Treatment of Metastatic Castration-Resistant Prostate Cancer with PSMA Expression

Diagnostic Confirmation and Treatment Algorithm

PSMA expression must be confirmed using PET imaging with either Ga-68 PSMA-11, F-18 piflufolastat, or F-18 flotufolastat before initiating 177Lu-PSMA-617 therapy, as recommended by the Journal of Clinical Oncology 1
Patients should not have PSMA non-expressing lesions, which would indicate poor response to PSMA-targeted therapy, according to the Annals of Oncology 2

For initial management of mCRPC, the American Urological Association recommends standard options including abiraterone plus prednisone 3, 2
The European Association of Urology suggests enzalutamide as a first-line treatment option for mCRPC 2
After progression on first-line therapy, the National Comprehensive Cancer Network recommends considering novel hormonal agents, such as abiraterone or enzalutamide, if not previously used 2

177Lu-PSMA-617 is indicated for patients with confirmed PSMA-positive disease on PET imaging, previous treatment with at least one androgen receptor pathway inhibitor, and previous treatment with at least one taxane regimen, as stated by the Annals of Oncology and the Journal of Clinical Oncology 2, 1
The American Society of Clinical Oncology recommends regular monitoring of PSA levels every 3-4 weeks initially to assess response, and imaging follow-up with CT scans and bone scintigraphy to evaluate treatment response 4
Blood counts, renal and hepatic function should be checked before each cycle of 177Lu-PSMA-617 therapy, according to the Journal of Clinical Oncology 1