Background: Radiotheranostic therapy (RTT) is an emerging form of personalised cancer care that combines radiopharmaceutical imaging and radiopharmaceutical therapy (RPT). While promising clinically, the value for money of RTT remains uncertain.
Objectives: To review the cost-effectiveness evidence of RTT in cancer and critically appraise the methodologies utilised in conducting the included economic evaluations.
Method: A systematic literature review was conducted in accordance with the PRISMA guidelines. A comprehensive search strategy encompassing key search terms related to economic evaluations of RTT in oncology was performed across seven electronic databases (CINAHL, the Cochrane Library (NHSEED), Econlit, Embase, PubMed, Scopus and Web of Science), as well as databases of health technology assessment (HTA) agencies (Canada’s Drug Agency, Medical Services Advisory Committee, and the National Institute for Health and Care Excellence). The final search was conducted in Sept 2025 and covered published articles, reports and HTA appraisals from 2015-2025. Methodological quality was assessed using the CHEQUE framework, while reporting quality was evaluated using the CHEERS checklist.
Results: Sixteen articles/reports and nine HTA appraisals were included. Among the radiopharmaceutical imaging studies, 80% evaluated 68Ga while all RPT studies assessed 177Lu. Half of the model-based economic evaluations focused on prostate cancer and the rest on neuroendocrine. The modelling approach in the evaluations varied, and the reported incremental cost-effectiveness ratio (ICER) ranged from $21,350 –$146,526/quality-adjusted life-year (QALY) for radiopharmaceutical imaging and $66,761-$397,342/QALY for RPTs. HTA agencies identified uncertainties in evidence, comparator choice, and model assumptions and highlighted the absence of real-world considerations such as supply, workforce, and infrastructure constraints.
Conclusion: This review identifies substantial heterogeneity and methodological gaps in the economic evaluation of RTTs, contributing to uncertainty around their value for money. These findings underscore the need for fit-for-purpose HTA frameworks that integrate the full theranostic pathway, address system-level constraints and equity considerations.