Xofigo (Radium-223): A Lot More than Just Pain Relief – Survival Benefits Too!
Not long ago I was doing some research for a Q&A on our website and I came across this quote: “Despite the life-extending properties of Xofigo, some experts have expressed frustration that oncologists largely regard Xofigo as simply a pain-relieving drug for prostate cancer patients.”1
I then checked our archive of articles for any discussion of Xofigo and discovered that we were also part of the problem -- referring to palliative qualities, but never mentioning that it is also a life-extending treatment. We have since remedied this in an article on radiopharmaceuticals.
We need to rethink Xofigo's use
We were certainly not alone in this oversight. The title of another article on the subject pretty much says it all -- “Rethinking Xofigo: Drug’s Benefits Go Beyond Pain Palliation in Prostate Cancer.”2 The necessity for the rethinking is summed up by Dr. Kenneth Koo, a radiologist at University of Colorado Hospital, stating “Despite the fact that it has been three years since this data from the pivotal ALSYMPCA trial was released and the drug was approved by the FDA, many oncologists still need to be educated regarding Xofigo’s benefits beyond pain palliation.”3
The ALSYMPCA trial Dr. Koo mentioned found “that radium-223 (Xofigo) improves overall survival [OS] in men with advanced prostate cancer that has spread to their bones compared with a placebo.”4 Men receiving radium-223 survived an average of 3.6 months longer. In addition, they went longer without skeletal-related events, fewer experienced serious adverse events, and they reported better quality of life.
Why some don’t realize Xofigo is therapeutic?
Xofigo is one of a class of drugs called radiopharmaceuticals, which are generally used to alleviate bone pain from metastatic cancer. Xofigo is the first of its kind to also show an increase in overall survival. In fact, other radiopharmaceuticals, such as Quadramet, can be problematic in relation to future treatment. “In clinical practice, those aren’t used very often because they do cause significant bone marrow suppression, which prevents oncologists from having the option of giving chemotherapy afterward if needed.”5 Utilization of Xofigo suffers because it is put in the same class as these other drugs, but when it comes to its action within the body it does not really belong there.
How does Xofigo work?
The primary difference is that Xofigo is an alpha emitter. What does this mean? The alpha particle radiation mimics calcium in the bones in that it goes to and accumulates in sections of bone that are experiencing increased turnover. As you may know, cancer has excessive cell turnover, thus the areas with bone metastasis is where the alpha particles go. When the drug is administered it binds with the minerals (primarily calcium), the low-level radiation is then emitted and only travels a very short distance to attack the cancer (talking about less than 100 microns or about four one-thousandths of an inch). In this way healthy surrounding tissue is spared and maximum damage to the cancer occurs.6
By this point, some of you may have realized that the articles citing the underuse of Xofigo are actually four years old and are wondering if this is still an issue. The answer is an emphatic yes. An article from 2019 reporting on testing of Xofigo in a combination therapy noted “Although radium-223 has a positive effect on OS in men with metastatic castration-resistant prostate cancer (mCRPC), there has been a paucity of reports from community practitioners.”7
Why is this treatment discovery important?
Besides the obvious of the originally reported increase in overall survival and better quality of life, recognizing the value of Xofigo is important because of what has been learned about the benefits of using Xofigo earlier in treatment and in combination therapy. Concerning combination therapy, Dr. Koo said “To me, this makes a lot of sense because Xofigo is very specific for bone... If you can hit the bone disease using Xofigo and hit soft-tissue disease with drugs like Zytiga (abiraterone) or Xtandi (enzalutamide) simultaneously, you will get great effect.”8 A subsequent study of Xofigo with either Zytiga or Xtandi found a median increase in OS of 10 months. In addition, patients with no or mild pain ended up with twice the OS as those with moderate or severe pain.9 So, unlike other radiopharmaceuticals, it is beneficial to utilize Xofigo earlier, as opposed to at end-stage.
It is kind of amazing that a drug can be underutilized for its most beneficial use seven years after approval. I can’t explain why this information doesn’t seem to be getting through to practitioners, but if patients finding out can help bring a useful treatment off the bench, I hope our publicizing it can help.
Continue the conversation and connect with other men who have used Xofigo to treat advanced prostate cancer in this community question: Anyone used radium 223 for advanced prostate cancer treatment?
Which prostate cancer treatment did you first receive?