|Year : 2022 | Volume
| Issue : 2 | Page : 71-76
Nuclear Oncology in Northeast India: Current scenario, challenges, and way forward
Kalpa Jyoti Das1, Jitendra Kumar Meena2, Abhinav Singhal1
1 Department of Nuclear Medicine, National Cancer Institute (AIIMS), Jhajjar, Haryana, India
2 Department of Preventive Oncology, National Cancer Institute (AIIMS), Jhajjar, Haryana, India
|Date of Submission||22-Jun-2022|
|Date of Decision||02-Jul-2022|
|Date of Acceptance||04-Jul-2022|
|Date of Web Publication||18-Nov-2022|
Dr. Kalpa Jyoti Das
National Cancer Institute - AIIMS (New Delhi), Jhajjar Campus, Haryana
Source of Support: None, Conflict of Interest: None
The recent ICMR-NCDIR population-based cancer registry data indicate that India's Northeast (NE) region is a hotbed of cancer cases, and has been dubbed as the “Cancer Capital of India” in the past literature. While the national average for cancer incidence cases is 80–110 per lakh, the Northeast region has almost double the rate at 150–200 cases per lakh population. In addition to a unique cancer profile and high incidence rates, the NE region has reported poor clinical prognosis and cancer survival rates. With the rising cancer burden and inadequate cancer care facilities in the region, a high proportion of patients seek treatment outside the region which further aggravates the physical and economic burden of care. It is high time that relevant stakeholders of the NE region come on board and earnestly address the inequitable status of cancer care services in the region. One important aim in developing a standard multimodality cancer care system in the region that needs immediate redressal is the deficit in Nuclear Oncology services. The Nuclear Oncology facilities host specialized services such as Position emission tomography/Computed tomography (PET/CT), positron emission tomography/magnetic resonance imaging (PET/MR), and Radionuclide therapy, which plays an important role across the spectrum of cancer diagnosis, management, and follow-up and therapy. Nuclear Oncology resources in the NE region are lagging far behind compared to the rest of India, considering the imminent and projected requirements. There is an acute shortage of nuclear medicine facilities, PET/CT, PET-MR, Cyclotrons, and trained men power in the NE region. We have attempted a desk review of the current scenario of Nuclear Oncology in the NE region and have extrapolated the burden-matched Nuclear Oncology resource that is required for the region.
Keywords: Cancer, Northeast India, nuclear oncology, positron emission tomography/computed tomography
|How to cite this article:|
Das KJ, Meena JK, Singhal A. Nuclear Oncology in Northeast India: Current scenario, challenges, and way forward. Ann Oncol Res Ther 2022;2:71-6
|How to cite this URL:|
Das KJ, Meena JK, Singhal A. Nuclear Oncology in Northeast India: Current scenario, challenges, and way forward. Ann Oncol Res Ther [serial online] 2022 [cited 2023 Mar 29];2:71-6. Available from: http://www.aort.info/text.asp?2022/2/2/71/361492
| Cancer Scenario in the North East Region|| |
The Indian Council of Medical Research (ICMR)-National Centre for Disease Informatics and Research (NCDIR) recently published a 5-year report (2012–2016) of the National Cancer Registry Programme of 28 population-based cancer registries across the country. The data imply that India's Northeast (NE) (Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura) region is a hotbed for cancer cases and has been plaintively placarded as the Cancer Capital of India across the literature. Despite covering a mere 3.76% of India's total population (2011 census), the registries covering the NE states have reported the highest age-adjusted incidence rates (AAR) and age-adjusted mortality rates/100,000 population for all cancer sites in India., While the national average for cancer incident cases is 80–110 per lakh population, the NE region reported a higher incidence of 150–200 cases per lakh population. A significant proportion of cases were reported at an advanced stage, leading to a poor clinical prognosis and survival rates., Much of the reasoning for such alarming scenarios can be attributed to a variety of socioepidemiological factors, lifestyle factors, tobacco use, betel nut consumption, spicy food consumption, lack of cancer awareness, insufficient health-care resources in terms of specialty treatment facilities (cancer care centers), advanced health-care equipment, lack of health policy and financing mechanisms, crippled with a huge shortage of specialized medical and technical workforce.,,
| Relevance of Nuclear Oncology|| |
While intensifying and strengthening the cancer care-related infrastructure in the NE region, one facet of the multimodality approach that often gets overlooked is the relevance of Nuclear Oncology services in the Cancer care continuum. Nuclear Oncology is a synchronal terminology for the role of nuclear medicine in Oncology with preeminence on positron emission tomography (PET). PET is a functional imaging modality which allows for both qualitative and quantitative assessment of tumors. Combined with computed tomography (CT) or magnetic resonance imaging (MRI), the hybrid modalities commonly abbreviated as PET/CT and PET/MR provide the dual advantage of both functional and anatomical information, thereby improving the overall diagnostic accuracy. The major incremental value of PET/CT over other imaging modalities is that it can serve as a one stop-shop for a whole-body investigation in a single visit and can be performed within a reasonably short duration of time. In the field of Oncology, PET plays a pivotal role across the ambit of cancer care management, including staging, restaging, radiotherapy planning, response assessment, recurrence detection, prediction of prognosis and survival, and identifying treatment targets for theranostic purposes. Although PET offers an array of radiopharmaceuticals, over the years, 18F-Fluoro-deoxy-Glucose (FDG), a glucose analog that mirrors glucose metabolism, has created a paradigm shift in cancer care management. Generally, detecting an aberrant hypermetabolic lesion on PET is often easier than detecting an unanticipated abnormal mass on CT, MRI, or Ultrasonography. With the advent of the state-of-the-art dedicated PET scanner with high sensitivity and spatial resolution, PET/CT allows for early detection of metabolically active tumors, a cardinal element of cancer care management. In addition to PET/CT, nuclear medicine centers also house the gamma camera/single positron emission CT (SPECT), which may or may not include a CT scan machine in combination. Although 18FDG-PET is the main workhorse in Oncological nuclear medicine, gamma camera techniques often perform akin to or provide complementary information to 18FDG-PET. The principal clinical application of these modalities in oncology has been in the diagnosis of skeletal metastases. Besides the diagnostic applications, Nuclear Oncology also encompasses the use of radionuclides for therapeutic purposes, such as radioiodine for thyroid cancer. PET's intrinsic ability to perform non-invasive visualization, quantification and characterization of tumours, allows for the identification of sites for targeted therapy. It has paved the way toward personalized and precision medicine by embedding the notion of theranostics.
| Resource Mapping of Nuclear Oncology in the North-East Region|| |
Where there was a parallel growth happening in the field of nuclear medicine in Northern and Western regions of India as early as 1960, culminating with the establishment of a nuclear medicine facility at Tata Memorial Hospital (TMH) in 1963 (later christened as the Radiation Medicine Centre [RMC]) and the Institute of Nuclear Medicine and Allied Sciences at Delhi 1964, respectively, the NE region was late to put forth its foot in this field. Although the initiative to start the first nuclear medicine department in the NE region began in the year 1990 at Dr. Bhubaneswar Borooah Cancer Institute (BBCI), the department became operational much later in the year 2002. However, the growth of Nuclear oncology in the region has been tardy, and the NE states still have a lot to catch up in this regard.
Institution and infrastructure
As of 2021, there are a total of 359 nuclear medicine facilities [Figure 1], 304 PET-CT, 4 PET-MR, 191 SPECT, and 89 SPECT-CT operational in India, with 138 centers offering high-dose therapy and 270 centers offering low dose therapy [Table 1]. Out of 359 NM facilities in the country, only seven atomic energy regulatory board (AERB) licensed, Nuclear medicine facilities exist in the entirety of NE India. Of these, five are in the state of Assam and one each in the state of Tripura and Manipur [Table 2]. Currently, only three out of eight states in the NE region have nuclear medicine facilities. The lack of nuclear medicine facilities in the rest of the NE States is highly concerning. States such as Mizoram and Arunachal Pradesh which have reported the highest AAR in men and women, respectively, in the recently published ICMR-NCDIR report, are yet to have a Nuclear Medicine or PET/CT facility. Few of the forthcoming nuclear medicine facilities in the NE region are the newly constructed All India Institute of Medical Sciences (AIIMS)-Guwahati, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS)-Shillong, and the four Assam cancer care foundation (ACCF) campuses in Assam Medical College-Dibrugarh, Fakhruddin Ali Ahmed Medical College and Hospital-Barpeta, Diphu Medical college and Hospital-Diphu and in Silchar Medical College and Hospital-Silchar [Table 3]. The ACCF is a joint initiative between the Government of Assam and the Tata Trust to create patient-centric cancer institutions across the state. Recently, the foundation has started seven state-of-the-art ACCF hospitals in the state of Assam, whereas the other NE states continue to lack such facilities.
|Figure 1: Geographical distribution (Statewise: Heat map) of Nuclear Medicine Facilities (public and private) in India|
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|Table 1: Category-wise nuclear medicine facilities in India and its Northeast region|
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|Table 2: List of existing atomic energy regulatory board approved nuclear medicine centers in North East region of India|
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|Table 3: List of upcoming nuclear medicine centers in North East Region of India|
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Currently, there are 25 medical cyclotrons operational in India, both public and commercial. The country's first Medical cyclotron was installed in the RMC, Mumbai, in 2002. The first and only medical cyclotron in the NE region is installed at the State Cancer Institute-Guwahati Medical College and Hospital (SCI-GMCH). Inaugurated in 2016, SCI-GMCH can be credited as the first state government-run health institution in the country to have this facility. Currently, besides providing 18F-FDG for in-house cancer patients, the SCI's cyclotron facility also supplies 18F-FDG to the rest of the nuclear medicine facilities in the NE region.
The country's first PET scanner was inaugurated in 2002 at RMC-Mumbai, and the first dedicated PET/CT scanner was commissioned in the Department of Molecular Imaging of TMH in 2004., Currently, there are 309 PET/CT scanners across the country. The first PET/CT to be installed in the NE region was in NECHRI in 2016. As of this date, there are a total of five PET/CT scanners operational in the entire Northeast region [Table 1]. The first PET-MRI in the country was installed at the House of Diagnostics/Apollo Hospital in Delhi in 2013. Much recently, the first and only PET/MR in the NE region was inaugurated at SCI-GMCH in 2022.
Radionuclide therapy for oncology started in India as early as 1964 when RMC became the first institute to use radioiodine for the management of thyroid cancer, Since then, significant therapeutic work has been carried over by institutions across the country. Treatment for thyroid cancer with radioactive Iodine has been well accepted in the country and is regularly performed. For example, AIIMS-New Delhi runs a dedicated Thyroid clinic for the treatment of both thyrotoxicosis and thyroid cancer. In the last few years, radionuclide therapy has expanded beyond the scope of thyroid cancer treatment. Some of the commonly performed nuclear medicine therapies in India include 177 Lutetium prostate-specific membrane antigen (177 Lu-PSMA) for treatment of metastatic castrate-resistant prostate cancer, 177 Lu-DOTATATE therapy for patients with Neuroendocrine Tumors (NETs), 131I-Meta-iodo-benzyl-guanidine (MIBG) Therapy for advanced Neuroblastoma and Actinium-225-PSMA for prostate cancer. The Clinical research, development and use of these radionuclides for treatment is progressing slowly but steadily. The first isolation ward for high-dose therapy in the country was established at RMC with a modest 2–3 beds in-door facility on the premise of TMH, which has now grown to 16 beds. The National Cancer Institute-AIIMS New Delhi at Jhajjar campus has a 21-bed isolation therapy ward, which once operational, will be the largest radionuclide therapy ward in the country. According to the latest AERB data, there are 138 therapeutic isolation wards in the country. The first radionuclide therapy ward in NE India was started at BBCI, Guwahati, with a 3-bedded facility. Besides radioiodine therapy BBCI, also offers I-131 MIBG therapy for nonoperable metastatic NETs and radionuclide bone pain palliation, Lu-177 PSMA for castrate-resistant prostate carcinoma, and Lu-177 PRRT for somatostatin expressing NET. Recently, Nucleomed imaging and diagnostics in Guwahati also received clearance from AERB to use Lutetium 177 PSMA and Lu-177 DOTATOC for treatment of advanced Prostate Cancer and NETs. Although it has begun on a promising note, the path of radionuclide therapy in the Northeast region is yet to establish and expand.
Nuclear medicine in the private sector
Dr. R D Lele bears the distinction of being India's first nuclear medicine practitioner in a private hospital. He established the first nuclear medicine department at Mumbai's Jaslok Hospital in 1974. In 2005, the Apollo-Gleneagles PET Centre in Hyderabad became the first in the private sector to commission a medical cyclotron and a PET-CT scanner. The first PET-MRI installed in the country was also under a private sector (House of Diagnostics/Apollo Hospital) in Delhi in 2013. In fact, as of 2018, the private sector accounted for approximately 86% of the nuclear medicine facilities in the country. The first private NM facility in the NE region was set up at Guwahati in 2006 at Nucleomed imaging and diagnostics. Currently of the seven AERB-approved Nuclear Medicine Facilities, four are run by private players in the NE region, accounting for approximately 67% in the region.
The first of its kind Nuclear medicine academic course in India was started by Lt Col Dr. SK Mazumdar as a 1-year postgraduate diploma in radiation medicine (DRM) in collaboration with the Science and Medical faculties of Delhi University in 1962. The National Board of Examinations (NBE), New Delhi, under the Ministry of Health and Family Welfare, recognized Nuclear Medicine as a broad specialty and accredited RMC in 1982 as the first institution in the country for postgraduate clinical training (post-DRM). The first residency program leading to an MD Nuclear Medicine degree was started at SGPGI in 1990 by Prof BK Das. The AIIMS, New Delhi, besides offering an MD degree, also commenced Doctorate of Medicine in Therapeutic Nuclear Medicine in 2015 under the mentorship of Prof C S Bal, which is the first of its kind course in the world. Currently, as per the National Medical Council (NMC) Information Desk, there are 14 medical colleges/institutions across the country offering MD courses, and as of the NBE information bulletin, there are 12 institutes/hospitals offering DNB residency programs in nuclear medicine., As per the AERB official list, there are currently 20-institutes across India approved for nuclear medicine technology (NMT) courses.
To emphasize, currently, none of the medical colleges/institutions/hospitals in any of the NE states offers residency programmers conferring MD or DNB degree in Nuclear Medicine or AERB-approved NMT courses. Hence, there is a massive dearth of Nuclear Medicine specialists in the region.
Projected cancer incidence matched estimation of nuclear oncology resource
PET/CT is a vital component of oncology services and the main workhorse of the Nuclear Oncology departments. The requirement of PET/CT in an NM facility for any region would largely depend on the incidence of new cancer cases. Based on a conservative approach with an estimation of 1.5 million new cases, the minimum expected PET/CT system requirement for the country is predicted to be 500 by 2025 Currently, there are 304 PET scans available in the country, which is 60% of the expected projected need. In a need-alike scenario for the Northeast region with an estimated projection of 57000 new cases by 2025, the minimum number of PET/CT systems required would be 19 for the region itself. Currently, there are only 5 PET/CT scans in the NE region, which is approximately 26% of the expected demand. India presently has a total of 25 medical cyclotrons, including the one in the NE region. A proportionate increase in the number of medical cyclotrons to approximately 50 will be needed by 2025 to meet the projected demands of 500 PET-CT centers. Similarly, assuming a cautious approach, the NE region's Cyclotron demand is projected to be at least two by 2025. Assuming a serviceably equipped diagnostic center with a PET/CT, SPECT/CT, and radionuclide therapy employing a minimum of three nuclear medicine physicians and an equal number of nuclear medicine technologists, the number of qualified nuclear medicine physicians required for the region would be 57, with an equal number of technologists by the year 2025. Currently, there are only four Nuclear Medicine Physicians working in the region. In a nutshell, there is an acute shortage of PET/CT scanners, cyclotron, and skilled workforce in the region.
| Challenges and Way Forward|| |
The ICMR and NCDIR report predict that cancer cases could rise by a steep 12.8% by 2025 in India and by 13.5% for the NE region. There is a looming challenge for cancer control in the NE region and the existing programs and policies seem ineffective to address the region's cancer crisis. The proportion of cancer patients from NE states who sought treatment outside the NE region is reported to be as high as 95.3% for Sikkim, followed by Nagaland (58.1%). Given the soaring cancer burden, inadequate cancer care facilities, and a high efflux of patients seeking treatment outside the region, the NE states cannot afford to be complacent. It is high time for all regional stakeholders to join hands and come on board to earnestly address the concerns related to effective cancer care management and cancer control through a multilevel and multidisciplinary approach. When contemplating or planning on the creation of new state-of-the-art cancer centers or strengthening the existing ones, the realm of Nuclear Oncology must not be left in the lurch. Despite some tardy advances, Nuclear medicine facilities in the NE region are still not anywhere near as compared to the rest of India. There is an acute shortage of PET/CT scanners, cyclotrons, and skilled workforce in the region. Compared to the rest of India, where there are 352 NM facilities and 299 PET/CT, there are only seven functional nuclear medicine facilities centered around three states, with only five PET/CT to cater to the entire NE region's needs. Currently, the only cyclotron of the region at SCI-GMCH is also not able to meet the demands of the NE region. Hence, the radioisotopes have to be flown from places across the country, such as Kolkata and Mumbai, which adds both logistics and financial implications on the centers and on the patients. Furthermore, the short half-life of the isotopes limits the fly time. With poor air connectivity in the region, delivering the isotopes to far-flung places in the region is far from reality. It is very crucial for the region to have another fully functional in-house cyclotron to meet the projected estimates for the region. Besides the state government, private entities can also play an indispensable role in establishing nuclear medicine diagnostic centers with or without therapeutic facilities in this region. Many diagnostic centers outside the NE region are being run by private players; the same can also be replicated in the NE region using public-private partnership models such as build operate transfer and build own. The high-initial investment cost of establishing a Nuclear Oncology center is a key impediment in setting up of cyclotron, PET/CT or PET/MR facilities in the private sector. The government can come up with policies to incentivize the private players in the NE region willing to take a leap in this direction.
Furthermore, there is a huge gap in the delivery of Nuclear Medical facilities between the rural and urban sectors as presently, all nuclear medicine facilities in the NE region are urban-centric, which covers approximately only 15.5% of the NE population Given that 85.5% of NE population resides in the rural area, a homogeneous distribution of health-care facilities including nuclear oncology need to be ensured to bridge these gaps. There is a massive dearth of nuclear medicine skilled workforce in the region. Aspiring students have to travel out of the region to pursue specialized courses, since currently none of the Medical Colleges or Institutions in the region are offering professional courses in the field of Nuclear Medicine. This compels migration of qualified medical professional, who eventually settle down in other regions of the country leading to a reasonable exodus of human capital flight from the region. This migration of expatriates has an adverse impact on the region health's system. It is therefore imperative for medical colleges or institutions of the region such as GMCH, NEIGRIHMS, BBCI, or the upcoming AIIMS-Guwahati to take a lead in this direction to put a brake on the brain drain from the region.
In addition, the medical fraternity and in particular, the oncologists of the NE region also need to be apprised about Nuclear Medicine facilities for wide-scale adoption of these modalities. Awareness about the advantages and usability of PET-CT imaging among medical practitioners is lacking. Initiatives such as workshops, continuing medical education, and conferences need to be undertaken to translate the potential benefit of Nuclear Oncology into payoffs. The nuclear medicine community of the NE region has a herculean task ahead toward the growth of this field in the region.
To summarize, a combined approach and efforts of academics, clinicians, private players, governments, and policymakers is the need of the hour to ensure that nuclear oncology vis-a-vis Nuclear Medicine is at par with its counterparts in the rest of India.
We, wish to sincerely thank Dr. Pankaj Tandon (AERB), Prof C S Bal (AIIMS, New Delhi), Dr. Anshul Rajnish Sharma (KDAH, Mumbai), Prof Lalit Kumar (IRCH, AIIMS-New Delhi), Dr. Kandarpa Saika (Nucleomed-Guwahati), Dr. Sandeep Taparia (Health City-Guwahati), Dr. Mandakini (GMCH), Dr. Dipjyoti Das and Mr. Jintu Borah (Assam Cancer Care Foundation), Mr. Arun Thokcham (EKO-Diagnostics, Kolkata) for their valuable inputs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]