Nuclear medicine is underutilised in South Africa despite its potential to improve health outcomes and reduce medical costs. This is according to Principal Specialist in Nuclear Medicine and Head of Nuclear Medicine at Durban’s Inkosi Albert Luthuli Central Hospital, Dr Nozipho Nyakale.
According to Dr Nyakale, South Africa currently boasts around 60 specialist nuclear medicine physicians and has 12 state hospitals with dedicated nuclear medicine departments where treatments are provided to thousands of state patients annually – but its impact could be far greater.
Greater awareness is needed
Nuclear medicine is a minimally invasive practice that uses small of amounts of radioactive isotopes, mostly for medical imaging procedures, to allow physicians to view the structure and the function of organs or systems in the human body. Because of the specialised imaging nuclear medicine makes possible, it can pick up certain diseases much earlier, which could mean patients would be able to start treatment earlier, which could save a lot of money not to mention improving the patient’s quality of life and their prognosis.
However, the problem is that by the time a disease causes obvious physical changes in the patient, the disease may have already progressed quite far. Most clinicians only come to nuclear medicine when they are stuck. They know what they want, but they don’t know what we can really help them with. If they knew more about what we are able to do, in some instances they could start with us rather than finish with us.
I understand the argument by some doctors that they need to exhaust methods that are affordable and more easily available first, but I think that the mind-set around nuclear medicine needs to change. Generally, treatments like lutetium-177 n.c.a. (Lu-177 nca) are reserved for patients who are not responding to any other treatment. But it has been shown that Lu-177 nca can also reduce the size of lesions and that it can increase the patient’s survival. And while one cycle of Lu-177 nca might be expensive, you have to compare it to what multiple cycles of another treatment might cost for the same disease. If nuclear medicine is used correctly, it can save money in the long run.
Using nuclear medicine more effectively
Nuclear medicine could be used a lot more effectively in terms of the burden of disease in public healthcare. If you look at tuberculosis (TB), in a known TB patient nuclear medicine can show if the disease is active, and can be effectively used to demonstrate the patient’s response to treatment, as many studies have shown. One can use the glucose analogue, F-18 FDG (fluorodeoxyglucose), to do a PET scan to see if he or she is responding to treatment, and determine whether to carry on with treatment, stop the treatment or adjust the treatment regimen. Sometimes patients are discharged because their initial six months is up, but they come back down the line because their TB has not responded and the sputum test was not able to accurately show this. If you had done a nuclear medicine study, you would have saved the patient’s time, and saved the state a whole lot of money. The trick is to personalise treatment for patients and know which patients would best benefit from these tests in order not to waste resources. This is one of the strengths of nuclear medicine, the possibility of personalised medicine.
Capacity building is needed
To be able to monitor disease you need to have seen a baseline study. That would mean each patient would have to go for a scan before starting treatment. We don’t currently have the facilities to do all of the TB patients in time. There’s just one state PET facility in the whole of KwaZulu-Natal (KZN), for example. There is also a lack of nuclear medicine physicians working for the state – we have just two in this province, this including myself. We are currently training a number of registrars. Many of our patients in KZN cannot afford to go to private practices. In order to make this possible, training of nuclear medicine physicians in state hospitals has to happen. You need to have the people, you need to have nuclear medicine departments, and you need to have the facilities.
Nuclear medicine is currently considered advanced medicine, and it’s only available at tertiary and quaternary hospitals, in public healthcare. But I believe nuclear medicine is an essential service and, for certain conditions, direct referrals at a primary healthcare level should be possible. Many people would disagree because of the cost, which is a major disadvantage with nuclear medicine – the medical radioisotopes are generally expensive, and it requires specialised equipment for imaging – but if the right systems were in place, a GP could refer the patient for nuclear medicine imaging even at that early stage, and could even end up treating the patient from their practice. Thyroid diseases are a good example of where this could work. GPs wouldn’t have to wait for patients to go into tertiary level treatment, they could send their patients directly to a nuclear medicine physician to get the correct diagnosis and refer the patient accordingly once they have the proper diagnosis. For this model to work, medical aids would also need to get involved, and approve the procedures.
At Inkosi Albert Luthuli Hospital we see between 30 and 40 patients per day, and usually see our patients within two weeks of them being scheduled by the referring doctor, depending on the type of study and availability of the radiopharmaceutical required. The therapies for the patients in our department are paid for by the state – we don’t routinely see any private patients. This gives non-private patients a real chance to benefit from nuclear medicine.