by Vera Martinella
Available only in 30 Italian hospitals for rare neuroendocrine tumors, they are proving effective for prostate and other types of cancer
They are used to diagnose the tumor, but also to treat it with extreme precision. They are as effective and powerful as radiation, which however is administered intravenously. Radioligands, drugs already used today to effectively treat some tumors, are, in practice, molecules capable of attaching themselves to diseased cells which are first “sent” to find them and then are “loaded” with a radioactive dose that destroys them precisely. To correctly inform clinicians, patients and institutions, the Italian Association of Medical Oncology (Aiom) has created the book «Radioligand therapy: 50 questions 50 answers» also signed by the Italian Association of Nuclear Medicine and Molecular Imaging (Aimn), presented in recent days during the national congress of the scientific society in Rome.
Theragnostics: therapy and diagnosis together
To better understand what it is, we need to start from the concept, little known for now, of theragnostics: «A new frontier of precision medicine in which diagnosis and therapy use the same molecule, the so-called “carrier”, the vector or transporter (i.e. the ligand), which is able to bind specifically and with high affinity only to neoplastic cells, bringing with it the radioactive particle capable of emitting therapeutic radiation – explains Saverio Cinieri, president of the Aiom Foundation -. In short, the ligand is able to recognize tumor cells and ensure that a radiopharmaceutical (i.e. the radioisotope) combines only with them to eliminate them with radioactive particles, but without damaging healthy cells.” It is the most significant evolution of the concept of theragnostics, which also brings savings for the healthcare system: «No other strategy is able to outline with as much accuracy and predictivity whether, how much and how the tumor target can be hit even before starting therapy – continues Cinieri -. The increasingly high level of personalization of treatments thanks to this approach can contribute to a better use of resources, with a reduction in costs and hospitalization times (one-maximum two days every six/eight weeks, for a total of 4 cycles), thus improving the quality and effectiveness of care and the governance of health spending”.
Neuroendocrine tumors, of the prostate and beyond
This strategy derives from therapy with iodine 131, used for decades for thyroid cancer: now, with the new generation of radioligands, multiple opportunities are opening up for the diagnosis and therapy of other pathologies. Radioligands, for now, are already used in Italy to treat neuroendocrine tumors (NETs in English), a heterogeneous group of rare neoplasms deriving from neuroendocrine cells, scattered practically everywhere in the human body, where they have been shown to improve survival and the quality of life of patients. And they are also demonstrating efficacy in metastatic prostate cancer, resistant to castration (i.e. treatment with hormone therapy), for which they have already received approval in the United States and Europe, but there are already indications of an advantage even in phases earlier, with excellent results on survival, disease control and quality of life. «The clinical experience of using radioligands derives precisely from the treatment of neuroendocrine tumors, which in most cases appear in the metastatic phase – says Marcello Tucci, director of Oncology at the Cardinal Massaia Hospital in Asti -. They are present in numerous organs such as the lungs, bronchi, intestine, rectum, appendix and pancreas. The most widespread, located in the gastro-entero-pancreatic tract, record around 2,200 new cases in Italy every year and require a complex diagnostic-therapeutic process. Starting from NETs, numerous international studies have evaluated the potential of radioligands in the diagnostic and therapeutic phase in various tumors such as breast, pancreas, lung, prostate, melanoma, lymphoma and multiple myeloma.”
Only 30 Centers in Italy (for now)
In Italy, around thirty centers are able to provide radioligand therapy: only dedicated multidisciplinary teams are able to direct this type of treatment, which must be conducted in reference nuclear medicine centres. Therefore, to make this innovation accessible to all patients who can benefit from it, it is necessary to improve its availability by overcoming administrative and organizational obstacles, as Maria Luisa De Rimini, president of Aimn, recalls: «Radioligand therapy, in its many aspects of management, requires an indispensable infrastructural adaptation, essential for its provision to be guaranteed and for the opportunity to be accessible uniformly throughout the territory. Overcoming the inhomogeneity of geographical distribution, increasing the number of nuclear medicine facilities capable of providing these treatments, will allow us to eliminate the phenomenon of healthcare migration which often forces patients and family members to inconvenience long journeys.” We therefore need to strengthen nuclear medicine centers so that they have sufficient specifically trained personnel. «And that the nuclear doctor is always part of the multidisciplinary team that must follow the patient, even more looking at the arrival of the radioligands – adds De Rimini –, as recommended by the National Oncology Plan 2022-2027».
Multidisciplinary team
The added value of multidisciplinary teams has been clearly demonstrated in the case of rare tumors, therefore also in neuroendocrine tumors (NETs), where it is more necessary than ever to bring together specific expertise. A team of specialists dedicated to NETs, simultaneously focused on the individual clinical case, represents the premise for the best diagnostic and therapeutic approach. On this basis, over the years, the reference centers have equipped themselves with groups dedicated to these specific pathologies, which include nuclear doctors, oncologists, endocrinologists, gastroenterologists, surgeons, pathologists, medical physics specialists and radiologists. «This management model is an indispensable requirement for the quality standard of care for patients with NETs, required for certification by the European Neuroendocrine Tumors Society and promoted by ItaNET, which since 2010 has brought together doctors belonging to the various specialties dealing with the management of neuroendocrine tumors – concludes Massimo Di Maio, president-elect of Aiom -. The most recent Aiom-ItaNET guidelines also highlight the importance of sharing therapeutic choices and the need to include the patient in an integrated and dedicated path, managed by a multidisciplinary team. Radioligand therapy cannot be provided by all hospitals, which is why it is even more important that the multidisciplinary teams of the peripheral centers are able to work as closely as possible with the experience of the structures that are able to take in charge of patients”.
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November 17, 2023 (modified November 17, 2023 | 10:59)
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