Chapter 1

The Case for RLT Workforce Upskilling

1.1 The Clinical Imperative

Radioligand therapy (RLT) is one of the earliest examples of precision medicine, combining targeted molecular imaging and targeted radionuclide therapy within a theranostic approach. Its origins date back more than 80 years, with the introduction of iodine-131 (¹³¹I) for the diagnosis and treatment of thyroid disease.¹ Subsequent developments included bone-seeking radiopharmaceuticals incorporating radionuclides such as strontium-89 (⁸⁹Sr), samarium-153 (¹⁵³Sm) and radium-223 (²²³Ra) for the management of painful skeletal metastases.²

Today, RLT has evolved from a niche treatment into a rapidly expanding, guideline-endorsed standard of care for several oncology indications. A growing body of clinical evidence has demonstrated the efficacy of prostate-specific membrane antigen (PSMA)-targeted radioligand therapy in metastatic castration-resistant prostate cancer (mCRPC), leading to regulatory approvals in Europe and the United States.³ More recent evidence supports the use of PSMA-targeted RLT earlier in the treatment pathway, expanding the eligible patient population.^4,5,6 Radioligand therapy targeting somatostatin receptors has become an established treatment option for patients with advanced, progressive neuroendocrine tumours.⁷

As indications continue to expand and more patients become eligible for treatment, healthcare systems face increasing pressure to develop the workforce, infrastructure and multidisciplinary capabilities required to deliver RLT safely, efficiently and equitably.

At the same time, advances in molecular imaging, including PSMA-targeted PET and SSTR-targeted PET, are reshaping patient selection and treatment decisions, increasing the need for multidisciplinary teams (MDTs) trained across the full theranostic pathway.⁸

As indications expand and RLT moves into earlier lines of therapy, the number of eligible patients in the EU-27 is projected to increase from 11,000-13,000 to approximately 130,000–180,000.⁹ European nuclear medicine services were not designed to accommodate this scale of growth.

Meeting this growing demand requires a coordinated multidisciplinary workforce with complementary clinical, technical, scientific and regulatory expertise (Figure 1). 

Throughout the theranostic care pathway, different professional groups contribute distinct expertise at each stage of RLT delivery. Safe and effective care depends not only on the expertise of individual professionals but also on effective collaboration across the multidisciplinary team. As demand grows, centres must both expand workforce capacity and develop the specialist competencies required for increasingly complex RLT delivery. 

Workforce readiness also includes preparing teams to meet increasing patient information and education needs. Examples may include patient questions regarding radiation safety, treatment sequencing alongside existing therapies, side effect management and patient support resources.

1.2 The Workforce Gap

Since RLT delivery depends on coordinated multidisciplinary working, workforce constraints affecting any one profession can limit the capacity of the entire service. This makes workforce capacity one of the major barriers to expanding RLT globally. 

While the scale and nature of workforce challenges vary between regions and countries, they typically have two distinct dimensions. First, many healthcare systems face shortages across the multidisciplinary workforce required to deliver RLT, limiting service capacity and patient access. Second, the professionals already delivering RLT require ongoing education and training as indications expand, technologies evolve, and increasingly complex theranostic pathways become standard practice. Therefore, addressing future demand requires both expanding the workforce pipeline and continuously developing the capabilities of the existing workforce. While both are essential, this playbook focuses primarily on workforce capability development within individual centres. 

Evidence from Europe illustrates the scale of the challenge. A survey of European medical societies found that 78% rated RLT training as very important, but only 26% were satisfied with current training provision. Additionally, 77% of nursing organisations reported limited RLT education, despite nurses playing a central role in treatment delivery (Figure 2).¹⁰

These training gaps are reflected in workforce shortages across the theranostic pathway. In Europe, more than 80% of nuclear medicine departments report open vacancies,¹¹ while training pathways, staffing levels and service capacity vary considerably between countries.^12,13 In France, a survey of nuclear medicine centres identified shortages of trained nurses, technologists, and physicians as major barriers to RLT delivery, particularly in centres with limited prior experience.¹⁴

Limited training capacity also restricts the pipeline of future trainers and specialists, creating a self-reinforcing cycle that risks widening the gap between workforce capacity and patient demand.¹⁵ 

1.3 Regulatory Variation and Equity of Access

Workforce challenges are often compounded by regulatory variation and unequal access to RLT. Regulatory requirements, reimbursement pathways, workforce models, and service delivery approaches can vary considerably between countries and regions, influencing how RLT services are established, delivered and scaled. 

Europe provides a clear example of these challenges. The Basic Safety Standards Directive (BSSD) sets EU-wide requirements for protection against the risks of ionising radiation. However, its implementation differs between countries, with variation in dosimetry requirements, medical physics involvement, patient release criteria, hospitalisation practices, and reimbursement pathways.^16,17

The impact on patient access is significant. It has been estimated that 50 million EU citizens currently lack access to RLT,¹⁸ and eligible patients in many countries continue to face delays or limited treatment availability. These disparities reflect differences in infrastructure, reimbursement, regulatory implementation, and workforce capacity across Europe.

Barriers to RLT integration are interconnected and extend beyond regulation alone:

• Limited awareness and understanding can affect recognition of RLT and readiness to adopt it.
• Unclear models of care can make responsibilities and patient pathways difficult to establish.
• Workforce constraints can limit the capacity to deliver and expand services. 

Beyond these centre-level barriers, inadequate infrastructure can restrict treatment capacity, gaps in evidence can hinder service planning and investment, and regulatory and policy requirements can shape how quickly new models can be implemented (Figure 3).¹⁷

Addressing these barriers requires action at different levels. Infrastructure, regulation and evidence generation may depend substantially on national, regional or system-level action, while centres can more directly influence awareness, models of care and workforce capability. Expanding the workforce pipeline and strengthening the capabilities of existing teams are therefore complementary priorities and represent some of the most immediate and actionable opportunities available to individual centres.

1.4 Workforce Development as an Ethical Imperative 

A major Lancet Oncology Commission identified workforce shortages as a key barrier to theranostics implementation and a contributor to inequitable patient access worldwide.19 Addressing these gaps is not only essential to expanding RLT capacity but also an ethical imperative, helping to reduce avoidable disparities in access to care.

Investment in the RLT workforce also delivers benefits beyond theranostics. Strengthening multidisciplinary collaboration, molecular imaging expertise, dosimetry capability, radiation safety and pathway redesign can enhance oncology services more broadly while supporting equitable access to RLT.

Failure to expand workforce capacity risks limiting the return on substantial investments already being made in radiopharmaceuticals, imaging infrastructure, and theranostic service development.

Understanding your centre’s current level of RLT workforce readiness is the first step towards building a sustainable workforce. Chapter 2 provides a practical framework for assessing your readiness and identifying the workforce priorities most relevant to your stage of service development.

Chapter 2

Identify Your Centre’s RLT Workforce Readiness Archetype

2.1 Why Archetypes Matter

Centres across the world are at different stages of RLT workforce readiness and development. Some are exploring what would be required to establish an RLT service. Others are preparing to launch programmes or already treating patients and seeking to expand capacity, strengthen workforce capability, or improve service consistency. A smaller number have developed mature programmes and are actively supporting workforce development beyond their own organisation.

As a result, workforce priorities differ considerably between centres. The challenges faced by a centre considering RLT for the first time are fundamentally different from those faced by a centre preparing for first-patient delivery, scaling an established service, or supporting regional workforce development.

The purpose of this chapter is to help you identify the RLT Workforce Readiness Archetype that best reflects your centre’s current stage of RLT development.

The four archetypes are:

Together, these archetypes provide a practical framework for understanding a centre’s current stage of RLT workforce readiness and the workforce priorities most likely to support future development.

While centres may demonstrate characteristics of more than one archetype, most will align more closely with a single dominant profile. If you are uncertain between two archetypes, begin with the lower archetype and revisit your classification after completing the Workforce Capability Gap Assessment in Chapter 3.

2.2 RLT Workforce Readiness Archetype Questionnaire

Use the decision tree in Figure 4 to identify your centre’s current RLT Workforce Readiness Archetype. To obtain the most accurate result, the assessment should ideally be completed with input from representatives of the key professional groups involved in RLT delivery (e.g., nuclear medicine physicians, nurses, technologists, medical physics experts, radiopharmacists/radiochemists, and service or departmental leads).

Once you have identified your archetype, use the guidance in Section 2.3 to understand the workforce priorities most relevant to your centre.

Workforce readiness is assessed within the broader context of overall RLT service readiness. Service readiness factors such as infrastructure, governance, licensing and organisational support influence workforce development requirements.

Questions informed by: Bugani et al. (2023)²⁰; Van den Wyngaert et al. (2026)²¹; Herrmann et al. (2022)²²; Calais et al., (2023)²³; Hristova et al. (2026)²⁴; Merkel et al. (2020)²⁵; Bly (2023)²⁶ 

2.3 Understanding your Archetype

Each archetype is associated with a distinct set of workforce priorities, challenges, and development needs. Figure 5 summarises the typical characteristics and priorities associated with each stage of RLT workforce readiness.

2.4 Actionable Recommendations

Having identified your RLT Workforce Readiness Archetype, the following recommendations provide practical next steps to begin workforce planning and prepare for subsequent chapters of the playbook.

Timeframe	Actions
0-3 months	Review your RLT workforce readiness assessment findings with the MDT. Build organisational awareness of your centre’s current workforce readiness and future RLT ambitions. Agree strategic objectives for workforce development aligned with your RLT Workforce Readiness Archetype. Begin planning the workforce development activities required to support future service delivery.
3-12 months	Complete the Workforce Capability Gap Assessment in Chapter 3 to identify priority workforce development needs.Develop a RLT Workforce Development Action Plan aligned with your RLT Workforce Readiness Archetype.Assign responsibility for workforce planning and implementation.Use Chapter 4 to select education programmes and training pathways that address your identified workforce priorities.

2.5 Looking Ahead

RLT workforce readiness and workforce development are dynamic rather than static. As services expand, infrastructure matures, and workforce capability develops, centres should expect to progress through the RLT Workforce Readiness Archetypes over time. The archetype identified in this chapter should be reviewed periodically rather than viewed as a permanent classification.

Chapter 3 builds on this assessment by helping centres identify workforce capability gaps, prioritise workforce development activities, and develop a practical RLT Workforce Development Action Plan.

Chapter 3

Define Your Key Workforce Development Needs

3.1 A Framework for Prioritising Workforce Development

Chapter 2 identified your centre’s RLT readiness archetype. This chapter builds on that assessment with a simple three-step process:

• Identify RLT workforce capability gaps by archetype
• Prioritise workforce development activities
• Develop a RLT Workforce Development Action Plan

3.2 Step 1: Identify RLT Workforce Capability Gaps by Archetype

Once your centre has identified its RLT Workforce Readiness Archetype (Chapter 2), the next step is to prioritise workforce capability development by need. Figure 6 and the following table show where workforce development is typically focused at each stage of readiness. Although all professional roles remain essential to safe multidisciplinary RLT delivery, the areas of greatest investment evolve as centres mature.

*Disease-specific specialists vary according to tumour type and local service model.

Note: Workforce development areas are aligned with international competency frameworks and clinical
implementation guidance. Professional roles and responsibilities vary according to national legislation, regulatory frameworks and local models of care. The roles described in this playbook represent functional capabilities required for safe and effective RLT delivery and should not be interpreted as prescribing professional scope of practice.

Individual workforce development needs will vary according to each centre’s existing workforce, service configuration, radionuclide portfolio and organisational priorities. To assess your centre’s current workforce capability, complete the RLT Workforce Capability Gap Assessment (Appendix, Tool 1). The assessment enables you to evaluate each workforce capability area as:

• Established
• In Development
• Not Yet in Place

This helps you identify the workforce capability gaps requiring the greatest development within your service. These findings will form the basis of your RLT Workforce Development Action Plan.

Additional resource: Centres seeking a more quantitative assessment may wish to use the IAEA QUANUM Staffing Needs Assessment Tool alongside their archetype assessment to support local workforce planning.

3.3 Step 2: Prioritise Workforce Development Activities

Having identified your centre’s workforce capability gaps, the next step is to determine which should be addressed first. Not every capability gap can be tackled simultaneously, so workforce development activities should be prioritised according to both their expected clinical impact and implementation feasibility.

Figure 7 provides a practical framework for prioritising workforce development activities. Activities within the Act First quadrant should generally be prioritised because they combine high clinical value with relatively straightforward implementation. Activities requiring greater organisational investment, specialist expertise or longer implementation timelines can then be incorporated into longer-term workforce development plans.

3.4 Step 3: Develop an RLT Workforce Development Action Plan

The final step is to translate the findings of the RLT Workforce Capability Gap Assessment into
a practical RLT Workforce Development Action Plan. The plan should prioritise the capabilities most likely to improve patient access, patient safety, patient experience and sustainable RLT service delivery at your current stage of RLT readiness.

Use the capabilities rated ‘In Development’ or ‘Not Yet in Place’ in the RLT Workforce
Capability Assessment as the starting point for your plan. For each workforce development priority, identify the:

• Individual responsible
• Implementation timeline
• Indicators of success
• Current implementation status

An RLT Workforce Development Action Plan template is provided in the Appendix (Tool 2). The plan should be reviewed regularly and updated as workforce capabilities develop and your centre progresses to the next RLT Workforce Readiness Archetype.

3.5 Actionable Recommendations

The completed RLT Workforce Development Action Plan provides the bridge between workforce planning and education selection. In Chapter 4, you can use this plan to identify the most suitable training pathway for your centre’s stage of RLT readiness.

Timeframe	Actions
0-3 months	Confirm your centre’s RLT Workforce Readiness Archetype (Chapter 2) Complete the RLT Workforce Capability Gap Assessment (Appendix, Tool 1) with input from representatives of each professional group to establish your current capability baseline.Identify the workforce capability areas requiring the greatest development (Figure 6) and the professional groups requiring additional workforce development.Apply the impact versus feasibility framework to identify the key workforce development activities (Figure 7).
3-12 months	Develop an RLT Workforce Development Action Plan (Appendix, Tool 2) aligned with your workforce priorities. Review progress regularly and update the action plan as workforce capability develops or your centre progresses to a new RLT Workforce Readiness Archetype.

Capability Summary

Total ticks calculated from each column.

*Disease-specific specialists vary according to tumour type and local service model.
Capability descriptors informed by: Pascual et al. (2024)²⁷ ; Herrmann et al. (2022)²⁸ ; Bugani et al. (2023)²⁹ ; Bly (2023).³⁰

Key RLT Workforce Development Actions

Record the three most important capability gaps requiring workforce development. Transfer these directly to the RLT Workforce Development Action Plan.

Next step

Transfer the capability areas rated ‘In Development’ or ‘Not Yet in Place’ to the RLT Workforce Development Action Plan (Appendix, Tool 2). Chapter 4 provides guidance on education resources and training pathways that can be used to address these key workforce capability gaps.

Note: Complete the Education programme(s) column after reviewing the recommended workforce education framework and education resources in Chapter 4.

Note: This action planning cycle should be iterative. Regular review ensures your workforce development plan remains aligned with your centre’s RLT Workforce Readiness Archetype, organisational priorities, and service delivery needs.

Chapter 4

Recommended Workforce Education Model

4.1 Translating RLT Workforce Capability Gaps into Education 

Chapter 3 identified your centre’s workforce development priorities. This chapter focuses on how to build those capabilities through structured education, competency development and recognised training programmes.

It is organised around three practical questions:

• What competencies should be developed? 
• How should workforce education be structured? 
• Which education resources best support implementation? 

Together, these components provide a flexible, evidence-informed education model that can be tailored to local workforce needs, regulatory requirements and service maturity.

4.2 Training Content Framework 

Effective workforce education begins with a clear understanding of the competencies required for each professional group involved in RLT delivery. Establishing these competencies ensures education is aligned with workforce needs and service development.

Figure 8 summarises the core training content areas required for multidisciplinary RLT delivery
and the professional groups most closely associated with each competency area. The framework
is informed by published workforce survey data and international competency guidance, providing a foundation for workforce education across all stages of RLT readiness.

4.3 Recommended Workforce Education Framework 

Once the core competencies have been defined, the next step is to determine how workforce education should be introduced as RLT services develop.

Figure 9 presents a recommended education framework for each RLT Workforce Readiness Archetype, illustrating how education can progress from foundational training to advanced practice. The framework is intended as a guide and should be adapted to reflect local service configuration, workforce capacity and available educational opportunities.

Four principles should guide RLT workforce education:

1. Start with foundational capability. 
Ensure the minimum competencies required for safe service delivery are established before progressing to more advanced education.

2. Develop multidisciplinary capability progressively. 
Expand education across all professional groups as workforce capability and service complexity increase. This should include the communication skills needed to help patients understand what
to expect, navigate the pathway and raise questions or concerns.

3. Build on established education programmes. 
Wherever possible, use recognised international and national education programmes, supplemented by local induction, governance processes and standard operating procedures.

4. Plan for future service development. 
As your RLT service matures, consider how additional capabilities, such as individualised dosimetry, advanced imaging or expanded radionuclide therapies, may be incorporated in line with local regulations, resources and clinical practice.

4.4 Education Resource Map

Once an education framework has been established, centres can identify the education resources that best support local workforce development.

Figure 10 maps the principal education resources to the workforce capabilities they are best suited to develop across the RLT Workforce Readiness Archetypes. Centres should select the combination of international, regional, national and local resources that best addresses their workforce development priorities, taking account of local regulatory requirements, workforce needs and service maturity. The framework is intended as a practical guide rather than a prescriptive curriculum.

Centres in the Exploring archetype may begin developing governance frameworks and draft standard operating procedures (SOPs) before first-patient delivery, although formal multidisciplinary training is typically introduced during service establishment.

4.5 Completing Your Workforce Development Action Plan

By this stage, you should have:

• Identified your priority RLT workforce capability gaps (Chapter 3).
• Determined the competencies required to address those gaps (Chapter 4, Figure 8).
• Selected an education framework appropriate for your RLT Workforce Readiness Archetype (Chapter 4, Figure 9).
• Identified the education resources best suited to support workforce development
  (Chapter 4, Figure 10).
• Considered how selected education resources prepare relevant staff to address patient information and support needs throughout the RLT pathway.

The final step is to update your Workforce Development Action Plan by recording the education resources and programmes that will be used to address each RLT workforce capability area.
This should include education that equips relevant team members to respond confidently to patient questions about areas such as radiation safety, treatment sequencing, side-effect management and available support resources. The plan should be reviewed regularly as your service matures and progresses through the RLT Workforce Readiness Archetypes.

Your centre is now ready to move from RLT workforce planning to implementation. Chapter 5 provides practical guidance on implementing, monitoring and continuously strengthening workforce capability.

Chapter 5

Implement, Track and Adapt

5.1 Reviewing RLT Workforce Development

RLT workforce development does not end once education has been delivered. Sustaining high-quality RLT services requires centres to regularly review progress, identify remaining gaps and update workforce development priorities as services evolve. This chapter presents a practical two-step process for embedding continuous workforce improvement.

1. Complete the RLT Workforce Development Review to assess workforce development progress, identify remaining gaps, and highlight any Immediate Action Flags.
2. Improve and adapt by agreeing priority actions, updating the RLT Workforce Development Action Plan, and reviewing progress at regular intervals.

Together, these steps establish a continuous cycle of workforce review and improvement that supports progression through the RLT Workforce Readiness Archetypes.

The Workforce Improvement Cycle in Figure 11 provides an overview of the continuous review process described in this chapter. The following sections explain each step in more detail.

5.2 Step 1: Complete the RLT Workforce Development Review

This structured review provides a strategic assessment of whether workforce development activities have been implemented successfully and are translating into improved RLT delivery.

Rather than acting as a detailed competency audit, the review is designed to be completed in approximately 15–20 minutes by the RLT Programme Lead and MDT representatives. It comprises four strategic review areas covering workforce engagement, capability development, service performance, and future workforce development.

Each review area is scored using a simple three-point scale (1–3).

Review Score	Status	Interpretation
3	Green	Fully achieved / target met
2	Amber	Mostly achieved; minor gaps remain
1	Red	Significant gaps remain; action required

Any finding relating to authorised user status, radiation protection, radiopharmaceutical handling or patient safety should be treated as an Immediate Action Flag (IAF) and addressed promptly, regardless of the overall score.

Once completed, the findings from the RLT Workforce Development Review can be summarised using the Center Summary of RLT Workforce Development Review (Figure 12). This one-page summary provides an at-a-glance overview of performance across the four review areas, highlighting strengths, workforce development needs, IAFs and agreed priority actions to support MDT discussion and decision-making. A template is included in the Appendix for local use.

5.3 Step 2: Improve and Adapt

Workforce development is a continuous improvement process rather than a one-off activity. Following implementation of the RLT Workforce Development Action Plan, centres should repeat the RLT Workforce Development Review according to the review cadence appropriate to their RLT Workforce Readiness Archetype.

RLT Readiness Archetype	Recommended Review Frequency
Exploring	Monthly
Establishing	Monthly, increasing to fortnightly before first-patient delivery
Developing	Quarterly
Leading	Six-monthly

Following each review, centres should identify up to three priority workforce development actions, implement them, and revisit progress at the next scheduled review.

Each review informs updates to the RLT Workforce Development Action Plan, ensuring workforce development remains aligned with the centre’s current RLT Workforce Readiness Archetype.

As workforce capability evolves, further development increasingly depends on collaboration beyond the organisation. Chapter 6 explores how continuing education, shared learning and network collaboration can help sustain RLT workforce capability and support the wider growth of RLT delivery

Questions informed by: Bugani et al. (2023)³¹; Calais et al., (2023)³²; Bly (2023)³³; Scott et al. (2023)^34,4

Appendix

Chapter 6

Sustain, Collaborate and Grow

6.1 Think Beyond Your Centre

Developing RLT workforce capability within individual centres is an essential first step towards expanding access to RLT. However, as RLT delivery expands, workforce development increasingly depends on collaboration beyond the boundaries of a single organisation.

By sharing experience, learning from established centres and contributing to the wider RLT community, centres can accelerate workforce development, strengthen service quality and support more consistent implementation of RLT globally.

6.2 Continue Learning

Radiotheranostics continues to evolve through new clinical evidence, technologies, treatment indications and regulatory developments. Following the education pathways described in Chapter 4, centres should continue engaging with national and international education programmes, scientific meetings and professional societies to remain current with emerging best practice.

Continuing professional development should become part of routine workforce planning, ensuring MDTs maintain and expand their expertise in efficient RLT delivery.

6.3 Build Capability Through Collaboration

Collaboration is most effective when supported through structured opportunities such as centre partnerships, mentorship programmes, observation visits and established national or international networks. Protected time, organisational commitment and, where appropriate, external support can help enable meaningful knowledge exchange and shared learning.

The most appropriate collaborative activities depend on a centre’s RLT Workforce Readiness Archetype and naturally evolve as workforce capability develops (Figure 13):

• Centres in the Exploring and Establishing archetypes may benefit most from observation visits, shared protocols and mentorship.
• Developing and Leading centres are well positioned to mentor others, share implementation experience and contribute to the wider RLT community.

Collaboration is more than professional networking. It accelerates capability development, supports consistent implementation and strengthens the wider radiotheranostics community.

6.4 Actionable Recommendations

The following recommendations will help centres sustain workforce capability beyond initial implementation by embedding continuing education, collaboration and shared learning into routine practice.

• Engage regularly with international, national and local education opportunities to maintain workforce capability as clinical practice evolves.
• Identify collaboration opportunities appropriate to your current RLT Workforce Readiness Archetype, such as observation visits, shared protocol development or structured mentorship.
• Share implementation experiences and lessons learned with collaborating centres and the wider RLT community to support continuous workforce development.
• Regularly review emerging education resources, evidence and professional guidance, incorporating relevant opportunities into local workforce development planning.

6.5 Closing Remarks

Ultimately, the future of RLT will depend not only on scientific innovation but also on collaboration across the RLT community. By sharing knowledge, mentoring emerging services and exchanging implementation experience, centres can help build a stronger, more connected workforce. In doing so, they will strengthen their own services while expanding access to safe, high-quality RLT for patients.

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