally, radiation oncologists and nuclear medicine physicians rarely encounter a patient with mCRPC, unless referred by a urologist or a medical oncologist. The MDC setting allows these specialists to provide clinical input into the management plan, especially in light of the potential use of radium-223. Radium-223 is a new treatment that, unlike earlier radionuclide therapies, has shown an overall survival advantage in a large randomized phase 3 trial (ALSYMPCA). In the ALSYMPCA study, patients receiving radium-223 had a significantly prolonged time to onset of their first symptomatic skeletal event (median, 15.6 months vs 9.8 months; hazard ratio =0.66; 95% CI, 0.52–0.83; P
<0.001) compared with those who received placebo. This treatment benefit and increased overall survival occurred independent of prior docetaxel therapy or concomitant bisphosphonate therapy.
Radium-223 is approved for treatment of patients with CRPC with symptomatic bone metastases and no known visceral metastases. The recommended dosing regimen is six cycles of 50 kBq/kg radium-223 therapy 4 weeks apart. As a calcium mimetic, radium-223 binds to hydroxyapatite at sites of osteogenesis associated with metastatic prostate cancer.
Figure. Flow of patients with mCRPC treated at The Miriam Hospital MDC
Abbreviations: mCRPC, metastatic castration-resistant prostate cancer; MDC, multidsciplinary clinic; GU, genitourinary; RN, registered Nurse
Radium-223 decays through emission of four high-energy alpha particles over an ultra-short distance, resulting in predominantly irreparable double-stranded DNA breaks in nearby cells that lead to cell death. The short range of alpha particles ensures that nearby cells (tumor) are affected to a greater extent than more distant (normal) tissues.