Creating positron emission tomography facility in remote areas

I read with great interest and curiosity the review article “avoidable challenges of nuclear medicine facility in a developing nation”, which appeared in the October–December, 2013 issue of the Indian Journal of Nuclear Medicine.[1] I am in total agreement with the observations made by the authors in this well-written article. Even in a developing country like India, there are many geographical areas where the ground realities confronted by the health care providers in terms of access to financial and human resources are similar to the ones discussed in the article. The challenges are even more complex for creating and sustaining a positron emission tomography (PET) imaging facility. It was in the late 1950s when the concept of emission and tomography was given by David E. Kuhl, Luke Chapman and Roy Edwards. Working on these initial concepts the tomography imaging techniques were further developed by Michel Ter-Pogossian, and Michael E. Phelps at the Washington University School of Medicine.[23] Significant contribution to PET technology was made at Massachusetts General Hospital by Gordon Bronwell, Charles Burnham and their associates.[4] In 1961, James Robertson et al. at the famous Brookhaven National Laboratory built the first single-plane PET device and gave it a funny nickname of the “head-shrinker.”[5] The present day hybrid PET-computed tomography (CT) imaging was also possible due to the development of labeled 2-fluorodeoxy-D-glucose (2 FDG) by the Brookhaven group under the excellent scientific guidance of Ido et al.[6] It was in 1976 that this compound was for the first time administered to two human volunteers by Abbas Alavi at the University of Pennsylvania.[7] The subsequent developments in PET technology witnessed the designing of two-dimensional array PC-1, which was completed in 1969 and reported in 1972. The present day proto type PET/PET-CT scanner based on circular array of detectors was proposed by Robertson et al. and Cho et al.[89] The PET-CT scanner was named as the medical invention of the year by TIME Magazine in 2000. Last decade has witnessed a phenomenal growth in the application of PET/PET-CT technology in various areas of medical practice creating a paradigm shift in the art and science of clinical decision making particularly in the fields of oncology and cardiology. However, the pattern of growth in PET technology in different parts of the world has not been satisfactory. At present, there are approximately 50-60 PET/PET-CT centers in India backed by about 16-17 medical cyclotrons. Most of these facilities are concentrated in the thickly populated urban metros like Mumbai, Delhi, Chennai, Hyderabad etc. The possible reasons of having most of the PET centers and medical cyclotrons concentrated in the urban areas are logistic and commercial. The PET facility for a significant segment of Indian population remains unavailable on account of relative remoteness of an area compounded by scarce state funding. Even the otherwise enthusiastic private sector is reluctant to invest in these areas due to low volume of patient reference creating an unfavorable investment: Profit equation. Shockingly! As on today most of the North Eastern India, Jammu and Kashmir, Himachal Pradesh and remote areas of other big states of India do not have a PET facility. The patients along with their attendants have to make long, expensive and uncomfortable journeys to distant urban centers for PET scans. With profit driven private industry reluctant to invest in remote areas it becomes morally incumbent on the National and respective state governments to create sustainable PET facility for its population. To my mind there are three principal aspects of PET technology. First, ensuring regular supply of desired quantity of F-18 FDG the isotope mostly used in PET imaging that is produced in a cyclotron, second the PET imaging device preferably a hybrid PET-CT and third having trained human resources for operation and maintenance of the cyclotron/PET facility.[10] Transporting the short half-life (110 min) isotope, F-18 FDG from a distant cyclotron facility is not possible on account of either not having the air transport facility or its unreliability due to uncertainty in flight schedules and inclement weather. For sustainable PET technology in remote areas at least one local cyclotron/PET is needed. This facility would generate the isotope for use in other centers as well including the private ones. The initial impediment always appears to be an inability to convince the national/state/institutional authorities to prioritize installation of PET/PET-CT. This indifference is mostly on account of ignorance even among the medical practitioners. As such establishing a cyclotron/PET facility in developing nations particularly in their remote areas can be a complicated and challenging task. It requires a visionary approach with an intelligent back up strategy. At the outset we need to create a multidisciplinary national/state task force for PET that would include the major stake holders such as health care planners, health care providers, heads of medical institutions and hospitals, epidemiologists, statisticians. This task force will need to draft a sound project document justifying the need for incorporating cyclotron/PET in the national/state/institutional health policy. This has to be supported by epidemiological data and other indices on prevalence of cancer, cardiovascular diseases, and neurological disorders etc., that need PET for maximizing the treatment benefits with a favorable cost benefit ratio. The complexity of installing cyclotron/PET gets compounded by a common belief that PET is an expensive alternative to the relatively cheaper and more available modalities like CT and magnetic resonance imaging. Scientifically validated benefits of PET technology on its own merits need to be disseminated through an elaborate campaign of education and information particularly among the medical practitioners. Currently the capital investment required for establishing a cyclotron/PET facility is approximately US $5-6 million (Rs. 30-35 Crores). An additional 10% of the capital cost per annum would be needed as operational and maintenance cost.[10] Such financial commitment for a health care facility often shocks the national/state/institutional authorities more so if they don’t have a prior sensitization into the long-term benefits in terms of reduced national/state/institutional health care spending. Getting financial commitment will perhaps be a tough task for the national/state task force on PET and will require an immense mental effort. Having ensured the financial support for the project from the national/state/institutional authorities the next step for the task force would be to prepare a feasibility report to ensure the implementation and sustainability of the project in terms of trained workforce for operational and maintenance aspects, appropriate site identification, approval from the regulatory authorities, cost structuring for the patients with mechanisms of reimbursement, issues of radiation protection and other safety concerns. A project of this magnitude will need continuous funding for its operation and maintenance. The short and long-term financial implications of the cyclotron/PET project will be the most critical part of the feasibility report.

Installing cyclotron/PET is a demanding task, which besides financial support requires a lot of mental toughness. If all goes well a cyclotron/PET facility takes 2-4 years on an average from the conceptual to operational phase. For any health care establishment contemplating to have this facility it is suggested to proceed in a logical step wise manner of, (1) creating a structured multidisciplinary PET task force, (2) preparing a detailed project document, (3) convincing the justification of the project to the national/state/institutional authorities, (4) securing a commitment for full financial and other supports to the project, (5) preparing and submitting a comprehensive and objective feasibility report, (6) getting the requisite finances released and starting the project. (7) Ensuring compliance with regulatory requirements and issues related to radiation safety have to be taken in various stages of installing the PET-CT facility and these include, (a) site and lay out plan approval, (b) pre-commissioning inspection, (c) approval for commissioning/routine operation, (d) implementation of rules for proper disposal of radioactive waste and other issues related to radiation safety, radiation monitoring of staff members, (e) Ensuring appointment and availability of properly qualified staff like nuclear medicine physician, nuclear medicine technologist, radiation safety officer-level-II.[11] Simplification of licensing procedures for establishing a PET facility and relaxing the existing rules related to transportation of PET tracers will definitely help in creating a level playing field to make PET technology beneficial to more and more people (patients). In the long run, the scientific fraternity, which has already made immense contribution in PET technology will need to put in extra efforts to synthesize newer molecules and make the chemistry of existing generator based PET tracers more friendly. The benefits of a technical innovation remain underutilized unless it is universally available, accessible, and affordable.