Theranostics

Theranostics is an innovative step towards personalised medicine, combining PET/CT imaging and radiopharmaceuticals to diagnose and treat metastatic disease.

Overview

Theranostics - meeting the clinical needs of patients with neuroendocrine tumours

Theranostics is described by some as the therapeutic equivalent of a ‘smart homing missile’ to seek and destroy cancer cells.It is an innovative approach using peptide receptor radionuclide therapy (PRRT) to seek out and destroy cancer cells. PRRT uses molecules that preferentially attach to the receptors on cancer cells to locate and deliver a dose of radiotherapy directly into the tumour site – exploiting the vulnerability of the cancer to detection and attack from its own signalling mechanisms.

At GenesisCare, our Theranostics service uses the radioactive isotope 68Gallium to identify and diagnose cancerous targets via tumour receptors in PET/CT imaging. It then uses a second radioactive isotope, 177Lutetium, to treat them using PRRT. If the tumour receptors are visible on a PET/CT scan, the 177Lutetium isotope can travel directly to the main tumour and any metastatic sites where it delivers a dose of radiation and destroys the cancerous cells, while avoiding healthy tissues.

A world-class service

A complete Theranostics diagnostic and treatment pathway is provided as an outpatient service in our purpose-built facilities including the latest generation PET/CT scanners. We produce our own radionuclides in our on-site radiopharmacy in Windsor.

Our Theranostics treatments are offered as outpatient appointments in our state-of-the-art therapy suites and are typically delivered in up to four to six cycles, with each treatment lasting between two to six hours

Governance and expertise in Theranostics

The service is provided by an experienced multidisciplinary team of nuclear medicine experts, including nuclear medicine physicians, physicists, imaging professionals and a dedicated radionuclide therapy nurse. Patient safety is a priority and we have a robust clinical governance framework, requiring a continuous process of peer review and credentialing, with protocols based on best practice from world centres of excellence.

Patient experience

A specialist radionuclide therapy nurse and a nuclear medicine physicist are available to support and answer any questions throughout the treatment. We also provide dedicated support via telephone for any post treatment questions. GenesisCare is proud to be in the top 1% of healthcare providers worldwide and we consistently achieve a net promoter (patient satisfaction) score over 95%.

177Lutetium octreotate therapy

177Lutetium octreotate therapy - a proven approach

At GenesisCare, we provide 177Lutetium octreotate therapy, a proven Theranostics approach, for people with neuroendocrine tumours (NETs). This therapy has shown particular benefit in the treatment of NETs and offers significantly improved quality of life, minimal side effects and survival.

We are excited to office this highly personalised approach to cancer medicine from July 2020.

Destroy - with 177Lutetium octreotate

Octreotate is paired with 177Lutetium to target NETs and destroy cancer cells. 177Lutetium is a ß- and γ-emitting radioisotope and often preferred for peptide receptor radionuclide therapy (PRRT) due its physical properties.

It is a medium energy emitter with a short maximal dose tissue penetration depth (2mm) and a relatively long half-life of 6.7 days.

Compared with external beam radiotherapy, PRRT has the potential to deliver 10–100 times the radiation dose direct to the target tumour tissue with minimum toxicity to healthy tissue. A patient will typically receive four cycles of treatment over an eight to ten-month period.

Side effects and toxicity

177Lutetium octreotate therapy is well tolerated with low toxicity (when compared with conventional treatments), allowing patients
to lead a relatively normal life during treatment. Side effects can include:

  • Fatigue
  • Nausea
  • Increased symptoms of cancer for a short time
  • Bone marrow suppression, particularly in patients who have already had radiotherapy or chemotherapy
  • Reduced renal function

177Lutetium octreotate therapy is well tolerated with low toxicity (when compared with conventional treatments), allowing patients to lead a relatively normal life during treatment.

The evidence base

A study of 229 patients with advanced, progressive, somatostatin receptor-positive midgut NETs investigated the efficacy and safety of 177Lutetium octreotate treatment.[1] The trial demonstrated that 177Lutetium octreotate treatment resulted in significantly higher tumour response rates (18%) and longer progression-free survival (65.2%) when compared with high-dose octreotide long-acting repeatable (LAR) treatment (3% and 10.8% respectively).

177Lutetium octreotate represented a 60% lower estimated risk of death than the control. 95% of patients in the 177Lutetium octreotate group and 86% of patients in the control group had at least one adverse event during the trial, however, the rates of grade three or four adverse events were similar in both groups.

The most common adverse effects in the 177Lutetium octreotate group were nausea and vomiting, however most of these cases were attributable to the amino acid infusions and were resolved once the infusions were completed. The study concluded the treatment was associated with limited toxic acute effects.

Who can you refer?

Our 177Lutetium octreoate therapy service will be available from July 2020. We will welcome and consider referrals for 177Lutetium octeotate therapy for patients with progressive neuroendocrine tumours (NETs) that are:

  • Unresectable or metastatic
  • Well-differentiated (grade 1 to 3)
  • Somatostatin receptor-positive
  • Unsuitable for, or haven’t responded to, other treatments such as chemotherapy

They must demonstrate adequate uptake of octreotate on the basis of a pre-therapy imaging study (68Gallium octreotate PET/CT) to be considered for treatment.

Full inclusion and exclusion criteria are available from:
TheranosticsUK@genesiscare.co.uk

What does a cycle of treatment involve?

  1. Each cycle is delivered as an outpatient appointment
  2. The treatment will start with an infusion of amino acids which will continue for four hours. Within 30 minutes of the start of this infusion, the 177Lutetium octreotate therapy dose will be infused for 20 to 30 minutes
  3. Post-treatment radioactivity level is measured hourly (recorded at a distance of one metre)
  4. When radioactivity reduces to safe levels, the nuclear medicine consultant and technician discharge the patient (after approximately six hours)
  5. The patient is given radiation protection information and provided with details of any restrictions that they should follow for the next 15 days

Refer for 177Lutetium octreotate therapy

We welcome enquiries and referrals for 177Lutetium octreotate therapy.

01753 418 444
TheranosticsUK@genesiscare.co.uk

References

  1.  Strosberg et al., 2017; New England Journal of Medicine

177Lutetium PSMA therapy

The UK’s first 177Lutetium PSMA therapy. A new future for advanced prostate cancer

Described as a totally new weapon in the anti-cancer armoury, Theranostics is an innovative approach using peptide receptor radionuclide therapy (PRRT) to seek out and destroy cancer cells. PRRT uses molecules that preferentially attach to the receptors on cancer cells to locate and deliver a dose of radiotherapy directly into the tumour site – exploiting the vulnerability of the cancer to detection and attack from its own signalling mechanisms.

This approach has shown particular benefits in the treatment of advanced prostate cancer and offers the potential for improved symptoms and quality of life, with minimal side effects. In May 2019, GenesisCare treated the first patient in the UK with 177Lutetium PSMA therapy, a proven Theranostic approach for metastatic castration- resistant prostate cancer (mCRPC).

The team has so far treated more people with this modality than any other provider in the UK and is accepting patients from across the UK, Middle East, USA and Europe.

Theranostics – harnessing the power of prostate specific membrane antigen (PSMA)

Theranostics is hailed as a major step forward in the diagnosis and treatment of metastatic castration-resistant prostate cancer (mCRPC), which has returned and spread to other sites after standard androgen- deprivation therapy has become ineffective. The objective is to slow tumour growth, reduce symptoms and improve quality of life.

Theranostics is a highly personalised approach to cancer medicine that combines two techniques in one: diagnostic imaging and therapy. The diagnostic approach uses a radioactive tracer bound to molecules (or ligands) that are specific to receptors found on the surface of cancer cells, enabling detection of metastases using PET/ CT.

The therapy, 177Lutetium PSMA, is equally specific and delivers targeted radiation to the same protein receptors (also called radioligand therapy). In the management of prostate cancer, PSMA-based compounds (ligands) are mostly used for both detection and treatment.

The PSMA protein is over-expressed on prostate cancer cells and has been the subject of numerous studies highlighting its suitability as a treatment target.1 For diagnosis and therapy, a PSMA ligand is paired with a suitable radionuclide, of which there are various options, although 177Lutetium and 68Gallium are discussed here and form the basis of the service provided at GenesisCare.

Destroy – with 177Lutetium PSMA therapy

In recent years, the potential for PSMA- targeting as a treatment approach has led to increased interest in peptide receptor radionuclide therapy (PRRT). Compared with external beam radiotherapy, PRRT has the potential to deliver 10 to 100 times the radiation dose direct to the target tumour tissue with minimum toxicity to healthy tissue. 177Lutetium is a ß- and γ-emitting radioisotope and often preferred for PRRT of prostate cancer due its physical properties. It is a medium energy emitter with a short maximal dose tissue penetration depth (2–3 mm) and a relatively long half-life of 6.7 days. The most commonly used for PSMA is 177Lu-PSMA-617 which shows strong accumulation in prostate cancer cells.

Side effects and toxicity
177Lutetium PSMA therapy is well tolerated with low toxicity (when compared with conventional treatments). The advantage of reduced side effects means that the next treatment cycle can start quickly and that treatment can be undertaken as an outpatient. A patient will typically receive four to six cycles of treatment.

The evidence base
A Phase II study concluded that men with metastatic castration-resistant prostate cancer (mCRPC) treated with177Lutetium PSMA therapy showed high response
rates, low toxicity and reduction in pain following progression after conventional treatment.[1] 57% of patients achieved a PSA decline of 50% or more. This data is very promising particularly when compared with established agents (e.g. 39% response observed after treatment with cabazitaxel). Objective response by imaging in the nodal or visceral disease was reported in 82% of patients with measurable disease. These results demonstrate that targeted radionuclide treatment with 177Lutetium PSMA therapy has high response rates, low toxicity and reduction of pain in mCRPC patients who progress after conventional treatments.

These results also demonstrated improved QoL indicators and overall survival rate from three to 13.5 months.

One year on – delivering positive outcomes for our patients

In June 2019 we launched our PSMA therapy in the UK and in our first year (until June 2020), we have had 85 prostate cancer patients referred to our 177Lutetium PSMA therapy service. A total of 62 patients have been treated to date and 206 cycles of 177Lutetium PSMA therapy have been delivered.

Our Theranostics 177Lutetium PSMA service delivers positive outcomes for men with metastatic castration-resistant prostate cancer. Results from patients who received four cycles of treatment (n=14) show that the median PSA value reduced from 17 before the first cycles, to 6 at completion of 177Lutetium PSMA therapy.

 

Of the patients who have received our 177Lutetium PSMA therapy in the first 12 months of its availability, 64% have displayed a reduction of 50% or more in their PSA value at the end of treatment, with the median reduction in PSA being 66%.

Who can you refer?

Previously, 177Lutetium PSMA therapy was only available in Germany and Australia, but it is now a treatment offered in the UK to patients where other therapeutic options have failed or are unable to be tolerated.

We consider referrals for 177Lutetium PSMA therapy for patients with metastatic castration-resistant prostate cancer (mCRPC) who have exhausted or are ineligible for approved alternative options. They must demonstrate adequate uptake of PSMA ligands on the basis of a pre- therapy imaging study to be considered for treatment.

Full inclusion and exclusion criteria are available from:
windsoradministration@genesiscare.co.uk

What does a cycle of treatment involve?

  1. 177Lutetium PSMA therapy is delivered as an outpatient appointment
  2. 177Lutetium PSMA therapy is infused with saline over a period of two hours
  3. Post-treatment radioactivity level is measured hourly (recorded at a distance of one metre)
  4. When radioactivity reduces to safe levels, the nuclear medicine consultant and technician discharge the patient (after approximately two to four hours)

The patient is given radiation protection information and provided with details of any restrictions that they should follow for the next three days.

Refer for 177Lutetium PSMA therapy

To refer a patient or enquire about 177Lutetium PSMA therapy, please send a referral letter to:
TheranosticsUK@genesiscare.co.uk

Your referral should include this information:

  • Patient clinical history
  • Results from a 68GalliumPSMA PET/CT if done within 28 days
  • Any recent blood tests and/or any other correlative imaging
  • Patient insurance details/payment status
  • Any translation services the patient may need

We welcome referrals from anywhere in Europe, the Middle East and the USA. Please enquire for our special international patient services.

Reference

  1. Hofman M et al., 2018; Lancet Oncol