Dr A Velumani shares about his vision and crusade to fight against cancer and reveals more about his latest venture Nueclear Healthcare in collaboration with GE Healthcare. Excerpts of interview
1. What is the current scenario of Medical Cyclotron and PETCT industry in India?
The first Medical Cyclotron and PET came to India in 2002. Today after almost a decade we have only 15 Cyclotrons and 60 odd PETCT facilities in the country. For example, a country like Japan has 100 cyclotrons for a 120 million population i.e. 1 cyclotron for every 1.2 million population. On the same premise, India with a population of 1.2 billion should have had 1000 cyclotrons in existence and operation. Likewise, India should also have had at least 1000 PETCT’s. Sadly it isn’t so.
2. What makes PETCT scan so expensive?
I can think of several reasons. But principally one that contributes to scan cost is the cost of the PETCT machine, cost of the FDG and cost towards manpower. The PETCT machine can easily cater to a load of 20-25 patients in a day. The volume of patients will be there provided the isotope is made available cheap.
3.How difficult is it to manage the regulatory authorities?
There is a wrong notion that regulatory authorities are the deterrents for progress of molecular imaging. In India, we have the Atomic Energy Regulatory Board (AERB) that regulates all radiological activities. AERB through their registration, licensing, regulations, stipulations, directives, safety codes, safety standards, training programs, updates and inspections ensure that various nuclear practices undertaken are conducted in a radiologically safe manner. The responsibility of AERB is much more when Nuclear Medicine facilities are being planned and commissioned in public domain. One needs to recognize the fact that the nuclear medicine industry is growing and would continue to grow. New technologies bring in new dilemmas, new problems and new questions. Answers and solutions to these will take time. Like any science, regulations too are an evolving science. Regulators are trying their best to be in tandem with the developments and are doing their part to facilitate the progress of nuclear medicine for improving the quantity and quality of patient life. As of now, Cyclotron and PETCT requires about 10-12 months and 3-6 months for getting clearances from AERB.
4.What difference can PET bring to the oncology field?
Positron Emission Tomography (PET) scanning is a nuclear medicine molecular imaging technique that provides the clinician with three-dimensional images and information about how organs and tissues inside the body are functioning at the molecular and cellular level. Majority of the studies in PET are performed using 18F-FDG (Fluorodeoxyglucose). For a PET scan, a patient is injected with a very small amount of 18F-FDG, which contains both a sugar and a radioactive element. The radiotracer travels through the body and is localized in tumor or cancer cells. Hybrid imaging using PET-CT scanners has brought in an important evolution in technology and this dual imaging modality has helped to bring molecular imaging to the forefront in cancer management. PET-CT imaging has demonstrated an increased level of accuracy and confidence in distinguishing pathology from normal, physiologic tracer uptake and precisely localizing abnormal foci, as compared with PET and CT studies acquired separately. The most important application of PET-CT continues to be in oncology and is being routinely used for:
(a) Tumour detection
(b) Differential diagnosis of benign and malignant lesions
(c) Tumour staging and prognostic stratification
(d) Evaluation of treatment response
(e) Restaging and detection of recurrent cancer
(f) Radiation treatment planning
5.What is the biggest challenge in managing cancer patients?
I believe it is the diagnosis at a much early stage which in clinical parlance is referred as Stage I of the disease. Cancer as we know if detected early can be treated effectively with a good prognosis.With PETCT becoming affordable with Nueclear, I am sure many cancer patients will benefit and oncologists would be able to improve cancer care management in the country.
6.What will be business model of Nueclear?
Model you may consider it as a Hub and Spoke model. A medical cyclotron would be installed in a city and it should be able to cater to the complete needs of at least 20 PETCT scanners within a radius of 300 kms. Nueclear to begin with would be installing cyclotrons and along with it facilitate setting up of PETCT centres franchised by us. Nueclear would be providing free PETCT and free 18F-FDG to the franchisee and the revenue earned would be shared.
7.Are you sure Franchising concept will work in this segment?
I believe it will and am confident. Since it is first of its kind concept in imaging industry there may be apprehensions around. But I am sure it will work and benefit the society at large and would allow growth of nuclear medicine.
8.What are the side effects of Nuclear scanning?
No side effects. Does one have any side effects while undergoing an X-ray or CT examination? No isn’t it. Likewise, molecular imaging is absolutely safe. The risks and hazards in terms of late effects are scientifically valid but practically unseen. To put it in simple words, nuclear scanning is not associated with any short-term or long-term biological effects.
9.How does PET actually work to detect cancer?
PET instrumentation heart is the scintillation detector. The radiopharmaceutical 18F-FDG has radioactive 18F which disintegrates by emission of a positron radiation. This positron combines with an electron and annihilates by emission of two penetrating photons that come out of the patients body. The PET scanner is composed of an array of detectors that receive radiations emitted by the radiotracer. The radiation energy absorbed by the detectors is converted into light energy. The light photons then are captured by the photomultiplier tubes in the detector system and converted into electric signals. Using reconstruction algorithms, the computer processes the signals into an image and provides information of the metabolic activity in various normal and pathological tissues. That’s how cancer tissues are detected as their metabolic activity is high compared to a normal tissue.
10.About the stages of cancer and PET's role in it
Cancer staging is nothing but profiling of extent of disease. Meaning whether the cancer is localised or spread and If spread, how distant is the spread. In a PETCT procedure, from a single injection of 18F-FDG the patient when scanned after an hour or so, can provide images indicating the disease status. PET helps not only in staging but also in evaluating the response to treatment. PET role in radiotherapy planning is another vital contribution.
11. Apart from Oncology, does PET help in other areas?
Yes! It has a role in neurology, cardiology and infection imaging.
12. What other technologies/ variations are available in molecular imaging?
Molecular imaging with SPECT is also available. But it is unable to provide spectrum of diagnostic solutions in oncology. Molecular imaging as of now as hybrid imaging for oncology solutions is PETCT and may be a decade from now, one may see PETMR making inroads in the country.
13.Does India have enough nuclear medicine professionals to meet the demands?
Sadly no! The supply to demand ratio is poor as of now, both in terms of nuclear medicine specialists and technologists. If Nuclear Medicine and Molecular Imaging has to grow in this country, government and regulatory bodies should encourage institutions to participate and conduct teaching programs and increase the strength of human resources. Only a dozen odd institutes are presently having this teaching and training courses and generate about close to a dozen physicians and two dozen technologists.
14. What is the projected growth of nuclear imaging industry in India
Nuclear imaging in India is expected to grow by 20% annually. The growth in the 1990’s was mainly in government institutions. With private participation there has been an exponential growth. We expect by 2020, India would have 1000 PETCT’s. ...............................................................................................................................................................................................................................................