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Abstract
Theranostics in men with metastatic castration-resistant prostate cancer (mCRPC) has been developed to target bone and the tumor itself. Currently, bone-directed targeted alpha therapy with radium-223 (223Ra) is the only theranostic agent proven to prolong survival in men with mCRPC who have symptomatic bone metastases and no known visceral metastases. The clinical utility and therapeutic success of 223Ra has encouraged the development of other tumor-targeting theranostic agents in mCRPC, primarily targeting prostate-specific membrane antigen (PSMA) with radioligand therapy (RLT). There is increasing evidence of promising response rates and a low toxicity profile with 177Lu-labeled PSMA RLT in patients with mCRPC. A phase III randomized study of 177Lu-labeled PSMA RLT has completed accrual and is awaiting results as to whether the drug improves radiographic progression-free survival and overall survival in men with mCRPC receiving standard of care treatments. Additional early clinical trials are investigating the role of tumor-directed targeted alpha therapy with radiotracers such as 225Ac. In this article, we review the current status of theranostics in prostate cancer, discussing the challenges and opportunities of combination therapies with more conventional agents such as androgen receptor inhibitors, cytotoxic chemotherapy, and immunotherapy.
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Miyahira AK, Pienta KJ, Babich JW, Bander NH, Calais J, Choyke P, Hofman MS, Larson SM, Lin FI, Morris MJ, Pomper MG, Sandhu S, Scher HI, Tagawa ST, Williams S, Soule HR. Meeting report from the Prostate Cancer Foundation PSMA theranostics state of the science meeting. Prostate 2020; 80:1273-1296. [PMID: 32865839 PMCID: PMC8442561 DOI: 10.1002/pros.24056] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Prostate Cancer Foundation (PCF) convened a PCF prostate-specific membrane antigen (PSMA) Theranostics State of the Science Meeting on 18 November 2019, at Weill Cornell Medicine, New York, NY. METHODS The meeting was attended by 22 basic, translational, and clinical researchers from around the globe, with expertise in PSMA biology, development and use of PSMA theranostics agents, and clinical trials. The goal of this meeting was to discuss the current state of knowledge, the most important biological and clinical questions, and critical next steps for the clinical development of PSMA positron emission tomography (PET) imaging agents and PSMA-targeted radionuclide agents for patients with prostate cancer. RESULTS Several major topic areas were discussed including the biology of PSMA, the role of PSMA-targeted PET imaging in prostate cancer, the physics and performance of different PSMA-targeted PET imaging agents, the current state of clinical development of PSMA-targeted radionuclide therapy (RNT) agents, the role of dosimetry in PSMA RNT treatment planning, barriers and challenges in PSMA RNT clinical development, optimization of patient selection for PSMA RNT trials, and promising combination treatment approaches with PSMA RNT. DISCUSSION This article summarizes the presentations from the meeting for the purpose of globally disseminating this knowledge to advance the use of PSMA-targeted theranostic agents for imaging and treatment of patients with prostate cancer.
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Affiliation(s)
- Andrea K. Miyahira
- Science Department, Prostate Cancer Foundation, Santa Monica, California
| | - Kenneth J. Pienta
- Department of Urology, The Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John W. Babich
- Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Neil H. Bander
- Laboratory of Urologic Oncology, Department of Urology and Meyer Cancer Center, Weill Cornell Medicine, New York, New York
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular & Medical Pharmacology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Peter Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Michael S. Hofman
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Steven M. Larson
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Frank I. Lin
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | - Michael J. Morris
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin G. Pomper
- Department of Urology, The Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shahneen Sandhu
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
- Department of Medical Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Howard I. Scher
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Scott T. Tagawa
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Scott Williams
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - Howard R. Soule
- Science Department, Prostate Cancer Foundation, Santa Monica, California
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Targeted Palliative Radionuclide Therapy for Metastatic Bone Pain. J Clin Med 2020; 9:jcm9082622. [PMID: 32806765 PMCID: PMC7464823 DOI: 10.3390/jcm9082622] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/22/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022] Open
Abstract
Bone metastasis develops in multiple malignancies with a wide range of incidence. The presence of multiple bone metastases, leading to a multitude of complications and poorer prognosis. The corresponding refractory bone pain is still a challenging issue managed through multidisciplinary approaches to enhance the quality of life. Radiopharmaceuticals are mainly used in the latest courses of the disease. Bone-pain palliation with easy-to-administer radionuclides offers advantages, including simultaneous treatment of multiple metastatic foci, the repeatability and also the combination with other therapies. Several β¯- and α-emitters as well as pharmaceuticals, from the very first [89Sr]strontium-dichloride to recently introduced [223Ra]radium-dichloride, are investigated to identify an optimum agent. In addition, the combination of bone-seeking radiopharmaceuticals with chemotherapy or radiotherapy has been employed to enhance the outcome. Radiopharmaceuticals demonstrate an acceptable response rate in pain relief. Nevertheless, survival benefits have been documented in only a limited number of studies. In this review, we provide an overview of bone-seeking radiopharmaceuticals used for bone-pain palliation, their effectiveness and toxicity, as well as the results of the combination with other therapies. Bone-pain palliation with radiopharmaceuticals has been employed for eight decades. However, there are still new aspects yet to be established.
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Morris MJ, Corey E, Guise TA, Gulley JL, Kevin Kelly W, Quinn DI, Scholz A, Sgouros G. Radium-223 mechanism of action: implications for use in treatment combinations. Nat Rev Urol 2019; 16:745-756. [PMID: 31712765 PMCID: PMC7515774 DOI: 10.1038/s41585-019-0251-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
Abstract
The targeted alpha therapy radium-223 (223Ra) can prolong survival in men with castration-resistant prostate cancer (CRPC) who have symptomatic bone metastases and no known visceral metastases. Preclinical studies demonstrate that 223Ra preferentially incorporates into newly formed bone matrix within osteoblastic metastatic lesions. The emitted high-energy alpha particles induce DNA double-strand breaks that might be irreparable and lead to cell death in nearby exposed tumour cells, osteoblasts and osteoclasts. Consequently, tumour growth and abnormal bone formation are inhibited by these direct effects and by the disruption of positive-feedback loops between tumour cells and the bone microenvironment. 223Ra might also modulate immune responses within the bone. The clinical utility of 223Ra has encouraged the development of other anticancer targeted alpha therapies. A thorough understanding of the mechanism of action could inform the design of new combinatorial treatment strategies that might be more efficacious than monotherapy. On the basis of the current mechanistic knowledge and potential clinical benefits, combination therapies of 223Ra with microtubule-stabilizing cytotoxic drugs and agents targeting the androgen receptor axis, immune checkpoint receptors or DNA damage response proteins are being explored in patients with CRPC and metastatic bone disease.
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Affiliation(s)
- Michael J Morris
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine, New York, NY, USA.
| | - Eva Corey
- Department of Urology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Theresa A Guise
- Indiana University, School of Medicine, Indianapolis, IN, USA
| | - James L Gulley
- Genitourinary Malignancies Branch, National Cancer Institute, NIH, Bethesda, MD, USA
| | - William Kevin Kelly
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - David I Quinn
- Norris Comprehensive Cancer Center, Los Angeles, CA, USA
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Arne Scholz
- Bayer AG, Drug Discovery, Pharmaceuticals, Berlin, Germany
| | - George Sgouros
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Geva R, Lopez J, Danson S, Joensuu H, Peer A, Harris SJ, Souza F, Pereira KMC, Perets R. Radium-223 in combination with paclitaxel in cancer patients with bone metastases: safety results from an open-label, multicenter phase Ib study. Eur J Nucl Med Mol Imaging 2018; 46:1092-1101. [PMID: 30547207 PMCID: PMC6451720 DOI: 10.1007/s00259-018-4234-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/03/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Concomitant treatment with radium-223 and paclitaxel is a potential option for cancer patients with bone metastases; however, myelosuppression risk during coadministration is unknown. This phase Ib study in cancer patients with bone metastases evaluated the safety of radium-223 and paclitaxel. METHODS Eligible patients had solid tumor malignancies with ≥2 bone metastases and were candidates for paclitaxel. Treatment included seven paclitaxel cycles (90 mg/m2 per week intravenously per local standard of care; 3 weeks on/1 week off) plus six radium-223 cycles (55 kBq/kg intravenously; one injection every 4 weeks, starting at paclitaxel cycle 2). The primary end point was percentage of patients with grade 3/4 neutropenia or thrombocytopenia during coadministration of radium-223 and paclitaxel (cycles 2, 3) versus paclitaxel alone (cycle 1). RESULTS Of 22 enrolled patients, 15 were treated (safety population), with 7 completing all six radium-223 cycles. Treated patients had primary cancers of breast (n = 7), prostate (n = 4), bladder (n = 1), non-small cell lung (n = 1), myxofibrosarcoma (n = 1), and neuroendocrine (n = 1). No patients discontinued treatment from toxicity of the combination. In the 13 patients who completed cycle 3, the rates of grade 3 neutropenia in cycles 2 and 3 were 31% and 8%, respectively, versus 23% in cycle 1; there were no cases of grade 4 neutropenia or grade 3/4 thrombocytopenia. Breast cancer subgroup safety results were similar to the overall safety population. CONCLUSION Radium-223 was tolerated when combined with weekly paclitaxel, with no clinically relevant additive toxicities. This combination should be explored further in patients with bone metastases.
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Affiliation(s)
- Ravit Geva
- Division of Oncology, Tel Aviv Sourasky Medical Center, Tel-Aviv University, 6 Weizmann Street, 64239, Tel Aviv, Israel.
| | - Juanita Lopez
- Drug Development Unit, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Sarah Danson
- Department of Oncology and Metabolism, Sheffield Experimental Cancer Medicine Centre, University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust, Whitham Road, Sheffield, S10 2SJ, UK
| | - Heikki Joensuu
- Department of Oncology, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00029, Helsinki, Finland
| | - Avivit Peer
- Oncology Division, Rambam Health Care Campus, 8 Haaliya Street, Haifa, Israel
| | - Samuel J Harris
- Department of Medical Oncology, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Fabricio Souza
- Clinical Pharmacology Leader Oncology, Bayer HealthCare Pharmaceuticals, 100 Bayer Boulevard, Whippany, NJ, USA
| | - Kaline M C Pereira
- Medical and Data Management, Bayer HealthCare Pharmaceuticals, 100 Bayer Boulevard, Whippany, NJ, USA
| | - Ruth Perets
- Oncology Division, Rambam Health Care Campus, 8 Ha'Aliya Hashniya, and Technion - Israel Institute of Technology, 1 Efron Street, Haifa, Israel
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Clinical response to radium-223 dichloride in men with metastatic castrate-resistant prostate cancer. Pract Radiat Oncol 2018; 8:452-457. [DOI: 10.1016/j.prro.2018.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 05/03/2018] [Accepted: 05/07/2018] [Indexed: 11/17/2022]
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Corn PG, Agarwal N, Araujo JC, Sonpavde G. Taxane-based Combination Therapies for Metastatic Prostate Cancer. Eur Urol Focus 2017; 5:369-380. [PMID: 29275145 DOI: 10.1016/j.euf.2017.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/10/2017] [Accepted: 11/15/2017] [Indexed: 12/19/2022]
Abstract
CONTEXT Multiple single-agent therapies improving survival are approved for the treatment of metastatic castration-resistant prostate cancer (mCRPC), including two chemotherapies, two androgen-signaling axis-targeting agents, an immunotherapeutic vaccine, and a radiopharmaceutical. Combination therapy can target multiple oncogenic pathways simultaneously, while potentially curbing the development of treatment resistance. OBJECTIVE To provide a succinct overview of taxane-based combination therapies currently being evaluated for the treatment of metastatic prostate cancer. EVIDENCE ACQUISITION We searched MEDLINE/PubMed® and relevant congress databases for literature focused on taxane-based combination therapies being evaluated for the treatment of metastatic prostate cancer. In addition, a systematic search of www.clinicaltrials.gov was performed to gather information regarding ongoing taxane-based combination trials in prostate cancer. This search included phase II or III trials starting after January 1, 2010, which included the terms "docetaxel" or "cabazitaxel" and "prostate", and was then manually filtered for combination studies. EVIDENCE SYNTHESIS Single-agent therapy yields modest increments in survival. The success of combining docetaxel with androgen deprivation to improve overall survival (OS) for metastatic hormone-sensitive disease suggests the potential of similar approaches in mCRPC. Several classes of biological drugs have previously been combined with docetaxel for mCRPC in clinical trials without improvement in OS. However, combining docetaxel or cabazitaxel with newer agents with established single-agent benefit, such as radium-223, second-generation androgen pathway-targeted agents, or other chemotherapies, has the potential to benefit patients when compared with taxane chemotherapy alone. Our search revealed that the majority of trials currently assessing taxanes are focused on combination therapies: a combination approach is being evaluated in 37 of 47 trials assessing docetaxel and in 18 of 34 trials assessing cabazitaxel. CONCLUSIONS Despite prior failures, novel taxane-based combination therapies have the potential to improve outcomes in mCRPC. Challenges include the absence of validated predictive biomarkers for the selection of suitable patients and the potential for enhanced toxicity. PATIENT SUMMARY Patients with metastatic prostate cancer have access to multiple therapies improving survival. Many advanced epithelial cancers are treated with combinations of drugs; however, prostate cancer has remained an exception. A number of clinical studies have shown that combining chemotherapy with other classes of therapy may improve patient outcomes in prostate cancer. Here, we summarize the various combinations that are tested in the clinic and review the results.
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Affiliation(s)
- Paul G Corn
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neeraj Agarwal
- Department of Medicine, Section of Medical Oncology, University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - John Charles Araujo
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Guru Sonpavde
- Genitourinary Oncology Section, Dana Farber Cancer Institute, Boston, MA, USA.
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Principes, modalités et indication de l’administration du Radium dans les cancers, focus sur le cancer de la prostate métastatique : état des lieux. Bull Cancer 2017; 104:762-770. [DOI: 10.1016/j.bulcan.2017.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/15/2017] [Accepted: 06/19/2017] [Indexed: 11/19/2022]
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Abstract
OPINION STATEMENT Prostate cancer is the most common non-cutaneous cancer diagnosed in men and the second leading cause of male cancer deaths in the USA. While most cases are diagnosed in early stages, some will present as or progress to metastatic disease and eventually castration-resistant prostate cancer (mCRPC) which has a mortality rate exceeding 50 %. There are currently six approved systemic life-prolonging therapies for use in mCRPC, yet little data to guide sequencing. Clinical factors, including the presence or absence of symptoms and the presence or absence of visceral metastases, should help determine the best therapeutic choice at each treatment node. Those with asymptomatic bone-only disease could be considered for sipuleucel-T, abiraterone, enzalutamide, or docetaxel in the first-line setting. For symptomatic disease, docetaxel could be used or radium-223 if disease is only present in the bone. In the second-line setting, sipuleucel-T or radium-223 can be used in the appropriate clinical setting. Taxane chemotherapy could be used if a novel androgen-directed therapy was used in the first-line setting. Cabazitaxel, if docetaxel was previously used, should be considered. There is scarce data on best treatment options in the third-line setting. In general, we recommend alternating between androgen-targeting agents and taxane chemotherapy. Finally, consideration should be given to testing for the androgen receptor splice variant AR-V7, which may be a relevant treatment-specific biomarker to aid in the selection of androgen-targeting therapy versus chemotherapy at each treatment juncture. Mutation testing for DNA damage repair defects can also be considered, as such patients may benefit from investigational poly ADP ribose polymerase (PARP) inhibitors or platinum-based chemotherapies. Several ongoing studies have been designed to answer some of these sequencing questions, including the biomarker questions, and will hopefully continue to inform us about rational therapy selection in mCRPC.
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