tldr longer response below if you feel like reading. Lots of new things changing, so ground is moving under our feet and things can be hard to predict. Private practices do hire nucs guys, but if you want to treat patients with theranostics, that will probably stay in academics. Theranostics are a loss leader, so DR PPs at this time don’t want to invest, all their nucs guys just read imaging. But who knows, maybe you can convince them—I think running a theranostics clinic with a few NPs would make it run green, and strengthen contract with hospital.
There are a lot of imaging agents in the pipeline that are kind of game-changing:
Fibroblast activation protein inhibitor imaging (PET) will likely become partner with FDG-PET for cancer imaging within the next 5-10 years, to image what FDG is bad at. Other imaging agents like
this one for acute thrombus will likely have sensitivity and specificity that surpasses CT pulmonary angiogram, probably also about 5-10 years away from clinical adoption.
18F-FES PET for ER+ breast cancer is slowly being adopted, and as you probably already know PSMA in the past two years has solidified itself as standard of care for prostate cancer.
Clinical trials currently being done for treating prostate cancer and NET earlier using 177-Lu therapies. SNMMI and EANM are dead serious about Nuc Med adapting itself as a clinical service line, and this is reflected in the type of articles you see published in JNM, like
this one from earlier this month that describes a newly discovered side effect to PSMA therapy and advises how to monitor for and treat it.
This paper describes FAP-I targeted treatment agents, which would be an enormous breakthrough, and worth billions of dollars, that major pharm companies are aggressively pursuing it. Leadership of SNMMI and EANM is strongly pushing for nuc med to rebrand itself as Nuclear Oncology worldwide. ABR has recently made decisions to support this, which is an incredibly strong backing.
A lot of people kind of poopoo NM because there was a big boom in the 90s with rapidly changing gen nucs tech and the advent of PET, where people were jumping on the bandwagon, and it kind of died there with FDG PET in the late 90s as high throughput drug screening hit a wall. But modern chemical techniques are much more adept now at generating highly sensitive and specific radiopharmaceuticals, that we’re seeing a whole bunch of new ones being rapidly developed in short order. I think the hype this type around is much more real.
All that being said, these changes to nuc med are still in their infancy, and making changes to standard of care takes a long time, so to really enjoy it
nowadays you kind of have to be an academic, because it’s where it’s happening. Right now NM therapy is a loss-leader (high overhead, low reimbursement), so a lot of DR PP’s don’t have NM divisions to really administer treatment agents. The NM docs they hire are for PET and Gen nucs imaging reads (another reason why, if you want to do the depth of NM, academics is where it’s at). My feeling is that what makes EBRT profitable for radonc won’t be applicable to NM, as our dosimetry while complicated is much less customizable. We don’t plan treatments and doses to normal organs like they do, we just administer the doses, and the body tells us what dose each tissue gets, and it will likely become the job of the NM doc to observe for, and respond to, these normal organ toxicities. Moreover, kidney and marrow injury from these agents are significant, and therefore these treatments will likely remain relegated to end-of-line treatments. Because of that, this will probably largely
remain at major academic/tertiary centers that are large enough that the overhead for a nuclear pharmacy doesn’t hurt. Some community radonc practices administer injected radiotherapy, but they don’t like it.
All that being said. Big change is happening, but the process of changing standard of care through FDA approval and NCCN guidelines is necessarily very slow. Despite this slowness, major changes have already happened in the past 2-3 years alone already. Seriously, just go to jnm, read the current issue, and you’ll see the depth and breadth of the current state of things. JNM and EJNMMI are required reading for nucs fellows.
