For some South African cancer patients, targeted radionuclide therapy (TRT) can offer another treatment option when conventional therapies have failed. But the treatment is available only to carefully selected patients, and costs and limited capacity can put it out of reach.
A KwaZulu-Natal woman whose father received the treatment in 2023 said he had metastatic prostate cancer and that most doctors had told “us” it was the end of the road.
“This treatment gave him, and us, hope, and it extended his life by about two years. I was told patient cases differ, but it was remarkable that there were barely any side effects. He had experienced a bit of dry mouth, but his appetite was really good, and he was eating well throughout the treatment,” she said.
The family’s access later became uncertain. The woman said that almost two years after her father had maintained a good quality of life, they returned to the public healthcare institution where he had previously been treated and were told there were funding problems and a long waiting list.
He later died.
“It was distressing to know that there was this treatment option available to reduce his suffering and to extend his life but that we no longer had access to it,” she explained.
TRT is a type of targeted nuclear medicine that delivers radiation to cancer cells while seeking to limit damage to surrounding healthy tissue. It is generally used to treat patients with advanced-stage, widespread cancer that has not responded to more traditional therapies like chemotherapy and radiotherapy, particularly when clinically indicated after specialist assessment.
Some of the injections grouped under TRT include Lutetium-177 (Lu-177-DOTATATE/PSMA), Actinium-225 (Ac-225-PSMA/DOTATATE), and Iodine-131 (I-131).
Lu-177-DOTATATE/PSMA therapy is among the injections used as part of a treatment programme for prostate cancer. According to nuclear physicians administering the treatment across the country, the price ranges from R60 000 to R80 000 per dose, and a patient needs four to six injections.
The treatment is available at selected private facilities as well as public hospitals in KwaZulu-Natal, the Western Cape, Gauteng and the Free State, with funding arrangements varying by facility and patient circumstances.
In terms of private-sector treatment, the cost may not be covered at all or may be partially covered by medical aid schemes, resulting in patients having to pay themselves. Due to affordability issues in the private sector, many of these patients are being referred to public healthcare facilities where the treatment is offered.
Professor Mariza Vorster, head of nuclear medicine at the University of KwaZulu-Natal, said that the most robust evidence available regarding the use of TRT exists for the treatment of patients with thyroid cancer, prostate cancer and neuroendocrine tumours.
Vorster said patient eligibility is considered during multidisciplinary meetings where doctors from different medical specialties meet to discuss patients’ treatment and decide on the most appropriate way forward.
“Usually we treat patients who have advanced-stage, widespread cancer which has not responded to more traditional forms of therapy, such as chemotherapy and radiotherapy. Such patients are typically referred by oncologists, urologists, endocrinologists and paediatricians and start with an imaging investigation at our department,” she said.
Vorster added that this is usually a PET/CT scan, which images the whole body in a single investigation and combines structural and functional information to determine the extent of disease involvement.
“Once a patient is found to be eligible, we exchange the isotope used to diagnose the patient for one that is treated by emission of radioactivity. The radiopharmaceutical can emit either an alpha or a beta particle, which then destroys the DNA within the cancer cells, causing these to shrink or die,” she said.
She stated that the treatment is provided on an outpatient basis and consists of a slow intravenous injection over a few minutes.
“Patients can go home the same day, and the next dose is usually given two months later. In total, patients usually undergo four to six injections, with two-month intervals. Side effects are usually minimal, with many patients reporting an improvement in their quality of life, less pain and increased mobility,” Vorster said.
However, the waiting lists are long. Dr Sthenjiswa Mhlongo, an oncologist at Mhlongo Oncology, said one of the most difficult situations is when there is another treatment available that could potentially help a patient, but the medical scheme will not fund it and the patient cannot afford it out of pocket.
“So, if you cannot access these treatments in the private sector, we have to then refer patients into the public healthcare system. When we refer patients across, there is another consultation that needs to be had, another assessment and a waiting list before a treatment can happen,” Mhlongo said.
“Sometimes, by the time the treatment has finally become available, the patient might not be a candidate for the treatment because they might be too unwell to receive the very treatment that we have been waiting for all along. And this is one of the major concerns for us as oncologists.”
Addressing the cost issue, Professor Nozipho Nyakale, president of the College of Nuclear Physicians, said the production and distribution of TRT is complex and subject to highly regulated production environments, pharmaceutical-grade quality control and radiation-safety requirements, among other factors.
“This pushes the cost of this treatment up. Radiopharmaceuticals have short shelf lives, making production and logistics particularly expensive. There is also, in some cases, the inevitable cost of importation, as some radiopharmaceuticals are not yet manufactured locally,” she said.
Nyakale said there is a viable model for public-private partnership that would be of particular benefit for radionuclide therapy because of the capacity constraints related to it.
She said a negotiated tariff, which is mutually beneficial, can be established in a way that would not disadvantage the public sector and private patients, respectively.
Dr Rudzani Nemutudi, acting managing director for the National Research Foundation’s iThemba LABS, which has been producing radioisotopes for both the local and international market for decades, said expanding local capability, developing new technologies, and working with healthcare and funding stakeholders can over time make advanced nuclear medicine more accessible to South African patients.
Nemutudi said the complexity is radioactive decay, as radionuclides have finite half-lives (low shelf life), meaning production, quality release, transportation, and clinical administration must be carefully coordinated.
“The economics of nuclear medicine therefore need to be considered across the complete treatment and supply chain, rather than attributing the final patient cost to the radiopharmaceutical producer alone,” Nemutudi said.
“NRF-iThemba LABS continuously seeks opportunities to improve production capability, reliability and efficiency while maintaining the stringent quality and safety requirements applicable to medical radioisotopes.”
Thoneshan Naidoo, CEO of Health Funders Association (HFA), said they support improved access to clinically effective cancer treatment; however, decisions about funding high-cost therapies must balance the needs of the individual patient with medical schemes’ obligation to protect the affordability and sustainability of cover for all members.
Naidoo said the HFA does not make individual clinical funding decisions or prescribe how member schemes should exercise their discretion.
“Where standard treatments have failed, schemes should have fair and transparent processes through which treating clinicians and patients can motivate for exceptional funding,” he said.
He stated that HFA would support structured engagement between government, medical schemes, clinicians and treatment facilities to determine whether a sustainable co-funding model is feasible.
“However, HFA cannot commit individual schemes to such arrangements,” he said.
Naidoo also said that any collective model would need to comply with competition law, procurement requirements, medicine regulation and the governance obligations of individual schemes. It would also require reliable information on eligible patient numbers, treatment volumes, wastage and the capacity of accredited facilities.
The Council for Medical Schemes (CMS) said it was undertaking the broader Prescribed Minimum Benefits (PMB) review process to ensure that the PMB package remains aligned with developments in health policy, current clinical practice and healthcare technology, while also addressing sustainability and affordability.
According to the Medical Schemes Act, 1998 and its regulations, qualifying PMB costs must be covered fully in accordance with the prescribed requirements, including applicable managed care protocols and designated service provider arrangements.
“Where evidence demonstrates that a particular nuclear-medicine intervention represents appropriate treatment for a PMB condition, the CMS can consider its inclusion in the relevant PMB definition,” the CMS stated.
“The assessment would need to consider the clinical indication, evidence of efficacy and safety, appropriate patient selection, treatment protocols and the appropriate level of care, as well as cost-effectiveness and affordability.”
Foster Mohale, spokesperson for the National Department of Health, acknowledged the high cost of Lutetium-177, among others.
He confirmed that NTP Radioisotopes, a subsidiary of the state-owned South African Nuclear Energy Corporation (Necsa), produces Lutetium-177 locally; however, he said the local production of the isotope does not necessarily mean that all inputs required for its production are sourced locally.
He added that the department will be engaging with NTP Radioisotopes to explore opportunities to reduce the cost, including through bulk purchasing, improved procurement arrangements and greater localisation of inputs where feasible.
Mohale added that public facilities currently use the Uniform Patient Fee Schedule (UPFS) to bill various categories of patients, including medical scheme beneficiaries.
“It is also important to emphasise that this issue should not be characterised as the private sector simply transferring patients to the public sector once benefits are exhausted. Where the service is a Prescribed Minimum Benefit, the medical scheme's statutory funding obligations remain in place and continue notwithstanding the exhaustion of ordinary benefits, subject to the provisions of the Medical Schemes Act and Regulations,” Mohale stated.
“The department continues to strengthen mechanisms and systems for ensuring appropriate reimbursement from third-party payers such as medical schemes, while ensuring that patients are not denied medically necessary care because of disputes between a provider and a medical scheme.”
gcwalisile.khanyile@nationalmg.co.za