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. Author manuscript; available in PMC: 2025 Jun 1.
Published in final edited form as: Lancet Oncol. 2024 Jun;25(6):e250–e259. doi: 10.1016/S1470-2045(24)00037-8

Trends in Nuclear Medicine and the Radiopharmaceutical Sciences in Oncology: Workforce Challenges and Training in the Age of Theranostics

Andrew M Scott 1,*, Brian M Zeglis 2,*, Suzanne E Lapi 3,*, Peter J H Scott 4,*, Albert D Windhorst 5,*, May Abdel-Wahab 6, Francesco Giammarile 7, Diana Paez 8, Amirreza Jalilian 9, Peter Knoll 10, Aruna Korde 11, Shrikant Vichare 12, Nayyereh Ayati 13, Sze Ting Lee 14, Serge K Lyashchenko 15, Jingjing Zhang 16, Jean-Luc Urbain 17,*, Jason S Lewis 18
PMCID: PMC11345887  NIHMSID: NIHMS2015091  PMID: 38821099

Abstract

While the promise of radionuclides for the diagnosis and treatment of disease was recognized soon after the discovery of radioactivity in the late 19th century, the systematic use of radionuclides in medicine only gradually increased over the subsequent hundred years. The last two decades, however, have played witness to a remarkable surge in the clinical application of diagnostic and therapeutic radiopharmaceuticals, particularly in oncology. Without a doubt, this is an exciting time for the use of theranostics in oncology, but the rapid growth of this area of nuclear medicine has created challenges as well. In particular, the infrastructure for the manufacturing and distribution of radiopharmaceuticals remains in development, and regulatory bodies are still optimizing guidelines for this new class of drugs. One issue of paramount importance for achieving equitable access to theranostics is building a sufficiently trained workforce in high-, middle-, and low-income countries. In this perspective, we discuss the key challenges and opportunities that face the field as it seeks to build its workforce for the 21st century.

Introduction

Nuclear medicine — a medical discipline focused on the use of radionuclides for the diagnosis and treatment of disease — traces its origins to the pioneering work of Henri Becquerel, Marie Skłodowska Curie, Pierre Curie, and George de Hevesy in the late 19th and early 20th centuries.1–3 The idea of deploying synthetic radionuclides in medicine was first realized when John Lawrence explored the behaviour of phosphorus-32 produced by his brother Ernest’s cyclotron in leukemic rats and humans.4,5 The discipline first emerged as a potential medical specialty a decade later, when Saul Hertz and Samuel Seidlin independently used radioiodine to treat hyperthyroidism and advanced thyroid cancer, respectively. In the 1950s, textbooks on the clinical use of radionuclides began to be published6,7, and, by 1960, the use of radioiodine for the treatment of thyroid disease had become widespread.1,2 In 1971, the American Medical Association officially acknowledged nuclear medicine as a medical specialty, an act echoed soon after by many countries around the world.3

Nuclear medicine is intrinsically a multifaceted discipline, as expertise in medicine, chemistry, physics, and biology is essential for preclinical research, clinical studies, and patient care. It is also a very dynamic discipline, as exemplified by the continuous development of a rich pipeline of novel diagnostic and therapeutic radiopharmaceuticals.8–11 A growing number of these radiopharmaceuticals are labelled with ‘theranostic pairs’ of radionuclides that facilitate the use of closely related probes for both imaging and therapy. Through their exquisite sensitivity and specificity, these theranostic radiopharmaceuticals — or ‘theranostics’, as they are commonly called — are poised to play a major role in the advent of precision medicine alongside other sophisticated emergent technologies such as hybrid scanners (i.e. SPECT/CT, PET/CT, and PET/MR).12–14

Over the last twenty years, the clinical use of radiopharmaceuticals in oncology has expanded rapidly and dramatically, a phenomenon that is at once exciting and challenging for the field as a whole. These trends promise to continue — if not accelerate — in the future. Indeed, market research projects that within 10 years, 60% of all nuclear medicine procedures will involve theranostics.12 Furthermore, Czernin et al. recently estimated that, in coming years, the U.S. population (for example) will need between 70 and 280 centres to administer FDA-approved radiopharmaceuticals.15 The ‘mainstreaming’ of theranostics in nuclear medicine offers immense benefits for patients. However, the systems responsible for the manufacturing, transportation, and distribution of radiopharmaceuticals remain in their infancy, and regulatory frameworks for the field are still under development worldwide. Yet another critical issue for the field is developing the education and training infrastructure to produce the diverse body of experienced medical professionals needed to effectively deploy theranostics in nuclear medicine departments (Table 1). Fully integrating radiotheranostics within nuclear medicine requires expertise in many fields, including oncology, radiology, physiology, pathology, radiobiology, molecular biology, radiochemistry, radiopharmacy, and medical physics (not to mention the logistics and economics of healthcare systems).

Table 1:

The diverse expertise needed for the nuclear medicine workforce, from probe development to clinical practice

Basic Science
Responsibilities Specialists
Targetry; accelerator and reactor development Cyclotron and reactor engineers
Production and isolation of radionuclides Nuclear chemists
Development of radiosynthetic methods and cGMP processes Radiochemists and radiopharmacists
Quality control testing and method validation Radioanalytical chemists
In vitro and in vivo evaluation Pharmacologists, radiopharmaceutical chemists, radiation biologists, and cancer biologists
Clinical Translation
Responsibilities Specialists
Preclinical proof-of-concept studies Pharmacologists, radiopharmaceutical chemists, radiation biologists, and cancer biologists
Preclinical dosimetry Medical physicists
Preclinical pharmacology and toxicology studies Pharmacologists and toxicologists
Generation of clinical protocols and preparation of regulatory filings. Nuclear medicine physicians, health physicists, medical physicists, radiochemists, radiopharmacists, and regulatory scientists.
cGMP manufacturing Radiochemists, QC chemists, and radiopharmacists
Clinical trials Nuclear medicine physicians, biostatisticians, clinical trial coordinators, and study coordinators
Routine Clinical Use
Responsibilities Specialists
Patient referral for imaging and treatment with radiopharmaceuticals Affiliated physicians (e.g., urologists, medical oncologists, radiation oncologists, and interventional radiologists, often via multidisciplinary tumour boards)
Administration of radiopharmaceutical tracers and supervision of clinical protocols Nuclear medicine physicians, radiation oncologists, nurses, and technologists
Interpretation of imaging data Nuclear medicine physicians and radiologists
Human dosimetry Medical physicists
Helping patients (and their loved ones) navigate the healthcare system Patient advocates
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The Global Nuclear Medicine Workforce

Information on the nuclear medicine workforce on a global level is scarce, and data on providers of theranostics within the worldwide nuclear medicine workforce is even scarcer. As a result, we undertook a detailed survey of the numbers of nuclear medicine physicians, medical physicists, nuclear medicine technologists, radiochemists, radiopharmacists, and nurses working around the world as part of the Lancet Oncology Commission on Radiotherapy and Theranostics. Detailed responses to our inquiries were received from nuclear medicine societies in 88 countries, and additional data for this project were obtained from the IAEA IMAGINE database, the work of the Lancet Oncology Commission on Medical Imaging and Nuclear Medicine,16 and consultation with nuclear medicine organisations and experts. Taken together, these efforts yielded data on the nuclear medicine workforce in 189 countries. The per capita workforce numbers for each country were stratified according to income-based designations and population values published by the World Bank and are shown in Table 2 and Figures 1A–E.17 In examining these data, it is noted that nuclear medicine extends beyond oncology and that even within oncologic nuclear medicine, there are many diagnostic procedures that do not involve radiopharmaceutical therapy. As a result, these numbers do not necessarily represent providers of theranostics but rather those that could be involved in the clinical deployment of theranostics at present.

Table 2:

Nuclear medicine workforce per million people by country income group

Index/Worker Nuclear Medicine Physicians Medical Physicists Nuclear Medicine Technologists Radiochemists and Radiopharmacists Nurses Other staff
High-income
Range 0.0-54.5 0.0-40.9 0.0-86.3 0.0-18.8 0.0-18.8 0.0-129.0
Mean (SD) 10.5 (10.9) 4.9 (9.9) 30.4 (18.8) 1.8 (3.5) 2.1 (4.5) 35.8 (30.0)
Median (IQR) 7.0 (1.6-11.6) 1.9 (0.0-5.2) 6.7 (0.0-15.5) 1.0 (0.4-2.6) 2.1 (0.0-5.5) 15.1 (7.2-27.0)
Upper-middle-income
Range 0.0-14.9 0.0-12.2 0.0-17.2 0.0-3.9 0.0-16.5 0.0-28.1
Mean (SD) 4.1 (3.6) 1.0 (2.1) 2.9 (3.5) 0.3 (0.9) 1.4 (3.6) 4.0 (7.1)
Median (IQR) 1.2 (0.0-3.4) 0.7 (0.0-2.1) 0.9 (0.0-2.5) 0.4 (0.2-1.2) 0.5 (0.0-1.9) 2.9 (1.6-9.0)
Lower-middle-income
Range 0.0-5.7 0.0-3.5 0.0-10.2 0.0-0.9 0.0-4.6 0.0-12.9
Mean (SD) 0.6 (1.0) 0.4 (0.8) 0.8 (1.7) 0.1 (0.2) 0.3 (0.9) 1.2 (2.8)
Median (IQR) 0.2 (0.0-0.9) 0.1 (0.0-0.5) 0.1 (0.0-0.7) 0.1 (0.0-0.2) 0.1 (0.0-0.5) 0.8 (0.2-2.1)
Low-income
Range 0.0-0.5 0.0-1.2 0.0-0.5 0.0-0.2 0.0-0.1 0.0-0.4
Mean (SD) 0.1 (0.1) 0.1 (0.2) 0.1 (0.1) 0.0 (0.1) 0.0 (0.0) 0.1 (0.2)
Median (IQR) 0.0 (0.0-0.1) 0.0 (0.0-0.0) 0.0 (0.0-0.1) 0.0 (0.0-0.0) 0.0 (0.0-0.0) 0.1 (0.0-0.1)
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Abbreviations: IQR=interquartile range, SD=standard deviation

Figure 1:

Figure 1:

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(A) Nuclear medicine physicians per million people; (B) Radiochemists and Radiopharmacists per million people; (C) Nuclear medicine technologists per million people; (D) Medical physicists per million people; (E) Nurses in nuclear medicine per million inhabitants

Perhaps not surprisingly, the data show stark differences between the workforces in high-income countries (HICs) and middle- and low-income countries (LMICs). Plainly put, LMICs lack the trained radiochemists, radiopharmacists, nuclear medicine physicians, and nurses required for the implementation of theranostic programs. Indeed, our survey underscores that even HICs lack the qualified personnel necessary to operate comprehensive theranostics operations, especially considering the emergence of new radiopharmaceuticals that expand the indications that can be served by the field. This is further supported by recent reviews covering the projected requirements for existing theranostics, which are not currently considered sufficient even in HICs.11,12,15 Clearly, the training and education of the nuclear medicine workforce is an urgent priority across the globe.

Educational Challenges and Opportunities

In a scenario reminiscent of medicine’s unpreparedness for the internet revolution of the late 20th century, the recent explosion of theranostics has left nuclear medicine communities around the world scrambling to provide the education and training needed for the safe and effective clinical deployment of radiopharmaceuticals. Indeed, creating a workforce with the knowledge, experience, and expertise needed to deploy these new tools represents a significant challenge for health care systems seeking to provide patients with state-of-the-art care. To complicate matters more, educational requirements for nuclear medicine vary from one country to another, largely dictated by local regulatory frameworks as well as the availability of training opportunities from university hospitals and/or accreditation bodies. Meeting this challenge requires not only training nuclear medicine physicians in theranostics but educating the entire nuclear medicine workforce, including healthcare professionals across the various specialties involved (directly or indirectly) with radiopharmaceuticals. Accordingly, the aim of this white paper is to express the views of some leading experts on the educational requirements for the diverse array of healthcare professionals who are already involved in — or desire to be involved in — the provision of theranostic radiopharmaceuticals.

Nuclear Medicine Physicians and Other Physicians

A recent paper published in the Journal of Nuclear Medicine by the Global Initiative Committee of the Society of Nuclear Medicine and Molecular Imaging underscores the need to educate and train nuclear medicine physicians around the globe in theranostics.18 The article also emphasizes the importance of mobilizing national and regional nuclear medicine societies to cooperate in providing meaningful tools, venues, and materials to support the entire theranostic workforce. Figure 1A presents a map of the current estimated number of nuclear medicine physicians per million inhabitants in countries around the world. The map reinforces the trends established by Table 2: there is a severe shortage of nuclear medicine physicians in both middle- and low-income countries. Yet the growth of nuclear medicine in the age of theranostics means that the numbers in most (if not at all) high-income countries are still insufficient to meet future demand. It is noted that in some countries, the administration of radiopharmaceutical therapies may also be performed by suitably qualified radiologists, radiation oncologists, and other credentialled specialists, depending on local training and licencing requirements. Nevertheless, the number of physicians that are suitably qualified to deliver radiotheranostics is a major concern for the access to and availability of this important new therapeutic modality, particularly in middle- and low-income countries.

The basic training requirements for physicians using theranostics should include (i) a formal medical degree with appropriate certification by the accrediting body; (ii) one year of clinical experience in a clinical medicine specialty, preferably in a field relevant to theranostics; (iii) a board certification in nuclear medicine as a specialty, or internal medicine, diagnostic radiology, or radiation oncology; and (iv) direct experience with the management of patients and administration of radiopharmaceutical therapies. On top of this, an additional residency or fellowship year in an accredited nuclear medicine or nuclear radiology centre or program is recommended. This program should operate in a multidisciplinary setting — ideally in a medical centre with a comprehensive oncology practice — and have proper and adequate infrastructure, personnel, and equipment to practice standard-of-care (preferably state-of-the-art) diagnostic and therapeutic nuclear medicine.19

Beyond these specific requirements, nuclear medicine physicians are expected to understand the diverse facets of the field, including the mathematics and statistics applied to diagnostic and therapeutic radiopharmaceuticals; natural, medical, and professional radiation exposure; radiation biology; radiopharmacy; radiochemistry; the equipment and instrumentation used in nuclear medicine; the principles of radiopharmaceutical therapy; the requirements of quality management systems; and regulatory issues. Nuclear medicine physicians should also have a detailed understanding of the physiology and anatomy of the specific organ or region being targeted; a thorough comprehension of the anatomy, pathophysiology, anatomic pathology, and histopathology of the disease being assessed and treated as well as its genomics and proteomics; a clear understanding of the current diagnostic and therapeutic workflows used by oncology providers to diagnose, stage, treat, and follow up with their patients; a knowledge of the pharmacokinetic profile and biodistribution of the diagnostic and therapeutic radiopharmaceutical used as well as its associated radionuclides; and an in-depth understanding of the side effects of the radiotheranostic in question. Knowledge of the differences in the regulatory requirements for the administration of theranostics in a research setting (i.e. clinical trials) and routine clinical practice is also required. Finally, nuclear medicine physicians should have performed a minimum number of theranostic procedures defined by their national accreditation and regulatory bodies and based on guidelines recommended by experienced theranostic specialist physicians via their national and international associations; a thorough understanding of quality management as applied to nuclear medicine; and sufficient knowledge of the cost and reimbursement of diagnostic and therapeutic procedures using radiopharmaceuticals.

Additional aspects of the training of nuclear medicine and other physicians include participation in tumor boards, multidisciplinary conferences, and other meetings relevant to their local theranostic practice; continuing scientific and medical education related to the field of theranostics; attendance at and active participation in medical and scientific meetings that are directly or indirectly related to theranostics; and participation in patient support and advocacy groups. Major nuclear medicine and oncology societies as well as the IAEA can play important roles in fostering these educational and training opportunities, thereby smoothing the path for nuclear medicine communities around the world. A recent consultancy meeting held at the headquarters of the IAEA developed a curriculum in theranostics for nuclear medicine doctors and other physicians that includes many of the components described above, paving the way for specialized therapeutic radiopharmaceuticals training programs in both HICs and LMICs.20

Radiopharmacists

Radiopharmacists — and the technologists under their purview — play a key role in the provision of radiopharmaceuticals in the clinic. The professional roles and responsibilities of radiopharmacists can be divided into several categories. Most radiopharmacists work in a traditional nuclear pharmacy setting where they oversee the preparation of radiopharmaceuticals that cannot be supplied by the manufacturer to the clinic as ‘ready-to-use’ products. This can be in a centralized commercial radiopharmacy or at a site where nuclear medicine procedures are performed. Aspects of this work include preparing radiopharmaceuticals from manufacturer-supplied ‘kits’, performing quality control procedures, dispensing patient-specific doses from a bulk product in a multidose vial, and compounding radiopharmaceuticals that cannot otherwise be supplied to patients (e.g. during shortages of approved drugs). In this setting, radiopharmacists operate in a supervisory role, focusing on the management of production operations and operator training, the implementation of standard operating procedures, the oversight of radiation safety, and the execution of quality control and quality assurance activities. This professional experience allows radiopharmacists to transition easily into complementary roles in the manufacturing of radiopharmaceuticals, where radiopharmacists are normally responsible for ensuring drug product quality, radiation safety, and regulatory compliance. A smaller cohort of radiopharmacists are centred in preclinical, translational, and clinical research. Additional responsibilities for this group include production of novel radiopharmaceuticals, developing analytical methods for these probes, arranging for pharmacology/toxicology testing, coordinating regulatory submissions and filings, assisting clinical investigators, and verifying the accuracy of doses. For both paths, the ultimate goal of all radiopharmacists is the same: guaranteeing that the correct dose of the correct medicine of the desired quality is provided to the correct patient at the appropriate time. Figure 1B shows the estimated number of radiopharmacists per million inhabitants throughout the globe. The concerning situation here echoes that for nuclear medicine physicians and may in fact be even more dire. Predictably, there is a stark lack of radiopharmacists in LMICs; but even HICs fall significantly short of the needed clinical expertise.

The profession of radiopharmacy — also referred to as nuclear pharmacy — has been established as a sub-branch of general pharmacy in recognition of the regulatory classification of radiopharmaceuticals as medicines and due to the unique nature of drugs that emit ionizing radiation. The educational and professional licensing requirements for radiopharmacists are designed to provide the professional skillset necessary to safely prepare and provide compounded radiopharmaceuticals for physicians and their patients. In addition to basic pharmacy education and training, radiopharmacists are legally obliged to complete didactic and professional internship training covering the principles of ionizing radiation, radiopharmaceutical chemistry, the handling of radioactive materials, radiation safety, and the management of radioactive waste. In the United States, for example, once the necessary educational and professional requirements have been met, the medical licensing authorities grant radiopharmacists both licensure as a pharmacist and certification, such as Authorized Nuclear Pharmacist (ANP). Such certification legally allows radiopharmacists to handle radioactive materials, compound radiopharmaceutical medications, and dispense patient-specific unit doses in independently operated, government-registered radiopharmacies. Since there is no additional professional oversight from nuclear medicine physicians in many locales, radiopharmacists are legally responsible for all aspects of radiopharmacy operation, including the quality of the products and the accuracy of doses. Training and credentialling programs in radiopharmacy exist in a number of countries, although they are lacking in many LMICs.

Nuclear Medicine Technologists (NMTs)

Nuclear medicine technologists (NMTs) are integral to the effective delivery of clinical nuclear medicine and radiotheranostics. Not surprisingly, the changing nature of the field will soon prompt a dramatic shift in the training of NMTs. Providing education, experience, and expertise in theranostics to the NMT community will be an enormous challenge, especially given worldwide shortages (Figure 1C).

Historically, NMT training programs have focused on the elements necessary to become an entry-level technologist. While entry-level degrees can serve as starting points for those in the field, in some countries NMTs undertake more advanced degrees (e.g. a bachelor of science). In addition, many on-campus and online educational programs exist for those with related medical technology experience or credentials. In recent years, the field’s myriad advancements have shifted this framework. The rapid integration of theranostics into clinical practice means that the technologists who are currently in practice must quickly acquire additional knowledge and experience. Most nuclear medicine technologist programs have begun integrating theranostics into their curricula. Moving forward, nuclear medicine societies from across the globe must work to provide education and training opportunities to both the current NMT workforce and those looking to enter this rapidly growing field. On-line training programs — such as those provided by IAEA, SNMMI, EANM and other professional nuclear medicine societies — are also being developed to ensure that training in theranostics is available for nuclear medicine technologists.

Nursing Staff and Nurse Practitioners

As the largest component of the global healthcare workforce, nurses play a critical role in many aspects of health care systems around the world. In the US, nurses have been involved in nuclear medicine for more than a quarter century. While in the early days they primarily supported nuclear cardiology testing, roles for nurses in nuclear medicine departments today can vary a great deal. Nonetheless, certain core functions are common. In particular, nuclear medicine nurses often assist in recognizing and addressing emergencies — most frequently hypo- and hyper-glycaemia as well as anaphylaxis — and problems associated with the critically ill. In the clinic, nuclear medicine nurses work alongside technologists to assess and monitor patients. In some departments, nurses are also responsible for obtaining venous access, and in some countries, they administer the radiopharmaceuticals themselves.

The ability to communicate effectively with both patients and healthcare professionals is a critical skill for nuclear medicine nurses. Nurses are often the main point of contact for patients during visits to nuclear medicine departments and thus can play an important role in explaining complex procedures, providing reassurance and advice about the radiation exposure (and potential side effects) associated with nuclear imaging and radiopharmaceutical therapy. Nurses also often act as the main point of contact between nuclear medicine departments and other healthcare professionals, establishing themselves as key nexuses within the multidisciplinary teams responsible for patient care.

Nuclear medicine nurses typically have at least 2 years of post-registration experience. Specific minimum training recommendations may be helpful for these nurses, deepening their understanding of nuclear medicine practice, including radiation protection issues. Figure 1E shows the current estimated number of nurses in nuclear medicine per million inhabitants. The graphic clearly reinforces many of the geographic trends in workforce numbers and also highlights that the number of dedicated nurses in nuclear medicine is currently quite variable even amongst HICs. The current rise in demand for theranostics along with the shortage of qualified nuclear medicine physicians could represent an opportunity for more senior and experienced nuclear medicine nurses, such as nurse practitioners.

Basic Scientists

The basic scientists that underpin nuclear medicine — radiochemists, medical physicists (Figure 1D), biologists (including radiation biologists), imaging scientists, engineers, etc. — typically receive standardised training while they pursue undergraduate degrees. While some countries offer specialised degree programs in the radiopharmaceutical sciences, most countries do not (though such programs have been proposed). Establishing permanent undergraduate training programs worldwide would greatly benefit the field.21

Undergraduate research also provides an excellent opportunity for trainees to become involved in radiation-related research early in their careers, either in academic environments or through internships at pharmaceutical companies. If a suitable position can be found, undergraduate students can learn radiochemistry, in vitro studies (e.g. cell studies, autoradiography, and immunohistochemistry), in vivo studies (e.g. PET imaging and biodistribution experiments), and data analysis. Alternatively, if aspiring to a more clinical career, an undergraduate intern could shadow cGMP production chemists, quality and regulatory personnel, nuclear pharmacists, medical physicists, or physicians. Upon graduation, these trainees would have sufficient training and experience to enter the workforce or pursue an advanced degree.

For basic scientists who want to pursue an advanced degree, a Ph.D. is the likely next step. Yet, as with undergraduate programs, very few formal graduate programs are specifically dedicated to the radiopharmaceutical sciences. Clearly, establishing such programs and expanding existing ones — funded either through dedicated fellowships or training grants — would be highly valuable for the field. As it stands, the radiopharmaceutical sciences must typically recruit PhD students from other departments, something that is easiest when members of radiology, nuclear medicine, and radiation oncology departments have co-appointments in departments dedicated to chemistry, medicinal chemistry, biochemistry, pharmacology, and biomedical engineering.

Other trainees enter the field as postdoctoral fellows after completing a Ph.D. in more fundamental disciplines such as chemistry, biology, or physics. Certain subdisciplines — like molecular imaging and bioconjugation chemistry — have enjoyed a recent influx of trainees due to mainstream attention arising from high-profile interdisciplinary collaborations.22 Other areas, in contrast, suffer from inadequate recruitment of both principal investigators and trainees. Notably, an area of particular concern is a global lack of radiochemists, specifically those capable of labelling molecules with long-lived radionuclides like 3H and 14C as well as emerging therapeutic radionuclides like 177Lu, 211At, and 225Ac. This predicament has been highlighted by agencies for over two decades, as revealed by the 2002 IAEA Report “Assessment of the Teaching and Application in Radiochemistry”,23 the 2004 DOE/NSF Nuclear Science Advisory Committee Report “Education in Nuclear Science”,24 the 2007 National Research Council Report, “The Future of Chemistry Research”,25 the 2012 National Research Council report “Assuring a Future U.S.-Based Nuclear and Radiochemistry Expertise”,26 and the 2020 paper in Nuclear Medicine and Biology, “Training the Next Generation of Radiopharmaceutical Scientists”.21 Thankfully, postgraduate programs in radiochemistry in the U.S., Europe, Asia, and Australia will help alleviate this shortage. Other areas experiencing critical shortages include kinetic modelling, PET data analysis, the preclinical evaluation of radiopharmaceuticals, preclinical and clinical dosimetry, and cyclotron targetry/separation chemistry. The latter is particularly pertinent in light of the wide variety of radionuclides (especially radiometals) that will be used in the theranostics of the future, many of which will be produced using solid target systems.

Referring Clinicians and Other Professionals

A wide variety of personnel — from referring providers to schedulers and administrative assistants to billing coders — will need to receive some degree of education in the field to support the clinical use of theranostics. As the field of nuclear medicine grows in the coming years, practitioners will need to play a critical role in various educational and training initiatives. Critically, however, this educational process will need to extend beyond medical professionals to include hospital administrators, national health care systems managers, and health insurance companies to ensure the successful implementation of theranostics across all levels of the modern medical establishment.

Patients and Patient Advocates

Finally, it is important to consider the education of patients and patient advocates. For instance, both the neuroendocrine tumour and prostate cancer patient populations — for which nuclear medicine currently offers theranostics — are extremely motivated and well-organised. A quick internet search reveals popular discussion forums where patients exchange information about which diagnostic scans and therapies to receive, where to get them, what side effects can be expected, and so on. Some of this information is accurate, while other material is incorrect due to innocent misunderstandings. We believe that the field of nuclear medicine has a responsibility to educate patients, family members, and patient advocates on the use of diagnostic and therapeutic radiopharmaceuticals, like efforts recently initiated by the International Centers for Precision Oncology Foundation.27 At the very least, this educational outreach should engage stakeholders through in-person events, capitalize on the benefits of online learning by updating frequently outdated materials hosted on government and society websites, and leverage new avenues of communication such as social media.

Theranostic Practice and Training in Developing Countries

The practice of theranostics in the developing world is characterized by tremendous diversity across countries. While some have made significant progress in the implementation of nuclear medicine practices using radiopharmaceuticals, others lag behind due to a variety of challenges.28 With respect to the latter, the scarcity of theranostics and their high cost — both the drugs themselves and the infrastructure and logistics required to produce and deliver them — are principal drivers of the problem. To wit, radiopharmaceuticals that have received level one evidence in phase three clinical trials and are approved in the United States and Europe will present particularly significant affordability and accessibility issues, especially in countries whose medical systems are newly incorporating the field.29 Negotiations with the pharmaceutical industry have lowered drug costs in LMICs for diseases such as HIV and Hepatitis C, and this approach may be considered here. Of course, conflict-affected countries face even greater challenges in establishing the use of theranostics, meaning that many patients in these already troubled nations are denied access to their diagnostic and therapeutic potential.30

In more positive news, some developing countries began their forays into radiotheranostics early and have already built up their capacity to perform in-house radiolabelling, quality control testing, and quality assurance oversight. Such efforts may allow for the use of novel radiopharmaceuticals via ‘compassionate access’ programs under the purview of local regulatory frameworks and international ethical and radiation safety standards. This will allow patients to benefit from novel treatments that are not yet widely available and will serve to further support the equitable global dissemination of theranostics. Also promising is the burgeoning investment of developing countries in research nuclear reactors that are capable of producing radionuclides for theranostics.31

Beyond these formidable economic and logistical challenges, the lack of adequate theranostic nuclear medicine training programs and national nuclear medicine professional societies further impedes the advancement of the field in developing countries. Though some of these nations have had nuclear medicine residency programs for decades, a lack of standardized training curricula and certification processes in theranostics hampers the development of a workforce that is prepared for the coming influx of these drugs. Not surprisingly — especially given the maps displayed throughout the work — these shortages are not limited to physicians, as many developing countries also lack a sufficient supply of trained nuclear medicine technologists, nuclear medicine nurses, radiopharmacists, and basic scientists.

Ultimately, the scarcity of trained professionals undermines the multidisciplinary framework required for the management of patients with theranostics. Going forward, it is incumbent upon the international scientific and medical communities as well as the IAEA to help developing countries foster the collaborative systems necessary to overcome the unique challenges faced by these nations and thus foster the further proliferation of theranostics.

Looking Forward

As the use of radiopharmaceuticals expands rapidly around the world, the growth of the nuclear medicine workforce must keep pace. This need for growth is complicated by the multidisciplinary nature of the teams responsible for the clinical deployment of these medicines, as nuclear medicine physicians must be complemented by a diverse array of highly specialized professionals such as radiochemists, nuclear medicine technologists, medical physicists, nuclear medicine nurses, and radiopharmacists. In contrast to the training of basic scientists, the training of clinical healthcare professionals involves more formalised education and licensing requirements. One difficulty when considering the education of the clinical workforce is that training, licensing, and certification requirements differ vastly from country to country. In practice, this means that a healthcare professional who can practice in one country may be unable to perform the equivalent work in other jurisdictions. Agreement with and endorsement of international guidance could address some of these issues and lead to greater flexibility in staffing across borders.

Recommendations

Successfully managing the growth of nuclear medicine in light of the burgeoning success of theranostics requires urgent attention to the retention and expansion of its workforce. While logistics, infrastructure, regulation, and funding are undeniably key factors in ensuring access to theranostics, a trained workforce lies at the core of the delivery of safe and effective theranostic treatments across the globe. With respect to training, we suggest enhancing existing nuclear medicine programs with educational opportunities in theranostics and oncology, ideally by establishing dedicated programs around the world. Along these lines, promising developments include ongoing efforts toward the development of curricula focused on radiopharmaceutical therapy for trainees in nuclear medicine and radiation oncology as well as opportunities for continuing medical education (CME) for established professionals.32,33

We urge funding agencies to support these programs by prioritising training and fellowship awards for basic scientists in areas that are essential for securing the future of nuclear medicine, including radiochemistry, kinetic modelling, and dosimetry. In addition, we also believe that freely accessible databases with fully analysed datasets from phantoms and patient studies should be established to facilitate the continued training of medical personnel. We also recommend grants to establish physician-scientist training programs focused on radiotheranostics. Taken together, these initiatives are critical for recruiting talented researchers and clinicians.

Maintenance of certification (e.g. board review, recertification) should also be considered to ensure that high standards and safe practices continue throughout an individual’s career. The COVID-19 pandemic has accelerated the migration to remote work and the development of digital infrastructure. This phenomenon can be leveraged for online training, facilitating recertification (e.g. via online CME) and providing trainees in emerging markets with access to materials that would otherwise be unavailable. As the use of theranostics becomes a universal standard-of-care, trainees, practitioners, and centres alike would benefit from the harmonisation of qualification requirements, regulatory oversight, and educational materials, which could facilitate the reallocation of trainees across borders to ameliorate critical staffing shortages. The IAEA and the EANM — through its European School of Multimodality Imaging and Therapy — aim to work toward this goal by providing many educational opportunities to the global nuclear medicine community.

The number of workers necessary to ensure sufficient and equitable access to theranostics in a given country will depend on a range of factors, including the availability of radionuclides and radiopharmaceuticals, the existence of well-developed supply chains, the maturity of the regulatory and funding landscapes, and the presence of fully equipped production sites. The workforce required for the administration of theranostics at a given site will also depend on whether an external supply of radiopharmaceuticals is possible or if the on-site production of radiopharmaceuticals is necessary. While the availability of theranostics is relatively high in HICs, access is far more restricted in LMICs. A central tenet of this white paper is that workforce numbers must be increased across the board to ensure equitable access in all nations. More specifically and more pressingly, we propose that workforce numbers in low-, lower-middle-, and upper-middle-income countries should be increased to the median level of the next income group within 5-10 years.

In summary, we believe the field could benefit most from the following five initiatives:

  • The development of dedicated training programs to foster the growth of the basic science workforce, including radiochemists, radiation biologists, radiation physicists, and imaging scientists

  • The standardisation of training, licensing, and certification programs in theranostics for physicians in nuclear medicine, radiation oncology, and closely related fields.

  • The expansion of training programs in theranostics for all levels of the clinical workforce, including radiopharmacists, technologists, physicists, nurses, and physicians

  • The development of maintenance-of-certification processes for the active medical workforce to ensure high standards and safe practices over the course of individuals’ careers

  • The creation of educational programs on theranostics for patients, patients’ families, and patient advocates

Acknowledgments:

The authors thank Mr. Garon Scott for his help in editing this manuscript. The authors also acknowledge the information provided by country nuclear medicine societies and experts on workforce numbers as part of the Lancet Oncology Commission on Radiotherapy and Theranostics.

Funding:

AMS is supported by NHMRC grant No. 1177837. SEL is supported by the Department of Energy as part of the DOE University Isotope Network under grant DESC0021269. PJHS is supported by NIH R01 EB021155. JSL is supported by NIH R35 CA232130.

Conflicts of interest:

Outside the submitted work: AMS reports trial funding from EMD Serono, ITM, Telix Pharmaceuticals, AVID Radiopharmaceuticals, Fusion Pharmaceuticals, and Cyclotek; research funding from Medimmune, AVID Radiopharmaceuticals, Adalta, Antengene, Humanigen, Telix Pharmaceuticals and Theramyc; and advisory boards of Imagion and ImmunOs; BMZ reports research funding from Evergreen Theragnostics; equity in Summit Biomedical Imaging; and technologies licensed to Clarity Pharmaceuticals. SEL reports research support from Navidea Biopharmaceuticals, Fusion Pharmaceuticals, Cytosite Biopharma Inc., Viewpoint Molecular Targeting, Inc, and Genzyme Corporation and has acted as an advisor for NorthStar Medical Radioisotopes and Trevarx biomedical; PJHS reports research support from BMS, Telix Pharmaceuticals and Radionetics Oncology, has acted as an adviser to Synfast Consulting LLC and Telix Pharmaceuticals, and holds equity in BMS, Telix Pharmaceuticals and Novartis; ADW reports his role as the Editor-in-Chief on Nuclear Medicine and Biology; MAW reports no relevant conflicts; FG reports no relevant conflicts; APK reports clinical trial funding from Novartis, Bayer, POINT, and Merck; unpaid consulting for Novartis; AJ reports no relevant conflicts; PK reports no relevant conflicts; SV reports no relevant conflicts; AK reports no relevant conflicts; STL reports no relevant conflicts; SKL reports no relevant conflicts; DP reports no relevant conflicts; JZ reports no relevant conflicts; JLU reports no relevant conflicts; JSL reports research support from Clarity Pharmaceuticals, Avid Radiopharmaceuticals has acted as an adviser of Alpha-9 Theranostics Inc, Clarity Pharmaceuticals, Earli Inc, Evergreen Theragnostics, Inhibrix Inc, Precirix, Telix Pharmaceuticals, and is a co-inventor on technologies licensed to Diaprost, Elucida Oncology, Theragnostics, Ltd., CheMatech, Clarity Pharmaceuticals and Samus Therapeutics LLC, and is the co-founder of pHLIP Inc., and holds equity in Summit Biomedical Imaging, Telix Pharmaceuticals, Clarity Pharmaceuticals and Evergreen Theragnostics. No authors are employed by the National Institutes of Health.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Search strategy and selection criteria: References were identified through searches of PubMed with the terms “theranostics”, “theragnostics”, and “radiotheranostics”, between Jan 1, 1990 and Sep 1, 2023. Articles were also identified through searches of the authors’ own files. Only papers published in English were reviewed. The final reference list was generated based on originality and relevance to the broad scope of this article.

Contributor Information

Andrew M. Scott, Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia; Professor, Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia.

Brian M. Zeglis, Department of Chemistry, Hunter College, City University of New York, New York, New York USA; Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Radiology, Weill Cornell Medical College, New York, New York, USA.

Suzanne E. Lapi, Departments of Radiology and Chemistry, O’Neal Comprehensive Cancer Center at UAB University of Alabama at Birmingham, Birmingham, Alabama, USA.

Peter J. H. Scott, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.

Albert D. Windhorst, Department of Radiology & Nuclear Medicine, Amsterdam UMC, Amsterdam, North Holland, The Netherlands; Cancer Center Amsterdam, Vrije Universiteit Amsterdam, North Holland, The Netherlands.

May Abdel-Wahab, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Francesco Giammarile, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Diana Paez, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Amirreza Jalilian, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Peter Knoll, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Aruna Korde, Division of Physical and Chemical Sciences, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Shrikant Vichare, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Vienna, Austria.

Nayyereh Ayati, Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia.

Sze Ting Lee, Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, Victoria, Australia; School of Cancer Medicine, La Trobe University, Melbourne, Victoria, Australia; Faculty of Medicine and Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia; School of Health and Biomedical Science, RMIT University, Melbourne, Australia.

Serge K. Lyashchenko, Department of Radiology, Memorial Sloan Kettering, New York, New York, USA. Department of Radiology, Weill Cornell Medical College, New York, New York, USA.

Jingjing Zhang, Department of Diagnostic Radiology, National University of Singapore, Singapore; Clinical Imaging Research Centre, Nanomedicine Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Jean-Luc Urbain, Department of Radiology/Nuclear Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA.

Jason S. Lewis, Department of Radiology and Program in Molecular Pharmacology, Memorial Sloan Kettering, New York, New York, USA; Departments of Radiology and Pharmacology, Weill Cornell Medical College, New York, New York USA.

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