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Pathmanandavel S, Crumbaker M, Nguyen A, Yam AO, Wilson P, Niman R, Ayers M, Sharma S, Eu P, Martin AJ, Stockler MR, Joshua AM, Emmett L. The Prognostic Value of Posttreatment 68Ga-PSMA-11 PET/CT and 18F-FDG PET/CT in Metastatic Castration-Resistant Prostate Cancer Treated with 177Lu-PSMA-617 and NOX66 in a Phase I/II Trial (LuPIN). J Nucl Med 2023; 64:69-74. [PMID: 35738906 PMCID: PMC9841258 DOI: 10.2967/jnumed.122.264104] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 01/28/2023] Open
Abstract
177Lu-PSMA-617 therapy has shown high prostate-specific antigen (PSA) response rates in men with metastatic castration-resistant prostate cancer. However, early treatment resistance is common. This LuPIN substudy aimed to determine the prognostic value of posttreatment quantitative PET for PSA progression-free survival (PFS) and overall survival (OS) with 177Lu-PSMA-617 therapy. Methods: Fifty-six men with progressive metastatic castration-resistant prostate cancer were enrolled in the LuPIN trial and received up to 6 doses of 177Lu-PSMA-617 and a radiation sensitizer (NOX66). 68Ga-PSMA-11 and 18F-FDG PET/CT, diagnostic CT, and bone scanning were performed at study entry and exit. Quantitative analysis tracked change in total tumor volume (TTV) and SUV. Univariable and multivariable analyses were conducted to examine the association of change in TTV (continuous and >30%), SUVmax, PSA, and radiographic progression with PSA PFS and OS. Results: All men (37/56) who underwent both screening and posttreatment molecular imaging were analyzed; 70% (26/37) had a PSA response of more than 50%. Median PSA PFS was 8.6 mo, and median OS was 22 mo. Clinical progression had occurred at trial exit in 54% (20/37). In response to treatment, a reduced PSMA SUVmax was demonstrated in 95% (35/37) and a reduced PSMA TTV in 68% (25/37). An increase in PSMA TTV by at least 30% was associated with worse OS (median, 10.2 vs. 23.6 mo; P = 0.002). Change in PSMA SUVmax was not associated with PSA PFS or OS. 18F-FDG SUVmax was reduced in 51% (18/35) and 18F-FDG TTV in 67% (22/35). An increased 18F-FDG SUVmax was associated with worse OS (median, 20.7 vs. 25.7 mo; P < 0.01). An 18F-FDG TTV increase by more than 30% was associated with a short PSA PFS (median, 3.5 vs. 8.6 mo; P < 0.001) but not OS. Both PSA and radiographic progression were associated with shorter OS (median, 14.5 vs. 25.7 mo [P < 0.001] and 12.2 vs. 23.6 mo [P = 0.002]). On multivariable analysis, only increased PSMA TTV and PSA progression remained independently prognostic of OS (hazard ratio, 5.1 [95% CI, 1.5-17.1; P = 0.008] and 3.5 [95% CI, 1.1-10.9; P = 0.03], respectively). Conclusion: Change in quantitative PSMA TTV has strong potential as a prognostic biomarker with 177Lu-PSMA-617 therapy, independent of 18F-FDG PET parameters, PSA, or radiographic progression. Further research into the value of posttreatment PET as an imaging biomarker is warranted.
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Affiliation(s)
- Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia; .,Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, New South Wales, Australia.,Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew O. Yam
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Peter Eu
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew J. Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; and
| | - Martin R. Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; and
| | - Anthony M. Joshua
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia;,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia;,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Murphy P, Claxton L, Hodgson R, Glynn D, Beresford L, Walton M, Llewellyn A, Palmer S, Dias S. Exploring Heterogeneity in Histology-Independent Technologies and the Implications for Cost-Effectiveness. Med Decis Making 2021; 41:165-178. [PMID: 33435846 PMCID: PMC7879234 DOI: 10.1177/0272989x20980327] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background The National Institute for Health and Care Excellence and a number of international health technology assessment agencies have recently undertaken appraisals of histology-independent technologies (HITs). A strong and untested assumption inherent in the submissions included identical clinical response across all tumour histologies, including new histologies unrepresented in the trial. Challenging this assumption and exploring the potential for heterogeneity has the potential to impact upon cost-effectiveness. Method Using published response data for a HIT, a Bayesian hierarchical model (BHM) was used to identify heterogeneity in response and to estimate the probability of response for each histology included in single-arm studies, which informed the submission for the HIT, larotrectinib. The probability of response for a new histology was estimated. Results were inputted into a simplified response-based economic model using hypothetical parameters. Histology-independent and histology-specific incremental cost-effectiveness ratios accounting for heterogeneity were generated. Results The results of the BHM show considerable heterogeneity in response rates across histologies. The predicted probability of response estimated by the BHM is 60.9% (95% credible interval 16.0; 91.8%), lower than the naively pooled probability of 74.5%. A mean response probability of 56.9% (0.2; 99.9%) is predicted for an unrepresented histology. Based on the economic analysis, the probability of the hypothetical HIT being cost-effective under the assumption of identical response is 78%. Allowing for heterogeneity, the probability of various approval decisions being cost-effective ranges from 93% to 11%. Conclusions Central to the challenge of reimbursement of HITs is the potential for heterogeneity. This study illustrates how heterogeneity in clinical effectiveness can result in highly variable and uncertain estimates of cost-effectiveness. This analysis can help improve understanding of the consequences of histology-independent versus histology-specific decisions.
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Affiliation(s)
- Peter Murphy
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Lindsay Claxton
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - David Glynn
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Lucy Beresford
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Matthew Walton
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
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