Therapeutic Radiopharmaceuticals

1. Therapeutic Radiopharmaceuticals 1. Who is doing what? 2. What services are utilized? 3. What else should we do? Teofilo O.L. San Luis, Jr., MD Dean, Asian School of Nuclear Medicine

3. Sub-Committee on WRPTC Survey Ajit K. Padhy (Singapore) Teofilo O.L. San Luis, Jr. (Philippines) Salah-Eddine Bouyoucef (Algeria)

4. National & Regional Surveyors (Asia) Raihan Hussain (Bangladesh) Song Shao-li / Rong Zheng (China) Partha S. Choudhury (India) Abbas Takavar (Iran)

5. National & Regional Surveyors (Asia)

6. National & Regional Surveyors (Europe) Sonia B. Sergieva (Bulgaria) Dražen Huic / Martina Ciglar (Croatia) Anne Poksi (Estonia)

7. National & Regional Surveyors (Africa) Saleh-Eddine Bouyoucef (Algeria) MM Sathekge (South Africa) A. Nafati (Libya)

8. National & Regional Surveyors (Latin America)

9. National & Regional Surveyors (Latin America)

10. 1. Who is doing what in Nuclear Medicine? What is the status of NM? Who composes NM? Who performs Diagnostic NM? Who performs Therapeutic NM?

11. What is the Status of Nuclear Medicine (NM)?

12. What is the Status of Nuclear Medicine (NM)? Nuclear Medicine exists as an independent specialty in most of the developing countries surveyed. Nuclear Medicine has a separate organization in most of the developing countries surveyed. Otherwise, Nuclear Medicine is conjoined to Radiology / Internal Medicine organizationally.

13. Who comprises NM?

14. Who comprises NM? In most countries Nuclear Medicine consists of qualified Physicians, Scientists, Technologists and Allied Professionals. In some countries, there exist separate organizations for Nuclear Physicians, Scientists and Technologists. Actual numbers / proportions of each sector vary from country-to-country.

15. Who performs Diagnostic NM?

16. Who performs Diagnostic NM ? In most countries, the Nuclear Physician is the formal responsible person of the Nuc Med facility. In some countries, Radiologists, Cardiologists and Oncologists are allowed to perform diagnostic procedures. In most countries, Technologists and other Allied Professionals perform diagnostic procedures under supervision of the Nuclear Physician.

17. Who performs Therapeutic NM?

18. Who performs Therapeutic NM? In most countries, the Nuclear Physician is the formal responsible person of the Nuc Med facility. In some countries, Radiologists, Endocrinologists, Rheumatologists and Oncologists are allowed to perform therapeutic procedures. In most countries, Technologists and other Allied Professionals assist the Nuclear Physician in doing therapy.

19. 2. What services are utilized? What therapies are being performed? What radiopharm are being used? How much do the therapies cost? Are NM therapeutic services actually being used?

20. What therapies are performed?

21. What therapies are performed? Variable number of therapies from country-to-country. Thyroid applications (benign and malignant) comprise more than 90% of the total. Bone pain palliation and radiosynovectomy constitute most of the remaining therapeutic applications. Lymphomas, solid tumours, haematological diseases and others are done on occasion.

22. How much do the therapies cost? Hyperthyroidism (as outpatient): I131 $ 25 (10 mCi) – $ 1,095 (30 mCi) Ave: $ 173 (10 mCi) $ 265 (20 mCi) $ 298 (30 mCi) Thyroid Cancer (3 days, inpatient): I131 $ 1,070 (200 mCi)

23. How much do the therapies cost? Bone Pain Palliation US$ 286 (P32); $ 1,865 (Sr89) Radiosynovectomy $ 1,480 (Yt90) Neuroendocrine tumors $ 2,580 (MIBG-I131) Lymphoma $ 10,200 (I131 Bexxar); $ 22,280 (Yt90 Zevalin)

24. Are therapeutic services actually being used? Availability of the procedure Need for the service Number of cases requiring treatment Cost of the radionuclide

25. 3. What else should we do? Increase awareness and clinical demand Lower RPs cost Develop expertise Encourage local production of RPs Foster interest in promising RPs Facilitate Government approvals & loosen regulations And …

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29. Radiopharmaceutical Therapy: specific items I131 Therapy for Hyperthyroidism I131 Therapy for Thyroid Cancer Bone Pain Palliation Therapy Treatment of Polycythemia Vera Rubra

30. Radiopharmaceutical Therapy: specific items MIBG Therapy for Neural Crest Tumors Treatment of Neuroendocrine & Other Tumors with Radiolabelled Peptides Radioimmunotherapy of Lymphoma

31. Radiopharmaceutical Therapy: specific items Radiosynovectomy Intra-arterial Application for Treatment of Cancer Intra-pleural, Intra-pericardial, Intra-peritoneal, Intra-thecal Applications Direct Intra-tumoral or Intra-cystic Applications

32. Issues arising in RP Therapy Availability of the procedure Need for the service Number of cases requiring treatment

33. Important considerations Cost of the radionuclide Awareness and clinical demand Expertise and interest Government restrictions Local production of radiopharmaceuticals

34. Role of WRPTC Consensus conferences Multicentric studies and coordinated programme Treatment guidelines, protocols and standards Advocacy to produce and procure cheaper products Identification of nodal institution for optimal resource management

35. Role of WRPTC Identification of experts for training manpower Consultancy for international institutions and governments of Member States Channel for unified communication among users Distance education in NM therapy

36. What comprises training in NM?

37. What comprises training in NM? In all countries, the Nuclear Physician must have appropriate medical degree. Most countries have formal practical training in Nuc Med (residency / fellowship) whose duration is variable (2 to 4 years). Some countries have only informal training or exposure in Nuc Med. Training in radioprotection is required by government or by the facilities.

38. What training is required?(for non-NM MD to do Diagnostics only)

39. What training is required?(for non-NM MD to do Diagnostic and Therapeutic NM) Most countries do not allow non-NM physicians to practice NM. In some countries, clinical training and radiation safety are requirements for NM practice. In few countries, non-NM physicians are required to undergo formal training in NM.

40. In which setting is NM done? Nuclear medicine diagnostic and therapeutic procedures are done more or less equally in private and public facilities. Number of bed allotment in NM is variable from country-to-country. Most therapies are done as out-patients.