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CC BY 4.0 · World J Nucl Med
DOI: 10.1055/s-0045-1807251
Original Article

Global Challenges in the Provision of Theranostic Services the International Atomic Energy Agency (IAEA) Perspective

Anita Brink 
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Juliano J. Cerci
2   Quanta Diagnostico e Terapia, Curitiba, Brazil
,
Francesco Giammarile 
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Danylo Yurystovskyi
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Aruna Korde
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Enrique Estrada-Lobato
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Miriam Mikhail-Lette 
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Olivier Pellet
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Homer A. Macapinlac
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
,
Diana Paez
1   International Atomic Energy Agency, Nuclear Applications Human Health, Wien, Vienna, Austria
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Abstract

The global expansion of theranostics, a field combining molecular imaging and targeted therapy, has accelerated with the Food and Drug Administration approvals of Lutathera and Pluvicto. However, significant challenges hinder equitable access, particularly in low- and middle-income countries (LMICs). These include infrastructure limitations, such as the high cost of gamma cameras, positron emission tomography/computed tomography scanners, cyclotrons, and maintenance, as well as disparities in the availability of radiopharmaceuticals. In LMICs, one single-photon emission computerized tomography scanner may serve 33 million people, compared with 57,000 in high-income countries. Furthermore, shortages of key isotopes like 99Mo and 177Lu highlight vulnerabilities in global supply chains.

Staffing and training are critical issues, as delivering theranostic services requires specialized teams that are often scarce in LMICs. The International Atomic Energy Agency (IAEA) addresses these challenges by offering training programs, developing databases like IMAGINE and NUMDAB, and fostering technical cooperation among member states. To improve access to theranostic services, strategies such as using alternative imaging methods and enhancing local radiopharmaceutical production are recommended.

The IAEA's Rays of Hope initiative aims to strengthen regional capacities, improve infrastructure, and address the critical shortage of trained professionals. A coordinated global effort is essential to overcome these barriers, reduce costs, and ensure equitable access to theranostics, particularly in resource-limited settings.

Keywords

global challenges - IMAGINE database - International Atomic Energy Agency - NUMDAB database - theranostics


Publication History

Article published online:
17 April 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Fahey FH, Grant FD, Thrall JH. Saul Hertz, MD, and the birth of radionuclide therapy. EJNMMI Phys 2017; 4 (01) 15
    CrossrefPubMedSearch in Google Scholar
  • 2 Weber WA, Barthel H, Bengel F, Eiber M, Herrmann K, Schäfers M. What is theranostics?. J Nucl Med 2023; 64 (05) 669-670
    PubMedSearch in Google Scholar
  • 3 Jensen K. Novartis wins FDA OK for radiopharmaceutical drug, cashing in on Endocyte deal [press release]. 2022 Biopharmadive. Accessed November 23, 2024 at https://www.biopharmadive.com/news/novartis-fda-approval-pluvicto-prostate-cancer-endocyte/620973/
  • 4 Kuo PH, Morris MJ, Hesterman J. et al. Quantitative 68Ga-PSMA-11 PET and clinical outcomes in metastatic castration-resistant prostate cancer following 177Lu-PSMA-617 (VISION trial). Radiology 2024; 312 (02) e233460
    PubMedSearch in Google Scholar
  • 5 Trikalinos NA, Kim H, Vijayan A, Amurao M, Prasad V. Use of approved Lu-177 radiopharmaceuticals in patients with end-stage renal disease: a review of the literature and proposed treatment algorithm. J Neuroendocrinol 2024; 36 (06) e13393
    PubMedSearch in Google Scholar
  • 6 IAEA Medical imAGIng and Nuclear mEdicine global resources database (IMAGINE) [Internet]. Accessed March 16, 2025 at: https://www.iaea.org/resources/hhc/nuclear-medicine/databases/imagine
  • 7 IAEA. NUMDAB: IAEA; [updated 22 October 2024. Accessed March 16, 2025 at: https://www.iaea.org/resources/databases/numdab
  • 8 Accelerator Knowledge Portal - Cyclotrons used for Radionuclide Production. In: IAEA, editor
  • 9 Abdel-Wahab M, Giammarile F, Carrara M. et al. Radiotherapy and theranostics: a Lancet Oncology Commission. The Lancet Oncology 25 (11) e545-e580
  • 10 Adedapo KS, Onimode YA, Ejeh JE, Adepoju AO. Avoidable challenges of a nuclear medicine facility in a developing nation. Indian J Nucl Med 2013; 28 (04) 195-199
    PubMedSearch in Google Scholar
  • 11 Giammarile F, Paez D, Zimmermann R. et al. Production and regulatory issues for theranostics. Lancet Oncol 2024; 25 (06) e260-e269
    PubMedSearch in Google Scholar
  • 12 Preparedness and Response for a Nuclear or Radiological Emergency Involving the Transport of Radioactive Material. Vienna: International Atomic Energy Agency; 2022
    Search in Google Scholar
  • 13 Pabst KM, Mei R, Lückerath K. et al. Detection of tumour heterogeneity in patients with advanced, metastatic castration-resistant prostate cancer on [(68)Ga]Ga-/[(18)F]F-PSMA-11/-1007, [(68)Ga]Ga-FAPI-46 and 2-[(18)F]FDG PET/CT: a pilot study. Eur J Nucl Med Mol Imaging 2024; 52 (01) 342-353
    PubMedSearch in Google Scholar
  • 14 Gherghe M, Lazăr AM, Stanciu AE. et al. The new radiolabeled peptide 99mTcEDDA/HYNIC-TOC: is it a feasible choice for diagnosing gastroenteropancreatic NETs?. Cancers (Basel) 2022; 14 (11) 2725
    PubMedSearch in Google Scholar
  • 15 Artiko V, Afgan A, Petrović J. et al. Evaluation of neuroendocrine tumors with 99mTc-EDDA/HYNIC TOC. Nucl Med Rev Cent East Eur 2016; 19 (02) 99-103
    PubMedSearch in Google Scholar
  • 16 Fallahi B, Khademi N, Karamzade-Ziarati N. et al. 99mTc-PSMA SPECT/CT versus 68Ga-PSMA PET/CT in the evaluation of metastatic prostate cancer. Clin Nucl Med 2021; 46 (02) e68-e74
    PubMedSearch in Google Scholar
  • 17 Kabunda J, Gabela L, Kalinda C, Aldous C, Pillay V, Nyakale N. Comparing 99mTc-PSMA to 99mTc-MDP in prostate cancer staging of the skeletal system. Clin Nucl Med 2021; 46 (07) 562-568
    PubMedSearch in Google Scholar
  • 18 IAEA. Competency Based Hospital Radiopharmacy training; 2010. Accessed September 23, 2024 at: https://www-pub.iaea.org/mtcd/publications/pdf/tcs-39_web.pdf
  • 19 IAEA. IAEA tool to assess staffing needs in nuclear medicine; 2020. Accessed September 23, 2024 at: https://iris.iaea.org/public/survey?cdoc=STFNM001
  • 20 A Model to Assess Staffing Needs in Nuclear Medicine. Vienna: International Atomic Energy Agency; 2022
    Search in Google Scholar
  • 21 IAEA. Medical Physics Staffing Needs in Diagnostic Imaging and Radionuclide Therapy: An Activity Based Approach; 2018. Accessed March 16, 2025 at: https://www.iaea.org/publications/12208/medical-physics-staffing-needs-in-diagnostic-imaging-and-radionuclide-therapy-an-activity-based-approach
  • 22 Pascual TNB, Paez D, Iagaru A. et al. Guiding principles on the education and practice of theranostics. Eur J Nucl Med Mol Imaging 2024; 51 (08) 2320-2331
    PubMedSearch in Google Scholar
  • 23 Brink A, Israel O, Nadel H. et al. Towards a more inclusive future: a comprehensive assessment of gender diversity in nuclear medicine education, training and workforce. Semin Nucl Med 2024; 54 (02) 184-190
    PubMedSearch in Google Scholar
  • 24 IAEA. Rays of Hope Anchor Centers. Accessed September 23, 2024 at: https://www.iaea.org/services/rays-of-hope/anchor-centres
  • 25 IAEA. The IAEA Marie Sklodowska-Curie Fellowship Programme (MSCFP), was created in an effort to increase the number of women in the nuclear field, support an inclusive workforce and drive innovation; 2023. Accessed May 24, 2023 at: https://www.niauk.org/iaea-marie-sklodowska-curie-fellowship-programme-mscfp/
  • 26 OECD/NEA. The Supply of Medical Isotopes: An Economic Diagnosis and Possible Solutions. Paris: OECD Publishing; 2019.
    CrossrefSearch in Google Scholar
  • 27 The Security of Supply of Medical Radioisotopes. Demand and Capacity Projections for 99Mo/99mTc for the 2023–2027 Period. Paris; 2023
    Search in Google Scholar
  • 28 National Academies of Sciences, Engineering, and Medicine. Molybdenum-99 for Medical Imaging. Washington, DC: The National Academies Press; 2016
    Search in Google Scholar
  • 29 Imminent Mo-99/Tc-99m Shortage Due to European Reactor Restart Delay [press release]. October 19, 2024
  • 30 The Security of Supply of Medical Radioisotopes. Demand and Capacity Projections for 99Mo/99mTc for the 2023–2027 Period. Paris: OECD Publishing, Paris; 2023
    Search in Google Scholar
  • 31 Morton W. NorthStar to end production of Mo-99 AuntMinnie.com; 2023. Accessed September 23, 2024 at: https://www.auntminnie.com/clinical-news/radiation-oncology-therapy/article/15636019/northstar-to-end-production-of-mo99
  • 32 Curium update - Global Shortage Supply [press release]. January 19, 2022
  • 33 Vogel WV, van der Marck SC, Versleijen MWJ. Challenges and future options for the production of lutetium-177. Eur J Nucl Med Mol Imaging 2021; 48 (08) 2329-2335
    PubMedSearch in Google Scholar
  • 34 Sartor O, de Bono J, Chi KN. et al; VISION Investigators. Lutetium-177-PSMA-617 for metastatic castration-resistant prostate cancer. N Engl J Med 2021; 385 (12) 1091-1103
    CrossrefPubMedSearch in Google Scholar
  • 35 Ghose A, Banerjee S, Choudhury PS. et al. 177Lu-PSMA-617 for metastatic prostate cancer in India. Lancet Reg Health Southeast Asia 2024; 30: 100484
    PubMedSearch in Google Scholar
  • 36 Quist SW, Paulissen JHJ, Wyndaele DNJ, Nagarajah J, Freriks RD. Costs of radium-223 and the pharmacy preparation 177Lu-PSMA-I&T for metastatic castration-resistant prostate cancer in Dutch hospitals. J Med Econ 2023; 26 (01) 366-375
    PubMedSearch in Google Scholar
  • 37 Mehrens D, Kramer KKM, Unterrainer LM. et al. Cost-effectiveness analysis of 177Lu-PSMA-617 radioligand therapy in metastatic castration-resistant prostate cancer. J Natl Compr Canc Netw 2023; 21 (01) 43-50.e2
    PubMedSearch in Google Scholar
  • 38 Ohm IK KB, Lidal IB, Gulliksrud K. et al. 177Lu-PSMA-617 for treatment of metastatic castration resistant prostate cancer: a health technology assessment. Norwegian Institute of Public Health Report No.: 978–82–8406–382–9
  • 39 WHO. WHO Drug Inf 2013; 27 (02) 119-128 . https://iris.who.int/bitstream/handle/10665/331176/DI272-119-128-eng.pdf
  • 40 Good Practice for Introducing Radiopharmaceuticals for Clinical Use. Vienna: International Atomic Energy Agency; 2016
    Search in Google Scholar
  • 41 Giammarile F, Knoll P, Kunikowska J. et al. Guardians of precision: advancing radiation protection, safety, and quality systems in nuclear medicine. Eur J Nucl Med Mol Imaging 2024; 51 (06) 1498-1505
    PubMedSearch in Google Scholar
  • 42 Herrmann K, Giovanella L, Santos A. et al. Joint EANM, SNMMI and IAEA enabling guide: how to set up a theranostics centre. Eur J Nucl Med Mol Imaging 2022; 49 (07) 2300-2309
    CrossrefPubMedSearch in Google Scholar
  • 43 Kratochwil C, Fendler WP, Eiber M. et al. Joint EANM/SNMMI procedure guideline for the use of 177Lu-labeled PSMA-targeted radioligand-therapy (177Lu-PSMA-RLT). Eur J Nucl Med Mol Imaging 2023; 50 (09) 2830-2845
    CrossrefPubMedSearch in Google Scholar
  • 44 Hope TA, Abbott A, Colucci K. et al. NANETS/SNMMI procedure standard for somatostatin receptor-based peptide receptor radionuclide therapy with 177Lu-DOTATATE. J Nucl Med 2019; 60 (07) 937-943
    CrossrefPubMedSearch in Google Scholar
  • 45 Giammarile F, Chiti A, Lassmann M, Brans B, Flux G. EANM. EANM procedure guidelines for 131I-meta-iodobenzylguanidine (131I-mIBG) therapy. Eur J Nucl Med Mol Imaging 2008; 35 (05) 1039-1047
    CrossrefPubMedSearch in Google Scholar