Indian Journal of Urology
UROSCAN
Year
: 2021  |  Volume : 37  |  Issue : 4  |  Page : 372--373

VISION trial: 177Lu-PSMA-617 for progressive metastatic castration-resistant prostate cancer


Gorrepati Rohith 
 Department of Urology, AIIMS, Bhubaneswar, Odisha, India

Correspondence Address:
Gorrepati Rohith
Department of Urology, AIIMS, Bhubaneswar, Odisha
India




How to cite this article:
Rohith G. VISION trial: 177Lu-PSMA-617 for progressive metastatic castration-resistant prostate cancer.Indian J Urol 2021;37:372-373


How to cite this URL:
Rohith G. VISION trial: 177Lu-PSMA-617 for progressive metastatic castration-resistant prostate cancer. Indian J Urol [serial online] 2021 [cited 2022 Aug 16 ];37:372-373
Available from: https://www.indianjurol.com/text.asp?2021/37/4/372/327377


Full Text

 Summary



The VISION trial[1] evaluated the advantages of 177Lu-PSMA-617 over best supportive care in improving the overall survival and image-based progression-free survival in patients with progressive metastatic castration-resistant prostate cancer (mCRPC). This was an international, multi-centric, phase three, open-label, randomized trial that recruited mCRPC patients who progressed even after receiving both androgen-receptor-pathway inhibitors (abiraterone or enzalutamide) and either one or two taxane regimens.

A total of 831 patients were included in the study. Subjects were assigned randomly into either 177Lu-PSMA-617 + standard care or standard care alone in 2:1 ratio. Five hundred and fifty-one patients were allotted to the 177Lu-PSMA-617 group and 280 patients to the standard care group. 7.4GBq of 177Lu-PSMA-617 was given every 6 weeks in 4–6 cycles to the patients in the first group. The primary outcome initially was only overall survival. Image-based progression-free survival was added as the second primary outcome after amending the initial protocol. Secondary outcome measures were objective response (based on RECIST, version 1.1), the safety profile of the drug, and health-related quality-of-life (Functional Assessment of Cancer Therapy–Prostate score), pain scores (Brief Pain Inventory Short Form [BPI-SF] score), and prostate-specific antigen (PSA) response. Adverse reactions were recorded from the day of initiation of the intervention to 30 days' poststoppage of the drug or initiation of a second-line drug. All the patients randomized in the study had a positive PSMA gallium-68–labeled PSMA-11 PET scans.

There was a significant improvement in the overall survival in the patients who received 177Lu-PSMA-617 and standard care compared to standard care alone (15.3 months vs. 11.3 months; hazard ratio [HR] - 0.62; 95% confidence interval [CI] - 0.52–0.74; P < 0.001). The second primary endpoint, image-based progression-free survival, also showed significant improvement in the patients who received 177Lu-PSMA-617 (HR - 0.40; 95% CI - 0.29–0.57; P = 0.008). Although a higher incidence of adverse effects was seen in the intervention group (52.7% vs. 38%), the quality of life remained the same with no significant changes. The longer treatment duration (7.6 months vs. 2.1 months) might have influenced this. Adverse effects such as fatigue (43%) and dry mouth (38%) were most commonly seen in the treatment group. There was a higher incidence of complications (grade three and above in severity) in the patients who had received 177Lu-PSMA-617. Around 46% (vs. 7.1% in control group) of the patients had >50% reduction and >33% (vs. 2% in control group), patients had >80% reduction in the PSA levels.

 Comments



With a large sample size (n = 831) and long follow-up (20.9 months), a significant improvement in the overall survival and radiographic progression-free survival was noted with 177Lu-PSMA-617 in this study. Although several prospective trials and small randomized trials tried to establish this, they were limited by their study design and small sample size.[2],[3] Seminal research was conducted in mCRPC patients using 177Lu-PSMA-617 in the Indian population, which demonstrated its effectiveness and better safety profile [Table 1].[3],[4],[5] However, this can be utilized only in mCRPC patients with positive PSMA scans, and nearly 85% of the mCRPC patients have PSMA-positive scans. The degree of positivity correlates with reduced overall survival. Thus, 177Lu-PSMA-617 has the potential to be invaluable in the treatment of this patient subset.{Table 1}

Ninety percent of the patients with mCRPC will have bone metastasis, and nearly half of the cases will develop a critical skeletal event within 2 years.[1] 177Lu-PSMA-617 showed a significant delay in the occurrence of symptomatic bone lesions. There was significant delay in the worsening of FACT-P (5.7 months vs. 2.2 months) and BPI-SF (5.9 months vs. 2.2 months) scores which demonstrates better quality of life despite the higher incidence of adverse events.

The study population is very heterogeneous, including patients with a wide range of treatment histories for varied durations. Although the control group had received supportive care, most of the patients received anti-cancer therapies, including glucocorticoids and androgen deprivation therapy. The lack of standardization of the standard treatment regimens in both the arms and the heterogeneous patient treatment profiles can be considered additional limitations. Furthermore, patients received varied number of lutetium cycles (4 + 2 cycles in a few patients and four cycles in few patients) in the treatment arm, which were not mentioned in the results section.

The mean survival rate of patients with mCRPC is only 9–36 months, with the cancer-specific mortality being driven by the resistance to hormonal therapy.[1] Thus, there is an imperative need for formulating an effective intervention for this population subset. With this largest prospective randomized trial till date showing favorable results, 177Lu-PSMA-617 stands as a new ray of hope in patients with progressive PSMA-positive mCRPC. Nevertheless, the agent's availability and the associated costs with the treatment are a significant hindrance for its extensive utilization in progressive mCRPC.

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.

References

1Sartor O, de Bono J, Chi KN, Fizazi K, Herrmann K, Rahbar K, et al. Lutetium-177-PSMA-617 for metastatic castration-resistant prostate cancer. N Engl J Med 2021;385:1091-103.
2Hofman MS, Emmett L, Sandhu S, Iravani A, Joshua AM, Goh JC, et al. [177Lu] Lu-PSMA-617 versus cabazitaxel in patients with metastatic castration-resistant prostate cancer (TheraP): A randomised, open-label, phase 2 trial. Lancet 2021;397:797-804.
3Yadav MP, Ballal S, Bal C, Sahoo RK, Damle NA, Tripathi M, et al. Efficacy and safety of 177Lu-PSMA-617 radioligand therapy in metastatic castration-resistant prostate cancer patients. Clin Nucl Med 2020;45:19-31.
4Yadav MP, Ballal S, Sahoo RK, Dwivedi SN, Bal C. Radioligand therapy with 177Lu-PSMA for metastatic castration-resistant prostate cancer: A systematic review and meta-analysis. AJR Am J Roentgenol 2019;213:275-85.
5Suman S, Parghane RV, Joshi A, Prabhash K, Bakshi G, Talole S, et al. Therapeutic efficacy, prognostic variables and clinical outcome of 177Lu-PSMA-617 PRLT in progressive mCRPC following multiple lines of treatment: Prognostic implications of high FDG uptake on dual tracer PET-CT vis-à-vis Gleason score in such cohort. Br J Radiol 2019;92:20190380.