As nuclear medicine therapies gain stature compared to nuclear medicine in diagnostic imaging, hospital administrators may be eyeing the potential of adding theranostics services.
Nuclear medicine physicians may be asked to participate in planning for theranostics, and their collaboration with hospital leaders is recommended in order to start gathering the right information for the strategy, according to Dmitry Beyder, a nuclear medicine technologist who grew into the role of theranostics practice administrator at Barnes-Jewish Hospital (BJH)/Washington University (WU) in St. Louis. Beyder led a theranostics practice management and logistics track at the recent Society of Nuclear Medicine and Molecular Imaging (SNMMI) annual meeting in Toronto.
Reshaping the hospital's nuclear medicine and radiopharmaceutical strategy toward theranostics involves intensive and inclusive planning, Beyder explained at SNMMI. A key mistake you can make early is not identifying your stakeholders, understanding their expertise, and including them. This oversight has led to program launch setbacks, Beyder explained.
As nuclear medicine therapies gain stature compared to nuclear medicine in diagnostic imaging, hospital administrators may be eyeing the potential of adding theranostics services.
Nuclear medicine physicians may be asked to participate in planning for theranostics, and their collaboration with hospital leaders is recommended in order to start gathering the right information for the strategy, according to Dmitry Beyder, a nuclear medicine technologist who grew into the role of theranostics practice administrator at Barnes-Jewish Hospital (BJH)/Washington University (WU) in St. Louis. Beyder led a theranostics practice management and logistics track at the recent Society of Nuclear Medicine and Molecular Imaging (SNMMI) annual meeting in Toronto.
Reshaping the hospital's nuclear medicine and radiopharmaceutical strategy toward theranostics involves intensive and inclusive planning, Beyder explained at SNMMI. A key mistake you can make early is not identifying your stakeholders, understanding their expertise, and including them. This oversight has led to program launch setbacks, Beyder explained.
Nuclear medicine technologist and theranostics practice administrator Dmitry Beyder (left) and Vikas Prasad, MD, PhD (right), lead the theranostics center at Barnes-Jewish Hospital/Washington University in Saint Louis, MO. Image courtesy of Washington University.
"We want to make sure that all of our stakeholders are very much in the loop of what we're doing and where we're going, and that's part of the way that we move the theranostics program forward," Beyder said. "If there are concerns there, we slow down, and we make sure we get support and approval before we move forward because, certainly, we've learned that if you don't do that, you go backward."
Beyder, along with Vikas Prasad, MD, PhD, and BJH/WU Radiation Oncology all played an integral role in launching the SNMMI radiopharmaceutical therapy (RPT) comprehensive center of excellence at WU, Barnes-Jewish Hospital, and Siteman Cancer Center last year.
Theranostics center development
First, Beyder recommended assessing the patient population in your facility's immediate area, referral patterns, and volume by cancer type.
Internal referrals compared with external referrals and the percentage of cancer patients your facility serves in your region can be eye-opening, Beyder said. "Budgeting encompasses projecting the quantitative values around expenses, revenue, and what's going to happen to your volume."
Theranostics center planners at BJH/WU projected how patient volume would divide between neuroendocrine tumor treatment, prostate-specific membrane antigen (PSMA) therapy, iodine therapy, and projecting a need for radium-223, for example. At the time, their cancer center served a significant cancer population in the region and maintained robust and ever-expanding PET diagnostics.
Importantly, Beyder said to compare the implications of different theranostic service levels, such as planning for a scenario of five theranostic procedures per week compared to five theranostic procedures per day. Considerations include facility buildout, radiopharmacy demand, and staffing.
A shortage of nuclear medicine technologists means a theranostics center may need to limit its patient volume. Above all, an "authorized user" is required by the U.S. Nuclear Regulatory Commission and is an integral part of a theranostics practice.
BJH/WU's joint theranostics program provides a full range of theranostic services, including diagnostic imaging, consultation, radiopharmaceutical infusions for both clinical and research treatments, and follow-up evaluations.
Theranostics offers hospital radiology departments the opportunity to keep more reimbursement dollars in the department, Beyder explained. Spending time on electronic medical record (EMR) system order sets early will translate into higher reimbursement.
"Your EMR order sets are essential because ordering physicians, oncologists, urologists, they have a lot going on. Giving them a clear path of what theranostics looks like on the imaging side, on the therapy side, on the lab side, on the follow-up side, on the post-therapy side, and on the dosimetry side -- we build that all into EMR order set," Beyder explained. "The more time you put into it, the easier it is for your ordering physicians to actually navigate the system and the easier everybody's job is downstream. Your reimbursement finance department is really happy with the results, too, because if you do this thing right, your reimbursement can be up to 10% better than if you don't do it right, and it's pretty impressive."
Beyder emphasized understanding front-end and back-end administrative issues. For example, a system for evaluating patient eligibility is key, and reducing costs, such as through the 340B Program which is supported by the U.S. Centers for Medicare and Medicaid (CMS) and manufacturers that agree to provide pharmaceuticals at significantly reduced rates for facilities that qualify.
Safety design
Safety design of the theranostics facility will be a major consideration. Tips shared during the SNMMI session include reducing the walking distance between a patient treatment room and the toilet. In addition, group treatment rooms together, which can mean the difference between interrupting service on an entire floor versus limiting a shutdown to a corner of the center, for example.
A system of using protective, disposable floor covering to minimize the chance for contamination spread in each treatment room, and therefore cleanup time, in the event of an incident is also recommended.
Time, distance, shielding, and contamination control are critical, explained Kyle Underwood, a certified health physicist at the Mayo Clinic Rochester and doctoral candidate at the University of Minnesota. Underwood led the nuclear medicine and radiopharmaceutical therapy team within radiation safety at Mayo Clinic and directly supports the program in Rochester. Also be mindful of design requirements in the U.S.; dose rate limits for public spaces, hot labs, and patient rooms; and necessary signage, Underwood said.
The bottom line? Involve radiation safety early in your therapy center development.
"If you come up with a design that works for your patient flow and you don't involve radiation safety, then at the end we may end up having to make changes," Underwood said.
Theranostics tumor board
Theranostics center patients will benefit from the collaboration and expertise of a dedicated tumor board, added Prasad, who serves as director of clinical theranostics in the division of nuclear medicine at Mallinckrodt Institute of Radiology. The theranostics tumor board (TTB) of Washington University in St. Louis is unique for radiopharmaceutical therapy patient triage, Prasad said.
"There are not really concrete guidelines on some of these real-world uses of radiopharmaceutical therapies, which often leaves physicians and technologists, as well as the medical physicists, with sometimes very difficult and uncertain choices," Prasad said at SNMMI 2024.
A theranostics tumor board can address dose modifications and personalized dosimetry, provide guidance in the management of adverse events, and recommend the sequence of treatments, Prasad said.
WU established a multidisciplinary continuing medical education (CME) and continuing education (CE)-accredited theranostics tumor board at the center. The theranostics tumor board at WU is part of a larger collaboration between the disciplines of nuclear medicine and radiation oncology.
Meeting twice a month, the theranostics tumor board includes experts from the fields of nuclear medicine, radiation oncology, medical oncology, and medical physics. Radiochemists and nuclear medicine technologists, as well as nursing staff, are part of the tumor board. Trainees in nuclear medicine, radiology, radiation oncology, and other disciplines are actively engaged as part of their educational programs.
"The tumor board gives recommendations that help treating physicians in the management of the patient and radiopharmaceutical therapy-related toxicities," Prasad told AuntMinnie.com via email, noting that tumor board proceedings support personalized treatment.
A companion poster presented at SNMMI 2024 showed the impact of WU's theranostics tumor board specifically. In 101 patients evaluated by the tumor board between July and December 2023, the team contributed to a change in management by 24%.
The WU team concluded that the multidisciplinary theranostics tumor board is a powerful tool in the management of patients referred for radiopharmaceutical therapies.
"In the modern era of personalized medicine, theranostics is the true exponent of precision oncology," Prasad told AuntMinnie.com. "Understanding and execution through strategic planning and education is the need of the hour, because cancer patients deserve to have better quality and potentially life-prolonging radiopharmaceutical therapies."
This is the fifth in a series of articles covering the rise of theranostics. Start at part I here.