ideas

Working out how much radiation a patient's kidneys and tumours received after a radioactive treatment normally means a specialist spending hours tracing organ outlines by hand on a scan. Software that draws those outlines automatically using artificial intelligence can do the same job in minutes, making personalised dose tracking available everywhere, not just in a few specialist centres.

Right now, most patients get the same number of treatment cycles at the same radioactive dose regardless of their own biology. Measuring how much radiation actually reaches each patient's kidneys after the first dose could let doctors safely give some patients more cycles and stop earlier in others, rather than using one fixed schedule for everyone.

When PSMA PET finds only a few spots after surgery, zap each spot with focused radiation and delay or avoid lifelong hormone therapy.

Most of the world's actinium-225, a rare radioactive metal used in some newer cancer treatments, comes from slowly extracting it from an old stockpile of another radioactive element. A different method — firing high-energy protons at ordinary thorium metal in an accelerator — can make much bigger batches, needed if actinium-225 treatments are ever to reach more than a small number of patients.

A same-day PET tracer could replace the two-day, low-resolution MIBG scan children now undergo repeatedly.

A handful of ageing research reactors make most cancer isotopes. Coordinating their maintenance and funding reserve capacity would prevent the shortages that stop treatments.

Most PSMA treatments use one molecule to take the pre-treatment scan and a slightly different molecule for the actual treatment, so the scan is only an approximate guide. A copper-based pair uses the identical molecule for both steps, just with a different form of copper, so the scan should be a much truer preview of where the treatment radiation will go.

Most new cancer imaging agents and radioactive drugs start in university hospitals. A network sharing production, quality files and regulatory paperwork would get them into multi-centre trials years faster.

Radiation from a targeted radioactive treatment can spill tumour debris that alerts the immune system. Giving an immunotherapy drug at the same time, to stop the immune system being switched off, is being tested to see if it makes the radioactive treatment work better.

A drug that blocks a cell's DNA-repair enzyme (PARP) is being added to PSMA-targeted radioactive treatment, on the theory that if a cell can't repair the small cuts radiation makes to its DNA, those cuts become fatal breaks that kill the cancer cell.

When prostate cancer comes back in just a handful of spots, doctors already zap those spots with precision radiotherapy. Adding a single dose of an alpha-particle radioactive drug at the same time, instead of the more established beta-particle version, might mop up cancer cells too small to see on a scan, because alpha radiation travels a much shorter distance and hits harder in that short range.

The lutetium used in approved prostate and neuroendocrine cancer treatments is made from an enriched metal that comes mostly from Russia. Making it elsewhere would secure supply.

Almost every clear-cell kidney cancer carries the CAIX protein. Image it with one radioactive antibody, then treat with the same antibody carrying a therapeutic isotope.

Scan for T cells inside the tumour a few weeks after starting immunotherapy. If they have not arrived, change course.

Measure the radiation each patient's tumour and kidneys actually absorb and adjust the number and size of doses, instead of giving everyone four identical cycles.

Instead of finding a different target for each cancer, hit the scaffolding cells that almost all solid tumours share.

Sarcomas, a group of rare and hard-to-treat cancers, often carry a marker called FAP not just on the supporting tissue around the tumour but on the cancer cells themselves. A radioactive drug built to find FAP is being tried as a treatment, but the small studies done so far disagree about whether it actually shrinks tumours.

Radioactive treatments lose strength every day as they travel from a central factory to the hospital, so by the time a dose arrives some of its power has decayed away. Installing compact, automated dose-preparation equipment inside individual hospitals, so they compound the treatment themselves from bulk material, could cut that wasted radioactivity and get treatment to more places.

For men with high-risk prostate cancer that hasn't spread yet, giving a dose or two of PSMA-targeted radioactive treatment before surgery, rather than only using it after the cancer has spread, might kill hidden cancer cells surgery alone would miss. It is still experimental and hasn't yet been shown to help patients live longer or avoid the cancer coming back.

PSMA scans could measure prostate cancer burden and response far better than PSA, but no one has done the standardisation work to make the measurement trustworthy across scanners.

Thousands of old radium sources sit in hospital and industrial storage. They are exactly the raw material needed to make actinium-225, the scarcest cancer isotope.

Actinium-225 can be made in particle accelerators, but the product contains a trace of a long-lived impurity that regulators have not agreed how to handle. Settle the limit and build the hubs.

Radioactive cancer drugs decay while they travel and get stuck at borders. Regional production and simpler transport rules would get more doses to patients on time.

Radioligand therapy for neuroendocrine tumours built on somatostatin receptor antagonists rather than the agonists used today: antagonists bind the receptor in every state and are not internalised, so they occupy several times more sites per cell and deliver more radiation per dose. The test is a randomised phase 2 against agonist lutetium therapy.

Terbium-161 is a close chemical cousin of lutetium-177 that, as well as giving off the same kind of radiation, also releases a shower of extremely short-range electrons. In theory that extra radiation could finish off single cancer cells and tiny clusters that a lutetium-177 treatment might miss, using the same targeting molecules already in use.

Ultra-sensitive whole-body scanners can measure exactly where a radioactive drug goes at tiny tracer doses, allowing each patient's therapeutic dose to be tailored.

Use a whole-body TROP2 scan instead of a single tissue stain to decide which patients get a TROP2 ADC, which one, and when to switch.

Not every prostate cancer cell carries the same marker: some show the PSMA protein that most scans target, others show a different marker called GRPR instead. A single tracer molecule built to stick to both markers at once could find and treat tumours that a PSMA-only or GRPR-only scan would miss.

Almost every alpha cancer therapy in development relies on one scarce isotope. Developing several alternatives at once would stop the whole field waiting on a single supply chain.

Instead of injecting a radioactive antibody that circulates in the blood for days, doctors first give a plain antibody that finds the tumour, wait for it to clear, then inject a small, fast-moving radioactive alpha payload that only attaches where the antibody is already waiting. This two-step trick could let radioactive antibodies treat solid tumours without poisoning the bone marrow.

New whole-body scanners are so much more sensitive than standard PET machines that they can produce a clear picture using a small fraction of the usual radioactive tracer dose. Most of that extra sensitivity has been used to make scans faster; using it instead to lower the radiation dose given to patients and staff is a separate, less-explored option.

Nobody publishes how much cancer isotope is made, where, or when supply will fall short. A public observatory would let hospitals and investors plan.

When ADCs against a surface protein stop working because the payload no longer kills, use the same protein to deliver radiation instead.

If Pluvicto helps at first diagnosis, an alpha version might do more against microscopic disease, when tumour burden is smallest.

Every hospital that treats patients with radioactive drugs measures how much radiation reached the tumour and healthy organs, but this data mostly stays locked in each hospital's own files. A shared, public library pooling that dosimetry data, with patient outcomes, would let researchers everywhere build and test better dosing rules, especially smaller centres that don't see enough patients alone.

When a blood test says 'cancer signal, origin unclear', a FAPI PET scan may find it where FDG cannot.