Radiopharmaceuticals remains a hot topic in 2026, with continued investment from both big and mid-sized pharma, and private equity in the last twelve months. Will Johnson, engagement manager, Lakshiv Dhingra, clinical fellow, and Victor Chua, Partner, at Mansfield Advisors outline key developments and potential asset classes for private equity investors considering the sector.
INTRODUCTION: An attractive sector driven by big pharma investment and recent blockbuster milestones
Radiopharmaceuticals are drug molecules containing radioactive isotopes, used for diagnostic and therapeutic purposes in human medicine. They have two key properties: selective accumulation in a tissue of interest, and emission of ionising radiation. In diagnostic imaging, the radiopharmaceutical (‘tracer’) localises to specific cells and emits radiation detected by a scanner as it leaves the body; this can provide functional/metabolic insights beyond those from a purely anatomical scan such as CT. In therapeutic applications, radiopharmaceuticals contain radioisotopes that emit radiation capable of killing target cells by inflicting DNA damage. Whilst radiopharmaceuticals have been used since the 1960s, interest has recently increased substantially following numerous advancements in ‘theranostic’ applications. Key milestones include two prostate cancer products reaching blockbuster status in 2024, and rapid growth is expected to continue, supported by over $16bn of big pharma investment since 2018 [Figure 1].
MARKET OVERVIEW: Radiopharma is evolving from broadly-applicable SPECT imaging to targeted PET and therapeutic products
In diagnostic radiopharma, there are two main imaging modalities: SPECT (single photon emission computed tomography) and PET (positron emission tomography). SPECT imaging was pioneered in the 1970-80s and accounts for ~80% of imaging by volume, but <50% of radiopharma product revenue. It primarily uses low price standardised technetium-99m (Tc-99m) based tracers (e.g. Sestamibi in myocardial perfusion imaging) and represents the mature segment of radiopharma worth ~$3.6bn in 2024.
PET is a more modern technology and high-growth radiopharma segment, driven by increasing access to PET scanners and the development of innovative tracers. >80% of PET scans use the staple FDG (fluorine-18 fluorodeoxyglucose) tracer for tumour imaging, pioneered in the 1990s-2000s, but development of new tracers is enabling imaging in more specific applications. Innovative tracers are also driving market growth by demanding significantly higher prices than commodity products like FDG, exemplified by the blockbuster success of Pylarify (Lantheus). Pylarify is used to image prostate cancer, and favourable reimbursement in the US supported growth to $1.1bn sales in 2024. It represents >25% of the global PET radiopharma products market despite being used in <5% of PET scans, and has driven rapid growth of this segment; estimated at ~$3.9bn in 2024.
Radiopharmaceutical therapy is not a new concept. Radioactive iodine (iodine-131) was FDA approved in 1951 as a treatment for hyperthyroidism, and Xofigo (radium-223) in 2013 for treatment of bone metastases. Both products work via natural physiological processes driving accumulation of the radioactive isotope in the target tissue. Whilst these ‘passive’ therapies have been in use for decades, recent developments have been in ‘directed’ radioligand therapies (RLTs). These are molecules using targeting ligands to precisely deliver radiation to specific cells. The value of this segment expanded dramatically following the launches of Lutathera (2017) and Pluvicto (2022), reaching global sales of $724m and $1.4bn in 2024 respectively. Both are lutetium-177 based products, which Novartis gained through acquisition of Advanced Accelerator Applications (AAA, $3.9bn, 2018) and Endocyte ($2.1bn, 2018), and together they represented ~80% of the ~$2.7bn therapeutic radiopharma market in 2024.
PIPELINES: Innovation in theranostic applications will drive substantial market growth into the 2030s
The rise of Pluvicto therapy alongside the rise of Pylarify is no coincidence, given these products both target the PSMA receptor to treat and image prostate cancer respectively. These products demonstrate the principle of theranostics: being able to precisely image what is being actively treated. Clinicians can use Pylarify to characterise a patient’s cancer at diagnosis, assess whether they are suitable for Pluvicto treatment, and monitor their response to the therapy.
The principle is clear: as long as cancer cells express a unique receptor on their surfaces, and an antibody/peptide can be found to bind to it, it is possible to create both a diagnostic tracer and a therapeutic radiopharmaceutical linked to it.
Significant biotech and big pharma investment means the pipelines for both directed PET tracers and RLTs are substantial: it’s estimated that there are over 100 RLT candidates in clinical development, and analysis of the Clinicaltrials.gov NCT database indicates that over 30 innovative PET tracer phase I clinical trials start per year.
In the short-term, numerous product launches are expected in the existing indications for theranostics, mCRPC (metastatic castration-resistant prostate cancer, Pluvicto’s indication) and GEP-NETs (gastroenteropancreatic neuroendrocrine tumours, Lutathera). These are proven large markets, which are still expanding rapidly as both treatments build data to support expansion into earlier-line use. For Pluvicto, PSMAfore trial data supported FDA label expansion to pre-chemotherapy mCRPC patients in March 2025, tripling the addressable patient pool in the US. The ongoing PSMAddition trial has also shown positive interim data, suggesting label expansion into metastatic hormone-sensitive prostate cancer could also follow, potentially further doubling the patient pool. Unsurprisingly, given the growth potential of this prostate cancer radiopharma market, there are at least 10 additional RLTs in development targeting this segment. Some pipeline candidates have traits that could help improve outcomes in certain patient subgroups (e.g. using alpha emitting isotopes rather than beta emitting lutetium-177), or expand access in markets outside the US (e.g. alternative pricing models).
In the medium and long term, growth will be supported by pipeline products targeting new indications beyond metastatic prostate cancer and GEP-NETs. >80% of assets in Phase II research and earlier target new areas. Beyond prostate cancer, the key indications with large patient populations to break into are breast cancer, lung cancer, and colorectal cancer; all areas where substantial research is being conducted. Outside oncology, Alzheimer’s disease and Parkinson’s are two areas with significant potential for innovative PET tracers (e.g. targeting amyloid plaques). Overall, the expanding usage of existing RLTs and targeted PET tracers, combined with new therapy launches, is expected to sustain >15% market growth in radiopharma for the next ten years.
VALUE CHAIN: Production is complex, requiring specialised equipment and coordination between numerous key players in the supply chain
Most private equity clients do not invest in innovative molecules: the binary risks of success/failure do not work with the risk profile of leveraged buyouts. However, there are many places to invest along the radiopharma supply chain, particularly in manufacturing and distribution.
The journey from the radioisotope to the “ready-to-inject” PET tracer or RLT is complex and varies by molecule. The key point of differentiation is whether the production of the final product occurs in a ‘centralised’ or ‘decentralised’ manner, which in turn is dependent on the half-life of the radioisotope. This can be best understood by comparing the manufacturing process of an FDG PET tracer with an Lu-177 based RLT [Figure 2].
Owing to the short half-life of F-18 (~2 hours), the synthesis of FDG tracers must be decentralised i.e. in facilities close to the end-user (PET imaging centres). In this process, H2O18 (a precursor to F-18) is first distributed to nuclear pharmacies. These nuclear pharmacies are equipped with particle accelerators (known as cyclotrons) that produce the F-18 radioisotope from H2O18, and hot cells where the isotope is then bound to the targeting ligand and the final tracer is dispensed. The ready-to-inject tracer is then delivered to nearby imaging centres. This supply chain underscores the need for networks of nuclear pharmacies that are located in close proximity to imaging centres. In many cases, these nuclear pharmacies are located on-site, for example where an imaging centre is located in a large regional hospital.
By contrast, Lu-177 has a much longer half-life (~6.6 days), and therefore RLTs such as Pluvicto and Lutathera can be manufactured centrally i.e. in facilities operated by Novartis. In the US, Novartis already has three RLT manufacturing sites in New Jersey, Indianapolis and California; they plan to invest $23 billion in US infrastructure between 2025 and 2030, with part of this ringfenced for the expansion of the 3 existing sites and the development of new sites in Florida (opening 2029) and Texas. In-house manufacturing enables developers to better-protect intellectual property and control drug supply, but also creates a crucial role for specialised courier services that can provide time-critical deliveries to geographically-distant treatment centres.
LANDSCAPE: Rapid innovation and supply chain complexity creates numerous classes of investment opportunities
In a similar way to other life science verticals, the radiopharma landscape is a complex integrated network. Players include product developers, sponsors, equipment manufacturers, and ‘hot’ or ‘cold’ reagent suppliers [Figure 3]. The high-growth emerging nature of the radiopharma market makes for numerous players of the scale and profile suitable for private equity investment.
Whilst big pharma sponsors have made significant progress in acquiring the biotech developers of radiopharma assets themselves, some remain available. Curium is one noteworthy example, recently being valued at ~€7bn as part of a CapVest continuation vehicle with new investors ICG, TPG, and CVC. A substantial portion of this value is based on its pipeline of PET and RLT products.
Radiopharma R&D and CDMO services are also a potential investment avenue, with Minerva Imaging, a specialist radiopharma CRDMO, acquired by Nordic Capital in a competitive process in mid-2025. Nucleus Pharma, a dedicated RLT CDMO, is another one to watch, receiving $56m Series A funding in 2023, and recently building out one of the largest RLT production facilities in the US. Siemens Healthineers PETNET Solutions, a leading manufacturer of PET tracers and imaging equipment, acquired the diagnostics division of AAA from Novartis for $224m in 2024; complementing its existing network of US nuclear pharmacies with 13 additional sites in Europe. Cardinal Health’s nuclear pharmacy division has also been considered for divestment in the past, with the potential to become a dedicated radiopharma CDMO like SOFIE, or to be acquired by a pharma sponsor looking to vertically integrate tracer production (analogous to Telix’s $250m acquisition of RLS Radiopharmacies in 2025).
Adjacent segments include production of non-radioactive precursor reagents and capital equipment (such as cyclotrons and hot cells), for which demand is substantially higher than current supply.
The requirement for time-critical delivery of radiopharma product creates a role for specialist radiopharma distributors, representing another class of acquisition target in the sector. Life Couriers (AUCTUS Capital Partners) is an example of such a specialist player, which has built an extensive distribution network in the US and Europe through strategic M&A, from initial platform investments in Same Day Logistics and Associated Couriers.
CONCLUSION: A high-growth market actionable for investors with a variety of strategies
In the broader context of patent cliffs in the pharmaceutical industry, investing in radiopharmaceuticals is a key way for big pharma to expand pipelines and represents a broader ecosystem where private equity can play a role. The development of innovative RLTs and PET tracers, in both novel therapeutic areas and using novel radioisotopes such as actinium-225 and copper-64, carries real commercial promise. For investors, there is potential for blockbuster returns in product-specific biotech developer investments, but even lower-risk product-agnostic platforms (equipment, logistics) have substantial potential underpinned by strong market growth at >15% CAGR. Vertically-integrated assets (such as Curium) can offer a more balanced risk profile. All avenues can be fruitful, provided the commercial story and underlying science receive equally rigorous due diligence.
