The radiopharmaceutical industry is investing billions of dollars in the next generation of cancer medicines. New isotopes are moving into clinical development, pharmaceutical companies are assembling radioligand therapy pipelines, manufacturers are building production capacity, and hospitals across the United States and Europe are preparing for what could become a much larger theranostics market.
But a paper published August 24 in the American Cancer Society journal Cancer points toward a much more fundamental challenge facing global oncology: large parts of the world still lack the infrastructure required to deliver cancer care that developed healthcare systems already consider routine.
The review, “Gynecologic cancers in low- and middle-income countries: Bridging the survival gap,” examines cervical, endometrial, ovarian, vaginal and vulvar cancers across low- and middle-income countries. Its numbers are striking. Approximately 1.47 million new gynecologic cancer cases and more than 680,000 deaths were reported globally in 2022, according to the authors.
Cervical cancer illustrates the disparity most dramatically. The review estimates that low- and middle-income countries account for approximately 94% of cervical cancer deaths worldwide, with the highest mortality reported in East Africa.
The problem isn't simply that better cancer drugs are needed. The authors describe systemic failures across prevention, early detection and treatment, including late-stage diagnosis, inadequate screening coverage, insufficient radiotherapy infrastructure, workforce shortages and restricted access to essential and newer therapies. And that should matter to radiopharma.
There are interventions capable of changing this trajectory now. HPV vaccination, HPV self-sampling, screen-and-treat programs, task shifting and international training partnerships could substantially reduce cervical cancer mortality when implemented at scale. Those interventions should come first; radiopharmaceutical therapy is not a substitute for vaccination, screening, surgery, chemotherapy or conventional radiation therapy.
But the infrastructure problem identified by the researchers becomes even more important as oncology moves toward increasingly sophisticated forms of precision medicine. Radiation therapy is already central to the treatment of many gynecologic cancers, particularly locally advanced cervical cancer, and shortages of equipment, trained personnel and accessible treatment centers remain significant obstacles in many lower-resource countries.
Now consider what happens as cancer treatment increasingly incorporates molecular imaging and radiopharmaceutical therapy. The infrastructure requirements don't become simpler. They become considerably more demanding.
Nuclear medicine already plays an important role in gynecologic oncology. FDG PET/CT can contribute to staging, lymph-node assessment, treatment-response evaluation and recurrence detection across several gynecologic cancers, while nuclear medicine techniques can also play a role in sentinel lymph-node mapping.
The direction of sophisticated cancer care is increasingly clear: more precise imaging, better characterization of disease, more personalized treatment planning and therapies selected according to molecular characteristics. The nuclear medicine industry is developing increasingly advanced tools that could become part of that evolution.
Yet the new Cancer review highlights a world in which many patients still struggle to access screening and conventional radiotherapy. That creates an uncomfortable question for precision oncology: what happens when the technology moves faster than the healthcare systems expected to use it?
Radiopharmaceutical therapy introduces an unusually demanding infrastructure equation. A conventional pharmaceutical can often be manufactured centrally, shipped through established pharmaceutical distribution networks and administered across a broad network of hospitals and clinics.
Radiopharmaceuticals are different. Depending on the product and market, they can require isotope production, radiopharmaceutical manufacturing, specialized transportation, nuclear pharmacies, licensed treatment facilities, radiation safety programs, nuclear medicine physicians, technologists, medical physicists, dosimetry capabilities and carefully coordinated patient scheduling. Some isotopes have half-lives measured in hours or days, making logistics and proximity to production part of the treatment equation.
In radiopharma, the supply chain effectively becomes part of the medicine.
That model is challenging enough in the United States and Europe, where companies are already investing heavily in manufacturing capacity and distribution infrastructure. Extending it into healthcare systems that may lack basic cancer treatment infrastructure will be considerably harder.
If radioligand therapy ultimately becomes a major pillar of oncology, the industry's addressable market therefore will not be determined solely by how many patients could biologically benefit from the drugs. It will also be determined by how many healthcare systems can actually administer them.
That could eventually turn today's infrastructure gap into one of nuclear medicine's largest long-term growth opportunities. Building nuclear medicine capacity across emerging healthcare markets would require far more than selling additional scanners.
It could mean regional isotope-production networks, cyclotrons, radiopharmacies, PET/CT and SPECT/CT systems, hot laboratories, radiation monitoring, treatment centers, specialized logistics networks, software, workforce training and regulatory infrastructure. The opportunity could extend across virtually the entire nuclear medicine supply chain.
It also suggests that some of the companies ultimately benefiting from radiopharma's globalization may not be pharmaceutical companies at all. Equipment manufacturers, isotope producers, radiopharmacies, logistics companies, engineering firms, software providers and training organizations could become essential participants in building the markets pharmaceutical companies eventually hope to enter.
The industry often discusses emerging markets primarily in terms of patient populations and drug sales. Radiopharma may need to think about them as infrastructure markets first and pharmaceutical markets second.
The pharmaceutical industry typically evaluates market opportunity through disease prevalence, eligible patient populations, reimbursement and potential penetration. Radiopharma may require another variable: deliverable patients.
There could eventually be millions of patients around the world whose cancers theoretically make them candidates for molecular imaging or radiopharmaceutical therapies but who live too far from the infrastructure necessary to receive them. A drug can receive regulatory approval and demonstrate excellent clinical results without creating a meaningful market in a country that lacks isotope supply, imaging capacity, licensed treatment facilities or trained personnel.
Closing that gap will require capital, but it will also require governments, hospitals, development organizations and private industry to think differently about nuclear medicine infrastructure. Instead of building isolated PET centers or purchasing individual pieces of equipment, countries may eventually need integrated nuclear medicine ecosystems connecting isotope supply, imaging, radiopharmacy, treatment, logistics, workforce development and regulation.
That is a much larger undertaking. It is also potentially a much larger market.
None of this should obscure the most important message from the new gynecologic cancer review. Many deaths occurring today do not require futuristic treatments to prevent. The authors emphasize scalable interventions including HPV vaccination, screening, self-sampling and earlier treatment. They also point toward the World Health Organization's 90–70–90 cervical cancer elimination targets, which call for vaccinating 90% of girls against HPV, screening 70% of women with high-performance tests and treating 90% of women identified with cervical disease.
Precision oncology cannot become an excuse for neglecting those fundamentals. But if those programs succeed, more cancers are detected earlier and healthcare systems become stronger, another question inevitably follows: what comes next?
Radiopharma's globalization may ultimately depend as much on infrastructure investment as pharmaceutical innovation. The industry can develop better targeting molecules, produce more therapeutic isotopes, build larger manufacturing plants and demonstrate increasingly impressive clinical results, but those medicines cannot reach patients without the physical and human infrastructure surrounding them.
The survival gap described in the new Cancer review is therefore more than a gynecologic oncology problem. It is an early warning about the future of precision medicine: cancer treatment is becoming more technologically sophisticated while enormous parts of the world are still building the foundations of modern cancer care.
For radiopharma, that gap represents both a responsibility and an opportunity. The next great expansion of nuclear medicine may not simply come from inventing another radiopharmaceutical. It may come from building the healthcare infrastructure that allows the rest of the world to use one.
