Optimizing the Use of Radium-223 Through Multidisciplinary Collaboration - Phillip Koo

July 25, 2022

In this conversation, Drs Alicia Morgans and Phillip Koo discuss optimizing the use of radium-223 through multidisciplinary collaboration. Dr. Koo highlights the transition from solely a diagnostic aspect of nuclear medicine practice, to now being more involved in therapies and patient-facing, There is a need to start developing the infrastructure to have more nuclear medicine clinics, where patients are seen, with the appropriate nursing support, and the knowledge to ensure delivery of optimal care.


Phillip J. Koo, MD, FACS Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center in Arizona.

Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, Massachusetts

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Alicia Morgans: Hi, I'm so excited to be at ASCO 2022, where I have the opportunity to speak with Dr. Philip Koo. Thank you so much for being here.

Philip Koo: My pleasure, thank you for having me.

Alicia Morgans: So, I really wanted to talk with you about radium-223, which is, of course, a treatment that we've had around for some time and are continuing to use. But I think there are a lot of questions about how we continue to use this in a most optimal way. And one of those ways is, of course, through multidisciplinary collaboration. As a nuclear medicine physician, you've been dealing with radium and other radiopharmaceuticals for many, many years. From your perspective, how can we as medical oncologists and urologists, radiation oncologists really work together with nuclear medicine teams to provide that optimal really multidisciplinary care for our patients when we use things like radium?

Philip Koo: You know, that's a great question. And if you think about cancer care, it truly is multidisciplinary. And every specialty really brings a unique perspective and expertise to the table when discussing these various therapies. These therapies are complicated, and they're even more complicated when you think about it in the context of all the other therapies and options and diagnostics and just the whole continuum of care for these patients. I think the one thing that we need to really embrace is the idea of nuclear oncology. So let's maybe no longer call it nuclear. We can continue to call it nuclear medicine, but within nuclear medicine, maybe there's a sub-specialty of nuclear oncology that can be embraced as the fourth pillar of a GU oncology program. I would argue today, given the advanced diagnostics that we have with PSMA PET imaging and the radiopharmaceuticals such as radium-223 and lutetium therapies. And as those radiopharmaceutical therapies grow, nuclear oncology needs to be the fourth pillar of any comprehensive cancer program.

Alicia Morgans: Well, that's a fantastic way to think about it, because truly, teams are becoming so much more specialized and focusing on oncology where they could be using nuclear medicine to do other things. But these are really a group of people that are focusing on oncology questions and patient populations. So that's really, really innovative, and I love that. So how do we optimize that collaboration though?

Philip Koo: I think number one is we need to communicate. As we all get better and better and more subspecialized in these different areas, obviously communication becomes a very key component to this. The tumor boards that we have really need to get to a higher level, in my opinion, and whether it's having multidisciplinary program meetings outside of the tumor boards that really help you develop your programs, whether it's having quality meetings, research meetings, all these different components, engaging all the various stakeholders I think will help continue to move that process forward. But also I think from my own personal perspective for our specialty, I think we need to do a better job. We need to start learning more and engaging more with the teams, learning more about the clinical space. If we are treating patients with prostate cancer, with radium-223 and other radiopharmaceuticals, we need to understand sequencing.

We need to understand what the medical oncologist is thinking when they make a decision on what to treat with, what the radiation oncologist is thinking, what the surgeons might be thinking, and be able to meet people closer to where they're at to really have that robust conversation in those tumor boards. And also, I think we need to be available to be a part of multidisciplinary clinics. And as you know, these are growing and growing in the community, they clearly provide a better patient experience. And how nice would it be if we could include nuclear medicine clinic visits for patients who are being considered for radium-223 or other radiopharmaceutical therapies?

Alicia Morgans: Well, I think that's such a wonderful idea and whether your multidisciplinary tumor boards are virtual, which we've all become more experienced with, whether they're in a geographically colocalized place, you're all there together at the same time in clinic or in your tumor board. These are ways where we can each bring our own areas of expertise to the table and bring that all to bear on an individual patient's case, which I think is, as you said, so valuable and important for patients to optimize their outcomes. From a nuclear medicine perspective, how do you engage on a day by day basis in the care of a patient who's receiving radium?

Philip Koo: So in a patient receiving radium, I think it's important for the nuclear medicine, whoever's administering the drug ... Doing this, perform an assessment of the patient. Is this patient appropriate? And have a checklist of items that we want to go through. You know, check the labs, obviously check bone health. Bone health is a topic that is really important. And what we've learned over the years is patients receiving radium, we need to optimize their bone health. Nuclear medicine physicians have a very important role in that. I think we need to understand the topic and the data behind bone health, and we also need to ensure in our SOPs that we make sure these patients are receiving optimal bone health before and during their course of radium-223.

Alicia Morgans: I think that's such an important message. So from a medical oncology standpoint or a urology standpoint, we would want to make sure that any patient with mCRPC receives up to monthly denosumab or zoledronic acid to prevent skeletal related events. And what's so important is that, although we know this information, it's not always implemented in practice. Patients aren't always receiving that. I spoke with a colleague, Brenda Martone, recently, and really described how in our clinical practice, we used radium almost like a checkbox to say, if a patient is getting radium, that patient clearly has mCRPC. Let's do a mental check and make sure that our patients are on bone health agents, and many were, but some weren't.

So this was a way for us to ensure that we were optimally treating our patients to have nuclear medicine, also be aware of this issue and make sure that our patients are on bone health agents by sending a message. Hey, your patient's starting radium, but is not on a bone health agent. Is this right? Is there a reason not to treat this patient? Is actually another check and really, really helpful.

Philip Koo: And I think that works really well in a lot of our multidisciplinary programs where you had that close working relationship with your medical oncology team and whatnot. Nuclear medicine, however, oftentimes we'll receive outside referrals where we don't have as much visibility with regards to what treatments they receive, what other therapies they're on, what supportive agents they're on as well.

That's where it's important for the nuclear medicine to take ownership of that, where you do need to pick up the phone, you do need to get the records, you do need to interview and do a complete history and physical on that patient to understand where they're at. Because in the end, nuclear medicine are the ones who are the authorized users, who are administering the drug, and then we also then obviously have that responsibility to make sure the patients are as safe as possible.

Alicia Morgans: So the final question I want to ask is how do you work with that multidisciplinary group to ensure that someone is also checking safety labs and making sure that if patients are developing adverse events or having symptoms related to their treatment or their disease, that those symptoms are addressed. How do you divide and conquer?

Philip Koo: That's a tricky question right now because it's really forcing nuclear medicine to change how we practice. Often we've been especially focused more on the diagnostic aspects of our practice, but now that we're involved in the therapies, we do need to be more patient facing. We do need to start developing the infrastructure to have more nuclear medicine clinics, where we meet patients, we have the appropriate nursing support, appropriate MA support, and obviously knowledge to make sure we are delivering the optimal care.

I think this is going to be a little bit of a shift, so I'm sure there are going to be a lot of practices out there that quite aren't getting what they need right now, but it's a challenge for all of us to change how we think of our specialty and adapt. And when I look into the future even further, I think the idea of disease focus or disease specialized specialization within our specialty makes sense as well. Right now, nuclear medicine is more of a modality type of subspecialty. However, I think moving forward, we can have more disease focus which elevates, I think, our knowledge and our ability to be a contributing member of those teams.

Alicia Morgans: That's a great message. I think in the short run and for many practices, that close collaboration and communication between nuclear medicine, urology, radiation oncology, and of course medical oncology can really help sort out from the beginning and ensure that somebody is owning those things and whoever's owning it continues to do so through the course of treatment too. And that may be different in any individual practice, but we are really happy to bring nuclear medicine docs or nuclear oncology docs onto the team to help participate in that care. I sincerely appreciate your time and your expertise and love your forward looking view.

Philip Koo: My pleasure. Thank you very much.