A Nuclear Medicine Facility in Northeastern Part of India, at Silchar – Genesis and Glimpses on Difficulties in Extending Patient Care

Nuclear medicine (NM) procedures represent the metabolic status of various organs and demonstrate anamoly with high specificity and sensitivity. In a cancer hospital, this department contributes in a big way, helping diagnosis, staging, management, and in proper follow-up of the patients. The addition of positron emission tomography (PET) in conjunction with computerized tomography provides high-resolution images with high specificity. It was highlighted in a recent communication[1] about growing radiotheranostics in India. Silchar is the capital of Cachar District in Barak Valley of the southern part of the State of Assam in the northeast. Cachar Cancer Hospital and Research Centre, one of the pioneers started by a voluntary society to alleviate the cancer burden in prevention, treatment, palliation, and terminal care since inception as early as 1993, as a nongovernmental effort. A state-of-the-art NM department project was conceived in 2016 and became a reality by commissioning a dual-head single photon emission computerized tomography (SPECT) scanner and PET-CT scanner in August and October 2023, respectively.

Formation of the NM department consisted of the proposal stage, approvals of schematic architectural designs both by institution and later by the regulatory authority, applying for funding from governmental agencies, after obtaining grants specifying and selection of equipment and accessories, after ordering equipment, going for development of infrastructure etc. When there was no human resources available with knowledge of NM how the administration went about to give acceptance of major equipment and making inventories, settling major claims from vendors, making equipment working, writing proposals on clinical activities for the first time, organizing clearances and approvals, all have taken place for the first time. All the above took place during 2016–2024. COVID-19 gave rise to a break of 2 years in the release of sanctioned funds, and subsequently, the project progressed. The Airport Authority of India (AAI) sanctioned financial grant-in-aid, and M/s Tata Trust, Mumbai, helped in the building of dedicated NM and molecular imaging block. Table 1 shows the various milestones in the developmental activities.

The personnel exposures estimated in connection with the use of PET-CT during this short span of 7 months, measured using digital pocket monitor, one fortnight randomly taken, is shown in Table 2. It is compared against the reported values in a similar hospital elsewhere,[2] as summarized in Table 3. Our department estimates agree well with the measured values in similar circumstances.

First NM Technologist (NMT) (MSc NMT qualified), joined in June 2023, left during September 2023 after initial commissioning tests and radiation protection survey documentations. Second NMT (BSc NMT qualified) joined in February 2024 and left in October 2024. A senior medical physicist of Radiation Oncology had been looking after the functioning of the equipment till March 2024. The hospital is facing noncompliance observations from the Atomic Energy Regulatory Board, involving impairment of progress in other departments. The prevailing status of NM services in India has been highlighted by Singh et al.[1] as: (1) an increase of the total number of NM institutions from 247 in 2015 to 506 in the middle of 2023, with and increase of 259 in 9 years at 29/year, (2) number of PET-CT scanners increased from 115 in 2015 to 437 in 2023 (327 in 9 years) at the rate of 36 numbers/year at 30/year, and (3) SPECT imaging equipment increased in number from 95 in 2015 to 247 in the year 2023, at a rate of 17 per year (18%/year).

This also reveals another paradoxical situation as enumerated below:

1. Need for addition of NM infrastructure against financial resource constraints

2. Release of financial grants to regions where inadequate NM services

3. Regions of inadequate NM services have already correlated to inadequacy in other medical, physics, and technical human resources

4. With large gap in human resources required to manage large number of added NM equipment, and maintain continuity in uninterrupted lifesaving patient care procedures becomes a nightmare.

Many Qualified NM consultants are available in major cities, but they do not elect to come and serve in district-level centers and medical colleges. We managed to get services from retired NMPhysician, for reporting and taking consultations through online methods. The doctor visits periodically to ensure that work is carried out satisfactorily. As a newly established NM department, except one consignment, conventional NM procedures with SPECT have not been routinely in use. Readily injectable formulations of PET isotopes were used in this short period. Preparation and quality control of related to radiopharmacy and streamlining the SPECT/NM studies presently in the project stage only.

Because of nonavailability of NMT, NM patient care diagnostic services are impaired for the last 9 months, highlighting an unfortunate situation. It was enumerated[1] that there are 25 institutions imparting training to produce about 50 medical NM postgraduates, and 150 technological graduates per year. In the last 9 months, our hospital could not employ an NMT, because without adhering to Cadre and Recruitment Rules, they claim remuneration of Rs 18–24 lakhs/annum, and such salary structures are not available in government and nongovernment philanthropic medical institutions. It is also observed that bulk of graduated NMTs from South India do not have competency certification by the Atomic Energy Regulatory Board (AERB). Getting technologists by deputation from other institutions or getting residents posted in our new department also did not materialize. CCHRC, Silchar gets FDG-PET radiopharmaceutical from Kolkata by flight arriving at 1:30 PM, and imaging starts around 3:30 PM each day, and patients waiting with preparations for the study. The track record in the past few years has shown that in the northeastern states of India, NM services were always interrupted in a similar manner in other hospitals for long time either due to equipment issues or HR issues.

A very crucial gap has been alluded to in this report. We also come to know that this is the same struggle that every NM setup, whether in a city or a remote area, is witnessing due to the inherent difficulty in bridging the supply–demand gap. It is also understood that this is not a regional disparity, as even in well-equipped larger cities and towns in other parts of the country, similar crisis is taking place. It is difficult to give statistics on how many institutions face such issues. However, one problem is routinely faced by all departments in teaching hospitals and medical colleges. Because of stand-alone diagnostic NM centers, offering remunerations without any guidelines, most of qualified NMTs are migrating to these centers. Their median service is <1–2 years, and invariably noncompliance status gets generated in regulatory records, stopping the supply of radioisotopes. For imaging purposes, sick patients are travelling long distances to faraway hospitals in Mumbai, Chennai, and Bengaluru, creating lot of distress to patient communities.

It should be a collective decision of Regulatory bodies and Academia to be consciously taken, considering the urgency of the cited difficulties and for the survival of this branch to be in service for mankind, as NM services are crucial in patient care management. If the Nuclear Medicine Society in alignment with AERB can do some changes in the existing scenario, it would go a long way in ensuring that NM survives the pangs. Any relaxations to allow unvalidated degree-qualified people will lead to compromised human resources. Therefore, qualified individuals from unaccredited centers have to complete competency certification by regulation. Another reason being that this group of individuals may not have any motivation to complete the approval process in the approved way and buy time and make hay during the prolonged crisis. However, if a window period of 1–2 years is given for them to complete the formalities, it still can be a good resuscitatory option. This framework shall not leave the personnel continuously migrating from one institution to another, surviving the window period. The supply versus demand has been very skewed in allied health services, especially in NM services.

There is a need felt to make awareness among youngsters to consider NM technology with a promising future needs to be ensured. The centers which are running the NM Technologists course should be allowed to increase their seats, and also several centers should be able to start this allied health course with the help of AERB. Many qualified individuals are migrating overseas this should be curbed by either enforcing a rule stating that they should serve their country for a certain period after completion, and only then a NOC should be given to presume their interests abroad. A few scientific institutions without clinical NM departments start postgraduate courses and award degrees. They apply for scientist position in NM, who neither fit for carrying out imaging, nor able to work in radiopharmacies, and they do not have eLORA registrations. Those candidates cannot be absorbed in any position in a hospital environment. Another temporary solution that can be considered is to train radiographers for an additional 1 year in NM technology procedures in well-equipped and established centers and allow these personnel to go through AERB certification and thereafter be employed as technical staff.

Since NM centers are expanding across the country, it is also important to ensure reservations to candidates to pursue this course according to the regional academic centers where students from that region may be willing to stay long term in their respective states or hometowns. Teaching centers should ensure that a certain number of seats are allocated for candidates deputed from deserving hospitals, so that permanent staff in the imaging discipline will find promotional avenues.