PET Imaging Mini Symposium: Original Article
Can positron emission tomography be more than a diagnostic tool? A survey on clinical practice among radiation oncologists in India Thomas HMT1, Balukrishna S2, Devakumar D3, Muthuswamy P4, Samuel EJJ1 Photonics, Nuclear and Medical Physics Division, School of Advanced Sciences, 3Survey Research Centre, VIT University, Departments of 2Radiotherapy, and 4Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India 1
Correspondence to: Ms. Hannah Mary Thomas T, E‑mail: [email protected] Abstract AIM: The purpose of the survey was to understand the role of positron emission tomography (PET) in clinical radiotherapy practice among the radiation oncologists’ in India. SETTINGS AND DESIGN: An online questionnaire was developed to survey the oncologists on their use of PET, viewing protocols, contouring techniques practiced, the barriers on the use of PET and the need for training in use of PET in radiotherapy. The questionnaire was sent to about 500 oncologists and 76 completed responses were received. RESULTS: The survey shows that radiation oncologists use PET largely to assess treatment response and staging but limitedly use it for radiotherapy treatment planning. Only manual contouring and fixed threshold based delineation techniques (e.g. 40% maximum standard uptake value [SUVmax] or SUV 2.5) are used. Cost is the major barrier in the wider use of PET, followed by limited availability of FDG radionuclide tracer. Limited or no training was available for the use of PET. CONCLUSIONS: Our survey revealed the vast difference between literature suggestions and actual clinical practice on the use of PET in radiotherapy. Additional training and standardization of protocols for use of PET in radiotherapy is essential for fully utilizing the capability of PET. Key Words: Positron emission tomography, radiotherapy, radiation oncologists, survey
Introduction The objective of this study was to survey the use of positron emission tomography (PET) in radiotherapy among radiation oncologists in India. Globally, molecular imaging is increasingly recognized as an important tool for diagnosis, determination of prognosis, treatment planning and response monitoring in oncology. More than 5,000 combined PET/computed tomography (CT) have been installed world‑wide and PET/CT is today considered one of the fastest‑growing imaging modalities.[1] In India the first PET scanner was installed in 2004 in Tata Memorial Center. Now the numbers stand at about 70 functional PET/CT scanners; with sanctions approved for another 75 scanners ready to be installed by 2015. The sharp increase is due to the growing evidence supporting the usefulness of PET/CT in oncology. In an article in 2009, Graham et al. and in 2011 Beyer et al. have reported in their survey that there is considerable variability in the way PET/CT scans are performed at academic institutions and other different centers, which makes it difficult to quantitatively compare studies. [1,2] Karantanis et al. said that the lack of standard guidelines for the appropriate use of PET/CT concerning clinical indications, imaging protocols and image interpretation have resulted in referring physicians expressing considerable uncertainty about the appropriate and best use of oncologic PET/CT.[3] Most of the studies have focused on establishing the diagnostic accuracy of PET while the clinical utility of PET on the decision making is poorly reported.[3] There have also been concerns about procedure costs [3‑6] and the quality of interpretation of PET across the oncology practicing community.[7‑10] Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.138247 PMID: *******
Indian Journal of Cancer | April–June 2014 | Volume 51 | Issue 2
With the increase in the availability of PET/CT in the last few years, we focused on the impact of PET on tumor management and the use of PET as a complimentary imaging modality in radiation oncology in India. The study does not focus largely on oncologists organizational issues, but is expected to provide meaningful information to radiation oncologists to help in forming standardization protocols for the use of PET/CT in radiotherapy. Subjects and Methods Questionnaire design
The 45‑item questionnaire was developed using QuestionPro software (Seattle, USA) to assess the following aspects of PET in regular radiotherapy practice; the availability of PET/CT scanner, areas PET/CT scan finds use among the respondents routinely in the radiotherapy context, protocols followed for the display/viewing of PET, contouring techniques practiced for PET based planning, change in treatment outcomes with the use of PET, the barriers preventing the use of PET and the current training available. Demographic information included age, geographical location (state in India) from which they are practicing and the professional qualifications information included highest academic degrees and clinical experience of the respondents. Most questions required a single best response to be selected from multiple choices and the completion time required was approximately 10 min. Questions on the preferences for training and possible barriers that influence the wider use of PET allowed multiple items to be simultaneously selected. Contact of potential respondents
Invitations to participate in the survey were sent as an email to all members of the Association of radiation oncologists of India. The email invitation had a brief introduction on the purpose of the survey and the link to the online survey questionnaire. To make the survey more viewable, the online survey link was also posted in the oncologists’ community forum (isocentre.org). First reminder was sent to all the oncologists after 2 weeks and second reminder was sent after 4 weeks. After 6 weeks, the survey was closed. The completed surveys were received electronically and the data was analyzed using SAS® analytics software (SAS Institute Inc, Cary, NC, USA). 145
Thomas, et al.: A survey on clinical practice of using PET among radiation oncologists in India
Results We collected an overall of 76 responses between February and April 2013, for an overall response rate of 15%. Anonymity was maintained during the analysis. Demographic information
Almost half (53%) of the respondents were from tertiary care centers, the remaining were from exclusive cancer care centers. A majority (56%) had professional experience from three to around 10 years and 26% had more than 10 years with highest qualification reported was MD (radiotherapy) for about 79% and 12% holding a diploma in national board specialized in radiotherapy. About half (51%) of the respondents were from South India, 27% were from north and central India, 16% from the western states, only 7% responded from the eastern states. No responses were recorded from the northeastern states, the Indian islands (Lakshadweep and Andaman and Nicobar) and Goa [Figure 1]. Majority (35%) reported to have PET/CT scanners installed by GE Healthcare, followed by Siemens Healthcare (27%) and Philips Healthcare (16%) systems and 21% reported they did not know the brand name of the PET/CT scanner. The waiting period for PET/CT appointments for majority (54%) was between 1 and 3 days; the rest reported
Can positron emission tomography be more than a diagnostic tool? A survey on clinical practice among radiation oncologists in India Thomas HMT1, Balukrishna S2, Devakumar D3, Muthuswamy P4, Samuel EJJ1 Photonics, Nuclear and Medical Physics Division, School of Advanced Sciences, 3Survey Research Centre, VIT University, Departments of 2Radiotherapy, and 4Nuclear Medicine, Christian Medical College, Vellore, Tamil Nadu, India 1
Correspondence to: Ms. Hannah Mary Thomas T, E‑mail: [email protected] Abstract AIM: The purpose of the survey was to understand the role of positron emission tomography (PET) in clinical radiotherapy practice among the radiation oncologists’ in India. SETTINGS AND DESIGN: An online questionnaire was developed to survey the oncologists on their use of PET, viewing protocols, contouring techniques practiced, the barriers on the use of PET and the need for training in use of PET in radiotherapy. The questionnaire was sent to about 500 oncologists and 76 completed responses were received. RESULTS: The survey shows that radiation oncologists use PET largely to assess treatment response and staging but limitedly use it for radiotherapy treatment planning. Only manual contouring and fixed threshold based delineation techniques (e.g. 40% maximum standard uptake value [SUVmax] or SUV 2.5) are used. Cost is the major barrier in the wider use of PET, followed by limited availability of FDG radionuclide tracer. Limited or no training was available for the use of PET. CONCLUSIONS: Our survey revealed the vast difference between literature suggestions and actual clinical practice on the use of PET in radiotherapy. Additional training and standardization of protocols for use of PET in radiotherapy is essential for fully utilizing the capability of PET. Key Words: Positron emission tomography, radiotherapy, radiation oncologists, survey
Introduction The objective of this study was to survey the use of positron emission tomography (PET) in radiotherapy among radiation oncologists in India. Globally, molecular imaging is increasingly recognized as an important tool for diagnosis, determination of prognosis, treatment planning and response monitoring in oncology. More than 5,000 combined PET/computed tomography (CT) have been installed world‑wide and PET/CT is today considered one of the fastest‑growing imaging modalities.[1] In India the first PET scanner was installed in 2004 in Tata Memorial Center. Now the numbers stand at about 70 functional PET/CT scanners; with sanctions approved for another 75 scanners ready to be installed by 2015. The sharp increase is due to the growing evidence supporting the usefulness of PET/CT in oncology. In an article in 2009, Graham et al. and in 2011 Beyer et al. have reported in their survey that there is considerable variability in the way PET/CT scans are performed at academic institutions and other different centers, which makes it difficult to quantitatively compare studies. [1,2] Karantanis et al. said that the lack of standard guidelines for the appropriate use of PET/CT concerning clinical indications, imaging protocols and image interpretation have resulted in referring physicians expressing considerable uncertainty about the appropriate and best use of oncologic PET/CT.[3] Most of the studies have focused on establishing the diagnostic accuracy of PET while the clinical utility of PET on the decision making is poorly reported.[3] There have also been concerns about procedure costs [3‑6] and the quality of interpretation of PET across the oncology practicing community.[7‑10] Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.138247 PMID: *******
Indian Journal of Cancer | April–June 2014 | Volume 51 | Issue 2
With the increase in the availability of PET/CT in the last few years, we focused on the impact of PET on tumor management and the use of PET as a complimentary imaging modality in radiation oncology in India. The study does not focus largely on oncologists organizational issues, but is expected to provide meaningful information to radiation oncologists to help in forming standardization protocols for the use of PET/CT in radiotherapy. Subjects and Methods Questionnaire design
The 45‑item questionnaire was developed using QuestionPro software (Seattle, USA) to assess the following aspects of PET in regular radiotherapy practice; the availability of PET/CT scanner, areas PET/CT scan finds use among the respondents routinely in the radiotherapy context, protocols followed for the display/viewing of PET, contouring techniques practiced for PET based planning, change in treatment outcomes with the use of PET, the barriers preventing the use of PET and the current training available. Demographic information included age, geographical location (state in India) from which they are practicing and the professional qualifications information included highest academic degrees and clinical experience of the respondents. Most questions required a single best response to be selected from multiple choices and the completion time required was approximately 10 min. Questions on the preferences for training and possible barriers that influence the wider use of PET allowed multiple items to be simultaneously selected. Contact of potential respondents
Invitations to participate in the survey were sent as an email to all members of the Association of radiation oncologists of India. The email invitation had a brief introduction on the purpose of the survey and the link to the online survey questionnaire. To make the survey more viewable, the online survey link was also posted in the oncologists’ community forum (isocentre.org). First reminder was sent to all the oncologists after 2 weeks and second reminder was sent after 4 weeks. After 6 weeks, the survey was closed. The completed surveys were received electronically and the data was analyzed using SAS® analytics software (SAS Institute Inc, Cary, NC, USA). 145
Thomas, et al.: A survey on clinical practice of using PET among radiation oncologists in India
Results We collected an overall of 76 responses between February and April 2013, for an overall response rate of 15%. Anonymity was maintained during the analysis. Demographic information
Almost half (53%) of the respondents were from tertiary care centers, the remaining were from exclusive cancer care centers. A majority (56%) had professional experience from three to around 10 years and 26% had more than 10 years with highest qualification reported was MD (radiotherapy) for about 79% and 12% holding a diploma in national board specialized in radiotherapy. About half (51%) of the respondents were from South India, 27% were from north and central India, 16% from the western states, only 7% responded from the eastern states. No responses were recorded from the northeastern states, the Indian islands (Lakshadweep and Andaman and Nicobar) and Goa [Figure 1]. Majority (35%) reported to have PET/CT scanners installed by GE Healthcare, followed by Siemens Healthcare (27%) and Philips Healthcare (16%) systems and 21% reported they did not know the brand name of the PET/CT scanner. The waiting period for PET/CT appointments for majority (54%) was between 1 and 3 days; the rest reported
