‘Popularity of PET-CT depends on its pricing and indigenisation’

Dr Atul Marwah is currently working as chief of department of nuclear medicine and Positron Emission Tomography (PET) at Bombay Hospital, Mumbai. A post-graduate in nuclear medicine from All India Institute of Medical Sciences (AIIMS), New Delhi, Dr Marwah holds the distinction of being one of the two doctors in the country to have secured a Diplomate Certification Board of Nuclear Cardiology (US). He has also received advanced training in PET-CT from Miami, Florida, US. He brought laurels to the country, on being awarded the ‘Young Investigator’ Award in the year 2000. In an interview with Shardul Nautiyal, Dr Marwah points out that the modality of PET-CT needs to be popularised aggressively among the medical fraternity and masses to expedite its growth.

What are the issues related to PET-CT in India?

The foremost issue is the awareness amongst the medical fraternity regarding the infinite utilities of this modality. Further, the availability of positron emitting radiotracer for use in PET-CT cameras is not available in most of the cities. As of today, only Mumbai has a functioning medical cyclotron and soon Delhi will follow suit. Plans to install the cyclotron in Bangalore, Hyderabad and Calcutta are also in the pipeline. There is also the issue of unavailablability of trained manpower with knowledge of the intricacies of PET imaging.

The modality of PET-CT is at a nascent stage. How are other imaging modalities complementing it?

Molecular imaging in general is the latest modality, which includes PET imaging, MRI, MRS, optical imaging and fusion imaging (PET-CT, PET-MRI, CT-SPECT). Molecular imaging will be the cornerstone of medical practice, helping in early and accurate diagnosis. The potential for molecular imaging applications are immense and countries like the US have acknowledged its future potential and the NIH roadmap initiative has placed molecular imaging on the forefront. This technology will be employed for monitoring and detecting evidence for failure or recurrence of disease activity at an earliest stage.

In comparison to the West, where does India stand vis-à-vis PET-CT?

We are definitely not on par with the West, when it comes to the wide spread application of the technology. This, of course, will change in a few years to come and India will surpass the West in the number of patient studies performed, the scientific literature published on PET-CT and the installed base of such scanners.

What are the current trends, issues and misconceptions in this field?

Current trends include integrating high-end CT scanners like 64 slice CT scanners along with PET. Newer radiopharmaceuticals are being introduced which are more disease-specific and are likely to play a significant role not only in patient care management, but also in research and development of new drugs and therapies.

Misconceptions and controversies in this field include the use of CT scanners along with the PET scanner. Many luminaries in the field of PET are actually debating the use of structural imaging (CT scans) for evaluating patients with various cancers. However, the current trends clearly point to the fact that CT scanners in conjunction with PET are almost indispensable as they are contributing significantly to increasing sensitivity and specificity of diagnosing disease process by combining these modalities.

Applications of this method include assessing derangement in the central nervous system physiology and metabolism in a multitude of diseases. PET-CT has added a major dimension to the utility of this powerful methodology. By combining structure and function in the same image, precise localisation of the disease is possible and this plays an important role in the optimal use of PET-CT technology. Fused PET-CT has proved significantly more accurate in assessing the overall TNM stage compared with stand-alone CT, stand-alone PET, and side-by-side CT plus PET in various clinical studies. PET-CT imaging has become the standard of care in radiation oncology in head and neck pathologies due to complexity of structures visualised.

Who are the leading manufacturers of PET-CT equipment? Will indigenisation help to popularise the technology?

Phillips, General Electric (GE) and Siemens are the leading manufacturers of PET-CT equipment. Indigeni-sation will definitely help in popularising this technology.

What are the suggestions to improve the current situation?

The focus should be on creating awareness by conducting CMEs for the medical fraternity. The challenges faced by imaging community also include the shortage of properly trained personnel to perform various tasks associated with PET-CT, Hence, training of manpower for this modality is of paramount importance. Pricing of this equipment and cost of the radio-isotopes used is an important issue, which will eventually determine the popularity of this modality. The popularity of a medical investigation will depend not only on the availability, but also the cost of the investigation. Another issue is the availability of cyclotrons and various short-lived radioisotopes in the vicinity of the PET-CT scanners, for which the government agencies and other multinational companies will have to take active interest.

How is the modality of PET-CT imaging evolving in India?

There is a tremendous potential of nuclear medicine as an emerging discipline in the field of molecular imaging. Medical literature in late 90’s on FDG-PET imaging has clearly shown that FDG-PET imaging is essential for optimal assessment of patients with a number of neurological disorders and malignancies. Its routine use is well justified.

PET-CT further improved the situation. The status of PET-CT imaging is at a nascent stage in India and needs to be popularised by various health care planners, institutions and the medical imaging community, for it would have a long-term impact on the clinical management of the patient. Increasingly, PET-CT imaging is being employed for the detection of orthopaedic infections, fever of unknown origins and inflammatory disorders, which form a large per cent of Indian patients. In addition, FDG-PET may prove to be an important method for detecting atherosclerosis, blood clots and muscle dysfunction.

What is the size of the industry and how is the industry oriented to satisfy the needs of the users?

While the potential is huge, the question is who is going to anticipate this and make use of the opportunity. We have seen how modalities like CT and MRI have successfully proliferated across the imaging centres of the country. The investment for the industry may be higher initially to support this upcoming modality. However, the returns are likely to be many-fold.

What role can the government and other agencies play popularising the modality?

Government participation in installing cyclotrons and distribution of radiotracer at non-profit making rates should be encouraged. The healthcare budget should allocate adequate funds so that various apex medical institutions could use this facility not only for patient care, but also for research and training of medical professionals.

The government should also look at making the environment in this direction investor friendly, so that multinationals could invest on this modality. The government authorities should formulate a duty-free structure on import of the PET-CT equipment and its associated components. Taxes like the value added tax (VAT) should be waived off.

shardul@expresshealthcaremgmt.com