Dr A Velumani, Creator, Nueclear Healthcare, shares his insights about PET-CT, a state-of-the-art imaging technology that allows for screening, diagnosis and monitoring of cancer
Cancer is perhaps the most devastating word and disease known to mankind. Known from the times of ancient Egyptians, cancer has so far eluded understanding and remains largely uncured till this day. It leaves in its wake debilitating pain, severe physical and mental trauma, and financial ruin – not only for those suffering from it but also for their loved ones.
India, with a population of over 130 crore people, has had to bear its share of misery and despair caused by cancer – every year, 7 lakh new cases are registered in our country, and more than 70 per cent of these cases die because of late detection. Many cases are not even registered because of the speed of the disease.
When detected early, localised cancers can be managed and treated. They can be surgically excised, and the patients can be regularly monitored.
PET-CT is a state-of-the-art imaging technology that allows for screening, diagnosis and monitoring of cancer and helps in improving clinical outcomes and survival rates.
This technology is heavily under-penetrated in India – we have <200 PET-CTs in India, mostly concentrated in metro cities. India needs more than 1,000 machines spread across the country – The global WHO standard is 1 PET-CT Scanner per 500,000 people.
PET-CT – A history
While the CT scanner was invented in the 1972 and the first Positron Emission Tomography (PET) Scanner was developed in 1974. More than 25 years passed before Davis Townsend and Ronald Nutt built and installed the first PET-CT system at the University of Pittsburgh in 1998.
The first commercial systems were made available in 2001, in which year the PET-CT scan was recognised by the TIME magazine on its cover as perhaps the most important medical invention over the previous decade.
In India, the first PET-CT was installed at the Radiation Medicine Centre of BARC in Mumbai.
What is PET-CT?
PET-CT is a fusion imaging technique in which a PET scanner and a CT scanner work together to acquire images of the human body, which are subsequently put together to give a more informed view of the state of the body to the doctors.
In one of the rare real-life situations where the whole is considerably more than the sum of its parts, the functional imaging obtained from the PET, which depicts the spatial distribution of metabolic or biochemical activity in the body can be more precisely aligned or correlated with anatomic imaging obtained by CT scanning.
PET-CT has revolutionised medical diagnosis in many fields, and has become the diagnostic imaging modality of choice for procedures in oncology, surgical planning, radiation therapy and cancer staging.
What is FDG?
While PET-CTs are almost miraculous in terms of what they can achieve, there is a significant obstacle to their widespread use. Production and transport of radio pharmaceuticals used for PET imaging is complicated, and extremely expensive.
The key radiotracer used for PET-CT scans is FDG (FluoroDeoxyGlucose). It is a molecule of glucose in which one of the oxygen atoms has been replaced with a radioactive Fluorine-18 (18F) atom. As this glucose is absorbed and metabolised by the body, the distribution of the glucose usage identifies cancers, which are effectively abnormal, uncontrolled growths consuming huge amounts of energy in the form of glucose.
The key challenge with FDG is the extremely short half-life of 18F – approximately two hours. In practice, it means that every two hours of travel time between the cyclotron (which produces the FDG) to the PET-CT scanner doubles the costs of FDG – which are the single largest variable cost in any PET-CT business.
How does PET-CT help the patients?
When detected early, localised cancers can be managed and treated. They can be surgically excised, and the patients can be regularly monitored.
By diagnosing cancers early, PET-CT helps the doctors not only improve survivability, but also allows them to cheaply and efficiently monitor the impact of the treatment. For a disease whose treatment is effectively injecting high doses of chemicals whose speed of killing the cancer cells is only very slightly faster than the speed at which it kills the human body, this is critical.
Non-invasive, cheap and quick monitoring using PET-CT scans helps save the patients from over treatment and the debilitating effects of chemotherapy which are capable of significantly reducing quality of life.
Even after a successful treatment, cancers often return, and when they do, they are even harder to treat. Once again, early detection is the key to successful treatment. Regular monitoring through planned PET-CT scans allows the doctors to efficiently monitor the recurrence of the disease.
Economics of PET-CT Business
While the typical PET-CT Scanner costs anywhere between Rs 7 to 10 crores, the Cyclotron, which produces the radio tracers, without which the PET-CT cannot function, costs more than Rs 40 crores.
This creates a huge entry barrier in what is an otherwise simple business.
Most of the costs other than FDG in a PET-CT scan business are fixed and do not scale up significantly with the number of scans – which means that volumes are the single most critical factor determining the viability of a PET-CT business.
In a typical set-up, a PET-CT breaks even at ~10 scans per day, while it makes good returns at ~15 scans per day. However, given the high costs of FDG, most service providers are pricing PET-CT scans quite high, trading volumes for margins that only serves to reduce the accessibility of this lifesaving technology for those who need it the most.
The key then, is to also own the cyclotron, which allows one to control the costs of FDG, and smart network development that optimises costs of real estate, logistics and manpower to create an efficient hub and spoke model.
However, it is sad to see that most PET-CT scan services are priced very high, and seem to be either ignoring, or unaware of the volume benefits in this space.
The cost angle, and how Nueclear is tackling it
In India, 80 per cent of healthcare spending is private, effectively meaning that pricing is critical to the ability of a patient to afford a treatment or diagnostic modality.
For a disease like cancer, for which treatment costs can exceed Rs 4-5 lakhs, the oncologist is often forced to treat the cancer aggressively, forgoing the information given by the scan because of the additional financial burden of the PET-CT scans, which are typically priced in India at Rs 15,000 to Rs 20,000. The high prices effectively make PET-CT Scans unaffordable for a very large strata of cancer patients. Nueclear Healthcare Limited (NHL) was created to challenge this status quo.
Nueclear has made a conscious decision to control every part of the value chain, right from the production of the FDG to owning the centres.
This allows NHL to offer tests at prices as low as INR 9999 – a discount of almost 50 per cent to the market. NHL uses state-of-the-art machines, employs some of the most qualified doctors in this field in India and provides unparalleled accuracy, affordability and accessibility to patients.
Nueclear is building a pan-Indian network of Cyclotrons and PET-CT centres. In the next three to five years, Nueclear will build a network of ~80 PET-CT machines and 4 cyclotrons serving the length and breadth of India.
Key challenges
The wider acceptance of PET-CT scans in India will be driven by the availability of qualified nuclear medicine doctors and better air connectivity linking cyclotrons with PET-CT machines. Airlines, AERB and the aviation regulator also need to work together to give priority handling to FDG – given its short half-life and life-saving potential.
Lastly, there is a conscious need for patients to be educated so that they are not blindly sent by doctors to specific centres, which have referral-based financial arrangements with the doctors. Such rent-seeking behaviour only harms them. Patients need to be informed that they have the right to choose any service provider of their choice, and that they should make this decision based on their convenience and affordability.
The way forward, and some personal thoughts
My personal journey with cancer has been one of trying to achieve a vision, and having first hand experienced the misery of cancer in my own family.
I have a small dream – that Nueclear performs one million scans in my lifetime. Nueclear has tremendous resources – capital, a driven and motivated team which is working tirelessly to achieve this vision, and the fact that we have performed ~60,000 scans over the last three years.
I invite anyone who wants to join hands with us to battle the scourge of cancer in our country to get in touch with us – we are looking for partners who share this vision, and I am confident that together, we will be able to reduce the suffering caused by this silent, deadly adversary.
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