|Year : 2016 | Volume
| Issue : 4 | Page : 251-254
Cancer and positron emission tomography imaging in India: Vision 2025
Shoukat Hussain Khan
Department of Nuclear Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||19-Sep-2016|
Shoukat Hussain Khan
Department of Nuclear Medicine, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Khan SH. Cancer and positron emission tomography imaging in India: Vision 2025. Indian J Nucl Med 2016;31:251-4
Nuclear medicine imaging in India has come a long way from the earlier rectilinear scanning to the present day hybrid imaging of metabolic positron emission tomography (PET) and structural computerized tomography (CT) or magnetic resonance (MR) imaging, commonly referred to as PET-CT and PET-MR. The concept of PET imaging which originated in the mid-1970s as a research tool in cardiology and neurology has in the past four decades evolved into the most sophisticated medical imaging system with its largest application in oncology. Ironically! The growth for this revolutionary imaging modality has been slow owing to issues related to high cost of PET scanner, ready availability of useful biomolecules, and trained technical workforce. Awareness about the usefulness and advantages of PET-CT imaging among the medical practitioners is still less. As of today, the installed base of PET/PET-CT systems in India is much less than CT scanners and MR machines [Table 1]. A published overview on nuclear medicine facilities in Asia shows Japan with just one-tenth the population of India having the highest PET-CT systems and other nuclear medicine resources. Other Asian countries such as Korea and China are also relatively advanced in terms of available nuclear medicine infrastructure [Table 2]. Heterogeneity in the distribution of nuclear medicine facilities including PET-CT facilities in India undermines the great potential of using this technology in a large segment of the patient population. In some of the developed nations, the expenses incurred on PET-CT imaging in cancer are reimbursed by medical insurance, but sadly individual health insurance is yet to take off in the developing countries like India making affordability one of the major constraints. Nevertheless! The emerging trends in positron imaging based on published data have created a noticeable paradigm shift in cancer management as a result of the early diagnosis, accurate staging, and treatment response evaluation resulting in substantial cost cutting by avoidance of unjustified surgeries and toxic-chemotherapies. The availability of wide range of newer biomolecules produced in compact self-shielded medical cyclotrons and easy to use portable PET generators has enabled targeted imaging resulting in the diagnosis of cancer at the time of metabolic dysregulations in the cells that usually predate the anatomical changes, a hallmark of advanced cancer. These developments though exciting are equally challenging for the health-care providers. Creating PET-CT facilities that are accessible and affordable to resource poor and remote populations requires the highest level of national commitment and a dedicated team of professionals who can oversee the project from conception to commissioning. Any attitudinal complacency today may create unbridgeable health care gaps tomorrow in executing a comprehensive cancer care and cancer control program. A visionary approach coupled with a timely strategy based on expected future cancer burden in the country needs to be adopted to address the anticipated increase in PET-CT imaging requirements.
|Table 1: Installed base of computerized tomography, magnetic resonance imaging, and positron emission tomography-computerized tomography in India and some other Asian countries|
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| Indian Cancer Scenario in the Next Decade and the Related Positron Emission Tomography-Computerized Tomography Demand|| |
Cancer is an important health problem in India with approximately one million new cases occurring every year. The International Cancer Agency GLOBCAN has predicted that the cancer incidence in India will almost double in next 20 years from nearly a million new cases in 2012 to more than 1.7 million new cases by 2035. The number of cancer deaths is also expected to rise from 0.68 million to 1.2 million in the same time period., A meager 1.5% of Gross domestic product (GDP) expenditure on healthcare in India is unlikely to reduce cancer mortality in the next decade. The estimated projected incidence of cancer in 2015 is likely to be 1.05 million and the projected incidence for 2020 is 1.25 million and for 2025 it is 1.50 million. The prevalence profile of different types of cancers show breast, cervical, oral, lung, stomach, colorectal, pharyngeal, esophageal, laryngeal, leukemia, prostate, and liver being the most common cancers in the descending order [Figure 1]. A majority of these cancers are Medicare approved oncological indications for PET-CT imaging. The PET-CT requirement in India will largely depend on the total incidence of new cancer patients and the proportion of these having indication of PET-CT for the management. If we presume that all the new cancer patients would require a minimum of three PET-CT scans in a year for staging, interim response evaluation, and response evaluation at treatment completion, we have a crude demand of 3.15 million, 3.75 million, and 4.5 million PET-CT scans for the years 2015, 2020, and 2025, respectively. At a conservative estimate of only half (50% of incidence) of new cancer patients requiring 3 PET-CT scans annually, we have an annual demand of 1.57 million, 1.87 million, and 2.25 million PET-CT scans for the years 2015, 2020, and 2025, respectively [Table 3]. At an average of 15 PET-CT scans on one scanner and 300 working days in a year, India needs 700, 833, and 1000 PET-CT systems for the years 2015, 2020, and 2025, respectively, for 100% incidence indication. For a 50% incidence indication, the number of PET-CT systems required would be 348, 415, and 500 for the years 2015, 2020, and 2025, respectively. At a minimum expected requirement, the country needs 500 PET-CT systems by 2025. Considering the existing wide gaps between the rural and urban population in health-care delivery system, the health-care planners have to ensure a homogenous nation-wide distribution of PET-CT facilities. PET-CT facility needs to be integrated into the National Cancer Control Programme by providing extra grants to create this facility in all the existing regional cancer centers in the country in the first phase and later extended to other need-based remote areas. At present, the majority 108 PET facilities in India are stationed in metropolitan cities performing around half million PET scans annually. India presently has 21 medical cyclotrons in the private and public sector supplying the cancer imaging PET isotope mostly F-18 fludeoxyglucose (FDG). Ten cyclotrons are located in Northern India, six cyclotrons in Southern India, three cyclotrons in Eastern India, and two cyclotrons in Western India [Table 4]. At an average estimate of 100 mCi of F-18 FDG for each PET-CT center, the country by the year 2025 at the minimum number of 500 PET-CT centers will require a daily production of 50 curies of F-18 FDG. A proportionate increase in the number of medical cyclotrons to approximately 50 will be needed by the year 2025 to meet the projected demands of PET-CT scans in cancer patients. With an extensive network of connecting flights in the country, the radioisotope can be flown to most of the distant places in the country within a span of 2–3 physical half-lives of F-18 FDG which is 3.5–5 hours flying time.
|Figure 1: Estimated projected incidence and mortality burden of all cancers in Indian men and women. Data from GLOBCAN 2012|
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|Table 3: Future, positron emission tomography-computerized tomography, and nuclear medicine workforce requirements|
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| Creating Trained and Adequate Human Resource|| |
One of the principal reasons for insufficient cancer care infrastructure and its skewed distribution is the shortage of trained medical and technical workforce. A staggering 70% of the population in India still lives in rural areas that have no or limited access to health care and ironically 80% of medical specialists in India live and practice in the urban areas. The inhomogeneity in the distribution of the available workforce is also due to personal preferences to work in urban areas that offer better economical opportunities, better civic amenities, and better schooling for children. Approximately, 300–400 qualified nuclear physician of India who presently work in about 226 nuclear medicine centers that include 108 PET-CT centers are stationed mostly in urban areas of the country. To realize the minimum target of 500 PET-CT centers by 2025 in India will also require three nuclear medicine physicians and a similar number of nuclear medicine technologists in each PET-CT center that in addition are likely to have other nuclear medicine facilities like single photon emission computed tomography/computed tomography-CT and radionuclide therapy. In all 1500 qualified nuclear physicians will be needed by 2025 [Table 3]. The accreditation bodies like Medical Council of India and the National Board of Examinations recommend a minimum of three nuclear physicians with a postgraduate degree for faculty and senior resident positions. At present, there are twenty recognized nuclear medicine physician training institutions in the country producing approximately forty postgraduate nuclear medicine physicians annually [Table 5]. In the next decade, we have to augment the number of training institutions and increase in the intake in institutions to achieve the target of one hundred postgraduate nuclear physicians passing out each year. The regulatory bodies will be required to conduct regular training workshops in radiation safety aspects, particularly the safe handling of diagnostic and therapeutic radionuclides. From the logistics point of view, centers running postgraduate nuclear physician courses must also conduct parallel training courses for nuclear medicine technologists leading to the award of postgraduate qualifications. The curriculum of training and teaching needs to be in accordance to the standards laid down by the national accreditation and regulatory bodies. The success of any national program including that of cancer is intimately connected with equity in the distribution of trained human resources and infrastructure thus bridging the gaps in health-care delivery that exist between the rural and urban population.
| Enhancing Awareness About Positron Emission Tomography-Computerized Tomography among the Medical Fraternity and the Role of Regulatory Authorities|| |
PET-CT scanners were introduced on a commercial scale in 2002. In the last 10–15 years, enough data have been published in standard medical journals confirming the usefulness of this imaging modality in management in a wide variety of cancers, particularly the solid tumors. An integrated PET-CT has been documented to have improved image interpretations in 49% of the patients and 30% of the sites. PET and PET-CT have an incremental value in terms of baseline preoperative staging, restaging, and evaluation of suspected recurrence. The studies published in the last decade have shown an overwhelming scientific evidence of PET/PET-CT having an accuracy ranging from 84% to 93% in comparison to 63–64% of CT alone. PET-CT has had a major impact in an otherwise blind area of detecting unknown primary tumor where otherwise no single imaging modality was successful. With the improvements in hardware and software technology, the accuracy and incremental values of PET-CT are likely to improve further. In 381 medical colleges offering 49,918 MBBS seats in India, there are just 423 seats available for postgraduate degrees in different streams of oncology. Only a small number of cancer patients have access to specialized care under the supervision of qualified and trained oncologist and this is likely to improve albeit marginally in the next decade. The bulk of cancer care will be offered by the broad specialty doctors working at various levels of health-care system. An education and awareness about the usefulness of PET-CT need to be undertaken for this vast pool of doctors involved in cancer care early during their MBBS training and subsequently through workshops, Continuing medical education (CMEs), updates, and conferences coordinated and funded by national and state agencies. These initiatives will eventually translate into dividends in the form of decrease in cancer-related mortalities, cost cutting by avoidance of unnecessary surgeries and toxic-chemotherapies, and improving the quality of life among cancer survivors.
The use of radiation generating equipment including PET-CT has to ensure that the radiation exposure to patients, radiation workers, and the general public is kept within the prescribed permissible annual limits. In the next decade, the Atomic Energy Regulatory Board (AERB) in India will have to process more applications for starting PET-CT units in different parts of the country. They will have to find mechanisms to reduce the time from “Application to Approval” for PET-CT projects since no work on any such project can start without the regulatory approval. The e-Licensing of Radiation Applications (eLORA) started by AERB in India has to a great extent facilitated the submission of applications; however, the processing time for approval or rejection needs to be shortened reasonably. The present eLORA portal needs to have an “Edit” option for correction of minor errors in application to avoid outright rejection necessitating a fresh application all over again. The validity period of 1-year for different types of licenses need to increase to a reasonable time keeping in view the busy cancer care work schedule of hospitals and health-care personnel in the country. The number of authorized centers undertaking calibration of various radiation measuring and monitoring equipment need to be increased in addition to bringing down the cost of calibration. The regulatory body must sensitize itself to the likely cancer scenario of India in 2025 when the projected incidence of cancer in the country will be 1.50 million requiring approximately anywhere between 2.25 and 4.50 million PET-CT scans annually. This will need a pragmatic and conformal adjustments in their procedures and protocols in line with the expected future challenges in cancer care for the country.
| Conclusion|| |
The existing quagmire of cancer care in India compounded by disturbing issues of economical disparities, social inequalities, and geographical disadvantages will continue to be a major challenge in the health-care delivery system of the country even in the next decade. India cannot afford the complacency and comfort of not being among the countries with the highest incidences of cancer in the world as it still has one of the highest age-related, cancer-related mortalities which is likely to cross 1.2 million in the year 2025. India's expenditure at 1.5% of GDP on healthcare when translated into per capita health care expenditure is one of the lowest in the world. The nation will have to come up with an exceptionally strong political will to turn around nation's health-care scenario. Equity in the distribution of health-care facilities, particularly the medical workforce and health-care equipment will address the nation's skewed distribution of cancer care facilities. In the field of cancer imaging, PET-CT has been a great breakthrough with greater accuracy and enhanced resolution. In future, the advancements in technology and availability of new PET tracers for more tumors, particularly those showing poor FDG avidity will open newer vistas in PET-CT imaging for cancer care. If we as a nation have to change the present and expected dynamics of cancer diagnosis and cancer care, we will need to make greater investment in national health care from our GDP and put in place a comprehensive strategy involving public and private sectors for achieving an equitable and affordable health care for all.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]