Norway leads global efforts in theranostics, a promising precision cancer treatment

Norwegian physicians, physicists and medical scientists are collaborating on a novel approach to treating metastasised cancer. Known as “theranostics”, this emerging field within nuclear medicine is a combination of therapeutics and diagnostics – thus the name.

Widespread metastases are the main cause of cancer mortality and remain a major clinical challenge. Yet optimism prevails. “Theranostics represents new hope for patients with various disseminated cancers,” states Mona-Elisabeth Rootwelt-Revheim, Head of The Intervention Centre and Professor at Oslo University Hospital.

“The excitement in the field stems from the finding that a proportion of patients with large metastatic burden show astonishing effects, and this outcome is catalysing the search for more radiotheranostics approaches,” she adds.

Theranostics (therapeutics + diagnostics) involves targeted therapy based on the identification and verification of a biological target. In nuclear medicine, theranostics entails diagnostic imaging using radioactively labelled tracers to identify a biological target structure, followed by internal radiation therapy using the same tracer. This ensures selective and targeted treatment of disease manifestations in the body.

The field of theranostics lies at the intersection of targeted radionuclide therapy (TRT), precision medicine and molecular imaging diagnostics.

“In the future, theranostics promises to improve patients’ quality of life, with fewer side effects from treatment and prolonged remission for a better overall survival rate,” she says.

For more than 25 years, Norwegian scientists have pioneered the use of nuclear medicine to diagnose and treat various diseases. In particular, Norway has excelled in the field of radiopharmaceuticals, drugs that contain radioactive forms of chemical elements known as radioisotopes.

One of the best known of these is radium 223 dichloride, given the brand name Xofigo™, which is used in a theranostics approach to cancer. Developed and produced in Norway for over two decades, Xofigo is now prescribed worldwide for patients with metastatic prostate cancer and is shown to have a high rate of efficacy. In 2014, Bayer acquired Xofigo, which is still the only approved alpha therapy for clinical use.

Of course, the cutting-edge work has not stopped here. Norwegian doctors and scientists continue to expand the potential of theranostics.

As Rootwelt-Revheim explains, each type of cancer requires a different and specific pair of radiopharmaceuticals. “Extensive research is being conducted on new radionuclide treatments, and a number of theranostic tracer pairs are being tested both preclinically and clinically.”

In addition, she emphasises Norway’s expertise in dosimetry, which is crucial for minimising toxicity and avoiding over- or undertreatment of patients. She also mentions the pioneering work with alpha-emitting radionuclides, which shows that targeted alpha therapy may be superior to targeted beta therapy in finding and killing specific cancer cells. The Institute for Cancer Research at Oslo University Hospital has established a dedicated research group for RLT (focusing on alpha therapy) in the Department of Radiation Biology.

Another aspect is Norway’s focus on PET technology. PET stands for positron emission tomography, and PET scanners are medical imaging devices that use radioactive tracers to create detailed images of biological processes in the body. The PET availability in Norway has more than doubled in the past 10 years, and Norway has world-class nuclear medicine facilities for both diagnosis and treatment.

Norway has a strong professional nuclear medicine community encompassing a complete value chain from ideas, radiopharmacy and production to preclinical research, clinical research and dosimetry.

The area around Oslo Science City area stands out as an R&D and innovation hub, especially in the growing field of radiopharmaceuticals. This includes Oslo University Hospital, the University of Oslo and the Oslo Cancer Cluster, to name a few.

Furthermore, in an ongoing national collaboration, Rootwelt-Revheim and other nuclear medicine physicians, physicists, and PET centre leaders meet regularly in the Theranostic Group to share knowledge and planning activities under the Norwegian National Competence Network for Personalised Medicine (NorPreM).

Moreover, she notes that GE HealthCare plays a significant role by covering the entire value chain –from producing cyclotrons and radiopharmaceuticals to developing scanners and software for diagnostics and dosimetry. The company also made a crucial investment together with the Research Council of Norway that enabled the establishment of the first PET centre in Norway at Rikshospitalet/Radiumhospitalet (now part of Oslo University Hospital).

In addition, the Norwegian Medical Cyclotron Centre (NMS) develops and produces radiopharmaceuticals for PET imaging and is the largest single investment in advanced medical research and diagnostics in Norway. Innovators such as ARTBIO, Thor Medical and Oncoinvent, which are clinical-stage radiopharmaceutical companies, are central to R&D in the field.

In Norway, the government, academia and private industry all actively support the development of radiopharma and radiotherapy, including theranostics.
Funding for activity across the value chain comes from the Norwegian government, not only through the public health system in general but also through specialty organisations such as Radforsk, which invests in infrastructure to develop better cancer treatments. Recently, Radforsk invested NOK 15 million (roughly USD 1.5 million) to build a platform on theranostics that focuses on alpha emitters (the TARACAN project).

Moreover, private investment continues to grow, from global heavyweights such as Bayer, GE HealthCare and PharmaLogic, which has just acquired the Norwegian radiopharmaceuticals CDMO Agilera, to individuals such as Trond Moen, a Norwegian private investor who has donated billions of kroner to establish PET facilities and support research projects around the country.

As one who has focused her research on nuclear medicine, Rootwelt-Revheim believes in Norway’s leading contribution to the field of theranostics. “We have strong collaborative structures, political goodwill and less stringent regulations compared to other countries,” she says.

“Theranostics represents major potential for future applications. In theory, it will be possible to treat all oncological diseases where there is a tracer that selectively recognises the pathological cells. In practice there will be numerous technical and biological challenges that need to be addressed first. Nevertheless, current developments indicate that such personalised treatment will be relevant for various patient populations in the future,” she concludes.