Duke Cancer Institute’s growing radiotheranostics program offers targeted treatment options for patients with prostate cancer, and potentially other cancers in the future. “With radiotheranostics, we don’t fly blind. We know the individual tumor’s molecular targets and deliver therapeutic agents directly to them,” says Terence Wong, MD, PhD, nuclear medicine specialist and chief of the Nuclear Medicine and Radiotheranostics Division.

Radiotheranostics involves utilizing radiolabeled probes to first image tumor targets with PET scans. Then, therapeutic radionuclide therapies are delivered by similar molecular probes. “We’re able to image the proposed molecular targets and treat them,” says Wong. “When we image the tumor targets, not all targets take it up, so we have more insight into why targeted therapies may or may not be working.”

Duke is one of the first cancer centers in the country to become designated as a Comprehensive Radiopharmaceutical Therapy Center of Excellence. “We participated in the trial that led to FDA approval of targeted radiopharmaceutical therapy for prostate cancer (177Lu-PSMA), and Duke was among the first centers to treat patients with it. We learned a lot from this trial and quickly expanded this service to patients after approval,” says Wong. 

Unlike systemic chemotherapy or radiation, radiopharmaceutical therapies have a more targeted delivery, carry a lower toxicity profile, and are often better tolerated by patients.

“Our GU [genitourinary] oncology program is unique in that we have a strong translational research component. We’re leading research to discover the next best treatments for GU cancers, and we quickly incorporate validated treatments into our practice,” adds 
Daniel George, MD, medical oncologist and director of Duke’s GU cancer program. 

Close collaboration between nuclear medicine and genitourinary oncology teams contributes to the program’s success. The team has completed nearly 1,000 radiotherapeutic treatments for 300 patients, most with metastatic castration-resistant prostate cancer (mCRPC). 

“By the time we currently treat patients, they have already gone through chemo and may have developed some resistance. That is something targeted therapies want to avoid by treating earlier, before chemo, when tumors have differentiated targets,” says Wong. “We feel if we treat earlier with radionuclides, we will be even more successful. We want to test if it could be effective as part of first- or second-line therapy rather than third-line as it is today.” 

The Center for Prostate and Urologic Cancers has embraced this therapy and its potential with a data-driven approach. Nuclear medicine and medical oncology fellows created a live database of patients receiving this therapy to study responses and progress over time. Wong explains that based on the FDA-approval trial, all patients receive a fixed dose and number of treatments. “We’re looking at these variables to see if that’s the best approach or if there are ways to improve or customize it.” 

The team is fully committed to continuous improvement and growing this service for patients. “It has the potential to help millions of men,” says Wong. Duke’s GU oncology group is in the best position to offer this treatment and other options for patients. “We’re on the cutting edge of prostate cancer care,” says George. “Referring patients to us ensures they have access to the most innovative, outcomes-based treatments.”

Radiotheranostics requires a higher level of care coordination and clinical service. “Duke has made significant operational investments to grow this program; the GU oncology group’s advanced practice providers support patients with end-to-end care through their entire treatment process,” says Wong. 

Because radiopharmaceuticals are customized for each patient, there’s an additional benefit of having an in-house radiopharmacy at Duke, which is rare among cancer centers. According to Wong, Duke’s radiopharmacy facilitates getting the right radiopharmaceutical and dosing for each patient. Coordinating the ordering and delivery of radiopharmaceuticals is crucial. “Radiopharmaceuticals have a shelf life, and they have to be delivered within 1 to 2 days of the patient's scheduled dose — another complexity of these treatments we can deliver well.”

In nuclear medicine, patient safety is a top priority. The Radiation Safety Division oversees all treatments. “Patients are prepared and instructed by this team, and they provide support to protect patients and staff against contamination and unnecessary radiation exposure. It’s one of the many moving parts of our process that deliver exceptional patient experiences,” says Wong.