The Lancet Oncology Commission

The Lancet Oncology Commission on Medical Imaging and Nuclear Medicine

MARCH, 2021

The ANZSNM, alongside its peers such as the SNMMI and EANM made up 27 institutions worldwide who supported resourcing and the compilation of this landmark report. Andrew Scott was one of the four co-lead authors of this commission. The report will form the foundation of future research. In this section we distill some key aspects for you.

Summary

The Commission was convened with the logistical support of the International Atomic Energy Agency (IAEA) to address three themes:

Evaluate status of equipment and workforce for cancer imaging in over 200 countries globally

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Identifying barriers to cancer imaging particularly in lowincome and middle 3 income countries

Determine the health and economic benefits of scaling up cancer imaging globally by region and country income level

The initial Commission analysis found that there was no available information on equipment or workforce for medical imaging and nuclear medicine on a country level globally. Therefore, a major initial project was to establish these parameters was undertaken with input from countries and regional societies. ANZSNM contributed equipment and workforce information for this project. Co-ordinated by the IAEA, a database was established for equipment and workforce for over 200 countries.

IAEA Medical imAGIng and Nuclear mEdicine (IMAGINE)

CLICK TO ACCESS IMAGINE DATABASE This database is readily accessible to the public and for future researchers to use. For SPECT and PET, the number of equipment in high income countries was found to be mean 18.2 and 3.6 per million population respectively: in Australia/New Zealand it is 8.7 and 2.8 per million population.

In order to initially establish the health outcome improvement of enhancing access to medical imaging and nuclear medicine in cancer patients, a simulation modelling approach was conducted for 11 cancers, where country-specific mortality rates, impact of optimal imaging and treatment (based on delphi analysis of opinion from international experts) on cancer outcomes, availability of treatment per country, and imaging equipment availability (from IMAGINE database) was undertaken. This complex analysis was undertaken by the Commission with experts from Harvard University, USA. Expanding access to imaging (e.g. ultrasound) was found to have greatest impact in low income countries, with MRI, PET and CT in middle-income countries, and PET, CT and SPECT in high income countries. It was found that combining improved access to imaging along with treatment and quality of care would improve 5 year net survival by ten fold in low income countries, and five fold in middle income countries. This highly impactful data was published in Lancet Oncology in 20201 .

In a landmark analysis, the impact of improving access to imaging on cancer patient survival for 11 common cancers at a global level, and financial benefits, was then evaluated. It was found that scale-up of imaging would prevent 2.46 million cancer deaths (3.2% of the projected total of 76 million worldwide deaths from 2020-2030) and save 54·92 million lifeyears. Even more strikingly, the analysis indicated that imaging amplifies the benefits of other cancer services: the model estimated that while scale-up of treatment and quality of care alone would prevent 5.37 million deaths (7% of the worldwide total), adding imaging to achieve comprehensive scaleup would prevent 9·55 million deaths (12.5% of the worldwide total) and save 232·30 million life-years2 . Further analyses using this approach as part of the Commission in cervical and breast cancer found simi-

breast cancer found similar high impact of access to imaging and treatment on overall survival3,4 .

With respect to economic impact, the analysis showed that a global scaleup of imaging from 2020— 2030 would cost $6.84 billion, and this would lead to productivity gains of $1.23 trillion for the cancer cases diagnosed in 2020— 2030 and a net benefit of $1.22 trillion, yielding a remarkable return of $179 for every dollar invested.

Combining imaging with improvement in access to treatment and quality of care would double the returns gained by investing in treatment and quality of care alone.

This highly impactful data was published earlier this year in Lancet Oncology2,5, and the major Commission report was included in a dedicated edition of Lancet Oncology with 7 commentaries6. This information will be used for major policy initiatives for enhancing access to imaging in low, middle and high income countries, with nuclear medicine (SPECT and PET) being shown to have an essential role in this approach to improving outcomes for cancer patients. As the final Commission report states..”the investment in population based health can be a tool towards a nation’s development, rather than a mere byproduct of it.’ Nuclear medicine often doesn’t get the profile it deserves within the healthcare spectrum. And, if you ever needed reminding about what effect your profession can or is making to global healthcare then this report is an objective reminder. Importantly there is a bright future for Nuclear Medicine in which we all can all play a part.

References

1. Z.J. Ward, A.M. Scott, H. Hricak, M. Abdel-Wahab, D. Paez, M.M. Lette, H.A. Vargas, T.P. Kingham, R. Atun. Estimating the impact of treatment and imaging modalities on 5-year net survival of 11 cancers in 200 countries – a simulation-based analysis. Lancet Oncology 21:1077-1088, 2020.

2. Z.J. Ward, A.M. Scott, H. Hricak, R. Atun. Global costs, health, and economic benefits of scaling up treatment and imaging modalities for survival of 11 cancers: a simulation-based analysis. Lancet Oncol 22:341-350, 2021.

3. Z.J. Ward, A.M. Scott, H. Hricak, M. Abdel-Wahab, D. Paez,

M.M. Lette, H.A. Vargas, T.P. Kingham, R. Atun. Estimating the impact of treatment and imaging modalities on 5-year net survival of 11 cancers in 200 countries – a simulation-based analysis. Lancet Oncology 21:1077-1088, 2020.

4. Z.J. Ward, R. Atun, H. Hricak, K. Asante, G. McGinty, E.J. Sutton,

L. Norton, A.M. Scott, L.N. Shulman. The impact of scaling up access to treatment and imaging modalities on global disparities in breast cancer survival: a simulation-based analysis. Lancet Oncology (in press)

5. H. Hricak, M. Abdel-Wahab, R. Atun, M. Mikhail Lette, D.

Paez, J.A. Brink, L. Donoso-Bach, G. Frija, M. Hierath, O.

Holmberg, P-L Khong, J.S. Lewis, G. McGinty, W.J.G. Oyen, L.N.

Shulman, Z.J. Ward, A.M. Scott. Lancet Oncology Commission on Medical Imaging and Nuclear Medicine. Lancet Oncol 22:e136-72, 2021.

6. https://www.thelancet.com/commissions/medical-imagingnuclear-medicine

At a Glance

WHAT ARE SOME OF THE REPORT FINDINGS?

• Global cancer incidence by 2040 is expected to rise by 62%. Between 2020 and 2030, 76 million deaths are being modelled for cancer

• Worldwide the overall survival rates for cancer are improving but less so in low and middle income countries

https://humanhealth.iaea.org/HHW/DBStatistics/IMAGINE.html

• Global inequities exist given the upfront capital costs with trained human resources

• The cost of investment is a barrier to adoption creating of cancer imaging including for older imaging technologies such as x-rays

• For $1 spent globally bridging the gap in availability of imaging there is a return of $179 • Further modelling showed that combined improved access to imaging and treatment and quality of care could save 9.5 million lives in a decade (the entire population of New Zealand nearly twice over)2 .

• Radiopharmaceutical supply and supply chains, especially with the challenges of half lives remain a problem3 .

• 1 CT scanner serves 25,000 people in high income countries. In low income countries it serves 1,700,000 — a factor of 68 times.

• 1 PET scanner serves around 300,000 people in high income countries. In low income countries, it is an astounding 1 PET scanner for 167 million

• 1 SPECT scanner is available per 50,000 people in high income countries, whereas in low income countries it serves 10 million people

• As a lead up to the report, a microsimulation model by Lancet Oncology showed for 11 cancers (which represent 60% of all diagnosed cancers) that simultaneous expansion of treatment, imaging and quality of care “could improve 5-year net survival rates by >10 times in low income countries.”1

WHAT ARE THE FINDINGS FOR AUSTRALIA AND NEW ZEALAND?

• Australia and New Zealand ranks similar to mean numbers for high-income countries globally for the number of PET (2.8) scanners per million population

• In terms of SPECT (8.7) scanners per million population Australia and New Zealand had slightly lower numbers compared to mean of high-income countries which is (18.2) scanners per million population

• Australia has 14 nuclear medicine specialists per million inhabitants, similar to the mean for high-income countries

What are the solutions proposed?

1. Aim to incorporate imaging for cancer patients into health policy and cancer control plans for countries globally

2. Investment in equipment and workforce to allow low and middle income countries to have infrastructure and human resources similar to next higher income group

3. The use of digital tools and innovations including artificial intelligence and telemedicine to improve access to imaging resources. Whilst a presence would be required to undertake scans for instance the use of telemedicine for ‘downstream’ data processing

4. Investment in training, research and innovation, including clinical trial capability

5. A need for collaboration across multiple stakeholders to address a scale up is required. Money alone simply will not achieve the outcomes and a comprehensive regional and country plan that combines workforce alongside dollars spent on equipment has to be considered

6. Imaging should be included as part of the comprehensive approaches to treatment of cancer alongside clinical decision making. This is especially the case in low and middle income countries in matching technologies with the treatments available locally as well as the resources

Interview

WITH PROFESSOR ANDREW SCOTT

one of the lead co-authors

Ever wondered how a report such as this is put together? One of the authors of the Lancet Commission for Oncology was our own, Professor Andrew Scott, AM.

Andrew is well known to us in the profession and serves as the Director of the Department of Molecular Imaging and Therapy at Austin Health, as well as a Professor at Melbourne University and La Trobe University, and Head of the Tumour Targeting Program at the Olivia Newton-John Cancer Research Institute. Andrew also sits on the ANZSNM Council and is chair of the International Relations Committee of the Society.

Given our close proximity to Andrew, we thought to ask some ‘behind the scenes’ questions. We focussed on the machinations of how a landmark and large scale report is put together. Here is what he told us.

Gamma Gazette (GG): Andrew, Congratulations on our behalf to you and your colleagues on the report. An outstanding achievement and of course more so given the challenges and distraction with the onset of COVID-19 last year. How did you come to be involved in the project?

Andrew Scott (AS): I was approached to be a lead Commissioner for this project in late 2018, principally because of my previous role as President of the World Federation of Nuclear Medicine and Biology, but also as I have had numerous interactions with the IAEA and other major societies such as SNMMI, EANM and AOFNMB. I also knew two of the other lead Commissioners quite well – Prof Hedi Hricak (New York) and Prof May Abdel-Wahab (IAEA). When I was asked to be a part of the Commission, I readily agreed. I thought it would be very interesting as any Lancet Oncology Commission is a major global initiative, and I also felt it was important to have someone with a Nuclear Medicine background involved in a senior role in such a major project.

(GG): With a project as large as this, incorporating the globe, how does one start? Is it you sitting down scoping out what you think it should include? People being assigned areas? What is the approach even to what should go into a report?

(AS): The approach to a large project like this is not dissimilar to any project – you must have a clear plan before starting as to what you propose to do, how it should be done, and who should be involved. Of course, there are surprises along the way, but this is not unexpected! A key component of a major endeavour like a Lancet Oncology Commission is what is expected at the end of the project, which in this case was a large paper with policy-changing data that would inform national governments and international organisations. We brought together a larger Commission group, consisting of 16 experts in imaging, nuclear medicine, radiology, oncology and public health, and defined an outline of the final paper and sections, and allocated leadership of sections to one of the Commissioners. As each part of the project came together, we enlisted input from an additional 21 "commissioners-at-large" for key input. Consultations occurred with all major nuclear medicine, radiology and oncology societies in Europe, North America, Latin America, Middle East, Africa, and Asia-Oceania. The results were far more impactful than we initially anticipated, hence there were 4 additional papers published apart from the main Lancet Oncology Commission paper.

(GG): The Report had many moving parts, the IMAGINE database, a financial model, and the report recommendations divided into eight sections. How is it all ultimately synthesised, and who ensures there is coherence to the different aspects?

(AS): It was not straightforward! The collection of equipment and workforce information for medical imaging and nuclear medicine was the initial biggest challenge, as we had to liase with the nuclear medicine and radiology societies and key contacts in 200 countries individually, as well as databases and industry connections – this took almost 9 months. The IAEA Division of Human Health was an essential part of this process. Then, to develop the financial model, key incidence and survival data from global cancer databases (GLOBOCAN, SEER and CONCORD-3) was obtained, and a delphi analysis of appropriate use of imaging and therapeutics in 11 main cancers types was elicited from panels of imaging (34 experts) and therapy (21 experts) participants we assembled from around the globe. Other sections were brought together by our expert groups. The final manuscript was written by the lead Commissioners, working closely together and ensuring consistency of language and messaging.

(GG): Could you please talk a little about the data analysis work in terms of the microsimulations done on the 11 cancers in 200 countries? Who and what was the process including compiling, interrogating and checking the data output?

(AS): This was a very interesting process, as it involved complex modelling undertaken by experts in the TH Chan School of Public Health at Harvard University (Zach Ward and Rifat Atun). This type of analysis is used for major public health analyses, such as used by WHO and governments to justify policy changes and health care expediture. It requires accurate input data on disease incidence, country-based statistics on health outcomes, justification for health care use, and expert opinion on clinically relevant practice. There may be 1,000 simulations performed for every variable, and this process requires major computing resources (such as at Harvard University). Checks of accuracy are built into the models, so that independent verification on results are made to ensure the validity of results. It is very technical, but a proven methodology for population-based analyses.

(GG): Related to the previous question the report makes compelling arguments for quality of life and lives saved. For instance $6.84 Billion would yield $1.23 trillion. A counter though perhaps fatuous argument to make given the high returns that are derived but, for low income countries (who are financially constrained), wouldn't investing in primary healthcare save more lives?

(AS): The implementation of screening for early detection of cancer is clearly justified, and in our Commission we made clear that this was a very important public health initiative that should be implemented particularly in low and middle income countries. Our Commission focused principally on patients once they were diagnosed with cancer, and how to improve outcomes based on current rates and stage of cancer at diagnosis. We were surprised at what financial returns could be achieved over 10 years just with improving access to imaging. For this reason we will be taking these results to international groups (eg WHO, UICC) to argue for policy changes that will be adopted by Governments. The results also highlighted where improvements in access to imaging (including nuclear medicine) even in high-income countries could be achieved, including Australia and New Zealand.

(GG): Coming back to the report, if you are assigned tasks within the plan for which there are deadlines (alongside your ‘normal’ work) how did you manage to complete your tasks? Tips for those of us less adept in managing our time Andrew?

(AS): We all lead busy lives, and for myself I do have a range of clinical commitments and administrative responsibilities that occupy most of my time during normal work hours. What I try to do is each day set a plan for what I aim to achieve, and be as efficient as I can be to complete these tasks. I always spend at least an hour (or two) early each morning and again every evening completing my emails and major tasks, and making calls to key collaborators. I rarely have time to write reports or papers in normal hours, and this is done in the evenings and weekends. With time I have found that I can multi-task quite effectively, and achieve deadlines. What is also quite important is to think "big picture" as least once a week – where are the main projects heading, what key issues need to be addressed and analyses performed, what deadlines have to be met, who do I need to speak to. Fitting all this into the week with home and family commitments can be a challenge, but it can be achieved!

(GG): In focussing on the organisation and conclusions of the report and given that you probably didn’t have face to face meetings due to COVID how did you overcome issues? For instance, academic disagreements and debate as to the items that should be made in the conclusion?

(AS): A lot of online webinar meetings, and phone calls! At the beginning of the project (pre-COVID) I was fortunate to be able to spend a month in Vienna, New York and Boston (as part of Sabbatical leave) with the lead Commissioners planning the project, and spending some time with the Harvard group understanding the health outcome and financial modelling process. Once the results started to come through the outcomes were reasonably straightforward. Having a structure of lead Commissioners did allow decisions to be made quickly, a small group of us wrote all the papers, and the other experts involved in the Commission were happy to give comments on final drafts.

(GG): In terms of your contributions and of course aside from your professional knowledge, experience and insights what do you think were the critical perspectives you could provide from being located in Australasia?

(AS): Australia and New Zealand have always had a reputation for quality academic outputs and health policy initiatives in Nuclear Medicine. This has been recognised by all major International societies, and key opinion leaders. We are also far away from the politics of health care in the US and Europe, but known to have strong engagement with Asia and Oceania in our field of medicine. In this context, I was able to be seen as an independent expert but also representing Nuclear Medicine in this project (and the only lead Commisioner with this background). I hope that my involvement in the Commission will give further credence to Australasia being a leader globally in nuclear medicine, and having a major impact in health outcomes for patients.

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