What Does Personalization of Radiopharmaceutical Therapy Require?

In a roundtable discussion hosted for RadOnc on the Run, Brandon Mancini, MD, MBA, FACRO, spoke with Mallika Marar, MD, MBA, and Neil K. Taunk, MD, MSCTS, about fixed-dosing options for radiopharmaceutical therapy and what truly personalized care might require from clinicians.

For the time being, Taunk said that significantly modifying dosing should be reserved for clinical trial settings, as true personalization will demand significant investment in infrastructure, training, and technology. Marar described radiopharmaceuticals as falling somewhere between localized and systemic therapy, and while full personalization may not arrive anytime soon, clinical benefit with adaptive treatment may still be feasible.

Mancini is the medical director at Bold Advanced Medical Future Health, a clinical associate professor in the Department of Radiology at Michigan State University College of Human Medicine, and the editor at large for RadOnc Review, a supplement of the journal ONCOLOGY®. Marar is a clinical assistant professor of Radiation Oncology - Radiation Therapy, a clinical assistant professor of Radiology - Rad/Nuclear Medicine, and the director of Theragnostics in the Department of Radiation Oncology at Stanford University. Taunk is an associate professor of Radiation Oncology and Radiology, as well as director of Brachytherapy, director of Imaging Sciences, and chief of Breast Radiation and Gynecologic Radiation Services at the University of Pennsylvania School of Medicine.

Listen to or watch the full conversation for additional details on the future of radiopharmaceutical therapy in oncology.

Transcript:

Mancini: When we look 10 years from now, do you think we’ll look back at fixed dosing and say, “Wow, I can’t believe we’re doing that,” or do you think we’re going to say, “Yeah, that made sense or still makes sense?” What’s your gut feeling, based on your experience?

Taunk: I would love to say I have experience with significantly modified dosing, but on paper, none of us really should, outside a trial setting. In my opinion, there will probably exist a population of patients who are treated with a fixed dose, and then subpopulations that may benefit from something else, like patients who are overwhelmingly likely to respond, perhaps with very robust uptake, or patients who are really sick, with some organ-limiting toxicity. But for most patients, if we think of this like traditional systemic therapies, there will be guidelines to start with. True personalization, dosing every single patient individually for every single dose, is going to require tremendous infrastructure investment, training, and technology to get there.

Marar: Trying to understand the potential benefit of adapting therapy and modifying the administered activity does need some prospective investigation. As Neil said, given all the effort it would take to truly personalize treatment by treatment, how much activity you’re giving, I’m not sure what the potential clinical benefit might be. Even if we’re changing an absorbed dose, does that actually translate to clinical benefit for a patient? Maybe not in the metastatic setting, but it might be more interesting to understand in the intact or curative-intent setting. I think we’re many years away from that, and you can’t discount the infrastructure and clinical investment that would be required for something like that.

At the end of the day, radiopharmaceuticals fall somewhere in between applying local treatment to several different tumors and just being another systemic therapy; they’re somewhere in between. I don’t know that we’ll get to full personalization anytime soon, but I still think we’re seeing a lot of clinical benefit for patients.