Radioligand therapy, or RLT, is an innovative cancer treatment that is generating considerable interest in the medical community. In this article, Rüdiger Schenk discusses the challenges and rewards of this targeted nuclear therapy.

RLT, which harnesses nuclear power to treat cancer, is truly remarkable. By delivering radiation to very specific areas of the body, it destroys cancerous cells while aiming to limit the damage to surrounding tissue. This is made possible by using ‘ligands’, molecular structures that specifically bind to cancer cells, and ‘radionuclides’, that deliver radiation to damage targeted cells.

RLT holds immense medical potential. At Novartis, we expect it to become a major pillar of oncological treatments in the coming years. But to unlock this potential, we’ll need to overcome some initial challenges that are inherent to treating patients with radioactive therapy. Whether in hospitals, healthcare systems or manufacturing companies, the processes involved in RLT are vastly different to those involved in traditional cancer therapy. This is due to complex logistics, the need for specialised skills and infrastructure and the additional layer of regulations that governs radioactive substances.

A race against time

First, let’s look at the logistics of delivering this radioactive treatment to patients. RLT is made at manufacturing sites, like those run by Novartis in Italy and Spain. Given its radioactive nature, RLT has a short shelf life: it loses strength over time. This is a key consideration. It means the strength of each dose will depend on the distance from the manufacturing site to the treatment centre. It also means precise timings are crucial. Unlike other medicines, we can’t stock RLT treatment and only have a few days to get it from the manufacturing site to the treatment centre.

So, once the treatment is manufactured, it must be transported right away. Again, the radioactive nature of RLT makes this a delicate operation, requiring specialised transport and specific customs clearances.

The complex logistics of RLT

Once the treatment reaches a hospital, it must be administered to the patient in a shielded room. And in Switzerland, the patient cannot be discharged until 48 hours after receiving the therapy. Even though the radiation involved in RLT travels only tiny distances – mere millimetres – these precautionary measures are taken to protect healthcare workers and caregivers from the radiation that is present in a patient’s body following treatment. Radiation levels decrease rapidly, so it is considered safe to discharge patients after two days.

In addition, we need dedicated infrastructure and resources to deliver RLT treatment. Hospitals need to plan and construct rooms where patients can shield. They need the right imaging equipment and the right disposal system for radioactive waste. And above all, they need the right people. From oncologists to nuclear medicine physicians, radiologists, radio pharmacists and nurses, a whole team of specialists must be in place and working in perfect coordination for a patient to be treated. It’s what we call ‘healthcare system readiness’.

How are RLTs reimbursed? 

Reimbursement poses another challenge when it comes to bringing RLT to patients. In Switzerland, the current reimbursement system limits hospitals’ ability to embrace and adopt innovative treatments such as RLT. Hospitals receive a fixed amount of money for each in-patient they treat, which is based on average historical costs incurred over the previous years for patients with the same disease. This does not, however, take into account the real costs of new therapies.

The reality is that hospitals must often use their own funds to cover this gap so that they can offer new treatments such as RLT. Institutions often make a loss for several years until the reimbursement amount for the given disease catches up with the real amount that’s needed to treat patients. And for a new treatment like RLT, the spending cap is quickly reached, so the number of patients that can be treated is limited. In other words, these financial restrictions mean that not all patients who might benefit from RLT are currently offered it as an option.

This limitation applies not only to RLT but to all innovative treatments used in hospitals. This gap in the Swiss healthcare system strongly limits the introduction of innovative new treatments for in-patients. Solutions already exist in other European countries, like Germany and France, and they should also be implemented here if Switzerland is to stay abreast of innovation.

A new pillar of cancer therapy?

At Novartis, we take a long-term perspective. Once we overcome the barriers mentioned above, RLT could well become an essential pillar of cancer care for several types of cancer. As we’ve seen, RLT therapy uses a ligand that’s specific to each type of cancer. We believe there’s potential to use different ligands for a wide range of cancers beyond those already explored. By investing in RLT research, building up expertise and increasing manufacturing capacity, our ambition is to discover further applications for RLT and to make it available to more patients.

We are lucky to work in Switzerland with some of the world’s most renowned nuclear medicine specialists. As Professor Schaefer explains in this interview, teamwork will be vital to unlocking the potential of RLT. No single stakeholder can tackle the complex challenges of RLT alone. But together, I believe we can realise the full benefits of this promising new therapy and hopefully improve the lives of many patients.

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