Ethical principles for practice building in the era of targeted radioligand therapy

Theranostics is emerging as a critical pillar of oncologic management, as exemplified by the success of Lu-177-PSMA-617 for the treatment of castration-resistant prostate cancer. The emergence of such theranostic agents represents an opportunity to reconsider facets of nuclear medicine practice that will enable its engagement in high-volume radioligand delivery. In this article, we aim to explore simple ethical principles that can guide the development of theranostics programs as radiopharmaceutical agents proliferate and the typical nuclear medicine physician transitions from a primarily diagnostic role to a mixed diagnostic and therapeutic role. Such a mixed role will demand all the attendant competencies of direct patient care. We argue that restructuring nuclear medicine practice to meet this challenge involves developing processes for promoting the principle of fairness in patient selection for theranostic agents and for promoting the principle of responsibility during the administration of theranostic agents. We further specify that this responsibility extends to the patient receiving the therapy, the local community of the patient, and the general community exposed to the population of patients receiving theranostic agents. PRéCIS: The expansion of radioligand therapy requires promoting the ethical principle of fairness in patient selection and the ethical principle of responsibility in the delivery of radioligand therapy.