The ARChives

Theranostics Access and Equity

Tue, 31 Mar 2026 20:34:44 GMT

As we celebrate World Theranostics Day and the amazing developments in this field, it is good to remember how access impacts populations not only from East Tennessee to Southwest Virginia, but around the world.

The Referral Opportunity You Don’t Want to Miss

Tue, 24 Mar 2026 22:04:15 GMT

Determining whether your patient is an appropriate candidate for currently available radiopharmaceutical therapies can be challenging. This guide helps demystify the process.

The Five Roles You Can't Launch Your Theranostics Program Without

Thu, 19 Mar 2026 21:56:31 GMT

Understanding the key players and their roles within a theranostic environment is critical to a successful program.

When I talk to centers interested in developing theranostic programs, their biggest concern is almost never dosimetry. It’s almost never regulatory paperwork. Those things certainly come up, but they’re not the primary driver of hesitation in starting a program.

The thing that keeps people up at night is staffing and infrastructure. Perhaps their setup is that they have two technologists, a part-time physicist, a nuclear pharmacist 40 minutes away, and a nuclear medicine physician who also reads diagnostic studies. Who does what? Who owns what? And what happens if someone does something they’re not supposed to, or doesn’t do something they were supposed to, and nobody finds out until a patient is already in the chair?

That’s not an irrational fear. It’s the right question. And the honest answer is that a radionculide therapy program without explicitly defined roles isn’t a program, it’s a liability waiting to happen.

This post maps the core roles a functional community Lu-177 program should understand and for which clear responsibilities should be defined.

The goal of this exercise isn't paperwork. It's making sure that on the day your first patient sits down for treatment, every person in the room knows exactly what they are responsible for and that nobody is improvising. If you want to work through this with a team that has done it, that's exactly what ARC's regional workshops are designed for. Registration is open now for our April 18th, 2026 workshop. Just navigate to our workshops page to register.

Walking The Referral Pathway

Mon, 16 Mar 2026 21:00:45 GMT

Walking the referral pathway can be challenging. But taking the right first steps can make sure the journey is as smooth as possible for you and your patient.

I want to start with an uncomfortable observation.

In conversations with oncologists and urologists across the country, I keep hearing the same thing: “I’ve been meaning to learn more about theranostics.” And then I ask how many patients they’ve referred for 177Lu-PSMA therapy, and the answer is usually small.

These aren’t providers who don’t care about their patients. They’re providers who are busy taking care of patients and working within a referral ecosystem that has never clearly explained how this particular pathway works.

The treatment exists. The FDA approved it in 2022. The phase 3 data is strong. The patients who qualify for it are sitting in waiting rooms across this region right now.

The gap between “approved and effective” and “being offered to patients in rural Appalachia” is an education and training problem. That’s the problem ARC exists to close.

This post is my attempt to give you the short version of what you need to know to start having the referral conversation. If you want the long version, full eligibility criteria, step-by-step referral pathway, documentation checklist, answers to the clinical questions that come up most, ARC is working on a full published referral pathway guide so stay tuned!

What 177Lu-PSMA Actually Is

The short version: it’s a drug that finds prostate cancer cells and hopefully kills them with targeted radiation — all using the same biological pathway.

PSMA (prostate-specific membrane antigen) is a protein that prostate cancer cells overexpress. We’ve been imaging it for staging with PSMA-PET/CT for years. What 177Lu-PSMA-617 (brand name Pluvicto) does is attach a radioactive payload to the same targeting molecule. The cancer lights up on the PET scan because it’s PSMA-avid. The therapy works for the same reason.

This is what makes theranostics conceptually elegant and practically powerful: the imaging doesn’t just stage the disease. It tells you whether the therapy has something to shoot at before you commit to treatment. If the PSMA-PET shows high expression across all sites, you have strong reason to expect the therapy will find its target. If it doesn’t, or if there are PSMA-negative lesions, that’s critical information too.

The Core Eligibility Question

The FDA approval is based on the VISION trial. The target population is patients with metastatic castration-resistant prostate cancer (mCRPC) who have progressed on at least one androgen receptor pathway inhibitor (enzalutamide, apalutamide, darolutamide, or abiraterone) and at least one taxane-based regimen (or who are ineligible for taxane chemotherapy).

It is worth reading that again: prior ARPI and prior taxane therapy are prerequisites, not disqualifiers. The patients who have already been through those treatments and are now progressing are exactly the population this was designed for.

The other requirement is a PSMA-PET/CT showing PSMA-positive disease. If your patient has had a recent PSMA-PET and it showed strong expression, that’s already most of the eligibility work done. If they haven’t had one, that’s where the pathway starts.

Organ function matters too, with adequate renal function and bone marrow, being important. Low platelets and renal impairment are the most common reasons for delays. Recent labs are a must to send to the treating provider and we order a full CBC, CMP, and PSA test when we perform our pre-therapy labs.

ECOG status is also important as patients should be reasonably mobile. ECOG 0-2 is preferred to ensure the patient has sufficient mobility to be able to care for themselves adequately during the time they will be radioactive. Worse ECOG status potentially can be treated but should be reviewed carefully by the care team to prevent unsafe exposures to the patient and family that may be around them after therapy.

The Three Things That Actually Hold Up Referrals

After enough of these conversations, the real barriers become predictable.

The first is the mistaken belief that being post-taxane means the patient is too sick or too far along. It means the opposite. That’s the population the trial enrolled. If your patient has been through ARPI and chemotherapy and is now progressing, the eligibility conversation is appropriate. Anecdotally, we find that the earlier in the process we start 177Lu-PSMA-617, the better the experience for the patient.

The second is not knowing who to call. This is the most legitimate barrier in community settings, and I’ll be direct: the referral pathway for theranostics is not typically as standardized as sending someone for radiation or a surgical consult. For providers in the Knoxville-to-Roanoke corridor, UT Medical Center and Carilion Clinic both have operational theranostics programs that have treated hundreds of patients. If you’re not sure who to contact, reach out through arctheranostics.org and we’ll help navigate it.

The third is concern that the patient won’t travel. This is real in Appalachia. I’m not going to pretend distance isn’t a barrier. But some patients, when they understand what the treatment is and what the data shows, will make the trip. The ones who won’t travel, deserve to make that choice themselves after hearing all of the details. For our patients, we spend 1-2 hours in the consult with the patient making sure they have all the information they need to make an informed decision on whether the therapy is right for them and their family.

What’s not acceptable is the option never being offered simply due to lack of perceived access. Building more community-based sites with trained staff, which is what ARC is working on, is how we reduce the distance problem over time.

What the Referral Actually Looks Like

Order a PSMA-PET/CT if not already done.
Pull a current CBC, CMP, and baseline PSA.
Send a referral to the appropriate theranostics team with the patient’s treatment history, PSA trend, PET result, and relevant comorbidities.

That’s the whole thing. A nuclear medicine or theranostics team takes it from there, reviewing the images directly, evaluating organ function, discussing risks, and scheduling the consultation visit if the patient is a candidate.

Treatment is outpatient IV infusion, typically every 6 weeks for up to 6 cycles. You stay involved as the primary oncologist throughout.

The most important thing you can tell your patient before referring: this is a conversation, not a commitment. The evaluation determines candidacy. Nothing is scheduled until both the clinical team and the patient have decided it’s the right path.

ARC’s regional workshops are built specifically around providing education on referral and implementation questions this post can only partially answer. If you want to work through real cases with nuclear medicine physicians and other referring providers in the same room, that’s what we’re building. Our first workshop is on April 18th, 2026 at the University of Tennessee Medical Center ( registration link here ).

The Distance Between Diagnosis and Treatment

Sat, 07 Mar 2026 02:40:59 GMT

In Appalachia, the distance between a cancer diagnosis and the best available treatment isn't measured in miles alone, it is measured in workforce gaps, missing infrastructure, and training that never reached the community.

Let me paint a picture that most of you in this region already recognize.

A patient presents to their primary care physician in a rural county in eastern Tennessee, southwestern Virginia, or West Virginia. After workup, they're diagnosed with metastatic castration-resistant prostate cancer. Their oncologist knows about 177Lu-PSMA-617. They've read the VISION trial data. They understand this therapy exists and that their patient is likely a candidate.

And then comes the honest conversation: "I'm going to refer you to a center that can do this. It's about three hours away. You'll need to go multiple times."

For many patients in Appalachia, that sentence ends the conversation. Not because they don't want treatment but because three hours might as well be thirty, when you factor in no reliable transportation, lost wages for a day of travel, a caregiver who can't take off work, or a body that simply isn't up to the trip. And that's assuming the referral gets made at all, which requires a referring provider who knows the therapy exists and feels confident enough to send the patient somewhere they may have never personally worked.

This is the access problem in Appalachia. And it's not unique to theranostics.

The Numbers Are Hard to Ignore

Appalachia consistently leads the nation in cancer mortality rates. The reasons are layered and multifactorial, higher rates of smoking, obesity, and occupational exposure, combined with lower rates of screening and earlier-stage diagnosis. But a significant and underappreciated contributor is delayed or absent access to advanced therapies, including radiopharmaceutical treatments that are now standard of care at major academic centers.

The map tells the story clearly. Drive from Knoxville to Roanoke and look at what you pass through. Beautiful, rural communities with real hospitals and real providers who are doing their best with the resources they have. But the density of nuclear medicine infrastructure, theranostic-capable programs, and clinical trial access thins out quickly the farther you get from the anchor cities.

Clinical Trials: The Access Gap Nobody Talks About Enough

This is the piece that doesn't get enough attention, even in conversations about rural healthcare disparities.

Clinical trials are where the next generation of theranostic therapies is being tested right now. Actinium-225 platforms, novel disease targeting molecules, new targets in breast, lung, and GI cancers. The science is moving fast. But the trial sites are concentrated. Enrollment criteria often require proximity to the treating institution for frequent monitoring visits. Community providers, even when they know a trial exists and have a patient who might qualify, frequently don't have a clear pathway to connect that patient to enrollment.

The result is a compounding disparity. Patients in rural Appalachia don't just miss out on currently approved therapies. They're largely excluded from the trials that will shape what's available five years from now. That's a harm that's hard to quantify but very real.

Why Workforce Is the Pivot Point

I want to be careful not to oversimplify this, because the access problem in Appalachia is genuinely multifactorial. Transportation, insurance coverage, broadband access for telehealth, social determinants of health, all of that is in the mix. But workforce and training is the piece ARC is positioned to actually move.

Here's the logic: if the community providers along the Appalachian corridor have the training, confidence, and workflow templates to deliver theranostics locally, the travel burden shrinks. The referral pathway shortens. The patient who might have declined a distant referral gets treated close to home. And a site that's delivering theranostics is also a site that can potentially support clinical trial satellite participation, meaning trial access expands too.

This is why education isn't just a nice-to-have. It's the functional prerequisite for everything else.

What We're Trying to Do About It

ARC's entire model and intent is built on this premise. The workshops, the online resource hub being developed, shared documents with critical startup templates, etc. Those resources are being designed because a community team that feels prepared is a community team that can confidently provide advanced care.

We're not under the illusion that training and information alone solves everything. But we're convinced it's the right place to start, and we're committed to making it as practical and accessible as we possibly can.

Your turn.

This community exists because the problem is real, and because the people experiencing it on the ground every day have knowledge and perspective that no grant proposal can fully capture.

If you are in the healthcare field, what issues do you experience that negatively impact patient access to care? We would love to hear from you.

Whether it's referral confusion, transportation logistics, staffing limitations, insurance barriers, or something specific to delivering or accessing theranostics in your community, your experience matters to what we build next. Drop us a line or leave a comment below. This conversation is exactly what ARC is for.

Welcome to ARC!

Fri, 27 Feb 2026 03:16:12 GMT

The appalachian radiotheranostic coalition (ARC) is a new regional initiative that hopes to increase awareness, education, and adoption of theranostics in the applachian region. This initiative is being created to serve as a blueprint for easy rollout into other areas across the United States and globally.

Web site...✅

First workshop scheduled...✅

Now for content.

Welcome to ARC Theranostics!

I'm Dustin Osborne, a medical physicist, chronic problem-solver, and someone who has spent the better part of two decades trying to make advanced imaging and therapy actually work in the real world, not just in the literature. My team includes Amy Swinson and Taylor Gillespie who are both experienced nuclear medicine technologists and serve as clinical research leaders on my team balancing clinical therapies with imaging, dosimetry, and novel clinical trials.

My official titles are dad, husband, Medical Physicist, Professor, and Director of the Molecular Imaging & Theranostic Research Program (MITRP) at the University of Tennessee with a string of boring board certifications I won't make you read. But the short version is this: I spend my days at the intersection of molecular imaging, quantitative dosimetry, and the messy, practical work of getting good care to patients who need it.

This site and this ARC initiative is something I've wanted to build for a long time. And honestly, it's overdue.

My partner in crime in this endeavor is James Crowley, MHA, CNMT who is based out of Carilion Clinic which is the northeast anchor of the ARC corridor. He is also an Adjunct Faculty at Virginia Tech in Roanoke, VA,. James brings the kind of frontline administrative and technologist perspective that no amount of physics training can manufacture: the "yes but what does that actually look like at 7 AM on a Monday with late doses and a full schedule" perspective that keeps this whole effort honest. If my posts tend toward the scientific and theoretical, James will be here to remind us all what actually happens in the real world. Consider him the editorial check on my optimism and their team at Carilion is a key anchor for ARC.

Why this matters to me personally

If you work anywhere in Appalachia, you already know the answer. You don't need a convoluted white paper to explain access gaps in our region. You've seen them and experience them every day. You've seen the four-hour drives. The delayed referrals. The patients who are perfect candidates for theranostics, but whose local team doesn't yet have the confidence or the infrastructure to deliver it safely. You've sat with the uncomfortable truth that the science isn't the bottleneck anymore; workforce and site readiness is.

Theranostics have become a genuine standard of care. But adoption in community practice still lags, and not because community teams aren't capable. It's because most of the training is centralized, informal, and hard to access if you're not already plugged into a major academic center.

That bothers me, and frankly, it should bother all of us.

The "why" behind ARC

The Appalachian Radiotheranostic Coalition was created because of one idea our regional team kept coming back to: education is implementation.

If we want these therapies to actually reach patients across rural Appalachia, the training model has to look different from what we've been doing. It has to be:

Practical: built for Monday morning workflows, not just conference slides
Multidisciplinary: technologists, physicians, referrers, physicists, and nursing all in the same room (or the same training platform)
Scalable: materials you can reuse, adapt, and pass along
Community-first: because this is a workforce problem that industry isn't positioned to solve, and we can't wait around hoping it will

ARC is anchored in a corridor I know well between Knoxville and Roanoke, with regional hubs and a real commitment to the community sites in between. It's not a grand theory. It's a working model, with designed intent to be useful.

What you'll actually find here:

I'm keeping this grounded in the needs of the two groups who matter most when it comes to access:

For nuclear medicine technologists , you'll find practical content on clinic-ready workflows and checklists, handling and safety fundamentals designed for community environments (not just academic centers), and the imaging and dosimetry basics that build confidence in implementing your own programs.

For referring physicians , you'll find clear referral pathways and timing, honest breakdowns of what the treatment workflow actually looks like, and a running conversation about how community adoption changes what your patients can realistically access without leaving their region.

An invitation...and I mean it

If you're a technologist or administrator building your program from scratch, a physician trying to figure out when and how to refer, or a community team asking "what do we actually need to be ready?" then this site will be for you.

Our goal is simple: shrink the gap between "this therapy exists" and "we can deliver it here, safely, for our patients."

If you're somewhere along the Knoxville–Roanoke corridor, or serving rural communities anywhere that looks like Appalachia, I genuinely want to hear from you. What's the sticking point? Referral confusion? Training gaps? Workflow templates? Staffing models? Dosimetry expectations?

Drop us a line . That conversation is exactly what this is for.