Trends in Nuclear Medicine in Developing Countries

Practice

The inferences presented here are drawn from information obtained to ascertain the extent and type of practice of nuclear medicine worldwide (excluding North America, western Europe, Australia, and Japan). Measured by the average number of cases per center, the practice of nuclear medicine showed a 15% increase in 2009 compared with 2008. The practice registered a decrease of 7% in 2010 compared with 2009, although the number of cases per center was higher than that in 2008. The subjective inputs indicated that a temporary shortage of technetium supplies and advancement in competing imaging modalities may have been responsible for this observed decline in usage (Fig. 1).

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FIGURE 1.

Trends in overall numbers of nuclear medicine procedures performed (average per center; shown on y-axis) in developing world (data from North America, western Europe, Australia, and Japan are not included). Decrease in 2010 relative to 2009 most likely was due to technetium shortage (see text).

Annual assessments of the use of nuclear medicine techniques by body system indicated that about two-thirds of the practice was used to perform bone, thyroid, and renal scans. Bone scans accounted for 25%–28% of all procedures performed over the 3-y period and remained the most widely used application of nuclear medicine worldwide. Thyroid scans (accounting for almost the total figure in the endocrine category) ranked in second place, but the use of nuclear medicine for this purpose decreased by 8 percentage points from 24% of all cases in 2008 to 16% in 2010 (Table 2). Remarkably, renal scans (in the genitourinary category) ranked in third place (16%–17%), as they remain widely applied in the developing world, probably reflecting the lack of more sophisticated investigational means. Cardiovascular applications, which account for the highest percentage of all nuclear medicine procedures performed in the United States, ranked in fourth place, and in 2010 they represented only about 12%–13% of the overall nuclear medicine practice in the developing world. Nuclear imaging of the central nervous system continues to draw the least interest in the practice despite its noted merits, probably because of improved MRI techniques and inadequate training of professionals in the field. There was a sustained interest in therapeutic applications of nuclear medicine across all 3 y, and there was also a systematic increase in the use of PET in overall nuclear medicine practice (Table 2).

Table 2 also shows that despite an overall decrease in the number of nuclear medicine procedures performed per center in 2010, increases in the use of PET and, to a more limited extent, therapeutic applications of nuclear medicine were witnessed between 2008 and 2010. Interestingly, there was a striking increase (>100%) in the use of PET every year from 2008 to 2010. Similarly, there was a steady increase (25%) in the absolute numbers of therapeutic applications performed in 2009 compared with 2008, and there was a 12% increase in 2010 compared with 2009.

Growth

A detailed evaluation of the growth of nuclear medicine across countries and regions indicates that practice has shown both homogeneous and heterogeneous trends across the world. Although the increase in therapeutic applications of nuclear medicine indicated some degree of homogeneity in all regions, the use of PET increased markedly in Asia and eastern Europe but only moderately in Latin America. The use of PET decreased markedly in the Middle East but remained stable in Africa (Fig. 2). The unusual trend in the Middle East, where nuclear medicine practice is usually supported by expatriates, seems to be related to a transient lack of adequate human resources and merits monitoring. In Africa, PET activity is limited largely to South Africa, where lack of reimbursement remains an issue; however, countries along the Mediterranean rim are actively pursuing the introduction of this technology into their health care systems. As is well known, the performance of imaging equipment, an important component of overall nuclear medicine service, usually declines with prolonged use.

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FIGURE 2.

Trends in average numbers of PET procedures performed (shown on y-axis) per center in 2008 (blue bars), 2009 (red bars), and 2010 (green bars) by region.

Both planar cameras and SPECT are in use worldwide. The present data indicate that the average equipment age is beyond 6 y for all types of cameras in all regions of the developing world (Table 3). Africa and the Middle East lead in average equipment age for SPECT cameras, whereas prolonged use of planar cameras is noted in Latin America, the Caribbean region, eastern Europe, and northern Asia, with some systems in use for more than 30 y. This prolonged use of planar instrumentation often goes beyond the obsolescence period, and in many cases analog cameras are still in use. This factor may account for the types of nuclear medicine services offered in these regions and for the difficulties in effective performance.

Particularly relevant are the relatively low number of cardiac procedures and their decrease over the 3 surveyed years. This decrease was not homogeneous across all regions (Fig. 3). For example, a decrease was not seen in eastern Europe, where the use of these procedures remained unchanged, and the use of these procedures remained quite limited in Africa. The decline, however, was quite steep in Latin America, where a decline of 40% was seen in 2010 compared with 2008, and in Asia, where a decline of 30% was seen in 2010 compared with 2009.

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FIGURE 3.

Trends in average numbers of myocardial perfusion imaging procedures performed (shown on y-axis) per center in 2008 (blue bars), 2009 (red bars), and 2010 (green bars) by region.

One possible explanation is the technetium shortage that followed the disruption of irradiation services from a few large and aging research reactors. This shortage posed a serious challenge to the molybdenum supply chain in 2008, resulting in a shortage in the availability of ^99mTc for the practice of nuclear medicine. Reductions in nuclear medicine services because of this shortage were reported to be at their maximum toward the end of 2009 and early 2010. This crisis had a noticeable impact on science and commerce related to technetium radiopharmaceuticals (12).

The relative increases in PET and therapeutic procedures may reflect not only the growing interest in the technology throughout the medical community but also the fact that the technology remained largely unaffected by the ^99mTc shortage because it does not require ^99mTc. The use of compounds other than ^99mTc-labeled radiopharmaceuticals may also explain the stability in the numbers of oncology procedures that did not include (in our database) bone scans, which are typically performed with ^99mTc-labeled compounds.

One of the challenges that may hamper the growth of nuclear medicine practice in the developing world is the ability of nuclear medicine facilities to respond to the needs of referring clinicians. This factor, in turn, has consequences for the level of acceptance of the practice by clinical practitioners and for the overall development of the practice. Indeed, in regions such as Africa, ^99mTc generators may be received on a fortnight basis, and the ability to respond to requests therefore may be compromised for several days every month. From responses provided to the question about this topic, it appears that as many as 41% of centers worldwide believe that they are not responding adequately to needs (Fig. 4A), but the responses to this question varied from region to region. The lowest departmental efficiency is noted in Latin America and Africa, whereas maximal efficiency is noted in Asia (Fig. 4B). These findings may reflect the aging equipment in use in the former regions.

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FIGURE 4.

Departmental efficiency depicted worldwide (A) and by region (B; values on y-axis are percentages) as perceived by participating centers. Participants were asked to rate efficiency of their departments in responding to requests from referring physicians as “very much” (i.e., highly efficient [blue bars]), “much” (i.e., efficient [red bars]), or “not as much” (i.e., not efficient [green bars]).

The questionnaire attempted to elicit responses to questions about why centers believed that they were not performing effectively (Fig. 5). The main reasons, in order of importance, appeared to be a lack of up-to-date or sufficient equipment, a lack of education or training, difficulties with supplies of radioisotopes and radiopharmaceuticals, and insufficient human resources. These findings are contrary to the popular notion held by many in the field of nuclear medicine that the practice is overregulated and that this overregulation hampers the delivery of nuclear medicine services. This notion is not substantiated by the data that we have collected: regulations were at the bottom of the list of elements adversely affecting nuclear medicine practice; only 5% of centers listed regulations as a possible reason for not performing effectively.

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FIGURE 5.

Relevant reasons for not performing effectively, as indicated by survey responses of participants.

Education and Training

Nuclear medicine education and training curricula have undergone a significant transformation, from 1–2 wk of postgraduate teaching limited to preclinical and clinical training courses to a full postgraduate training program with a duration of 2–5 y. Curricular changes are being considered because they not only reflect technologic advances but also include the necessary emerging clinical competencies (13). Large nuclear medicine organizations in developed countries, such as the Society of Nuclear Medicine, the European Association of Nuclear Medicine, and the British Nuclear Medicine Society, provide exceptional training courses and publish guidelines and procedures to provide lifelong learning opportunities to their members. Such strong educational platforms and stringent requirements are in place to ensure that nuclear medicine professionals are adequately trained to provide patients with optimal and safe care (14).

However, these ideal types of structured, highly supported mechanisms for nuclear medicine training for physicians are accessible mostly in the developed world, where there is good support from governments, national organizations, and the industry. In the developing world, several factors may directly hamper nuclear medicine training for physicians. Legislative hurdles, limited human resources, and health care system restrictions limit easy access to basic nuclear medicine technology and newer developments in the field, such as PET/CT (15). An interplay of these factors widens the gap between developed and developing countries’ access to standard and advanced nuclear medicine knowledge.

Nuclear medicine and radiology have witnessed significant changes in technology in recent years, particularly with the introduction of hybrid imaging devices. These changes have led to the consideration of cross-training of physicians with nuclear medicine and radiology backgrounds. A revamping of training and residency programs by regional, national, and international initiatives is required to ensure a supply of imaging experts with skills in multiple modalities.

Regional differences or diversity in content, structure, and duration of training programs in nuclear medicine can be observed in the developing world. In some countries with existing nuclear medicine residency programs, there is no standardized syllabus for training. Pathways to postgraduate nuclear medicine training usually include entry into an academic or university program leading to a degree (such as Master in Science or Master of Philosophy) or a professional program. Some countries, such as Argentina, Bangladesh, Brazil, Colombia, Cuba, Chile, Egypt, India, Malaysia, Mexico, Pakistan, and South Africa, typically follow this type of training scheme, in which an academic program leading to a degree includes entrance into a structured training program within a university and concurrent involvement in a clinical setting, such as a hospital. The duration of training can vary from 2 y to 5 y, depending on the program. Training usually leads to a degree in nuclear medicine such as Diploma, Master in Science, Master of Philosophy, Master of Medicine, or Doctor of Medicine, which qualifies the student to take a board examination, if applicable. The other pathway involves professional training in nuclear medicine; prospective trainees enter a 2- to 4-y residency training program (depending on previous qualifications) within an accredited training hospital approved by the government and professional bodies with or without university linkages. This type of program does not lead to an academic degree but, if applicable, would enable the candidate to pursue specialty board certification in his or her respective country after the completion of training. This scheme is typically patterned after the U.S. model for specialist training in nuclear medicine and can be observed in developing countries such as Algeria, the Philippines, Brazil, Chile, Colombia, Mexico, Peru, and Uruguay.

A recurring issue is that availability and diversity in the structure, duration, and implementation of nuclear medicine training programs in the context of the developing world can have several consequences for the practice of nuclear medicine. A contextual setting includes the availability of infrastructure and technologies, such as SPECT/CT and PET/CT, that can be used to meet the clinical needs of the country and for training.

The present evaluation indicates heterogeneity in the training needs of various regions (Table 4). The leading areas requiring training in Africa are cardiology, applications of SPECT, quality management, and therapeutic nuclear medicine, whereas those in Asia are PET, quality management, receptor imaging, and neuropsychiatry.

Most developing countries lack specific training programs for nuclear medicine professionals, including physicians, physicists, radiopharmacists, and technologists. For the existing work force of nuclear medicine practitioners, there is a need for continuing medical education, particularly in new technologies, such as hybrid modalities, as well as for a more comprehensive understanding of some clinical applications, such as pediatrics. Among the various staff worldwide engaged in nuclear medicine, technologists lead in having the maximum need for training.

Moreover, both socioeconomic disparities and academic heterogeneity have resulted in unbalanced development in infrastructure, resulting in a wide range of unmet needs across the world. There are middle-income countries with strong academic centers equipped with top-of-the-line scanners comparable to those available in the developed world, emerging countries with the ability to fulfill only basic care needs, and several underdeveloped countries with no nuclear medicine infrastructure or a markedly outdated infrastructure.

The lack of existing training programs for nuclear medicine specialists or an organized regulatory body to oversee training can also be an issue, as can the lack of availability of fellowships or advanced training programs in nuclear medicine, such as those for nuclear cardiology, therapy, pediatric nuclear medicine, and PET/CT. In such situations, students must obtain training in neighboring middle-income or developed countries independently, a process that can be expensive and complex, or with the assistance of governments and organizations such as the IAEA (see more on this topic later in the article).