26 Nov 2018 - 28 Nov 2018
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TAKING STOCK - Taking Stock
EAPM Director Dialogues - Arturo Chiti
Arturo Chiti is the President of the European Association of Nuclear Medicine and is based at the Istituto Clinico Humanitas in Italy.
As he says: “Our field is nuclear medicine, which is, of course, well-connected to imaging and is also connected with treatments. The common denominator of nuclear medicine is the use of radio-pharmaceuticals. These radio-pharmaceuticals are able to produce imaging of particular metabolic or pathologic processes and, by targeting a particular organ or structure we can also do therapy.”
So how does it relate to personalised medicine? Chiti says: “Well, this is a nice concept because, most of the time, you can actually see what you are going to treat – the target - and this, let’s say, is a pillar of personalised medicine. The moment that you see the target, that means that you can treat it. So, in our view this is really personalised medicine.
”Also, the advantages are that radio-pharmaceuticals are more sensitive most of the time. For some tumors, the early response to therapy is of paramount importance, so you start the therapy and you can change or not change it according the results of our tests.”
But there are modern challenges it seems. He says: “What we are really doing is medicine with these radio-pharmaceuticals, and all the challenges are related to that. (Such as) the availability of radio-pharmaceuticals throughout Europe. Because these days you can have cutting-edge imagining in one country, but if you cross the border then the pharmaceutical may not be available.
”Why? Because radio-pharmaceuticals are considered drugs, so there is a strong national influence on the availability of these radio-pharmaceuticals. It’s exactly what you have with non-radioactive pharmaceuticals.
“So one challenge is to have all the radio-pharmaceuticals, which have proved to be effective for imaging treatment, within a pool available Europe-wide. But this is not the case. In Germany you have good availability because they allow compassionate use, whereas in France you have very little because they can only use those with commercial authorisation. So it’s really different in different countries.
”The second challenge is regarding education, especially as we are moving to multi-modality imaging, so we really see the necessity in having just one imager to look at everything – we are probably going to have one big machine, one imager – and this is something that has to be combined with the national and European certification. Nowadays, in many countries, there are different specialties – which is fine for most of the applications but, for some of the applications we do need nuclear medicine physicians with the knowledge of the radiologists, and vice-versa.
“We also need education for the non-medical professionals involved in imaging therapy and radio-pharmaceuticals. So we need education for technologists, nurses and the very peculiar category of radio-pharmacists, and physicists of course.”
But it doesn’t end there. Chiti says: “Now, in the Netherlands, they have a joint specialty. So, radiology and nuclear medicine are not two independent specialties anymore. In a few years we are going to have this specialist group and we do not know how they will fit into the other countries. Let’s imagine that one of these specialists wants to move from the Netherlands to Belgium…we don’t know what he or she will be allowed to do, nuclear medicine or radiology or both?”
“Then there is the challenge of evaluating the response of new drugs, the biological drugs, the drugs that are able to induce the immuno-response, and there is a challenge for us in how imaging can help in tailoring the treatment.”
”The last challenge - last but not least - is the standardisation of procedures. There is no standard in place for interpretation (of results). This is something that is very important, so the message that we give in Spain to the medical oncologists is the same message that should be given to those in the Czech Republic. Basically, there are data regarding technical standardisation, but there are very few efforts to have interpretation standards.”
Asked for a wish list for the EU, Chiti says: “What I would ask for from the health commissioner is, in the context of radio-pharmaceuticals, give more power to the EMA. And for education, install a kind of coordination of the education that is given to doctors after their degree. So that this post-specialisation education should be more harmonised.
“And what we really need is to have more imaging available to set standards. To give a very clear example: within EORTC we are trying to set the standards for the more commonly used radio-pharmaceuticals and what we realised is that many of the data which are available at top-level hospitals, which collaborated with EORTC, cannot be used to set these standards because they are not collected in the same way.
”So, as soon as we are able to have a standard for everybody it will really represent added value. It would help a great deal if we were able to collect data, not only for clinical trials, but for everyday practice in a standardised way. Because this way we would never waste any data.”
Chiti adds: “We could have a problem with how everybody works, because the moment you set a standard you need everybody to comply with it, and the quality should be at a higher level than it is now. So again, that should be a proposal from the EU to ask the governments to set a standard for imaging in general.
”One of the problems that we have is that industry doesn’t like the standards a lot because if you are (company) A, you want to be able to say that my machine is better than that provided by (company) B. So, if they are the same because they have to stay within a standard, then it’s going to be difficult to convince you to buy my machine.”
But Chiti has a solution: “This can be solved by having two different levels. For instance, the high-level machine with a full patent standard and then, let’s say, one at the basic level that can be used for collecting data.”
Finally, another problem, he concedes, is that the kind of technology he is referring to is quite expensive. “Nowadays, if you are expensive, you are not nice,” he laughs.Author: Denis Horgan