At the 2024 ASTRO Annual Meeting, immediate past ASTRO chair Jeff Michalski, MD, MBA, FASTRO, reviewed the radiopharmaceutical landscape in prostate cancer and touched on the rationale for the involvement of radiation oncologists in delivering newer radiopharmaceutical therapies.

Following these proceedings, featured expert Oliver Sartor, MD, was interviewed by Conference Reporter Editor-in-Chief Tom Iarocci, MD. Dr Sartor’s clinical perspectives on these findings are presented here.

In his talk at ASTRO 2024 titled “Radiopharmaceuticals for Prostate Cancer,” Dr Michalski provided a nice overview of bone-seeking isotopes for metastatic prostate cancer before delving into prostate-specific membrane antigen (PSMA)–directed radioligand therapy, clinical trials, and future directions. Toward the end of the presentation, he noted the strong rationale for radiation oncologists to be involved with radiopharmaceutical therapy, including that they manage the full spectrum of disease states and that their patients may need radiopharmaceutical therapy in follow-up.

I personally think that “all of the above” is a good answer when it comes time to think about those who can administer therapy. I do not want to neglect our colleagues in nuclear medicine who invest much time and effort in gaining expertise and providing the facilities necessary for treatment. At the same time, however, it is a very important finding that radiation oncologists are interested in these new therapies because new therapies need to be administered closer to patients’ homes, if feasible. And the radiation oncologists who are treating the patients are numerous and are distributed widely across the United States, including at centers that do not have nuclear medicine physicians. So, radiation oncologists provide a solution in that regard.

Radiation oncologists are authorized users and, based on their day-to-day experiences, are familiar with the natural history of the cancer. They are also familiar with the nuances of external beam radiation therapy. They are well equipped when it comes to therapeutic modalities (ie, they have the clinical infrastructure for patient assessment, treatment, and monitoring), whereas, in nuclear medicine, many physicians have, primarily, a diagnostic focus. Also, it is important to remember that radiation oncologists may already be involved (eg, in delivering palliative radiation for painful bone lesions). So, I believe that, increasingly, our colleagues in radiation oncology will play a larger role in the theranostics space as we go forward.

Now, regarding the question of whether one modality might ultimately come to dominate this space, I am more of a complementary person, in the sense that these approaches are complementary. Even when we are using ¹⁷⁷Lu-PSMA-617 in the advanced stages of prostate cancer, we are also using ADT, perhaps along with an AR pathway inhibitor, and we have the external beam as part of our armamentarium. And we are perhaps going to be using bone health agents as well.

It is not just one modality at a time, particularly for these patients with advanced prostate cancer. We are thinking in a multidisciplinary way. We are thinking in a multimodality way. I think that this is a good way to think, for the benefit of our patients.