Development of a Safe Administration PRRT Process in an Ambulatory Academic Setting

Neuroendocrine cancers are a rare heterogeneous subset of tumors, but with newer diagnostic testing and advances in our understanding of this uncommon disease, we have seen an increase in the incidence each year. One of the most recently approved treatments for the disease is peptide receptor radionuclide therapy (PRRT). There are key steps oncology nurses should take to ensure safety for both patients and providers on PRRT.

The PRRT program at Rush University Medical Center requires a multidisciplinary approach, which is necessary to plan and implement a successful PRRT program. At the core of the team is the nursing staff, who are critical in preparing and administering the treatment. Patient education regarding postprocedure radiation safety is also key.

WHAT IS PRRT?

Neuroendocrine tumors (NETs), including gastroenteropancreatic NETs, or GEP-NETs, arise from neuroendocrine cells of either the stomach, gut, or pancreas or from other organs such as the lung, ovary, and thyroid.¹

Lutetium Lu 177 dotatate (Lutathera) is a radiolabeled somatostatin analog and PRRTtargeted therapy approved by the FDA in January 2018 for the treatment of somatostatin receptor—positive GEP-NETs in the second-line setting.¹ Patients who qualify for PRRT therapy should undergo receptor-based imaging, such as a dotatate scan, to assess receptor status prior to initiating treatment. Lu 177 dotatate works by binding to somatostatin receptors and emitting radiation to treat NETs. Serious adverse events (AEs) may include loss of renal function, pancytopenia, and secondary myelodysplastic syndrome.¹

A limited number of sites across the United States offer PRRT, and Rush University Cancer Center was the first institution in Illinois to offer imaging with a dotatate scanner and treatment with PRRT therapy.

CREATING A SAFE WORKING ENVIRONMENT

Lu 177 dotatate carries radiation directly into a cell, killing tumor cells. Because of its mechanism of action, utilization of this therapy requires safe-handling practices for the prevention of radiation exposure and contamination.² To create our outpatient PRRT program, a working group that included physicians, pharmacists, nuclear medicine staff, radiation safety, financial services, and nurses was formed to address the complex process of administering this treatment in the ambulatory setting within the Nuclear Medicine Department.

A space dedicated to patients receiving these treatments, including a separate bathroom, was necessary to minimize the risk of exposure to other patients and staff. Nursing took the lead in identifying key capital expenses, nurse staffing, and education to ensure safe administration. These included an intravenous pump, portable workstation on wheels, monitoring system for vital signs, and monitoring during a hypersensitivity reaction. The oncology nurses set up the entire working environment, arranging the space for the nuclear medicine physician and administering the amino acid solution. A 2-channel pump and proper set up to dispense the radionucleotide via the pump is needed to properly provide the therapy. First, however, patients receive an amino acid solution 30 minutes prior to the infusion, which protects their kidneys by decreasing the amount of radiation they absorb. There are several types of amino acid formulations. Patients may also require aggressive antiemetic prophylaxis, as this treatment can be highly emetogenic.²

The patient’s blood and body fluids are considered radioactive during the administration of treatment, so proper personal protective equipment and supplies for contamination and potential spills must be in place. To ensure patients and staff are safe from potential radiation exposure, a radiation safety officer or health physicist is always present during administration.

Patients are monitored by an oncology nurse during the entire infusion. Some AEs that may occur include nausea, vomiting, diarrhea, and, rarely, neuroendocrine hormonal crises, for which there is a 1% risk. If the patient experiences this rare phenomenon, presenting symptoms may include diarrhea, flushing, hypotension, and bronchoconstriction during or within a 24-hour period.³ The nurses taking care of these patients are certified in advanced cardiovascular life support and trained on how emergency response.

Within 4 to 24 hours post treatment, the patient is given a long-acting octreotide injection. This can help to decrease potential AEs. Providing this injection requires an additional level of coordination with the ambulatory infusion pharmacy in order for the medication to be delivered to the Nuclear Medicine Department for administration. The oncology nurse is also educated on all pre- and posttreatment care. They will educate the patient on what to expect before, during, and after the infusion. Prior to the patient leaving, the radiation safety officer or health physicist reiterates the importance of radiation safety and gives the patient information to take home. The nurse will continue to follow up with the patient after they leave to monitor for AEs.

All patients receiving PRRT therapy are considered releasable under current US Nuclear Regulatory Commission (NRC) and NRC agreement state regulations. The regulations require that they receive instructions on how to minimize radiation dose to family members and the public. Prior to the patients leaving the facility, they are all given a wallet card with precautions for how to interact with the public for 7 days after treatment. These precautions include remaining at least 3 feet from adults for 3 days and from children and pregnant women for 7 days, use a separate toilet, sit while urinating and flush twice after each use, drink plenty of fluids, and more. There are many pieces to building a PRRT program within an ambulatory setting. This process takes careful planning with multiple departments. Given the risk of radiation exposure, radiation safety is a vital part to ensuring safe patient care and protecting staff. The oncology nurse must have extensive training on radiation safety and possible AEs, as well as knowledge of what education to give the patient.

In our cancer center, our team is made of many key stakeholders and clinicians from several departments. However, the nursing team is at the center of the planning and execution of this PRRT program and has been an integral part of the development of this program within our academic ambulatory center.

References

1.Boucher J, Sommers R. Targeted therapy: new radiolabeled somatostatin analogs to treat gastroenteropancreatic neuroendocrine tumors. Clin J Oncol Nurs. 2018;22(5): 565-568. doi: 10.1188/18.cjon.565-568.

2. Hosono M, Ikebuchi H, Nakamura Y. et al. Manual on the proper use of lutetium-177-labeled somatostatin analogue (Lu-177-DOTA-TATE) injectable in radionuclide therapy (2nd ed.). Ann Nucl Med. 2018;32(3):217-235. doi: 10.1007/s12149-018-1230-7.

3. Strosberg J, El-Haddad G, Wolin E, et al; NETTER-1 Trial Investigators. Phase 3 trial of ¹⁷⁷lu-dotatate for midgut neuroendocrine tumors. N Engl J Med. 2017;376(2):125-135. doi: 10.1056/NEJMoa1607427