A $30 Billion Cancer Breakthrough Is Under Threat From Global Conflicts

(Bloomberg) — At the Hirslanden clinic overlooking Switzerland’s picturesque Lake Lucerne, prostate cancer patient Jörg Pegelow lies on a reclining chair as a doctor wearing two sets of gloves — one made with lead — injects a saline solution laced with a radioactive drug into a vein in his arm.

For the 82-year-old retired former head of purchasing at German supermarket chain Rewe, the treatment is the latest in his almost two-decade-long battle with the disease: He tried radiation, which “destroyed” his intestines, and hormone blockers that gave him osteoporosis. On his second cycle of the radioactive-drug treatment, the octogenarian has high hopes for the therapy.

“I can go home tomorrow, and then there’s nothing, except that my wife needs to keep some distance for a few days,” Pegelow says, talking excitedly about a trip to Greece he’s planning. “Unlike chemo, which really wipes you out, traveling is no problem at all with this treatment.”

Radioligand therapy, the targeted delivery of a radioactive drug to kill diseased cells, is quickly turning into a breakthrough strategy for cancer. Unlike external radiation, which irradiates broad areas, or chemotherapy, which indiscriminately hits rapidly dividing cells, the treatment directly targets cancer cells, sparing most surrounding healthy tissues.

With thousands of patients trying it globally, the therapy is emerging as one of the fastest-growing corners in the world of oncology — one currently spearheaded by European companies like Novartis AG, with US and Chinese players nipping at their heels. The global radioligand therapies market was valued at about $3.2 billion in 2025 and is set to grow to about $30 billion by 2034. It’s among the most promising of a handful of emerging new technologies in the more than $280 billion cancer-treatment market.

But as wars and geopolitical turmoil threaten the supply chains for radioactive material, the industry is scouring the world for alternative sources to avert a slowdown in momentum for the treatment. Russia’s invasion of Ukraine and China’s export restrictions on several rare earth elements have hastened the search for other suppliers of isotopes. And the Iran war forced some drug developers to stockpile raw materials.

The global tensions come on top of other hurdles for the therapy. Producing the medicine requires access to a nuclear reactor, while the short lifespan of radioactive material means the drugs need to be prepared relatively close to where they’re going to be administered. Additionally, hospitals need isolated wards, waste-management infrastructure and qualified staff to handle radioactive material. With about six cycles of treatment needed and the list price for a prostate cancer drug of about £20,000 ($27,000) a pop in the UK and roughly $50,000 in the US, the therapy is also not cheap.

But none of that is deterring companies.

Swiss pharma giant Novartis dominates the market currently because of its two US Food and Drug Administration-approved radioligand therapies — Pluvicto for prostate cancer and Lutathera for neuroendocrine tumors — which together generated $2.8 billion in net sales last year. The company is now dedicating 40% of its cancer research and development budget to radioligand therapies, and expects Pluvicto alone to generate $5 billion in sales in 2030.

Germany’s closely held ITM Isotope Technologies Munich SE is awaiting US regulatory approval for its experimental drug to rival Lutathera, with a decision expected over the summer. Also trying to enter this market are companies like Bristol-Myers Squibb Co., AstraZeneca Plc and Eli Lilly & Co., while many European hospitals have access to in-house formulations or brews similar to the yet-to-be approved drug from Boston-based Curium.

“Radiopharmaceuticals are a game changer and we believe have the potential to become a mainstream treatment,” Victor Bulto, president of Novartis’ US operations, said in an interview.

In February, the American Society for Radiation Oncology’s symposium in California cited an analysis of Medicare claims data showing a more than 2,000% growth in intravenous radiopharmaceutical therapy in the decade to 2023. The industry is in its very early stages, with the potential to broaden its use in diagnosis and treatment across a wide range of cancers.

“Radioactivity has cell-destroying capability; we essentially destroy the genetic material of the tumor,” says Janusch Blautzik, head of the therapy unit at the Hirslanden clinic’s Institute of Radiology and Nuclear Medicine. “More emitters will come to the market. That will be the future.”

Here’s how the therapy works: A small amount of radioactive material, called a radioisotope, is paired with a ligand, or a molecule that binds to a receptor present in cancer cells. The radioactive isotopes emit radiation that penetrates the cancer cells, damages their DNA and results in their death. The therapy has the ability to target cancer cells even in metastatic areas — where the disease has spread.

“There are two parts to the process: the first is making the hot radioactive isotope — that’s the bit which will kill the cancer cell. Step two is taking that hot radioactive isotope and attaching it to a chemical that can take it to the target. That’s the warhead that you’re attaching to a missile that will find the cancer,” Andrew Cavey, ITM’s chief executive officer, explains in an interview.

Making radioisotopes like lutetium-177, deployed in Pluvicto and Lutathera, is a complex process and uses an isotope of a rare earth element known as ytterbium mined in countries like China, Australia, Russia and the US. Until a few years ago, almost all of the ytterbium-176 — nuclear medicine’s preferred isotope — came from Russia, something companies are trying to move away from.

“ITM made a very deliberate effort seven years ago on diversifying our supply away from Russia towards a North American supplier,” Cavey said, adding that the pivot accelerated after the invasion of Ukraine in February 2022, even though medical isotopes are exempt from sanctions. “We find that it helps de-risk our business to have a North American supply source and not be subject to the evolutions of geopolitics.” The Iran war prompted the company to protectively reorder materials like helium needed in its production process.

It also hasn’t helped that China added ytterbium in October to its list of rare earths subject to controls. Although implementation has been suspended until November this year, it has added to the sector’s uncertainty.

“Assuming that China would continue to allow exports of controlled materials for medical applications, there are other risks there — they are now requiring detailed info from buyers in export license applications, including what some companies have described as trade secrets,” said Chris Kennedy, an analyst at Bloomberg Economics.

Access to nuclear reactors remains another challenge. Enriched ytterbium-176 needs to be bombarded with neutrons at a nuclear reactor to make it radioactive and transform it into lutetium-177.

With Russian atomic centers an increasingly unattractive option, European drug producers now rely on aging research reactors susceptible to maintenance shutdowns. One such reactor in the Dutch village of Petten temporarily went offline in 2024 — with thousands of patient appointments at hospitals, mostly for medical imaging, canceled as a result.

The European Commission’s recent push may spur the roll out of small modular reactors, but their focus is mostly on chemical industries and data centers rather than the production of medical radioisotopes. That’s driving companies further afield. ITM, for instance, has a partnership with Canada’s Bruce Power.

On the outskirts of Munich, under tight security, ITM operates what it says is the world’s largest lutetium-177 production site. A Bloomberg reporter — like the plant’s employees — had to wear protective clothing, shoe covers and a radioactivity-measuring dosimeter. ITM gets enriched ytterbium-176 — which looks like white powder — from a North American partner.

The material, which the company says is “way more expensive than gold,” is sealed into ampules and sent to reactors — like its Canadian partner’s nuclear plant — where it’s irradiated to create lutetium-177. It is then returned to ITM for a patented purification process before being shipped to customers including Novartis.

Once prepared, the medicine faces yet another challenge: half-life, or the time it takes for the radioisotope to decay by half, affecting its potency to kill cancer cells. Lutetium-177 has a half-life of 6.6 days; actinium-225, a radioisotope that’s garnering a lot of interest from drugmakers, has a half-life of 9.9 days, according to Andy Hsieh, an analyst at William Blair. Technetium-99m, the world’s most widely used diagnostic isotope, decays within hours. That means medicines using these unstable elements can’t sit on shelves for months — or even weeks.

The medicine’s ephemeral nature means it has to be produced close to where it’s needed or near a transport center that can get it there. ITM supplies to more than 400 destinations a week, using a network of airlines, specialist road haulage firms and logistics partners. Novartis, meanwhile, has three radioligand manufacturing sites in the US and four in Europe, with plans to build two more in each of those regions. It is also building two in Asia, one each in Japan and China.

The reliance on planes came into focus amid the conflict in the Middle East, with airspaces closed or airports damaged. Transporting radioactive drugs by sea isn’t always an option because of the limited shelf life. ITM said it could “rapidly reroute” medical radioisotope shipments away from Middle East transit routes thanks to its experience with pandemic-era supply chains. For its part, Novartis, which has contended with air freight disruptions during snow storms, is beefing up its US ground network and has even hired its own truck drivers.

“Infrastructure both for manufacturing as well as the delivery of the therapy are challenges,” said Jeff Jones, an analyst at Oppenheimer & Co. “You’re handling a radioactive product, so you need trained personnel, you need facilities, you need waste handling.”

At the University Hospital in Essen, Germany, patients are housed in the building’s lower levels, with windows and doors lined with lead to prevent radiation from escaping. Toilet contents from patient rooms are stored in containers in the basement until radiation levels fall before being released into the sewage system.

The rooms have a thick concrete wall to shield nurses from patients. A small robot delivers snacks and water to patients while they are still radioactive. The isolation can be difficult, said Enrico, 46, who was diagnosed with a pancreatic tumor in 2020 and later developed a metastasis in his liver. While he had considered chemotherapy, he saw radioligand therapy as a better option.

“I didn’t have any side effects” aside from a slight feeling of dizziness for a few minutes at the beginning of the treatment, he said.

Demand for the therapy is high. The Essen hospital has limited capacity, and bed availability is a key bottleneck, said Ken Herrmann, chair of the nuclear medicine department. Unlike in the US, where it’s often an outpatient treatment, in Germany patients stay for about 48 hours. With only eight beds, the hospital can handle just over 1,000 cases a year, he said. A new building set to open this summer will make it one of the biggest nuclear medicine hubs in Europe.

“Radioligands are no longer seen as a niche curiosity, and are increasingly regarded as an important therapeutic platform with clear relevance in prostate cancer and neuroendocrine tumors, and potentially broader applications over time,” said Ailsa Craig, a portfolio manager at the International Biotechnology Trust. “The field is still defined by three unresolved questions: which patients should receive them, how toxicity can be reduced, and where they should sit in the treatment sequence relative to chemotherapy, hormonal therapy, and emerging targeted agents.”

The therapy might also not work for all cancers since some tumors are known to be more sensitive to radiation than others. It’s most effective when there is clear target expression on imaging, such as prostate-specific membrane antigen, or PSMA, Craig said.

In spite of those limitations, the medical industry is convinced radiopharmaceuticals are finally having their day in the sun — roughly a century after their potential was first seen. Although nuclear medicine, or the application of radioactive substances in the diagnosis and treatment of disease, traces its roots to the 1920s, its march has been slow.

“The industry didn’t invent it, but it did conduct the studies that led to the breakthrough,” said Michael Nader, head of radiopharmacy at the University Hospital in Essen. “There’s now something of a gold rush. Big Pharma used to have no interest in nuclear medicine. Now all the major players are moving in.”

Novartis’ interest in it goes back to at least 1997. But it was researchers in the Netherlands who began studying the use of an experimental drug with lutetium-177 to treat gastroenteropancreatic neuroendocrine tumors, a rare type of cancer that grows in areas such as the stomach, small intestine and pancreas. Doctors at the Erasmus Medical Center in Rotterdam soon started treating patients from all over the world, including Apple Inc. co-founder Steve Jobs.

Several doctors from the Rotterdam hospital banded to form a startup in 2001 called BioSynthema Inc., which was then sold for €10.7 million ($12.2 million) in 2010 to Advanced Accelerator Applications SA, a spin-off radiopharmaceutical firm established by Stefano Buono, a former physicist at the European Organization for Nuclear Research, known as CERN.

“No pharma company had ever had experience in radioactive material and drugs,” Buono said in an interview. “The meeting of engineers, chemistry and pharmaceuticals, this merging of competencies, made our solution so effective.”

AAA reformulated the medicine to create a ready-to-use injectable drug and carried out clinical trials, paving the way for its commercial use. By the time Novartis completed its $3.9 billion acquisition of AAA in early 2018, the drug now known as Lutathera had won European regulatory approval and was on the cusp of getting US clearance.

Interest accelerated with the emergence of Pluvicto for prostate cancer — the most common cancer in men in much of the world, according to the Lancet Commission.

Pluvicto also had its roots in Europe. In 2014, the German Cancer Research Center gave a company called ABX an exclusive worldwide license on a lutetium-based drug for the treatment of prostate cancer. ABX took it to mid-stage clinical trials and also licensed it to Endocyte, which Novartis bought, with the drug going on to become Pluvicto.

The late-stage study results for Pluvicto, which had impressive data in terms of the reduction in the risk of disease recurrence or death, “really put radiopharmaceuticals on the map,” said William Blair’s Hsieh. “It was no longer just a niche modality.”

Bayer AG, which years ago had shown some interest in the technology, is hoping its early-stage actinium-225-based alpha therapy can be a potential successor to Pluvicto.

“The promise of radioligand therapy today is pretty much in prostate cancer,” said Christine Roth, Bayer’s head of global product strategy and commercialization. “I think the big question is can you move this treatment modality into other tumor types? We have even more work going on early in our pipeline to look at opportunities there.”

Companies like Switzerland’s Nuclidium AG are trying copper-67 as an alternative to lutetium-177 because it avoids nuclear reactors, reduces hospital waste issues and is not dependent on Russian-origin raw materials. But the radioisotope’s half life of just 2.6 days could complicate its use.

In the US, Bristol-Myers Squibb is conducting late-stage trials for a drug using actinium-225 to treat neuroendocrine tumors. It’s also in early testing for breast cancer. Eli Lilly bought Point Biopharma Global Inc. in 2023, gaining access to its facility in Indianapolis and a research and development center in Toronto. Lilly also entered into a pact with Radionetics Oncology Inc. in 2024.

China has identified radiopharmaceuticals as an area of drug research it wants to accelerate. Chinese companies are starting to generate early clinical data for new cancer targets, Oppenheimer’s Jones wrote in a note in January.

As the treatment starts to take root across the globe, at the Swiss clinic, Pegelow is optimistic.

“If I survive another five to six years with this, maybe there will be new therapies,” he said.

©2026 Bloomberg L.P.