VISION: What the Prostate Cancer Trial Found

A scan decides who can have the treatment

PSMA is a protein sitting on the surface of most prostate cancer cells. Lutetium-177 PSMA-617 is built from two halves: a molecule that latches onto PSMA, and a radioactive atom that delivers a short-range dose of radiation once it arrives.

That design has a consequence. If a person's cancer does not show up as PSMA-positive on a scan, the drug has nothing to attach to. So a gallium-68 PSMA-11 PET-CT scan came first, and it decided who could enter the trial. In VISION, the scan stopped being a way to stage cancer and became a gate.

Who was screened and who got in

1,179 men were screened and 831 were randomly assigned, between June 2018 and October 2019. That leaves 348 who were screened but not enrolled.

Everyone had metastatic castration-resistant prostate cancer. All had already had at least one androgen-receptor-pathway drug, and one or two taxane chemotherapy regimens. All had PSMA-positive scans.

Assignment was 2 to 1. Two thirds received lutetium-177 PSMA-617 plus standard care. One third received standard care alone. Treatment was 7.4 GBq every six weeks, for four to six cycles.

Four extra months on the median

Median overall survival was 15.3 months with the radioligand added and 11.3 months with standard care alone. The hazard ratio for death was 0.62 (95% CI 0.52 to 0.74; p<0.001), about a 38% lower risk of dying at any moment.

Imaging-based progression-free survival was 8.7 months against 3.4 months (hazard ratio 0.40; 99.2% CI 0.29 to 0.57; p<0.001). All the key secondary measures favoured the radioligand as well. Median follow-up was 20.9 months.

Severe side effects, grade 3 or above, were more common with the treatment: 52.7% against 38.0%. Even so, quality of life as patients reported it was not made worse.

The comparison was deliberately narrow

This is the part that needs care. "Standard care" in VISION was defined to exclude chemotherapy, immunotherapy, radium-223 and investigational drugs.

That was done for a reason: the trial wanted a comparison it could interpret. But it also means the control group received less than a real clinic might offer. A wider comparison would probably have produced a smaller gap.

What this does and doesn't change

• It made a new kind of treatment available after hormone drugs and chemotherapy, working by radiation delivered from inside rather than aimed from outside.
• It does not apply to men whose cancer is not PSMA-positive on a PET scan.
• It does not show this treatment is better than chemotherapy, because chemotherapy was excluded from the comparison.
• It does not remove the practical barrier. The drug needs a nuclear medicine facility, which not every hospital has.

Questions about PSMA therapy

• Have I had a PSMA PET scan, and did it show enough uptake?
• Which treatments have I already had, and does that make me eligible?
• Where would the treatment be given, and how far would I travel?
• What precautions are needed at home after each dose?

Sources

This article was written from the sources below, which were checked on the source-check date shown above.

• NEJM: Lutetium-177-PSMA-617 for Metastatic Castration-Resistant Prostate Cancer (VISION) (primary)

How this article was prepared

Prepared by Cancer Explained's AI-assisted editorial system and checked against the sources listed below. This article has not been reviewed by a healthcare professional unless a named reviewer is specifically shown.

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