The Sh1 million a dose new prostate cancer treatment

It works best for men with advanced prostate cancer who have not responded to first-line therapies such as hormone therapy or chemotherapy.

“We are talking about patients with stage 4 disease. Prostate cancer usually spreads to the bones and the lymph nodes, but it can also go to other organs [liver and lungs]. Traditionally, patients are treated using two main treatments: hormone therapy and chemotherapy. So this new treatment is for patients whose prostate cancer has spread and resisted first-line treatments,” says Prof Mansoor Saleh, the Aga Khan University Hospital chair in the Department of Haematology and Oncology.

The treatment combines a compound that targets a protein on the surface of prostate cancer cells, called prostate-specific membrane antigen, or PSMA, with a radioactive particle that attacks the cells.

“When injected, the radioactive materials go into the tumour, and they destroy the cancerous cells. It is a form of precision-targeted therapy. We call it the magic bullet therapy,” he adds.

Because the treatment is targeted, doctors say they can give high doses of treatment, increasing chances of killing the cancer cells that have resisted other treatments, unlike, say, radiotherapy, which is given in lower doses to lessen damage to surrounding tissue.

“The more cancerous cells in the body, the more receptors there are. So, this drug, when given, goes and deposits in those disease burden areas. Once it gets deposited, it starts emitting the radiation. So, it goes and kills specifically the cancer cell, the other normal cells are not affected,” says Dr Harish Nagaraj, the head of Kenyatta University Teaching, Referral and Research Hospital [KUTRRH]’s Integrated Molecular Imaging Centre.

KUTRRH became the first public hospital to provide the therapy, a milestone in expanding access to advanced cancer care. For now, the only other facility offering Lutetium-177 PSMA treatment is Aga Khan University Hospital.

Dr Nagaraj says KUTRRH has had two patients since the treatment was introduced.

“And there are at least six patients who are waiting,” he says, adding, “we’re getting the feedback from oncologists and also urologists that there are more patients who are interested in the treatment and there is no need for them to leave to India, UK, South Africa or wherever.”

The cost

However, not all prostate cancer patients can receive this treatment. First, a patient has to meet stringent requirements to have it, and secondly, it does not come cheap.

Each treatment cycle costs between $8,000 and $10,000 (Sh1 million to Sh1.3 million). A patient needs at least four to six cycles, which means a person needs at least Sh4 million to Sh6 million.

“A patient may need up to four to six doses of this Lutetium therapy, given about six to eight weeks apart. The response is good, and we’re seeing improvement in patients,” says Prof Saleh.

A US clinical trial involving men with castration-resistant prostate cancer, whose disease had advanced despite chemotherapy and hormone therapy, found that the new radioactive treatment cut deaths by nearly 40 percent, offering hope where options had run out.

Are there cases where, according to studies, a patient’s tumours clear with just one dose of treatment?

“Yes, there are. It varies from patient to patient. Sometimes by the third or fourth dose, the disease is cleared, and no more doses are given. Patients are then monitored to see if the disease returns. Very rarely, there are patients who may not respond, and in those cases, the treatment is not continued,” Prof Saleh says.

Patient precautions

Regarding the requirements one must meet, Dr Nagaraj explains: “We make sure that the patient isn’t having any active infection and is not anaemic.”

Just like Prof Saleh, he notes that the treatment is best for patients whose cancer has spread, which doctors refer to as metastatic cancer, and where traditional treatments have failed.

“Meaning these are the patients who have a lot of metastatic disease burden which has been detected on the PET [positron emission tomography] scans,” says Dr Nagaraj.

While undergoing that kind of treatment, a patient has to exercise precautions.

“The treatment is given intravenously, over a short period of time, often just a few minutes or up to about half an hour. After that, the patient is kept in a special room designed for radioactive patients, where the walls are thick enough to ensure the radioactive doses don’t escape. The patient stays for a day. They are not expected to feel any side effects, but must drink many litres of water and keep emptying the bladder so that any radioactivity not absorbed by the target cells is flushed out in the urine,” Prof Saleh adds.

“A day later, we measure the radioactivity at one metre. When it is within normal limits, usually by the next day, we release the patients to go home with certain precautions.”

Dr Nagaraj explains that they counsel the patients for radiation safety.

“This is for both the patient and the relatives,” he says. “If a patient comes with relatives, they can go home with them. The only thing we advise them is to maintain a distance of between one and two metres from the patient. They can also drive themselves home. But if there are children or even pregnant women, we discourage them from staying in that house.”

In terms of interacting with others, the doctor says anyone coming close to a person undergoing such medication should not stay for more than six hours.

“We allow up to six hours for them to stay together, provided they keep a distance of between one and two metres,” says Dr Nagaraj.
The patient is also advised to avoid airports, as radioactivity detectors might go off.

“We tell them not to travel immediately because this gets detected in the airport,” he says. “They have to wait for a minimum of four days for the radioactivity to come down.”

He notes that the patients undergoing the treatment also need to use separate toilets from other family members.

“Be it a long call or short call, it’s radioactive. We need to make sure that no other person uses the same toilet because of this. Regarding eating, they can eat anything. There is no restriction on this,” says Dr Nagaraj.

All the hassle, Dr Nagaraj notes, is worth it because the type of treatment is known for reducing the pain in patients.

“Cancer weakens the body, and one is always in pain. This treatment is completely pain-free; that’s the beauty of this treatment. If you compare it with chemotherapy, one might be treated with a good drug, but experience bad side effects, making the patient weak. But with this kind of precision medicine, you feel normal and do your normal chores,” he says.

The doctor adds that with Lutetium-177 PSMA therapy, they “treat what we see and we see what we treated”, meaning that it eliminates the need for guesswork.

“If I have given the medication to this patient with a high disease burden, after two cycles, we literally see nothing [cancer cells] on the scan. So, that means that you have cleared the disease,” he says.

However, in case of cancer recurrence, he says other checks can flag it.

“We keep doing a monthly baseline blood test. We also check something called a prostate-specific antigen, or PSA. When the PSA level starts going up, we start suspecting there could be a recurrence there,” he says.

The treatment, Prof Mansoor adds, offers new hope because Kenya has a high rate of prostate cancers, which also tend to be more aggressive.

“Many patients have stage four disease. So the possibility of having an impact in terms of quality of life, extending survival, and achieving periods free of disease progression makes this treatment significant,” he says.

Prostate cancer is the leading cancer among Kenyan men, with an estimated 3,582 men being diagnosed with the disease at some point in their lives. Can the treatment work in stage 1 or stage 2 prostate cancer?

“There are studies underway to start offering the treatment earlier, when the disease is at stage two or one, with fewer tumour cells. It may turn out to be an effective treatment at that level, potentially replacing other conventional treatments,” Prof Saleh adds.

Currently, Kenya imports radioactive materials from various sources.

“At present, we are getting them from South Africa, which has a nuclear reactor. They produce the lutetium and the PSMA, which we then label in-house in Kenya. We have the expertise.”

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