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Dustin Boothe: Hey, good morning. My name is Dustin Boothe. I'm a radiation oncologist, and I'm coming from Intermountain Health. I also cover the theranostic program at a private clinic, Utah Cancer Specialists. These are my disclosures.

And today, we're going to talk about the radiation oncology perspective in the private practice as well as describe a health system-based RLT program. I also want to take some time to describe a multidisciplinary program that we've developed that includes both radiation oncology and nuclear medicine.

A little bit about our footprint: we cover seven states, 25 hospitals. We have dozens of medical oncologists, radiation oncologists. We work with an independent radiology group. And we also cover Utah Cancer Specialists, which covers a part of that footprint.

I thought I'd share a little bit about our story. So we developed the PSMA RLT program in 2022. It's when we launched after the FDA approval. It was about midway through the year, and we started in a central location, Salt Lake City. And we serviced patients from really all throughout the Mountain West.

We had patients coming from Montana, from Wyoming, Idaho, actually quite a bit from southern Utah, as well as western Colorado. And when we started, it was just me—it was a radiation oncologist in Salt Lake City taking care of it. And I'll share how that changed over time, but there were challenges that we had.

So some challenges were that when the winter months came, we had fewer patients come. These were due to treatment discontinuations and the difficulty in travel. And we had fewer new starts. Really, this was mostly prominent in the southern portion of Utah, where patients were coming from warmer weather and had to get through harsh weather to get there.

We also had some logistical challenges with managing patients remotely, coming from a variety of referral sources. And we were also getting referrals that were relatively inappropriate at the time. When it wasn’t approved post-chemotherapy, we were getting patients referred for that. And also patients that had no PSMA avidity, among other situations.

And really, we asked ourselves this question because we knew this was going to grow. And so we asked ourselves: How do we scale RLT delivery to address a population without compromising quality? How do we do it really well? And quality can be defined a couple of different ways. The Institute of Medicine defines it as the likelihood of achieving desired health outcomes consistent with professional knowledge. And they have this framework.

Really, we boil it down to three things we really cared about in our system. We really cared about focusing on access and doing it with the principle of being outcomes-driven as well as guideline-adherent. But what does it mean? What does that look like in practice?

And so we looked at, OK, what does a practice look like that does this? Well, we thought it'd be important to have an authorized user provide continuity of care throughout their entire course. We thought it would be important to have face-to-face encounters wherever these patients are, bringing the therapies closer to home.

We also felt that there was a lot of value in incorporating nuclear medicine fellowship reads—radiologists that were trained to really use these scans to help us make good decisions for patients. And this also was important to us: we felt like this should be done by nuclear medicine technologists. This is actually a debate in the community. But these are professionals that do this—they inject radiopharmaceuticals every day, dozens of times—and we anchored on that experience.

And then finally, we thought that it would be important to have a centralized tumor board, an RLT tumor board that received cases throughout our entire system. But then there's the question of who would be the authorized user

And sometimes, when we first started, we weren't quite sure if we were fighting or hugging at times as we worked together with nuclear medicine. And I want to credit Tom Buiki for this meme. But in the end, there was a little bit of a turf war in our institution. I didn't know it when I started, but I hurt some feelings when we started this program kind of without them.

But when we looked at what this really was—a turf war has been described as an organizational pathology. It means that we weren't organized. And really, when it comes to access, turf wars are actually counterproductive to access, and especially to quality care access. And really, based on the principles of oncology, we know that multidisciplinary care—over and over—results in better outcomes.

And so we decided collaborative leadership was the way to go between radiation oncology, nuclear medicine, and medical oncology. These are trusted and wonderful colleagues and friends. We also knew that there needed to be a shared authorized usership model. And we thought, how can we do this?

Well, we thought that we would divide it based on presentation. And that also would be based on the principle of likelihood of external beam radiation usage. And really, as I talked with my colleagues in radiation oncology, we got more excited about doing radiopharmaceutical therapy when we can use both sides of our brains—wear both hats.

And so we developed this algorithm for how we divide this at our weekly—or biweekly—tumor board. If patients had a diagnosis where radiation oncologists historically were involved, well, they would be involved potentially in the care. If it was a diagnosis where they weren’t—for example, NETs (neuroendocrine tumors)—then maybe it'd be primarily driven by our nuc med staff.

Among patients who had such a diagnosis, we really just stuck to limited or low-volume disease, patients who had need of palliation upfront, or high-risk lesions that they may need radiation for down the line. And what this ended up being is a split and a divide that ended up being pretty equitable between our two specialties.

This was the dream. The dream was that at every location—and now, this year, we’ll be opening up our seventh—is that we would have a radiation oncologist and nuclear medicine as an authorized user to work together at these sites. This is the reality. As we tried to do this, it worked really well in Salt Lake City, where we had our nuclear medicine group, and they were willing to participate and drive the program there.

But as I went to all these different sites, it was hard to find radiologists that would attend the meetings or be willing to participate. And so we had to adjust our model a little bit. And we went more to a hub-and-spoke. And that hub is where—in Salt Lake City at our main center—we’d have nuclear medicine and radiation oncology work together and use that shared model.

But that also would be kind of where we’d have our administrative support and where our clinical trials would go. And our spokes would be where we’d have predominantly radiation oncologists as authorized users. And the advantage would be to have face-to-face continuity of care, and then also to maintain those referral pathways, which in the community are really important.

Anchoring this—and what is very special to our program—is our RLT tumor board. We meet biweekly. All new RLT cases in the system are presented. All team members, from nuclear medicine technologists to administrators and physicists, are involved. And we also do clinical trial patient evaluation.

Kind of looking at our timeline: from mid-2022 toward the end of the year is when we introduced this multidisciplinary program. Shortly after, we worked together to implement the SPECT/CT program in the community that scales our system. We opened three additional sites.

We opened our first trial. We obtained a Mars Shot grant from SNMMI for remote dosimetry. We had our first clinical dosimetry patient earlier this year. And now, we're on the verge of opening our phase I RLT trial program and opening two additional sites.

But honestly, the thing that I’m most proud of is what happened in southern Utah. And that’s in December of 2023—we had zero patients on treatment in that winter. And now, it is our busiest site in our whole system. We have 22 patients—4 receiving Lutathera and 18 patients receiving PSMA RLT.

In conclusion, health system-based RLT is possible. It should be done thoughtfully and with a concerted effort. In multidisciplinary programs that include both radiation oncology and nuclear medicine, we can work together, and we can deliver high-quality RLT in the community and do something special. So thank you. This was a really special thing for me.