April 30, 2026
Diagnostic Technology Advancements for Neuroendocrine Tumor Mapping Resulted in Dramatic Shifts in Access to Theranostics Care
A new study from the Harvey L. Neiman Health Policy Institute found that the introduction of PET-based Gallium-68 DOTATATE/DOTATOC radiotracers for imaging neuroendocrine tumors created substantial differences in patient access during its first four years of use. Compared with the older imaging agent, Indium-111 pentetreotide (Octreoscan™), patients in small town-rural areas traveled 134.9 additional miles on average to access Gallium-68 DOTATATE/DOTATOC. By comparison, patients in metropolitan-micropolitan areas traveled only 26.7 additional miles. The study, published in the Journal of the American College of Radiology, analyzed 3,365 claims for neuroendocrine tumor radiotracers.
Radiotracers are engineered to localize to specific cellular targets for precise visualization of the cancer. A recent advancement is that the tumor may be treatable using the same approach, using the same target to deliver stronger radiation to kill the targeted cells while sparing healthy tissue. This two-step process is known as theranostics—THERApeutics + diagNOSTICS. This study focused on access to the diagnostic step.
Before 2017, staging/restaging of neuroendocrine tumors was limited to the SPECT-based In-111 pentetreotide. Its relatively long half-life (2.8 days) facilitated broad geographic distribution and availability. However, there was no subsequent therapeutic step available. Starting in 2017, clinically superior PET-based radiotracers were available, beginning with Gallium-68 DOTATATE/DOTATOC in 2017. Shortly followed by a therapeutic radioligand in 2018, Lutetium-177 DOTATATE. However, Gallium-68’s very short half-life (68 minutes) limited its distribution.
“PET/CT-based imaging with gallium-68 can only be performed when the radiotracer is produced locally due to its extremely short half-life. For this reason, patients living in small town-rural areas had to travel long distances,” said Cindy Yuan, MD, Assistant Professor of Clinical Radiology at the Indiana University School of Medicine and study lead author. “We found that the introduction of gallium-based radiotracers resulted in substantial access differences, with small-rural patients traveling 134.9 additional miles compared with only 26.7 additional miles for metropolitan-micropolitan patients.”
“These access disparities to the diagnostic radioligands likely reflected similar access disparities to the therapeutic radioligands, given that the diagnostic step proceeds the therapeutic step,” said Elizabeth Rula, PhD, executive director of the Neiman Institute and study co-author.
A second PET-based radiotracer—Copper-64 DOTATATE with a longer half-life (12.7 hours)—was introduced in 2021, as an alternative to Gallium-68 DOTATATE/DOTATOC.
“We found that introduction a copper-64 based radiotracer helped restore parity in urbanicity-based access to PET-based radiotracers that did not exist when Gallium-68 based radiotracers were the only PET-based option,” said Eric Christensen, PhD, Research Director at the Neiman Institute and study senior author.
“Importantly, the introduction of Copper-64 DOTATATE in 2021 largely eliminated the metropolitan-micropolitan versus small-rural differences in access to PET-based radiotracers,” Dr. Yuan added. “Patients still traveled a little farther for PET-based radiotracers than for Indium-111 pentetreotide, likely reflecting the geographic availability of PET scanners, but the willingness to travel farther is likely due to the clinical superiority of PET-based radiotracers.”
Use patterns changed rapidly over the study period. In its first year on the market in 2017, Gallium-68 DOTATATE/DOTATOC captured 33.8% of radiotracer use, growing to 90.9% by 2020, with Indium-111 pentetreotide accounting for the remainder. After Copper-64 DOTATATE entered the market in 2021, it captured 21.0% share. By 2023, Gallium-68 DOTATATE/DOTATOC remained the most widely used agent at 57.4%, followed by Copper-64 DOTATATE at 40.6%, while Indium-111 pentetreotide had declined to 2.0%.
“While Gallium-68 DOTATATE has clinical advantages over Copper-64 DOTATATE, that is not the only consideration. Logistic and economic constraints also matter,” Dr. Christensen noted. “Given these realities, it may be beneficial to continue using gallium-68 in larger markets where its local production costs may be more broadly diffused, while using copper-64 in smaller markets may facilitate substantially broader access for small-rural patients.”
To arrange an interview with a spokesperson, contact Nichole Gonzalez at ngonzalez@neimanhpi.org.
About the Harvey L. Neiman Health Policy Institute
The Harvey L. Neiman Health Policy Institute is one of the nation’s leading medical imaging socioeconomic research organizations. The Neiman Institute studies the role and value of radiology and radiologists in evolving health care delivery and payment systems and the impact of medical imaging on the cost, quality, safety and efficiency of health care. Visit us at www.neimanhpi.org and follow us on X, BlueSky or LinkedIn.