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.[2
3] 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.[8
9] 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.