Radioligand therapy (RLT) is one of the most promising advancements in cancer care, capturing massive interest and investment from the biopharma sector. With billions of dollars now directed toward its development, RLT has the potential to transform cancer treatment. The excitement is driving cancer centers worldwide to expand theranostic trials which pair RLT with novel radiopharmaceutical PET or SPECT imaging. However, one critical challenge looms: a shortage of radiology and nuclear medicine physician experts, technologists, and nursing staff capable of delivering this therapy at scale.

RLT works by delivering targeted radiation directly to cancer cells throughout the body. Specific molecules bind to cancer cells and are tagged with radioactive isotopes, which release radiation upon binding. This precision minimizes damage to surrounding healthy tissue, making RLT a highly promising treatment with fewer side effects than traditional therapies. For example, lutetium-177 (Lu-177) targets prostate-specific membrane antigen (PSMA) on prostate cancer cells, with multiple clinical trials demonstrating efficacy for patients with advanced, treatment-resistant cancers. With current RLT agents in use for prostate cancer and neuroendocrine tumors, clinical trials are underway to test RLT on a variety of cancer types including lung, brain, pancreatic, sarcoma, and breast cancers.  

The Rapid Growth of Radioligand Therapy

The developmental pipeline for RLT therapies is extensive. As of September 2024, there are approximately 67 industry-sponsored trials in preclinical phases, 28 in Phase 1, 9 in Phase 2, and 8 in Phase 3, with Lutathera and Pluvicto already approved for clinical use. If even a fraction of these pipeline therapies reach clinical approval, the demand for RLT-trained personnel and facilities will be enormous.

The stakes are high: if 10% of the current pipeline succeeds, this would bring 11 new RLT compounds to market; a 25% success rate could mean as many as 28 compounds, all of which require specialized infrastructure and staff.

Notable 2023-2024 investments reflect the optimism surrounding RLT, with about $400 million in venture financing and significant acquisitions by major pharmaceutical companies, including:

• Novartis acquiring Mariana Oncology for about $1 billion

• Eli Lilly acquiring Point Biopharma for $1.4 billion

• Bristol Myers Squibb acquiring RayzeBio for $4.1 billion

• AstraZeneca acquiring Fusion Pharmaceuticals for $2 billion.

In addition, recent funding rounds in September/October 2024 secured hundreds of millions for further RLT research and development, with companies like Aktis, Alpha-09, and ITM Radiopharma leading the charge.

Rising Demand for Authorized Users and Clinical Staff

While radiopharmaceutical companies can scale up RLT production, building a sufficiently large clinical workforce remains a significant challenge. The designation of Authorized User (AU)—a certification required to administer radioactive treatments—is critical, yet in short supply at many centers. AUs must undergo specialized training in nuclear radiology, nuclear medicine, or radiation oncology, a qualification that cannot be acquired quickly. As few nuclear medicine physicians are certified each year, AUs are on track to become among the most sought-after specialists in oncology programs.

The clinical demand is underscored by recent sales milestones: Pluvicto crossed the blockbuster threshold, generating $1.04 billion in sales in the first nine months of 2024, and Lutathera is experiencing double-digit growth with adoption in first-line treatment settings. Yet the reality remains: while companies can produce RLTs, creating enough qualified staff to deliver these therapies is another matter entirely.

The Road Ahead for RLT Implementation

Expand the RLT Workforce and Infrastructure: In addition to oncologists and other oncology staff, investment in nuclear radiologists, nuclear medicine physicians, radiation oncologists, technologists, and dosimetry physicists is critical. Facilities must prioritize space and access to PET/CT and SPECT/CT equipment, as well as specially designed treatment facilities. Centers that act now will be better positioned to manage the anticipated demand surge and maintain competitive clinical services.

Strengthen the Authorized User Pipeline: The AU role is indispensable for RLT, yet this workforce remains limited. Expanding a pipeline of AUs, while raising awareness about their pivotal role in RLT-oncology, is essential for increasing RLT capabilities.

Radioligand therapy offers vast potential to transform cancer treatment, but its full impact depends on building a robust clinical infrastructure and specialized workforce. Institutions that proactively address these needs are likely to lead this transformative field, ensuring patients have timely access to life-saving therapies.

Do you want to contribute to The Radiology Review Insider?

The article submission process is simple: email your proposed article to theradiologyreview@gmail.com.  Include with your article your name and professional affiliation.  Submission does not guarantee publication.