Theranostics center of excellence: transforming oncology care

Nebraska Cancer Specialists in the midwestern region of the United States serves as a model of excellence in theranostics. While caring for the local community and attracting patients from across the country, the center also operates an extensive clinical trials program. 

Photography by Maria Julie Borer | Data courtesy of Nebraska Cancer Specialists, Nebraska, USA

Theranostics, which is an innovative form of personalized therapy that focuses on both the accurate selection of patients and providing them with targeted radioligand therapy to improve their prognosis,¹ is part of a broader commitment at Nebraska Cancer Specialists (NCS) to offer patients cutting-edge treatments at convenient locations.

“I strongly believe that theranostics care should be a service line within a medical oncology practice,” says Samuel Mehr, MD, director of Nuclear Oncology at NCS. “Just as a medical oncology practice would not refer their chemotherapy or immunotherapy patients to outside sources for therapy, I believe that theranostics should also be offered within the medical oncology practice. This concept appears to be resonating throughout the medical oncology community.”

Medical oncologist Joel Michalski, MD, PhD, points out that fragmented care burdens patients with travel, and it has been linked to adverse outcomes.² He says that having a theranostics program within the medical facility dramatically lowers the pressure on patients by offering them advanced, personalized care close to home. 

“One of the things that drew me to this practice is that we can provide an oncologic home for our patients, and an important part of that is theranostics,” Michalski says. “There’s not much that we cannot offer our patients that they would otherwise get at a university setting.”

In 2013, NCS began offering theranostics after radium-223 was approved by the U.S. Food and Drug Administration for the treatment of patients with castration-resistant prostate cancer (CRPC) and bone metastases. Medical oncologist Ralph Hauke, MD, approached Mehr, who at that time was a faculty member at the Creighton University School of Medicine and conducting a clinical trial with ¹⁷⁷Lu-DOTATATE for the treatment of neuroendocrine tumors, about offering the treatment at NCS. Physicians within the practice saw an opportunity to improve the care they offer to patients, and they seized it. 

“Radionuclide therapy within the practice of NCS was an immediate success,” Mehr says. “And part of the reason for that is all of the medical oncologists in this practice are engaged with the dynamics of the practice and are supportive of what everyone else is doing.”

Today, NCS has approximately 60 patients undergoing theranostics treatment at any given time. It offers theranostics to patients at its flagship facility in Omaha and 100 miles (161 km) to the west in the city of Grand Island.

“In 2021 we acquired our Biograph™ Horizon PET/CT scanner, and that’s really what led to the quick expansion of our program,” says Scott Degenhardt, director of Radiology and Theranostics. “We added a couple additional therapy and uptake rooms. We added another nuclear medicine technologist and a full-time nurse who is dedicated to our theranostics program in our PET/CT department. Today we have a Symbia Pro.specta™ SPECT/CT, ten dedicated therapy and uptake rooms, and two hot labs. And our staff has grown to eight full-time employees. As you can see, it’s just quickly grown.”

Mehr describes PET/CT as a gatekeeper for theranostics, noting that it plays an essential role in determining eligibility for treatment. He says the sensitivity and speed of the Biograph Horizon PET/ CT ensure small lesions are detected quickly to keep scan times to a minimum for the patient. The reliability of the scanner minimizes workflow disruptions, he adds. 

In the treatment phase, quantitative accuracy and reproducibility are critical, “and the system that we have is spot on,” Mehr says, referring to Symbia Pro.specta SPECT/CT. “There’s virtually no variability using the parameters that have been established.” 

SPECT/CT dosimetry is used for determining the optimal therapy for individual patients. The scanner that NCS uses is tailored to their needs with protocol optimization for routine patient care and clinical trials. 

“Siemens Healthineers has been very responsive in becoming partners on this effort of looking at software modifications or additions,” Mehr says. “They have made it clear that they’re committed to theranostics, and they’ve shown that commitment in what they do and how they develop their products and software.” 

Using xSPECT Quant™, Mehr and his colleagues obtain quantitative uptake values that are accurate to within 5% and highly reproducible.^a The tool helps deliver personalized care that maximizes radiation dose to tumors while limiting potential toxicity. Automatic SPECT motion correction that enhances image quality is particularly beneficial in patients with abnormalities near the diaphragm, he adds.

In addition to using its Symbia Pro.specta SPECT/CT for nuclear medicine patients, NCS also uses it as a dedicated and sophisticated CT scanner. “Oftentimes we’re flipping back and forth on those modalities throughout the day,” Degenhardt says. “From a workflow standpoint, we’re able to accomplish a wide variety of needs all on that single unit.” 

PET/CT is used to monitor for progression, recurrence, or resolution of disease. “The CT component addresses size, and more importantly, especially in our neuroendocrine tumors, the semi-quantitative component of SUV_max monitors receptor expression,” Mehr says. “In many of these tumors, the size of the tumor is less important than the degree of biologic activity, and we’re well covered on both of those fronts.” 

NCS serves as a model theranostics program through the OnCare Alliance, an integrated network of community oncology practices. It is also a model center for theranostics research in the Exigent Research network, a nationally recognized integrated research network. 

“As part of the consultative process, we make specific equipment recommendations to those practices,” Mehr says. “For our last several consultative experiences since acquiring our PET/CT and SPECT/CT, we’ve recommended Siemens Healthineers.”

NCS is heavily involved in theranostics clinical trials that range from first in human phase one studies to phase three studies. 

“Research is critical to patient care, not only for patients in the future, but for current patients,” Michalski says. “If you go through National Comprehensive Cancer Network (NCCN) guidelines, just about every step along the way is ‘consider a clinical trial.'“

Disease states that are currently being studied at NCS include neuroendocrine tumors, prostate cancer, breast cancer, small cell lung cancer, and melanoma, among others. “There is a move now to make theranostics care agnostic, where we’re not so much concerned about what the tumor type is, but whether or not that tumor expresses the materials necessary for successful theranostic treatment,” Mehr says. 

Michalski points out that several of the trials are designed to explore the safety and efficacy of positioning theranostics as a first-line therapy. “That’s the typical evolution of all new and exciting cancer treatments,” he says. “They start off in later lines, and if we get a signal for success we work hard to try and bring that technology efficiently and quickly to the forefront so that we’re helping more patients.”

The right technology is a necessary component of an effective theranostics program, but investing in the human infrastructure is a critical first step. 

Degenhardt says that at a minimum, a theranostics program in the U.S. requires an authorized user with the Nuclear Regulatory Commission, a nuclear medicine technologist to administer radiopharmaceuticals, and a nurse case manager. 

At NCS, the nurse case manager, also known as a theranostics navigator, is a single point of contact for patients who coordinates with nuclear medicine, medical oncology, and other treatment providers to ensure that patients are scheduled appropriately for their imaging and procedures. The theranostics navigator is with the patient during their initial consultation and supports them for the duration of their treatment journey. 

“Oftentimes patients are undergoing combination therapy where they are receiving chemotherapy, immune therapy, or another type of cancer treatment along with their theranostics,” Degenhardt says. “When questions arise about side effects or symptoms, that nurse case manager can be there to triage and say ‘this is really a nuclear medicine question that we should take to that team’ or ‘this is a medical oncology question and it can be directed towards them.”

The patient-centered approach that NCS prides itself on has helped draw patients from across the U.S. By sharing their expertise with other practices, they seek to make theranostics more broadly available so that more patients can benefit from personalized care while staying closer to their homes and loved ones. 

“We’re working hard with the medical oncology community to encourage medical oncologists to obtain the necessary training and credentials to practice theranostics on their own,” Mehr says. “Just as chemotherapy and immunotherapy belong within the purview of the medical oncologist, so does theranostics.”

Sameh Fahmy, MS, is an award-winning freelance medical and technology journalist based in Athens, Georgia, USA.