Site readiness and referral pathway delays
Getting a patient from 'this treatment might help you' to actually receiving it can take weeks or months, because the scan, the specialist review and the treatment often happen at different places, and not every hospital is equipped to give the treatment at all.
Overview
Radioligand therapy referral is a multi-step journey: a treating physician suspects eligibility, the patient needs a PSMA- or somatostatin-receptor PET scan (often at a different centre from where the eligibility decision or treatment happens), a multidisciplinary team reviews the scan, and only then is the patient scheduled at a licensed, hot-lab-equipped centre. A 2025 IQVIA Institute study of the mCRPC referral pathway in Germany, France, Italy and China found this took a minimum of about 7 weeks in Germany, 8-9 weeks in France and China, and roughly 11 weeks in Italy, with limited PSMA PET-CT capacity and unclear division of responsibility between urologists, oncologists and nuclear medicine physicians cited as common barriers across all four countries.
A report from Dana-Farber Cancer Institute tracking 146 patients referred for 177Lu-PSMA-617 between May and October 2022 found the median time from tumour-board review to first treatment cycle rose from 41 days in May to 96 days in October as supply tightened; 35% of patients (45 of 146) started or continued a different therapy rather than wait, and 5% of approved patients (6 of 127) died during the wait. A 2022 international SNMMI survey of prostate cancer theranostics sites found a mean PSMA PET waiting time of 17±16 days (median 10, range 1-120), with the longest waits reported in Africa, and one-third of responding centres saying they lacked sufficient PET imaging capacity to meet demand.
Imaging-capacity concentration compounds the problem: a UK health-system-readiness review found only ten centres nationally offer gallium-68 DOTATATE/TOC PET-CT for neuroendocrine tumours, nine of them in or around London, forcing many patients to travel long distances simply to be assessed for eligibility before any decision about treatment itself.
- The referral pathway crosses multiple specialties (urology/oncology, nuclear medicine, radiology) with no universally standardised handoff or shared ownership.
- PSMA- and SSTR-PET imaging capacity, which is required to confirm eligibility, is concentrated at a small number of centres, often geographically distant from the referring clinic.
- Community oncology and urology clinics frequently lack the NRC/Agreement-State licensure and hot-lab infrastructure to administer the therapy themselves, so patients must be referred out.
- Disease can progress or the patient's clinical status can change during the referral-to-treatment interval, sometimes invalidating the original eligibility scan.
- IQVIA Institute's proposed streamlined seven-step RLT referral pathway, estimated to cut referral-to-treatment time by one to four weeks depending on country and starting point.
- Multidisciplinary tumour-board models bringing referring physicians, nuclear medicine physicians and radiologists together earlier in the pathway.
- Ordering PSMA PET scans earlier in the disease course (before frank progression) to avoid the scan itself becoming the bottleneck at the point of eligibility.
- UK NHS and other national health-system readiness reviews assessing where new PET-CT and radioligand therapy capacity is most needed.
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