Amanda Wilde (Host): Theranostics, what is it? Who is it for and how does it work? Steven Wozniak is here to explain Theranostics. He is the Associate Director of Molecular Imaging and Theranostics at 210 PET Imaging and 210 Theranostics. This is WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.

I'm Amanda Wilde. Steven Wozniak, welcome. Thank you so much for being here.

Steven Wozniak, BS, CNMT, PET: Thank you for having me.

Host: Let's start at the beginning, because a lot of us haven't heard this name before. What is Theranostics?

Steven Wozniak, BS, CNMT, PET: Theranostics, simply put is a relatively recent term that basically means a combination of therapy and diagnostics.

Host: Oh, it combines those two words, theranostics.

Steven Wozniak, BS, CNMT, PET: Correct. So the diagnostic component is typically a PET CT scan, certainly when we're speaking about this in my space. And then the treatment component, the therapy component would be RADIOLIGAND therapy or RLT, which is the nuclear medicine version of radiation therapy.

Host: So how is this different from other radiation treatments and chemotherapy in treatment for tumors?

Steven Wozniak, BS, CNMT, PET: Well, there's hormone therapy out there to treat cancer, chemotherapy, which utilizes drugs, and that's typically a long infusion over many hours, over a period of weeks, chemotherapy circulates throughout the entire body and as many of us know someone who's gone through it, we all know that there could be significant side effects.

It can damage healthy tissue. Radiation therapy in today's technology has become more targeted, more specific, but it is high energy radiation. So radiation therapy utilizes high energy radiation to treat cancer and it could damage surrounding healthy tissue. And patients also can experience unpleasant side effects with that.

Theranostics differs from chemo and radiation therapy in that the treatment is molecularly targeted. It's very specific to attack the cancer only. It has minimal impact to surrounding tissue, minimal side effects. When we're talking about prostate cancer treatment, it's what we call a treat to street.

It's a simple injection, and the patients are free to leave almost immediately. One of our longer treatments is for neuroendocrine tumors, but the patient's only here a few hours once every six weeks, so it's much easier for the patient.

Host: How does Theranostics work? Is it also a form of radiation?

Steven Wozniak, BS, CNMT, PET: Yes, in the nuclear medicine space, which has also in recent years, been referred to as molecular imaging as well, so nuclear medicine and molecular imaging, those two terms are interchangeable because we work at the molecular level. So simply put, in nuclear medicine, we take a non-radioactive material that we know will go to the area in the body in which we want to look at.

If we give that compound or that non-radioactive pharmaceutical, a radioactive piggyback, we will be able to see it with our scanner. So simply put, if we wanted to look at bone, if we took a radioactive material that the nuclear medicine scanner can see well, and we attach it to something called MDP, inject the patient with it, let it circulate for a little while. When we put the patient under the scanner, we will see bone. If we take that same radioactive material and attach it to something called sulfur colloid and inject it into the patient, after it's circulated for a period of time and we scan the patient, we will see just the liver.

So simply put, you take a radioactive material that the scanner can see well, attach it to something that goes to the region of interest, introduce it to the patient, and that's what you will see. Theranostics takes it a step further, and instead of using a radioactive material that is a diagnostic level of radiation, we call it gamma radiation, we attach it to an alpha or beta emitter which actually destroys tissue. So the great example I like to give the average person is if you wanted to look at prostate cancer in the patient with a PET CT scanner, we would take something called PSMA, which is prostate specific membrane antigen. And if we attach that to a radioactive material, the PET scanner can see well, which is F18; when we inject the patient, let that circulate about 45 to 60 minutes, the PSMA goes to cancer and it brings along the F18 on its back. And when we scan the patient, we will see any prostate cancer that is in the body. So Theranostics takes it one step further. The science is very complicated, but the concept is simple.

Some genius along the way said, Hey, if F18 sticks to PSMA and will allow us to visualize prostate cancer, what if we were to find a radioactive piggyback that actually will destroy the cancer? So, the PSMA will carry it to the cancer and this new radioactive material will kill it. And they found that in radium 223 or LUTETIUM 177.

You may have seen the commercials for PLUVICTO, and that's exactly what that is. It's LUTETIUM 177 attached to PSMA, and when introduced to the body, the PSMA carries that lutetium to all of the cancer cells and kills them at the local level. And that's why it's more comfortable for the patient. It's very personalized medicine.

It's very targeted, and it is not widespread throughout the body like chemotherapy. So that's why it's targeted and it's better for the patient with less side effects, significantly less side effects than some of the other options out there.

Host: You mentioned prostate cancer. What types of cancer can be treated with Theranostics?

Steven Wozniak, BS, CNMT, PET: Well, the three most popular ones out there right now are Xofigo and PLUVICTO for the treatment of different types of prostate cancer. And we use them both here at 210 Theranostics. And we also have a product called Lutathera, which is for the Theranostic treatment of different types of neuroendocrine tumors.

So we're offering those three here at 210 Theranostics. They are the most frequently used in our world right now,  Xofigo and Lutathera have been around for about 10 years.  PLUVICTO's been around the last couple of years and has recently been approved for pre-chemo treatment. So patients don't have to go through chemotherapy first to be considered as a candidate for  PLUVICTO , so that makes this option available to three times more patients with prostate cancer than before.

Host: And are we treating other kinds of cancers with Theranostics?

Steven Wozniak, BS, CNMT, PET: There are other treatment options for Theranostics. Actually, what got me into the field over 35 years ago was a Theranostics type of treatment. They just didn't use that term back then. Nuclear medicine's been around for 50 plus years. It has largely been a diagnostic modality, excelling in function and disease detection.

Not so great for anatomy. We've come full circle where we excel in both now with hybrid imaging like a PET CT scanner, the PET is great for disease and cancer detection. The CT's great for anatomy, so if you put the both together in one scanner, which we have, you get the best of both worlds. So 35 plus years ago, I had a thyroid condition.

I was diagnosed in nuclear medicine. I was diagnosed with a gamma emitter called I 123. When the results came back, my treatment options were surgery or treatment in nuclear medicine with a beta emitter I 131. So I had one of the earlier forms of Theranostics and that's what introduced me to the field, and I was very interested and very excited about it, and pursued that as a career option, and have been doing it for over 35 years now.

Host: Oh, so it touched you personally, and now it's the focus of your professional life.

Steven Wozniak, BS, CNMT, PET: Correct. So I find it very rewarding. And there are currently over 200 Theranostics agents in the works at various stages of clinical trials. It is the new and exciting thing in nuclear medicine, molecular imaging these days, and the manufacturers are all working on what we call Theranostic pairs.

During my time in nuclear medicine, a new imaging agent might come out, the quote unquote therapy agents, in the early period of my career were more palliative and less curative, with the exception that got me into the field, the thyroid. Most of them were to treat patients at the end stage of cancer to alleviate pain and improve quality of life, but they weren't really treating or curing cancer.

Nowadays, nuclear manufacturers are looking at Theranostics pairs where they're actually taking the material to see if it will go to breast cancer, go to prostate cancer, go to renal cancer, and looking for both a diagnostic agent to bring it there to visualize with a PET CT or PET MRI, and then a beta or alpha component that they could use later for treatment if the patient is identified as a candidate.

And it's exciting that there's over 200 in the works right now.

Host: How do you identify a patient that you would recommend Theranostics for?

Steven Wozniak, BS, CNMT, PET: Typically our patients come either through urology, perhaps oncology, and in going through their normal workup with their primary care physician or their specialist, if they are determined to have cancer or highly suspicious of having a form of cancer, they would come to have a PET scan with us at 210 PET Imaging. If that scan is positive for a type of cancer, typically it's used for staging or restaging.

And it confirms the diagnosis; the physician, along with other previous scans and tests the patient had, can consider the patient for Theranostics as an option. They have a wide range of tools in the toolbox, right? They could do hormone therapy. Surgery may be an option. Radiation, traditional radiation therapy might be an option.

But now, depending on the type of cancer, Theranostics treatment may also be an option. And this is something oncologists are aware of. Physicians can also consult with our chief nuclear medicine physician about options in Theranostics and we can offer those services if it's in the best interest of the patient.

Host: How effective is Theranostics? Is it highly effective?

Steven Wozniak, BS, CNMT, PET: Yes, the therapies that we're offering, the Theranostics procedures at 210 Theranostics have been proven to be highly effective with minimal side effects or reactions to the patient, and have been shown in various studies to increase of quality life. And increase lifespan, versus other forms of treatment or those treatments alone without Theranostics.

Theranostics can be used in conjunction with other treatments, but they have proven to be very successful.

Host: Steven, you've seen this field as it has advanced and unfolded, and you touched earlier on cancers that Theranostics in the future will be able to treat. What do you think is next in Theranostics research?

Steven Wozniak, BS, CNMT, PET: I think breast, GI cancers and renal cancers are probably the big three that we should be seeing in the near future. Of course, there will be other types of prostate cancers treatments available because of the radioactive material. Once the manufacturers and the researchers develop an agent such as PLUVICTO and lutathera, which use LUTETIUM 177, they also look at other radioactive materials that might be more efficient carriers, which might provide more potency to treating certain cancers with even less side effects.

So even though we have tried and proven agents available to us; they're always looking for better ligands, which is what attaches itself to the cancer cell, and they're always looking for better radioactive materials that might be more effective. So I would anticipate seeing more prostate cancer treatment, Theranostic agents becoming available.

I know that there are more neuroendocrine tumor Theranostics agents becoming available that are currently in trials and about to be released. And as far as brand new Theranostics, as I mentioned previously, I would anticipate breast, renal and gastrointestinal be among the top three.

Host: So this is exciting that you are growing the applications for this precise targeted tissue sparing treatment.

Steven Wozniak, BS, CNMT, PET: Yes, it's very exciting and we can only imagine what's on the horizon. In just the four years that 210 PET and Theranostics has been in business, we started with just one radioactive tracer in our first month and progressed to several within the first year, and now we have 11 radio tracers in our arsenal, including Theranostic agents.

And what that means is we can evaluate different diseases with CT, with MRI, with our other modalities within radiology. By and large, it's the scanner that gives you your image.

In the nuclear medicine space, what gives you your image is the radiopharmaceutical that you administer to the patient. The scans are almost all the same, but what you inject determines what disease you may be able to visualize.

And there's new radiopharmaceuticals coming out all the time and our volume has grown exponentially with each new radiopharmaceutical that has become available to our patients. For example, in our first year that August PSMA imaging became available, a new product called PYLARIFY for the detection of prostate cancer became available to us.

That doubled our patient volume just by adding that one radio tracer. And we were the largest provider of that imaging in the entire Southeast as they rolled that product out geographically. Now it's available nationwide. Similarly, in recent months, a new product called Amyvid became available, which is for our neurology imaging, and that is for the detection of amyloid plaque and is a requirement for patients to receive Alzheimer's treatments from one of two different drugs that are in the marketplace.

So once Amyvid became available to us and we started offering that service, we took a huge jump in volume once again. And as I mentioned previously, the vendors aren't just coming out with imaging products, they're coming out with Theranostic pairs, and although they may not be released at the same time, that is the intent.

If we're going to come out with a diagnostic agent, we are going to come out with its Theranostics counterpart.

Host: This is amazing medical technology and good to hear that it is growingly accessible. Steven, thank you so much for explaining Theranostics in a detailed but yet understandable way. Really appreciate you sharing this information.

Steven Wozniak, BS, CNMT, PET: You're welcome.

Host: Steven Wozniak is the Associate Director of Molecular Imaging and Theranostics at 210 PET Imaging and 210 Theranostics, a joint venture between Raleigh Radiology and WakeMed. To learn more about Theranostics treatment, visit wakemed.org. If you found this podcast helpful, please share it on your social channels. You can check out our entire podcast library for other topics of interest to you. This is WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.