Lutetium-177 PSMA therapy, private in London.

Prices vary by centre, by radiopharmacy sourcing, by whether the eligibility PSMA-PET is bundled, and by the number of cycles actually completed. Where NHS access via NICE TA1000 fits, we say so.

• Metastatic castration-resistant prostate cancer

  Disease progression on continuous ADT with a castrate testosterone, radiologically confirmed on CT, MRI or bone scan.

• Post-taxane chemotherapy

  Progression after or intolerance of docetaxel and, in most cases, cabazitaxel. This is the licensed VISION-trial population.

• Post abiraterone or enzalutamide

  Progression on at least one androgen receptor pathway inhibitor. Most candidates have had both by the time Pluvicto is discussed.

• PSMA-avid disease on PSMA-PET

  At least one lesion with uptake above liver background, and no dominant PSMA-negative disease on the eligibility scan.

• ECOG 0 to 2 and adequate organ function

  Well enough for a six-cycle course. Haemoglobin, platelets, neutrophils, GFR and liver enzymes within VISION-trial thresholds.

• Not suitable if dominant PSMA-negative disease

  Visceral lesions that light up on FDG-PET but not PSMA-PET suggest de-differentiated disease that will not respond. We say so.

• Not suitable if marrow reserve is exhausted

  Heavy prior radium-223, wide-field external beam or platinum chemotherapy can leave the marrow too fragile for six lutetium cycles.

• Red flag: cord compression or uncontrolled pain

  Impending cord compression, uncontrolled bone pain or acute renal obstruction is a hospital admission, not a private booking. Ring 999 or go to A&E.

• Dry mouth (xerostomia) in 40 to 50 per cent

  The commonest side effect. PSMA is expressed in salivary glands, so they take a dose. Ice packs during infusion, sugar-free gum and pilocarpine sprays help. Usually mild to moderate and reversible.

• Fatigue during the course

  Cumulative fatigue is common by cycles 4 to 6. It settles within a few weeks of finishing. Plan lighter weeks around each cycle and stay well hydrated.

• Nausea and altered taste

  Mild nausea in the 24 to 48 hours after each cycle. A single dose of ondansetron before the infusion is usually enough. Metallic taste for a few days is common.

• Cytopenias (anaemia, thrombocytopenia)

  Marrow suppression is dose-limiting. Grade 3 or 4 anaemia in around 13 per cent and thrombocytopenia in around 8 per cent in VISION. Bloods before every cycle.

• Renal impairment

  PSMA is expressed in the proximal tubule, so kidneys take a dose. GFR is checked before each cycle. Clinically relevant renal impairment is uncommon at 7.4 GBq x 6.

• Radiation precautions for a few days

  Frequent toilet flushing, careful hand hygiene, sleeping alone for a night or two and keeping distance from young children and pregnant women for the first few days after each cycle.

• Fertility and contraception

  Lu-177 PSMA is not for men who might father a child during or shortly after treatment. Effective contraception is advised for at least 14 weeks after the last cycle.

• Rare late effects

  Second malignancy, including therapy-related myelodysplasia, is a rare late risk documented in radioligand therapy series. Long-term follow-up remains important.

• Red flags after discharge

  Fever above 38C, unexplained bruising or bleeding, breathlessness, reduced urine output or severe back pain: call the unit or go to A&E the same day.