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Doctors and drug developers who first saw scans from a new targeted form of radiotherapy were amazed. For some patients in the clinical trial, Novartis’ radioligand therapy had – in just six months – completely cleared cancer that had spread around their bodies. 

Michael Morris, an oncologist at New York’s Memorial Sloan Kettering Cancer Center, said it was “incredible” and “never seen before”. In the first trial he worked on, the scans were clear of cancer for about 9% of the participants. In the second trial, it was 21%.

“We can’t cure metastatic disease, but in most cases, treatment [also] really doesn’t impact how the disease appears on a scan,” he said. “We have something very different here.” 

Novartis has been involved in developing cancer drugs for decades, but it became a pioneer in radioligand therapy after acquiring the technology in two deals. In 2017, it bought Advanced Accelerator Applications, which was founded by scientists from CERN, the European organisation for nuclear research. The following year it announced a $2.1 billion (CHF1.7 billion) deal for US biotech Endocyte.

Radiotherapy, which is used to treat about half of all cancer patients, is usually delivered from outside the body to kill cancerous cells, but healthy tissues are damaged in the process. Radioligand therapy is given intravenously as an infusion containing radioactive isotopes attached to a ligand. These are molecules that bind to receptors on cancer cells and allow a much more targeted dose of radiation to be delivered.

Logistical challenges

Lutathera, a radioligand therapy that Novartis acquired in the AAA deal, was first approved in 2017 as a treatment for some gastrointestinal cancers. The Swiss drugmaker received its first US approval for its prostate cancer drug Pluvicto in 2022 and has since expanded into treating patients with earlier stage disease.

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Why Switzerland pays more for cancer care than Sweden

This content was published on

Apr 1, 2025


More money is spent on cancer in Switzerland per capita than any other country in Europe, but this doesn’t translate to higher survival rates.

Read more: Why Switzerland pays more for cancer care than Sweden

In 2021, chief executive Vas Narasimhan estimated the market could be worth about $10 billion. Earlier this year, he told the Financial Times that if the therapy lives up to its promise, it could be a $25 billion to $30 billion market.

“We think there’s a whole set of targets that are unique that we think could only be targeted with radioligand therapy,” he said. 

But the promising therapy comes with major logistical challenges. The radioisotopes must be made in a nuclear reactor, then the radioactive drug has to be safely manufactured, transported and delivered to patients.

Novartis has spent years working to overcome these hurdles. Yet other companies see the opportunities in the therapy and are racing to catch up. In 2023 and 2024, US drugmaker Lilly, UK pharmaceutical company AstraZeneca, and French company Sanofi all bought start-ups developing radioligand therapies. 

Philipp Holzer, executive director of radioligand therapy chemistry at Novartis, said companies were now popping up like “mushrooms”, and so were the suppliers of the isotopes. “There’s a market being created now,” he said. 

Novartis has seven potential radioligand therapies in 15 clinical trials, with more in pre-clinical testing. It is exploring different isotopes, and therapies in combination, and expanding into other cancers including lung, breast, pancreatic and colon. 

On the Novartis campus in Basel, the main radioligand lab had to be reinforced so 40 tonnes of lead could be installed to prevent radiation seeping into the rest of the building. All the scientists that work in it wear two dosimeters, including a mini one on their finger, to measure their radioactive exposure. 

They are trying to find ways to make the therapy work for a wider range of cancers. This includes finding drugs that will bind to genetic mutations that are very common in tumours, but not elsewhere, to avoid irradiating healthy tissues. 

“For every cancer type, it’ll be a unique solution,” said Narasimhan. “Very little in the human body is just like plug and play. You have to solve the challenges.” 

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Medicine access

Whatever happened to the world’s most expensive drug?

This content was published on

Apr 23, 2024


Swiss pharma giant Novartis launched Zolgensma five years ago with a price tag of $2.1 million. What happened to it?

Read more: Whatever happened to the world’s most expensive drug?

‘Future for cancer treatment’

Once new radioligand therapies are approved, the challenge is making them at scale. Novartis has purchased much of the supply of the radioactive isotope lutetium, so other companies are looking at alternatives such as actinium. Much of this isotope is sourced from Russia, so they are also looking for supplies elsewhere. 

Once the radioactive material has been made, the company has only three to five days to create the drug and deliver it to the patient before the decay process starts to make it less effective. Each vial is made for an individual patient, tailored to their planned treatment date. Novartis has previously struggled to keep up with demand for Pluvicto, but 99.5% of injections are now administered on the planned day, it said. 

Steffen Lang, president of operations at Novartis, said the isotope must be bound to the molecule that targets the cancer in the right concentration, and then checked for quality. “It’s not only quick, it needs to be right the first time.”

Then, a team works 24/7 to track GPS-tagged vials. Novartis is starting to use generative AI to help it anticipate logistical problems and select routes to hospitals. To get closer to hospitals and patients, it is expanding manufacturing plants from its current six in the US and Europe, adding more in China, Japan, and the US. 

“Air traffic problems, severe weather conditions – we’ve seen it all,” Lang said.

There are further challenges when the radioligand therapy is given to patients: unlike with external radiotherapy, the radioactive material remains in the body, continuing to work after the dose is delivered. In some countries, including Germany and Japan, patients must remain isolated overnight in a radiation-proof hospital room. At the moment, there are few companies that can build this type of specialist facility. 

Clinicians also need to be trained in how to care for these patients. In some countries, patients’ urine must be collected and stored for 70 days until the radioactive material in it has decayed. 

Carla Bänziger, portfolio manager at asset manager Vontobel, a Novartis shareholder, said that despite the hurdles, targeted therapies like this are the “future for cancer treatment”. 

She said this year is important for Novartis, partly because it received expanded approval for Pluvicto, doubling the potential patient population. Yet she believes it will still take ten to 15 years to build the ecosystem required for radioligand therapy to be mainstream. 

Novartis has surmounted many of the problems, especially scaling production, creating a “high barrier to entry for other competitors”, she said.

Narasimhan agrees Novartis has an advantage. “When you enter this field by acquiring a biotech, which some of our peers have done, it gives you a start. But it’s a lot of work and investment to figure this out,” he said. “We have a five-year head start.” 

Copyright The Financial Times Limited 2025

This study’s results showed that prehospital IBP measurement in critically ill patients is feasible even for teams with limited exposure to critically ill patients in a wide range of emergency indications. The frequency of complications associated with the puncture appears to be negligible. Cardiovascular failure and the need for airway management with catecholamine administration were the most common reasons for arterial cannulation. Here in particular, pronounced hypotension is to be expected, which has fatal consequences and requires continuous monitoring of blood pressure and therapy [16].

Overall, the frequency of prehospital arterial puncture in our patients was very low: an indication for invasive blood pressure measurement was only given in every 35th emergency call. Strict IBP criteria confronted a broadly dispatched emergency physicians by the German indication catalog for emergency medical services 2023 [15]. This low-threshold dispatch model for emergency physicians is controversial and contributes to a lack of routine in managing critically ill patients. That could be a reason why arterial punctures were not performed in about one third of the emergencies in which IBP measurement was indicated.

Since the high non-IBP attempt rates were not attributable to years of work experience and we are investigating a new procedure, the rarity of the indication may have an influence on the attempt rates. IBP attempts were often forgotten due to their rarity. Since Butterfield et al. reported an increase in IBP rate over time as teams have become more familiar with the technique [13], lack of routine and high rates of decision against IBP might only be temporally. Motivation to perform the IBP may also have influenced the low IBP rates: two physicians accounted for 13 unattempted punctures, representing one-third of all missed puncture opportunities.

In nursing homes, we had a significantly lower rate of IBP attempts, but we saw no difference in age distribution between the groups. Beside that elderly trauma patients are under-triage [17], this result might be due to the judged futility.

The selected IBP procedure depended on the experience of the team members. The advantage of direct puncture is possibly the time advantage, since we do not use sterile gloves and covers. The Seldinger technique offers the advantage of easier puncture with the disadvantage of longer preparation, a sterile approach and requires adequate skills. It is widely accepted, that direct puncture is more demanding and associated with higher failure rate [18]. In opposite to the literature, our prehospital data showed a higher failure rate in the Seldinger technique. Because emergency physicians could freely select the puncture method, a selection bias is likely: in cases with poor vascular access and anticipated difficulties, they tended to choose the Seldinger technique, which may explain its higher failure rate. Nevertheless, the overall rate of failure rate was low and comparable to other studies [11, 12]. Our data showed that, despite this new procedure, the focus remained on life-saving measures and that teams with limited exposure to critically ill patients also discontinue the effort according to protocol. As outlined in the protocol, during the initial two months, the arterial pressure system was prepared every morning by the crew to reduce the procedure time. After considering the ecological aspects of not using the system 8 out of 10 times, we switched to the strategy of preparing the system on-scene. Assembling the IBP system gives team members with limited prior exposure a valuable opportunity to familiarize themselves with its components. In EMS systems that encounter critically ill patients more frequently, the preparation at the beginning of the shift with 24 h shelf life can reduce on scene time.

The IBP measurement results in an average time delay of about 7.5 min. The time delay is significant even when adjusting all tested confounders. It remains unclear whether the calculated delay is due to puncture attempts, or due to unmeasured confounders: our IBP times are not measured but calculated on the difference in total on-scene time (difference between documented arrival time at the patient’s site and departure time to the target clinic). Measured times suggest that the IBP alone are unlikely to prolong the overall prehospital interval with a mean preparation time of 3 min and cannulation time of 2 min [12]. Further studies must show whether the time difference is also detectable in larger patient collectives and if the delay has a negative impact on outcome. In the study, it was up to the medical team to decide whether IBP had a positive impact on the outcome. For this reason, arterial puncture was often not performed due to the priority of transport and short transportation times.

It must be considered whether this time advantage outweighs the potential risk of hypotension. Every provider should be aware that non-invasive blood pressure measurement has a low accuracy in hypotensive patients, especially in the prehospital settings [6, 7]. IBP measurement can be advantageous if correctly indicated, even if time plays a decisive role. Even a time delay of 7.4 min may not affect the outcome of patients. Of course, this must be considered on an individual basis, and more measures could be detrimental to trauma patients [19]. In our study polytrauma patients most frequently had leading TBI symptoms. In patients with severe TBI, prehospital hypotension has a negative effect on mortality, but time on scene does not [20] and the time to CT with prehospital IBP and intrahospital IBP were equivalent [21]. These findings are likewise reproducible in intubated patients presenting with suspected stroke [22]. It remains to be seen whether IBP measurement reduces the cumulative time with hypotension to hospital admission and whether it affects the outcome.

In our opinion, the advantages of prehospital IBP measurement in critically ill patients are the direct monitoring of fluid or catecholamine therapy, the visibility of the effects of malignant cardiac arrhythmia on blood pressure and aiding in decision-making. A synergistic combination with prehospital blood-gas analysis could unlock additional therapeutic options. We recommend preclinical arterial puncture in critically ill patients who require airway management or when severe hypotension with volume or catecholamine administration is expected. A therapeutic consequence should always be present and the focus of the measure, as a time delay must be expected. Arterial puncture during CPR should only be performed once all essential advanced life support interventions have been initiated. We emphasize that teams must be familiar with material and technique, because otherwise a high inhibition threshold will often prevent arterial punctures despite indication.