PSMA SPECT-CT Evidence

Do you practice in British Columbia?YesNo

Where do you practice?

What is your current role in prostate cancer radioligand therapy? *

What have you read about post Lu177 PSMA SPECT-CT? *NothingI have read the joint EANM/SNMMI guideline on Lu177 PSMA radioligand therapy that recommends PSMA imaging follow-up on therapyI have read the SNMMI/ACNM guideline that specifies technical aspects and frequency of PSMA SPECT-CT recommended useI have read clinical guidelines that recommend against it’s routine use.I have read review articlesI have read original papers or abstracts of observational studiesI have read about it’s role in interventional studies

Which references that specifically advise against it's routine use have you read?

Relevant guideline references used in current clinical protocol development:

Joint EANM/SNMMI procedure guideline for use of Lu177 PSMA RLT (2023)

SNMMI/ACNM Procedure Standard for Post-Treatment Imaging of Lu177 based radiopharmaceuticals

NCCN Prostate Cancer Guidelines

Optional Method of Follow up: “Use of post-treatment SPECT or PET/CT imaging can be considered to monitor PSMA expression for adaptive dosing.”

What have you heard about post Lu177 PSMA SPECT-CT before today? *NothingI have attended accredited Nuclear Medicine oriented CMEI have attended accredited Radiation Oncology oriented CMEI have attended Medical Oncology Oriented CMEI have attended accredited Urology oriented CMEI have attended events sponsored by medical imaging device manufacturersI have attended events sponsored by the pharmaceutical industryOther

How was PSMA SPECT-CT presented in the pharmaceutical industry sponsored presentation? *It was presented as for investigational use only.It was presented as a part of routine standard of careRoutine clinical use of SPECT-CT was encouraged.Routine clinical use of SPECT-CT was discouraged.It was presented in a neutral fashionPresentations on SPECT felt unbiasedPresentations on SPECT felt biasedOther

How was PSMA SPECT-CT presented in the medical imaging device company sponsored presentation? *It was presented as for investigational use only.It was presented as a part of routine standard of care.Routine clinical use of SPECT-CT was encouraged.Routine clinical use of SPECT-CT was discouraged.Presentations on SPECT felt unbiased.Presentations on SPECT felt biased.Other

What were your opinions on current use of PSMA SPECT-CT prior to this talk? *I had no strong opinions on the matter.I thought it was useful for prognosis.I was uncertain of it’s value for prognosisI did not think it was useful for prognosisI thought it had added value above serum PSA and conventional imagingI did not think it had added value above serum PSA and conventional imagingI thought it was impactful to patient managementI was uncertain of it’s impact on patient management.I did not think it should affect management decisions.

What are your feelings on the prognostic value of PSMA SPECT-CT? *I have no opinionIt is a useful prognostic biomarkerIt has some value as a prognostic biomarker.I would like to see more data or a more structured review before making a judgment

Does PSMA SPECT-CT imaging have added value above PSA and conventional imaging? *I have no opinionYesI am uncertainNo

Exceptional Response / Complete Response Definitions

Exceptional response would include:

TheraP trial definition:

A marked reduction in uptake at all sites of disease, appearing as minimally avid or non-PSMA-avid on 24 hour post-treatment SPECT-CT imaging.

7/99 patients in TheraP trial met this definition and were given treatment holidays.

RECIP Definition of Complete Response:

Absence of any PSMA uptake on follow up PSMA imaging.

What are your feelings on the management implications for PSMA SPECT-CT in exceptional response cases? *I think it is reasonable to discuss treatment holidays for these patients.I think it is reasonable to discuss extending cycle intervals in these patients.I think these patients should continue for 6 cycles at standard intervals even if there is no PSMA measurable diseaseI think these patients should continue for 6 cycles at standard intervals even if PSA is undetectableI think we should conduct an experimental trial to provide better answers to questions around treatment holidaysOther

Would it be reasonable to allow treatment holidays similar to other Canadian provinces and similar to countries that use ANZUP (TheraP) criteria for exceptional response? *I don’t think I know enough to answer.The PSMA therapy steering committee should explore this.We should allow this.We should not allow this until there is an experimental trial validating one approach over the other.

PCWG4 criteria for PSMA imaging progression on PET.

Bone, lymph nodes, lung (non-RECIST qualifying lesions on PET):

5 or fewer lesions: confirm 2 new lesions on subsequent PSMA PET

6 or more lesions: Progression confirmed

Liver parenchyma and non-pulmonary viscera:

Any single new lesion.

What should we do if new lesions are detected on PSMA SPECT in excess of PCWG4 criteria? *Select all that applyIgnore it and keep goingArrange a confirmatory PSMA PET-CTRepeat Contrast Enhanced CTConfirm on Bone ScanStop Lu177 PSMA therapyDiscuss switching to other available standard of care Interventions

RECIP criteria for PSMA imaging progression on PET or SPECT.

Over 20% increase in volume of PSMA avid disease from baseline with the presence of new lesions.

What should we do if a patient meets RECIP criteria for progression on SPECT but NOT PCWG4 criteria? *Select all that applyDiscuss switching to other available standard of care treatmentsExplore patient eligibility for clinical trialsIgnore it and keep goingStop Lu177 PSMA therapyArrange a PSMA PET-CTRepeat Contrast Enhanced CTConfirm on Bone Scan

Was the video a reasonable presentation of the current literature in your opinion? *YesNo

If no, then why not?

Has this changed your opinion on SPECT-CT in any way? *YesNo

Other comments or recommendations for improvements in content.

Have you had Lu177-PSMA therapy (Pluvicto)?YesNo

Have you had Lu177-PSMA SPECT scan? *YesNo

Have these videos changed your perspective on this test? *YesNo

Other patient comments on PSMA SPECT-CT

Data validation.

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