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The molecular imaging guru chats with DOTmed about the boundless promise of the field and its timely capability to benefit from population monitoring through electronic health records.

In preparing our June issue, DOTmed Business News spoke with Henry Wagner, M.D., professor emeritus at Johns Hopkins Bloomberg School of Public Health.

[DM: This will be the 33rd year in which you report to the SNM on highlights in nuclear medicine and molecular imaging. What exciting advances are on the horizon?]

HW: The theme for my talk is creating a new, smarter health care system. I think the times are fantastic for nuclear medicine because of personalized medicine. Right now we define disease in terms of molecules. We have moved from the cellular to the molecular level. The cells are still obviously very important but we have been able to get inside the cells with molecular imaging.

Molecular imaging makes it possible to characterize the molecules sending messages throughout the body and the receptors that receive them. In my opinion, no specialty of medicine today is better equipped to transfer the advances in molecular biology and genetics to take care of patients in prevention of disease.

[DM: Does that play into possible health care reform in the U.S.?]

HW: We really don't have the details of what the government is proposing for health care reform. They are putting $15-16 billion into electronic health records. They postulate that by 2013 electronic health records will really improve medical practice. They have stressed things like the administrative improvements, scheduling and preventing drug errors but I think analyzing all that data is going to be a tremendous way to improve medical practice at the clinical level.

Most people would agree that a lot of things are done in clinical medicine today that are not ideal because the doctors don't have the proper information. So a nationwide electronic health information system can play a major role in producing smarter health care.

[DM: How does that population information feed into molecular imaging?]

HW: The data from the patient can be analyzed in light of the molecular imaging information that is obtained. There are many studies being performed right now that fit into that category but they are only being analyzed in relatively small groups by individual research studies. The [electronic health record] database will store a tremendous amount of data that is now being done piecemeal by essentially including every patient in the study.

The data that will be stored in these electronic health records can tell how molecular imaging can differentiate helpful from unhelpful care. It will help eliminate costly, unhelpful care and therefore more care can be provided to more people because you will be doing it much more efficiency per patient.

[DM: How does the field of nuclear medicine stand to benefit?]

HW: The new reforms are going to help nuclear medicine if properly used, not the way they are proposing. What you read about are things like patient scheduling and transfer of records from one hospital to another. What I am saying is that recording and analyzing the data from these patients will really improve patient care and decrease costs.

You can do what's called data mining, take all this data and mine it for what helps and what doesn't help and change practice patterns.

For example there are nuclear imaging studies that show that coronary angiography could have been avoided. The University Hospital of Zurich [BA Herzog et al] showed that in a large series of patients where they did both invasive coronary angiography and the SPECT studies that they could have avoided the coronary angiography in 60 percent of the patients, which is a great savings in cost.

[DM: Now you are speaking the government's, or the payors', language]

HW: Medicine can be divided into research, clinical and the economic. The economic is coming to the forefront right now. It really puts nuclear medicine into a tremendously important position. There are millions of studies being done but billions of patients being treated so [our understanding] will expand from the millions to the billions [if we implement and mine electronic records]. Those types of studies are what nuclear medicine is doing very well right now.

[DM: What about the promise of genetics? Is your field in the position to fulfill that promise?]

HW: Genetics was over-hyped. It is extremely useful but was oversold. An enormous amount of effort has gone into it but produced some less than useful stuff so far. The combination of phenotype measuring, where you measure how genes express themselves in the manifestations of diseases, will greatly improve the field of genomics. But genomics has been somewhat disappointing in its clinical application.

I would say that the measurement of phenotypes, which is what we do in molecular imaging, will help fit genomics better into the health care system.

[DM: What are some other examples of how electronic records will synch will molecular imaging or some other real clinical application to improve health care delivery?]

HW: PET and SPECT measure molecules in the body. And moving the disease orientation down to the cellular and molecular level is a very important advance. People today are doing more [molecular imaging] studies but are recognizing that they are very costly. The combination of PET and CT, where you have both the chemistry and the structure combined, is really great but it's expensive. But people don't realize that, although it increases the cost of putting a PET or SPECT system into an institution such as a hospital, if you approach it at the individual patient level, it decreases the costs of taking care of specific patients. That's called productivity. So as productivity goes up, costs go down and the availability [of health services] to more people goes up.

People have emphasized that these [scans] are expensive but small [research] studies show that [molecular imaging] can decrease the cost of caring for an individual patient. Smarter health care lets you decrease the cost of caring for a specific patient and makes more money available for taking care of more patients.

[DM: What about pharmaceutical breakthroughs?]

HW: There are 20,000 different types of molecules in the body. So you can see that the future is fantastic for studying these molecules in relationship to disease. Either the cells are putting out the wrong message or not receiving the right messages properly. This idea of recognition of molecules binding to recognition sites is a broad field that will continue for hundreds of years. Personalized medicine from a molecular imaging standpoint is putting the patient's problem in terms of manifestations of disease at the molecular level. The pharmaceutical industry and drug development ties right into that because then you can operate on the molecules. So you operate on the molecules rather than operating on the organs.

Another thing being presented at the [SNM] meeting is that you have to have radiation involved-radionuclide therapy to really cure cancer. It is now becoming clear that you not only have to get the molecular messages to the tumor cells but they need a radionuclide attached to them to damage the cancer cells and few surrounding cells. Radionuclide therapy is a field coming into its own and will only increase.

[DM: What about the subspecialties that overlap into nuclear medicine? Does that cause friction? Maybe we shouldn't go there.]

HW: I want to comment about that. I have long believed that a major human failing is territoriality. And I have been in the field 50 years and have always fought people who want to limit the technology to a particular specialty. From the early days I encouraged cardiologists to do nuclear medicine procedures. Excessive territoriality limits the field and taking care of the patient. I think these techniques should be used by qualified people whatever specialty is written on their pad.

I am delighted if cardiologists fall in love with nuclear cardiology. I am delighted if oncologists are beginning to fall in love with nuclear oncology, although this question of politics and economics of chemotherapy is hindering the application of things like radio immunotherapy drugs. That will change. The relative value of these procedures will be uncovered.

The orientation toward organs is old fashioned. We are now interested in the body as a whole, going down to and including the molecular level.