The State of Theragnostics in BRICS Nations: A Data-Driven Multicentre Report

Study design

This was a multicentre, cross-sectional, descriptive survey designed to assess the current status of theragnostic practices, infrastructure, and challenges across nuclear medicine centres in BRICS member and partner countries. The study was conducted over a three-month period from 06 January to 02 April 2026. A structured, self-administered, web-based questionnaire was used to collect aggregated institutional-level data.

Study population and sampling

The target population consisted of nuclear medicine departments and theragnostic centres actively involved in or preparing to provide radionuclide therapy services in BRICS member countries (Brazil, Russia, India, China, South Africa, Egypt, Ethiopia, Iran, Saudi Arabia, the United Arab Emirates, and Indonesia) and affiliated partner nations (including Belarus, Bolivia, Cuba, Kazakhstan, Malaysia, Nigeria, Thailand, Uganda, Uzbekistan, and Vietnam). Both established and developing theragnostic programs were eligible for inclusion. Centres were recruited through professional networks, national nuclear medicine societies, BRICS nuclear medicine forums, and direct invitations to known theragnostic centres. Purposive and snowball sampling techniques were employed to ensure broad geographic representation in the absence of a centralised registry. A total of 137 centres from 14 countries participated in the final analysis.

Questionnaire development and domains

The questionnaire was developed by a core team of nuclear medicine physicians and researchers with expertise in theragnostic. It underwent content validation by senior experts before distribution. The instrument comprised both closed-ended (multiple-choice and select-all-that-apply) and limited open-ended questions organised into the following major domains [Table 1].

• Institutional profile and type of centre

• Dedicated theragnostic service status (Established /Developing / Not available)

• Approximate annual theragnostic procedure volume

• Radiopharmaceutical targets used (DOTATATE-based, PSMA-based, and others)

• Therapeutic radionuclides administered (¹⁷⁷Lu, ¹³¹I, ²²⁵Ac, ¹⁶¹Tb, and ¹⁸⁸Re, and others) with approximate annual dose ranges

• Clinical indications treated with radionuclide therapy

• Implementation of patient-specific dosimetry and imaging modalities used (SPECT, SPECT/CT, PET/CT, planar imaging)

• Main barriers to implementing patient-specific dosimetry

• Major challenges categorised into logistics/supply chain, regulatory/policy, and clinical/operational domains

• Preferred solutions and support required (training workshops, multicentre protocols, regional supply coordination, guideline development, fellowships)

• Willingness to participate in BRICS collaborative initiatives (multicentre research studies, training programs, guideline development)

• Additional open-ended comments and suggestions (limited to 100 words)

Data collection

The questionnaire was distributed electronically through a secure online platform. Responses were collected anonymously at the institutional level. No patient-level or identifiable data were gathered. Participating centres were encouraged to provide approximate figures based on institutional records and standard practices.

Data management and statistical analysis

Raw data were exported and cleaned using Microsoft Excel. Country names and categorical responses with minor spelling, capitalisation, or spacing variations were standardised and consolidated. Multi-select questions were analysed, allowing cumulative percentages to exceed 100%. All quantitative variables were summarised using descriptive statistics – frequencies and percentages rounded to one decimal place. No inferential statistical analysis was performed, as the primary aim was to provide a descriptive overview of current practices and challenges.

Data limitations

This study has several limitations. First, the use of purposive and snowball sampling may introduce selection bias, potentially overrepresenting centres with established theragnostic capabilities. Second, data were self-reported and not independently validated, which may introduce reporting bias. Third, variability in response completeness across domains may affect the precision of some estimates. Finally, the cross-sectional design captures practices at a single time point and may not fully reflect the rapidly evolving landscape of theragnostic services.

Ethical considerations

As the survey collected only aggregated, de-identified institutional data and posed no risk to patients or participants, formal ethical approval was not required by most participating institutions. Completion of the questionnaire was considered implied consent. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

Current landscape of theragnostic practices in BRICS and oncology burden

The foundation for enhanced BRICS collaboration in nuclear medicine and theragnostics was laid at the first BRICS International Forum on Nuclear Medicine, held in Saint Petersburg, Russia, from 19–21 June 2024. Jointly organised by the Russian Ministry of Health and the State Corporation Rosatom, the forum brought together approximately 200 participants from BRICS member countries (Brazil, Russia, India, China, and South Africa) as well as associate members from Iran, the United Arab Emirates, Saudi Arabia, Egypt, and Ethiopia. Over four technical sessions, delegates addressed critical topics including education and training in nuclear medicine and radiopharmacy, radiopharmacy industry growth, equipment availability, production of key radionuclides (⁹⁹Mo, ¹³¹I, ¹⁷⁷Lu, and ²²⁵Ac), clinical trials and regulatory harmonisation, and the development of innovative radiopharmaceuticals.^[19] This landmark meeting underscored the growing momentum for regional cooperation and directly contributed to the establishment of the BRICS Nuclear Medicine Working Group, reflecting growing momentum for coordinated regional action.

Theragnostics has evolved as a key modality in precision oncology, integrating molecular imaging and targeted radionuclide therapy via shared tumour-specific biomarkers. This “see-and-treat” strategy employs PET or SPECT for patient stratification and disease characterisation, followed by administration of the same ligand labelled with β- or α-emitting radionuclides. Table 9 describes the currently approved therapeutic radionuclide therapies in oncology as of March 2026. Most approved therapies are beta-emitting agents, with increasing adoption of alpha-emitter therapies and ongoing development of novel radionuclides and molecular targets expanding the theragnostic landscape. Randomised trials, including the NETTER-1, NETTER-2 trials and VISION trial, have demonstrated significant improvements in overall survival and quality of life, reinforcing its clinical utility across diverse tumour types, including breast, pancreatic, sarcoma, hepatocellular and colorectal cancers.^[7-14]

Despite these advances, BRICS nations—representing approximately 4.0 billion people, nearly half of the global population—face a disproportionately high and rapidly increasing cancer burden.^[20] However, theragnostic infrastructure remains limited relative to demand, with advanced services concentrated in major urban centres. This imbalance underscores the urgent need for decentralised and scalable theragnostic models, including the development of satellite centres, to improve access and meet the growing demand for precision oncology across the BRICS network.

Institutional profile and annual theragnostic workload

The survey of 137 centres from 14 countries provides the first comprehensive snapshot of theragnostic practices within the BRICS ecosystem. The participating centres showed notable diversity in institutional type, with private hospitals or clinics comprising the majority (51.1%), followed by academic or university hospitals (26.3%) and government or public hospitals (19.0%). Dedicated theragnostic services were already established in 71.3% of the 136 centres reporting this information, while 25.0% were still developing, and 3.7% had no such service among centres reporting annual theragnostic activity; most operated at low to moderate procedural volumes. A total of 47 centres (34.3%) performed fewer than 50 procedures per year, while 43 centres (31.4%) reported performing between 50 and 200 procedures annually. Higher-volume activity was less common, with 23 centres (16.8%) performing 201–500 procedures and 18 centres (13.1%) reporting more than 500 procedures per year. A small proportion of centres (6, 4.4%) did not report their annual procedural volume. The predominance of low- to moderate-volume centres suggests that, while theragnostic services are increasingly established across the BRICS network, they have not yet reached full operational scale. Most centres continue to deliver services at relatively modest procedural volumes, with only a small proportion functioning as high-volume hubs. This distribution reflects an early-to-intermediate stage of programme maturity, where infrastructure and clinical capability are in place but not yet optimally utilised. It also underscores the need for targeted capacity-building initiatives, improved referral pathways, and strategic decentralisation to expand access and enhance service efficiency across the region.

Key clinical activity and practice patterns

Clinical activity and practice patterns revealed a strong focus on prostate and neuroendocrine tumours, alongside the long-standing dominance of thyroid cancer management. The widespread adoption of PSMA-based theragnostics highlights the rapid uptake of prostate cancer–focused radioligand therapy across BRICS centres. In this survey, PSMA-targeted therapies were available in 82.3% of centres, while DOTATATE-based therapies were reported by 70.8%, reflecting the broad integration of targeted radioligand therapy into clinical practice. This high level of adoption underscores the central role of prostate cancer and neuroendocrine tumours as primary drivers of theragnostic implementation in the region. Notably, the substantial overlap between PSMA and DOTATATE platforms suggests that advanced theragnostic capabilities are concentrated within centres that have already established the necessary infrastructure, expertise, and multidisciplinary workflows. Collectively, these findings indicate not only strong momentum in the uptake of established theragnostic applications but also a solid foundation for expanding into emerging molecular targets and novel radionuclide therapies across the BRICS network. In addition to these established targets, several centres reported using Fibroblast Activation Protein Inhibitor (FAPI)-based theragnostics and other emerging agents.

Regarding therapeutic radionuclides, ¹³¹I was the most frequently used (86.1%), followed by ¹⁷⁷Lu (73.7%). Other radionuclides were reported by 24.1% of centres, while ²²⁵Ac was employed by 14.6%, ¹⁶¹Tb by 6.6%, and ¹⁸⁸Re by 2.9%. Notably, ¹⁸⁸Re benefits from on-site generator production, offering greater logistical efficiency and more reliable therapy access in resource-limited settings. Meanwhile, ¹⁶¹Tb, with its combined beta and Auger electron emission, is showing promising theragnostic results in early clinical studies.^[21-23]

The leading clinical indications were thyroid cancer (90.8%), prostate cancer (82.4%), neuroendocrine tumours (70.2%), and bone metastases (60.3%). Hepatocellular carcinoma was treated in 29.8% of centres, with a smaller proportion reporting lymphoma and other malignancies. These patterns indicate that while core theragnostic applications are well established, there is growing interest in expanding to additional molecular targets and tumour types across the BRICS region.

Patient-specific dosimetry practice, imaging modalities, dosimetry indications, and implementation barriers

Patient-specific dosimetry was performed in less than half of the participating centres. Slightly more than half (51.1%, n = 70) reported that they did not perform patient-specific dosimetry at all, while it was applied selectively in 35.8% (n = 49) and routinely in only 8.0% (n = 11). Among centres that did perform dosimetry, SPECT/CT was the predominant imaging modality, used either alone or in combination with other techniques. When dosimetry was implemented, it was most commonly applied to ¹³¹I therapies, ¹⁷⁷Lu therapies, or research protocols. A notable proportion of centres (31.4%, n = 43) did not specify any particular indication for dosimetry, which aligns with the large number of centres that reported not performing it. The limited adoption of patient-specific dosimetry represents a significant gap between guideline recommendations and real-world clinical practice. As detailed in Tables 5 and 6, quantitative dosimetry remains underutilised across BRICS centres, with most institutions either not implementing it or applying it selectively. This disparity highlights key barriers, including limited access to appropriate software and hardware, insufficient training, and the lack of standardised, practical protocols. Addressing these challenges will be essential to support wider implementation of dosimetry, optimise treatment personalisation, and align clinical practice with evolving international standards in theragnostic care.^[24,25]

Major challenges identified

The survey revealed several interconnected challenges that currently limit the expansion of theragnostic services across BRICS nations. In the logistics and supply chain domain, limited availability of therapeutic radionuclides was the most prominent barrier, reported by 82.4% of responding centres, followed by import/export delays (56.3%). Regulatory and policy challenges were also substantial, with a lack of harmonised regulations cited by 72.5% and licensing or authorisation delays by 55.9% of respondents in this domain. Restrictions on alpha-emitting radionuclides further complicated practice for 42.2% of centres. On the clinical and operational side, reimbursement and funding issues emerged as the leading concern (77.4%), followed closely by insufficiently trained personnel (67.0%) and suboptimal patient referral pathways (63.7%). Infrastructure limitations, including inadequate hot laboratories and isolation wards, were noted by 31.5% of centres. These findings highlight systemic barriers spanning supply security, regulatory fragmentation, workforce capacity, and financial constraints that collectively hinder equitable access to theragnostic therapies.

Capacity building, infrastructure solutions, and strategic advantages

We recognise that BRICS nations are diverse in culture, population size, and healthcare infrastructure. Nevertheless, the burden of cancer and its associated morbidity and mortality is shared uniformly across the region.^[20] Theragnostic offers life-saving treatment options for a wide range of malignancies, including prostate cancer, neuroendocrine tumours, and thyroid cancer, with potential expansion to many other tumour types, while providing a favourable therapeutic index and better quality of life compared with many conventional therapies.^[7-14] Given the rapidly increasing demand and the current concentration of advanced services in a limited number of urban centres, the expansion and decentralisation of theragnostic services must be prioritised. To address the growing demand and enhance access across diverse settings, the establishment of satellite and decentralised theragnostic therapy centres presents a feasible and strategically important solution. A basic functional theragnostic centre requires SPECT or SPECT/CT for imaging, diagnostic receptor imaging using ^99mTc with peptide kits, baseline renogram, and post-therapy scanning with SPECT or SPECT/CT. Safe preparation of ¹⁷⁷Lu-labelled therapies necessitates a dedicated hot laboratory with appropriate shielding, validated quality control, and regulatory compliance.^[26] Manual labelling with reagent kits remains the most flexible, cost-effective, and easily teachable approach for new or smaller centres, making it particularly suitable for decentralised expansion across BRICS nations.

A distinct strength of the BRICS network lies in the advanced and efficient domestic radionuclide production capabilities of Russia, China, South Africa, and Iran. These countries have demonstrated reliable capacity to supply key therapeutic isotopes, including ¹³¹I, ¹⁷⁷Lu, and ²²⁵Ac (as well as ^99mMo for generator-based imaging). Complementing this production advantage is the availability of highly experienced experts within the BRICS Nuclear Medicine community, who are well-positioned to provide training, mentorship, and technical support for infrastructure development in emerging centres. This unique combination of manufacturing capacity and human expertise represents a major regional asset that can significantly accelerate the safe expansion and decentralisation of theragnostic services across BRICS nations.^[19]

Opportunities for BRICS collaboration

Despite these limitations, this study represents the largest multicentre assessment of theragnostic practices across BRICS nations to date, providing valuable real-world insights into current capabilities and challenges. The findings highlight clear priorities for strengthening theragnostic capacity, with a strong emphasis on workforce development, standardisation, and collaborative infrastructure.

Key areas identified include the development of multicentre clinical protocols (66.9%), fellowships or exchange programmes (62.3%), and structured training programmes in radionuclide therapy (59.2%), closely followed by hands-on dosimetry workshops (58.5%) and improved regional coordination of radionuclide supply (57.7%). Together, these priorities underscore the critical role of training and harmonised clinical practice in addressing disparities arising from variable expertise, infrastructure, and resource availability across participating countries.

Additionally, nearly half of centres emphasised the need for regulatory guidance and harmonisation (47.7%), reflecting persistent challenges related to fragmented regulatory frameworks and inconsistent approval pathways. Encouragingly, willingness to engage in collaborative BRICS initiatives was high, with 73.0% of centres expressing readiness to participate across all major domains, including multicentre research, training, and guideline development. Overall, more than 95% of centres indicated willingness to engage in at least one form of collaboration, demonstrating strong momentum for coordinated, network-driven approaches to advancing theragnostic services across the region.

To address the identified gaps, the BRICS Nuclear Medicine Working Group has outlined several priority solutions as part of a sustained post-survey initiative. These include structured capacity building to establish new theragnostic centres, radiopharmaceutical support, clinical expertise sharing, and improved access to essential resources. In particular, the development of regional regulatory harmonisation frameworks, centralised radionuclide procurement models, and designated training hubs will be critical to reducing fragmentation, improving supply reliability, and strengthening workforce capacity across the network. Collaboration can be further enhanced through improved logistics coordination, streamlined customs clearance processes, reliable regional isotope supply chains, multicentre clinical trials, regular networking events, joint task forces, and the development of standardised clinical protocols. Additional key actions include promoting the decentralisation of theragnostic services through the establishment of basic SPECT and hot-lab facilities as accessible therapy entry points, alongside regulatory alignment to facilitate more efficient and timely patient care [Fig 5].

Close

Fig 5: Conceptual framework illustrating key barriers, proposed solutions, and expected outcomes for strengthening theragnostic services across BRICS nations. Major barriers include limitations in radionuclide supply, regulatory fragmentation, workforce shortages, and limited implementation of dosimetry. Proposed solutions focus on regulatory harmonisation, centralised procurement models, development of training hubs, and implementation of multicentre protocols. These strategies are expected to improve access, standardise clinical practice, enable scalable service delivery, and enhance patient outcomes. BRICS: BRICS member and associate member states

Export to PPT

Successful implementation of these strategies will require sustained commitment and coordination among key stakeholders — including governments, regulatory authorities, academic institutions, and industry partners — to ensure scalable and equitable expansion of theragnostic services. The BRICS Nuclear Medicine Working Group provides a strong platform to support this effort through structured training programmes, expert mentorship, infrastructure guidance, and regional collaboration, enabling established centres to support emerging programmes and collectively advance theragnostic care across the region.