Terence Wong, MD, PhD, right, meets with a patient before his PSMA PET/CT scan. Duke is a leader in this type of imaging, which is used in combination with a radiotracer to identify if there's a druggable molecular target. (A version of this photo originally appeared in a Duke Health article in February 2022: "PSMA PET/CT Scan Improves Prostate Cancer Detection and Treatment")
Nuclear Medicine at Duke Garners National Recognition
Duke Cancer Institute nuclear radiologist Terence Wong, MD, PhD, and Stacy Wood, a Duke Health nuclear medicine technologist, provides treatment to a patient. Duke is currently the leading site for treating prostate cancer patients with Pluvicto, a new radiopharmaceutical therapy. (The above photo originally appeared in a Duke Health article in June 2022: "Duke Cancer Center Offers New Treatment for Metastatic Prostate Cancer")
In addition to having technical expertise and appropriate treatment facilities, Centers must meet rigorous training, regulatory, and performance criteria, and are required to provide education and scientific contributions to this growing field. They must administer more than 40 RPT treatments per year in at least two of these disease-specific therapy areas — thyroid, neuro-endocrine tumor, and prostate.
“Duke has a long history of research and clinical experience with radiopharmaceutical therapies; dating back to the late 1990s when radio-labeled antibodies were developed at Duke by Darell Bigner (Preston Robert Tisch Brain Tumor Center) and Michael R. Zalutsky (Department of Radiology) to treat malignant brain tumors,” notes Duke Cancer Institute nuclear radiologist Terence Z. Wong, MD, PhD, FACR, chief of the Division of Nuclear Medicine and Radiotheranostics, a clinical division of Duke Radiology. “The designation as a Comprehensive Radiopharmaceutical Therapy Center of Excellence reflects the culmination of many years of teamwork.”
The Division has utilized radioiodine to treat thyroid diseases (including cancer) for decades and has been one of the leaders in the field using 131I-MIBG (a drug containing a form of radioactive iodine, also called AzedraTM and iobenguane I 131) to treat pheochromocytomas (cancer of the adrenal gland) and carcinoid tumors (a type of neuroendocrine tumor). Duke has been a national leader in treating patients with neuroendocrine tumors using LutatheraTM (177Lu-DOTATATE) since 2018, when it was approved by the FDA. More recently, Duke was one of the first cancer centers to offer PluvictoTM (177Lu-PSMA) to treat metastatic prostate cancer following its FDA approval in March 2022, and is currently the leading site in the U.S. for treating prostate cancer patients with this new radiopharmaceutical therapy.
“Large clinical trials have shown that the radiotheranostic approach can provide clinical benefit for patients with neuroendocrine tumors and prostate cancer, even in patients with advanced disease that is refractory (unresponsive) to other treatments,” explains Wong, who has a secondary faculty appointment as a professor in the Duke Department of Medicine, Division of Medical Oncology. “As a National Cancer Institute-Designated Comprehensive Cancer Center, Duke Cancer Institute is well-equipped to provide these novel treatments.”
“Radiotheranostics” is the concept of using a molecular probe directed at cancer cells to both identify and treat that cancer. Azedra, Lutathera, and Pluvicto are all delivered this way.
First the molecular probe is labeled with a small amount of radioactivity called a radiotracer, which allows the potential treatment sites to be identified by imaging. Duke has been a leader in this type of imaging; 68Ga-DOTATATE PET/CT for neuroendocrine tumors and PSMA PET/CT in prostate cancer.
If the imaging shows that the tumor cells have a druggable molecular target, the area can then be treated with the targeted radiopharmaceutical therapy using the same or similar molecular probe — delivering a high radiation dose to the specific tumor sites while sparing adjacent normal tissue.
Radiotheranostics has progressed rapidly over the last decade and is moving quickly into the mainstream of cancer therapeutics. It was this “recognition of the present and future potential of radiolabeled targeted therapy,” notes Wong, that led to the Division of Nuclear Medicine being renamed the Division of Nuclear Medicine and Radiotheranostics in 2020.
Your Nuclear Oncologist
In a recent email message, Wong congratulated Division and DCI colleagues for their “tireless work” on achieving the Comprehensive Radiopharmaceutical Therapy Center of Excellence designation and for “making Duke a leader in this field.”
He stresses that the Division of Nuclear Medicine and Radiotheranostics is only one component of the Comprehensive Radiopharmaceutical Center of Excellence recognition.
“It is important to note that our Division is fully integrated with the Duke Cancer Institute, working closely with the neuroendocrine GI Oncology group and the DCI Center for Prostate & Urologic Cancers,” says Wong. “Patients at DCI are evaluated by multidisciplinary teams to provide individualized treatment plans and to determine whether radiopharmaceutical therapy is the best option.”
In addition to an experienced team of nuclear medicine physicians, technologists, nurses, and physician assistants, Duke has a dedicated Radiopharmacy to manage ordering and scheduling the delivery of radiotracers and radiopharmaceuticals. Every high dose radiopharmaceutical administration is also overseen by a member of the Duke Radiation Safety Division who meets with the patient to provide individualized post-treatment recommendations.
The SNMMI website lists the Comprehensive Radiopharmaceutical Therapy Centers of Excellence, provides educational resources (research articles and continuing education) about radiopharmaceutical therapies for technologists and has recently added a Patient Resources portal where patients and families can access easy-to-understand fact sheets, guidelines, and informational videos to help better understand nuclear medicine treatment.
“The goal of the (SNMMI) program is to ensure patients have reliable access to high quality radiopharmaceutical therapy, well-integrated into their pathway of care, delivered by highly qualified therapy teams, at technically qualified sites, and led by physicians appropriately trained in nuclear medicine acting as the patient’s ‘nuclear oncologist,’” wrote SNMMI president Richard L. Wahl, MD, FACR, in an official letter this May notifying Wong of the newly-earned designation. “SNMMI is delighted that you and your colleagues share in this important endeavor.”
Related News
In August 2023, a team of volunteers led by Trinitia Cannon, MD (third from left), Leda Scearce, CCC-SLP, MM, MS, and Dina Abouelella, MPH, which also included Tammara Watts, MD, PhD (center) and Katharine Ciarrocca, DMD, MSEd, partnered with North Raleigh International Baptist Church and Duke Raleigh Hospital to offer head and neck cancer screenings. Dozens of families from the Cedar Creek Apartment Complex community came out for the free screenings, education, and games, and Duke Raleigh Hospital donated backpacks full of school supplies.
TheDuke University School of Medicine Department of Head and Neck Surgery & Communication Sciences (HNS&CS) recently launched Project CHECKERS (Community Head and NEck Cancer Knowledge, Engagement, Research and Screening) a Duke Cancer Institute-funded pilot project to bring head and neck cancer resources and education to the broader Durham community.
Led by DCI head and neck surgeon Trinitia Cannon, MD, an associate professor in the Department, the project will be the Department’s first community-based participatory research project and the first such head and neck cancer screening and cancer prevention education project in North Carolina.
Evolving Community Research
The Project CHECKERS team will use a mixed methodology, which includes traditional surveys and screenings as well as interviews and focus groups.
One of their community partners will be the Cedar Creek Apartment Complex community in North Raleigh. Many of these families are refugees — from at least seven different countries in Africa, Asia, and the Middle East — who speak Farsi, French, Swahili, Arabic, and other languages. They are building new lives in North Carolina, in a culture and language that is new to many of them. As is the case with many similar communities, their healthcare needs often go unmet.
The investigators believe that, compared to traditional methods, mixed-method research is an improved way to establish a community partnership, highlight gaps in the community’s knowledge and risk perception, and pave the way for successful future health interventions.
According to co-PI Nosayaba (Nosa) Osazuwa-Peters, BDS, MPH, PhD, an associate professor in the Department of Head and Neck Surgery & Communication Sciences, Project CHECKERS takes an important step in improving community engagement.
“Traditional research is very systematic, very top-down. The researchers have knowledge and decide what they believe the community needs. But these outside scientific experts do not know the values, the culture, the knowledge, or the risks inherent in that community,” he explained.
For example, traditional surveys restrict participants to answering either yes or no; for many people, that binary does not tell a complete story.
“Project CHECKERS will help us understand the lived experiences of people in these communities,” added Osazuwa-Peters. “We’ll learn about context, and we’ll learn to ask questions that allow community members to express themselves. We’ll get responses we would never get based on yes or no.”
Building a Partnership
Project CHECKERS kicked off this fall with focus groups and interviews with community members facilitated by Laura Fish, PhD, MPH, assistant professor in Family Medicine and Community Health, Duke University School of Medicine, and program director for the Behavioral Health and Survey Research Core (a DCI shared resource). An advisory board will provide feedback from both clinical and community perspectives.
Lessons learned from these conversations will help the team develop a knowledge and risk factor survey that will be administered during two head and neck cancer screening events with the community in 2024.
The CHECKERS team will also recruit providers outside the department to participate in these events to address other health concerns in the community such as primary care, mental health, and women’s health.
The long-term goal of Project CHECKERS is to show the benefits of tailoring head and neck cancer screening programs to the communities being served, and how that personalization can improve prevention, early detection, and overall survival in high-risk individuals who have limited access to care.
Noted Osazuwa-Peters, “The mixed-methods framework helps us understand not just whether an intervention works, but how, why, and for whom.”
Community Partners
Another plus to mixed-methods research is its appeal to community partners who might otherwise be hesitant to work with researchers.
“The design places a high value on the stories behind the numbers,” explained Cannon, “so these projects are especially attractive to community partners such as faith-based organizations, whose priority is improving practice and outcomes, more so than research and advancing knowledge.”
Project CHECKERS will provide a valuable bridge between Duke and the North Raleigh International Baptist Church (NRIBC), which ministers to a large immigrant community. NRIBC’s Pastor, Patrick Warutere, invited Duke to participate in the church’s inaugural Health and Dignity for All Fair in Raleigh in 2022. Cannon and CHECKERS co-PI Leda Searce,CCC-SLP, MM, MS, a Duke speech pathologist, recruited nurses, medical students, and resident volunteers to provide HNC screenings for the event.
“We immediately felt a kinship with NRIBC’s Pastor Patrick Warutere and his leadership team,” shared Searce. “By the end of the day, we knew we wanted to continue to work together and set up a meeting the following week.”
Duke HNS&CS and the NRIBC team worked closely to develop the research plan and ensure that the goals and expectations of each group were aligned and transparent.
“That relationship with NRIBC has enabled us to incorporate the community’s perspectives into the development of Project CHECKERS,” said Searce. “Our aim was to amplify the assets and expertise of the community members themselves.”
Cannon anticipates that Project CHECKERS will become a framework for future projects.
“We are looking forward to similar initiatives in hearing health for older adults, right-hemisphere stroke awareness, and more.”
Everardo Macias, PhD, assistant professor in the Department of Pathology, assistant research professor in the Department of Cell Biology, and a member of the Duke Cancer Institute.
Everardo Macias, PhD, assistant professor of Pathology at Duke University School of Medicine, explores the complexities of prostate cancer, the second leading cause of cancer death in men.
His quest to find innovative cancer treatments mirrors his own incredible journey – from a migrant farm worker to a groundbreaking scientist.
Years ago, the future he envisioned for himself was entirely different. A first-generation high school graduate working in the fields of Minnesota as a migrant farm worker, he never even planned to go to college.
Today he leads cutting-edge research, using human cancer genetics and advanced gene testing, to tackle one of prostate cancer’s trickiest players: cancer cells that dodge usual treatments. In lab studies, his method of targeting a protein called NUAK2 successfully slowed down the lethal spread of these cells.
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