In March 2013 I was working in Steve Biko Academic Hospital (SBAH) in Pretoria. One of my patients had just been diagnosed with Lung Cancer and the professor who is the head of our unit asked me to book a PET-CT scan. I had no idea what that was but assumed that if I called the Radiology Department, where the normal CT scanner was, they would be able to assist me. I was wrong; this mysterious PET-CT scanner actually belonged to the Nuclear Medicine Department: another very unfamiliar aspect of medicine to me.
Only now, since starting to research groundbreaking technology in South Africa, that I realize how fortunate we were in Pretoria to have such a scanner. There are only a handful of them in South Africa, and the majority are found in Gauteng. One at SBAH, another at Chris Hani- Baragwanath Hospital, and a third is at Charlotte Maxeke Johannesburg Academic Hospital.
The PET-CT scanner is now at the forefront of diagnostics for many cancers and it can change the management and outcome in up to 33% of cancer cases. It is used in four main avenues: diagnosing; staging cancers; monitoring treatment; and, restaging.
It is a hybrid machine that combines a PET scanner (Positron Emission Tomography) which detects a radioactive substance called a tracer as it is metabolized by the body (thus studying the physiology of the body.) It can detect increased cellular activity which is a trademark in almost all cancers. The other component of the scanner is the CT scanner. Computed Tomography works as if dissecting the body into very thin slices, where each of those slices is looked at in succession. CT scanners let doctors see the structure of the human body (anatomy). These two images are then superimposed and the doctor can see where exactly the increased cellular activity is taking place.
An important issue to address when any new technology is being introduced is whether the infrastructure and training is in place so that the machine can be used to its full capacity.
A few obstacles that South African Healthcare is facing with the PET- CT scanners is the extreme cost to operate it. Costing over R10,000 per scan, the private medical aid schemes are very apprehensive to pay for patients to have the scans done. So with fewer scans being done per day than anticipated, the PET- CT scanner is losing money and there is risk of closing them down.
Another unforeseen problem is the process of getting the scan done. The doctor and their patient have to submit their case in front of a panel who then decides which patient can get the scan. This results in a lengthy, traumatic wait of more than 2 weeks and while they wait, the cancer grows.
An issue that I noticed specifically in SBAH is that though some of the patients were healthy enough to be cared for at home, the list for the scan is longer for outpatients. As a result, doctors admitted those patients into the hospital ward so that the scan would be expedited. This costs the State a lot more money because now the patient is occupying a hospital bed, using medication, resources, etc. for weeks at a time, all of which is unnecessary.
The guidelines are heavily influenced by evidence-based medicine done in the UK and the USA. Thus patients diagnosed with uncommon cancers are rarely referred to the Nuclear Medicine Department because there is not enough evidence supporting whether the PET- CT scan will be beneficial. This is something that countries around the world are trying to change by documenting and thus increasing evidence for use for other cancers. This is imperative to ensure the scanners remain operational.
The South African Government knew the PET-CT scanner would be beneficial for its population. Of the 11 cancers that the PET- CT scanner is used for, nine of these cancers are in the top ten most common cancers in South Africa amongst adults (male and female) and children! These cancers are: lymphoma (Hodgkins, Non-Hodgkins and Burkitts), head and neck cancers, breast cancer, stomach cancer, colorectal, oesophageal, ovarian cancer, malignant melanoma and lung cancer.
The PET- CT has the potential to truly change hundreds of thousands of patients’ lives and also save the State money by minimizing unnecessary surgeries and biopsies. The two Johannesburg hospitals see over 60,000 oncology patients per year (including pediatrics, radiation and medical oncology). Not to mention the scanner in the Gauteng Hospital that not only helps patients in Gauteng; but it also helps patients in the neighboring provinces of Limpopo and Mpumalanga.