The Therapy Transformation

Quick Answer

Nuclear medicine is shifting from a primarily diagnostic specialty to a therapeutic one. Radiopharmaceutical therapy (RPT) — delivering targeted radiation to a molecular address — is growing explosively, and the rate-limiting step has become trained people, not molecules. Understanding this transformation is essential for anyone in the field: it is redefining what a nuclear medicine physician does, where the jobs are, and what training must cover.

The scale of the shift

The numbers describe a field being rebuilt in real time: RPT is projected to grow from roughly $750 million (2022) to ~$5.5 billion by 2028; 80+ radioligand therapies are in clinical development; and pharmaceutical companies have invested billions. The Lancet Oncology Commission estimated global demand exceeding half a million PSMA-therapy doses per year, requiring "hundreds of new centers and more experts." A 2022 estimate put eligible prostate and neuroendocrine patients at ~41,500, translating to ~150,000 treatment cycles annually — for two indications alone, before the pipeline arrives.

What is driving it

A handful of validated theranostic pairs proved the model, and the pipeline is widening it:

Two forces compound the growth: therapies are moving to earlier lines of treatment (each approval multiplies the eligible population), and new targets and alpha emitters are entering trials. The ²²⁵Ac supply that once throttled alpha therapy is now scaling up — removing a structural barrier to the next wave.

The workforce gap — the real bottleneck

Demand for RPT far exceeds current capacity to deliver it safely. The shortage spans the entire team — physicians, technologists, radiochemists, medical physicists, radiopharmacists, and allied staff — and there are not enough of any of them. The field's own literature is blunt that administering RPT without appropriate training and experience poses real risks to patients. This is the central challenge of the transformation: scaling delivery without compromising the safety and dosimetric rigor that make RPT work. In response, SNMMI has launched RPT Centers of Excellence and accreditation standards to spread capacity while holding quality.

What the field needs now

The transformation reframes the specialty's priorities: patient selection by imaging biomarkers (and recognizing discordant, target-negative disease); personalized dosimetry rather than fixed activities; longitudinal patient management across therapy cycles, including toxicity; radiation-safety and authorized-user competence at scale; and program-building skill — the ability to stand up a theranostics service. These are the competencies a modern nuclear medicine physician must own, and they are exactly what a training resource must now teach alongside classic diagnostic interpretation.

Why it matters for this atlas

A reference for this field can no longer be a diagnostic-imaging catalog with therapy as an afterthought. The atlas treats Therapy & Theranostics as a first-class domain — tracers, targets, dosimetry, response criteria, the landmark trials, and the safety/regulatory framework — precisely because that is where the field is going. The goal is that a physician anywhere in the world can use it to deliver modern, evidence-based radiopharmaceutical therapy safely, and that a trainee can build the therapeutic competencies the transformation demands.

Related pages

• Theranostics Overview and the Therapy & Theranostics domain — the clinical practice.
• Landmark Trials — the evidence base (VISION, NETTER-1/2, TheraP, ALSYMPCA, PSMAfore, ENZA-p).
• Why Nuclear Medicine and Becoming a Nuclear Medicine Physician — the case and the pathways.

Key References

• White paper on radiopharmaceutical therapy growth, workforce, and training needs, J Nucl Med 2025.
• Lancet Oncology Commission and reviews on theranostics workforce and training in the age of radiopharmaceutical therapy.