2 Professional perspectives Theranostics: A career opportunity for Nuclear Medicine Technologists RADIOLOGY Theranostics radiophamaceuti- cal drug treatments are expected to revitalize interest in nuclear medicine as an innovating im- aging technology. Theranostics also offer new opportunities for nuclear technologists. But they need to prepare and act now to become an advanced clinical practitioner radio- nuclide therapy, attendees at the 2024 annual meeting of the So- ciety of Nuclear Medicine and Molecular (SNMMI) held in June in Toronto, Ontario were advised. Imaging (ACP) in In a presentation entitled ‘What’s Next for Technologists ’, Luísa Rol- dão Pereira, an ACP in Nuclear Medical Therapies at Maidstone and Tunbridge Wells NHS Trust in the United Kingdom (UK), urged nuclear medicine technologists to step outside their comfort zone, educate themselves and take on additional responsibilities. Pereira works in a large, acute hospital trust in southeast England serving a population of about 760,000. Its cancer centre provides specialist services to about 1.9 million people living in Kent, Medway, and East Sussex. for nuclear ‘The position of ACP is being es- tablished in the UK and offers op- portunities in research and clinical management tech- nologists,’ said Pereira. ‘Advanced level practice is not a doctor or medical physicist substitute. It is a hybrid approach between nursing, allied health care professionals, and medicine to meet patient needs to provide a range of ad- ditional value and benefits. It com- plements and supplements the care that a multi-professional team can deliver.’ A deep dive into the complexity of patient cases She pointed out that technologists have not historically had many op- portunities for advancement if they wish to still interact with patients. Traditionally, after starting as a technologist, they may progress to senior technologist level, event- ually become a department man- ager, and/or leave a clinical posi- tion to work in industry. ‘Current demand exceeds capacity for ACPs,’ she explained. ‘It is an excellent time to bring research into our work, and to take a more proactive role with respect to our knowledge of nuclear medicine. In addition to volunteering to par- ticipate in clinical trials, we can help implement new guidance and protocols, work on service im- provement committees, and be- come subject matter experts in nu- clear medicine.’ ACPs who are nuclear tech- nologists are “naturals” to have per- sonal in-depth conversations with patients. Patients may be confused about their treatment, their stage of disease, and how they will be im- pacted. They may have no one to openly talk to about their treat- ment or the long-term implications of having cancer. The technologist can proactively probe and act on concerns, as well as ask or alert a clinical colleague to have these dif- ficult conversations. ‘Don’t assume that one patient is like another. A patient with bone metastases requiring six radium in- that experiencing jections may be a more complex patient than initially appears,’ cau- tioned Pereira. ‘They may have a bowel condition interferes with excretion routes. They may be increasingly dif- ficulties in pain management, or have comorbidities that can be im- pacted by cancer therapy. An ACP delves into the potential com- plications, alerts the care team of potentially overlooked needs, and works collaboratively to address them.’ Details matter It’s important to learn a patient’s profile and be confident in risk as- sessment, finding out what matters to the patient and consider prac- ticalities: How do they get home after a treatment Will they be ac- companied by family member, are they planning on using public transport or taking a taxi, and if the latter, are they physically able to do so unaided after treatment Is the patient independent in daily life Do they need personal assist- ance What are their home circum- stances Are there children at home Even details such as the number of toilets at home may be important. What is going to be done about decontamination of a bathroom at home – and at the workplace, if the patient is still working An ACP needs to make physical, psychological, and social assess- ments each treatment cycle. If clini- cal red flags of deterioration be- come apparent, the ACP should alert the wider patient’s care team. This is especially important in cases when an oncologist is re- motely located. ‘If a patient needs hospital admis- sion following radionuclide treat- ment, the ACP should review radi- ation safety practicalities with hospital staff. Sometimes we only consider a “standard patient”, but in reality, we must think about the practicalities of inpatient’s needs, such as a private room set up to minimize decontamination clean up, handling of laundry, waste management, feasibility of visitors, and unique to patient is- sues such as decontamination of dialysis equipment,’ said Pereira. the ‘Theranostics is on our doorstep’ She added, ’You should check on response to therapy on a personal level, too. Make a follow-up call to see how the patient and the family are coping. Is the patient experi- encing toxicities, and do these need additional clinical manage- ment A personal telephone con- versation is also an opportunity to reinforce compliance by reminding the patient of radiation protection requirements.’ ‘In the role of ACP, questions to ask ourselves include: Are we doing enough and providing the best care that we possibly can Are we struggling with other professions’ overprotective attitude Are we hid- ing behind our professional bar- riers We should never lose sight of the main goal – exceptional patient care,’ she said. Nuclear medicine technologists who wish to become an ACP also need to be aware about pro- fessional insurance and should learn about liability and statutory regulations. They need to spend time with leadership teams, learn Luísa Roldão Pereira Luísa Roldão Pereira, based in the United Kingdom, is currently an Ad- vanced Practice Trust Lead at Maid- stone and Tunbridge Wells NHS Trust, bringing experience from previous roles at Maidstone and Tunbridge Wells NHS Trust, European Associ- ation of Nuclear Medicine Technol- ogists Committee and NHS England. She takes on roles in the training and equivalence assessment of Nuclear Medicine Technologists, through the Institute of Physics and Engineering applied to Medicine, and the in the Register of Clinical Technologists. She also has a keen interest for Quality and Audit, participating in external assessments and inspections. about and offer to participate in studies and in department and/or hospital improvement and inno- vation projects. ‘What is next for nuclear tech- nologists is not next, it is now. The- ranostics is on our doorstep. It rep- resents a huge opportunity for career development. But if we don’t prepare for this role, another healthcare professional will,’ cau- tioned Pereira. ■ Article: Cynthia E. Keen Prostate cancer: benefits of therapy deescalation Two reduced dose radiophar- maceutical therapy approaches for advanced stage metastatic castrate-resistant prostate cancer have been shown to be just as ef- fective as the standard dose, ac- cording to new research now published in the Journal of Nu- clear Medicine. Treatment with deescalated 225Ac- PSMA-617 or a cocktail therapy of 177Lu/225Ac-PSMA-617 resulted in similar median overall survival and prostate specific antigen (PSA) re- sponse rates as the standard 225Ac- PSMA-617 dose and was better- tolerated among patients. The standard dose for 225Ac-PSMA targeted radiopharmaceutical alpha-therapy is 100 kBq per kilo- gram of body weight or an ap- proximation of eight MBq. After multiple treatment cycles of this dose, salivary gland toxicity often increases and patients experience dry mouth. For some patients this impact on their quality of life causes them to discontinue treat- ment. ‘Preliminary data from other studies has shown that reduced doses of PSMA treatment result in lower rates of dry mouth while still maintaining promising anti-tumour activity,’ said Hendrik Rathke, MD, from the Department of Nuclear Medicine at Heidelberg University Hospital, Germany. ‘In our study we aimed to determine the toler- ability, PSA response rate, and overall survival observed in pa- tients who received a regimen of less than 100 kBq of 225Ac-PSMA or an 177Lu/225Ac-PSMA-617 cocktail therapy.’ Researchers conducted a retrospec- tive analysis of 233 patients who were treated with 225Ac-PSMA; 104 received a median of six MBq of 225Ac-PSMA monotherapy and 129 received an 177Lu/225Ac-PSMA-617 cocktail therapy. Of the patients who received 225Ac- PSMA monotherapy, 55 patients (53%) presented with a best PSA response of at least 50%. In the 177Lu/225Ac-PSMA-617 cocktail group, a best PSA response of at least 50% was observed in 74 pa- tients (57%). The median overall survival was nine months in the 225Ac-PSMA monotherapy and 15 177Lu/225Ac- months PSMA-617 cocktail group. Adjusted for prognostic baseline char- acteristics, the efficacy of both regimens was not significantly dif- ferent. ■ the in Source: Society of Nuclear Medicine and Molecular Imaging ©SNMMI; from: Rathke H et al, Journal of Nuclear Medicine 2024 EUROPEAN HOSPITAL Vol 33 Issue 3/24

4 Transformative technology Generative AI: More than a chatbot RADIOLOGY ‘Computer, why did the doctor take that MRI scan of my leg And what did it show ’: Popu- larized by OpenAI’s ChatGPT, generative artificial intelligence (AI) is already beginning to see practical applications in medical settings. The technology holds immense potential, with benefits for patients, clinicians, and even hospital administration, accord- ing to Shez Partovi, MD. We spoke with the Chief Innovation & Strategy Officer and Chief Business Leader of Enterprise Informatics at Philips about per- sonalized medical information, hospital workflow optimization, digital clinical twins, and other plans the company has for gener- ative AI in healthcare. Talking about how healthcare can benefit from this technology, Parto- vi does not seem afraid to set the bar high: ‘The shift that generative AI will bring is nothing like any- thing that we have seen. It will be like the discovery of penicillin or insulin; it will be the most tectonic shift for healthcare that we will see in our lifetime.’ Unlike predictive models, which rely on extensive datasets and meticulous training, generative AI finds associations be- tween data points to generate new content, the expert explains. To harness this potential, Philips is de- veloping several products based on the technology, some of which have already arrived in clinical practice. ‘In the future, people will talk to their medical record’ Among these is a tool that reph- rases physician’s notes in a way that is easier to understand. Pre- vious research has shown that medical information, even material intended for patients, is often too complex. ‘The idea is that the AI translates this complicated medical terminology to simple high-school level English and other languages,’ Partovi explains. With its ability to quickly generate customized text, generative AI will take this approach even further, Shez Partovi, MD Shez Partovi, MD is Chief Inno- vation & Strategy Officer and Chief Business Leader of Enterprise In- formatics at Royal Philips, where he drives cloud transformation and AI in healthcare. Previously, he spear- headed global business development efforts at Amazon Web Services. s p i l i h P © the expert predicts: ‘In the future, people will talk to their medical record. They can ask the AI why their doctor performed an MRI scan on them, or why they were prescribed specific medication, and it will explain the medical indi- cation in a way they can under- stand.’ With planned market intro- duction this conversational access to a patient’s medical record could be used to bridge the knowledge gap between doctors and patients, and help pa- tients make informed decisions about medical procedures, Partovi is convinced. this year, later A similar approach can be applied to provide physicians with relevant relevant background patient information, for example before consultations: ‘Reviewing a patient’s medical history can be very time-consuming. To mitigate this, the AI can quickly analyse the dataset and generate a summary which provides the physician with the in- formation.’ As a result, less time is spent on preparation, leaving more for the actual visit, Partovi argues. ‘More and more medical data is generated for each patient, which can prove overwhelming for the clinicians. For a three-minute visit, the doctor may have to spend up to 20 minutes to look through the medical records. We want to use AI to reverse that ratio, so the doctor has more time for the patient.’ Finally, generative AI can con- tribute to more efficient workflows – both on department and hospital levels, Partovi points out. For example, at the beginning of their shift, the director of a hospital’s emergency department could task the AI with generating a succinct overview of the situation – patient volume, staff attendance, even a prediction of upcoming workload changes – to be able to act and plan ahead. ‘This, too, will take place as a conversation with the AI, which represents a digital twin of the hospital,’ the expert describes, pointing out that the applications can benefit every member of the hospital team up to the adminis- trative level. Liquified data to enable comprehensive analyses However, to exploit this potential, the existing data must be liqui- dated, made available to the AI, he continues: ‘Almost every medical device is generating data, but most of this information is sitting inside silos, and the AI cannot make as- sociations because it is all separate. We have therefore created a sol- ution called Capsule, a platform to integrate all the medical device data. These can then be used by the AI for predictive and generative models.’ ■ Article: Wolfgang Behrends Deep Learning improves image quality, reduces radiation dose DL reconstruction in paediatric imaging Recent developments in deep learning techniques are enhanc- ing clinical imaging quality and reducing radiation exposure for patients while also maintaining diagnostic accuracy. The latest AI component to clinical imaging – referred to as deep learning re- construction (DLR) – is having a particular benefit in paediatric imaging, according to Dr Samuel Brady from Cincinnati Children’s Hospital Medical Center, US. Speaking during a series of webin- ars hosted by Canon Medical Sys- tems Europe, providing in-depth insights into aspects of paediatric imaging, his presentation specifi- cally focused on the impact of AI on CT image quality and dose. Brady discussed advantages and limitations of FBP (filtered back projection) and IR (iterative recon- struction) algorithms for CT image reconstruction. He noted that while IR is good at removing spurious image noise and helps see body structures/organs clearer, it can soften structural and organ bound- aries, leading to an image that may appear slightly blurry to the eye. However, DLR has demonstrated the ability to remove image noise while maintaining and sharp image and providing the ‘potential to further reduce radiation dose to patients undergoing CT,’ said Brady. As a result, the technique is increasingly preferred within pae- diatric imaging as it enables lower radiation dose, thus reducing risks for children where tissues are still developing and are more suscep- tible to radiation damage. Increasing diagnostic confidence The expert noted how CT recon- struction has undergone substan- tial changes, particularly with the ability of DLR to improve image quality and offer low-contrast de- tectability. Brady, who is Chief of the Clinical Medical Physics Sec- tion in the Medical Center’s Depart- ment of Radiology, said AI for CT reconstruction enables cleaner, noise reduced and sharper images with a stronger edge definition than current IR algorithms. ‘These improved images have been shown to increase diagnostic confidence for radiologist performance: they are able to see smaller, more subtle, structures with greater con- fidence – even at the lower radi- ation dose levels afforded by DLR.’ reduced The reduction of image noise – the statistical fluctuation in the recon- struction algorithm that overlays the image and can obscure the underlying anatomy – has been a major benefit, the expert pointed out. ‘For the last 15 years, IR al- gorithms have image noise in CT images, but at the cost of softening organ boundaries, giv- ing the image a blurry, soft, and sometimes plastic look. That inter- feres with radiologist’s ability to identify low-contrast objects, such as cancer or infections, in the image. DLR now removes the image noise while keeping object edges sharp.’ ‘A huge win for paediatric imaging’ Historically, the only way to re- move image noise in a CT image was to increase patient radiation exposure. But with DLR trained to differentiate between noise and anatomical structure, image noise can be removed without turning up the radiation dose, said Brady. He pointed to Canon’s proprietary DLR algorithm called “Advanced Intelligent Clear-IQ Engine (AiCE)” on CT platforms as advancing the field and particularly the new ver- sion of DLR, “Precise IQ Engine (PIQE)”, designed to further in- crease object-edge sharpness. ‘The ability to see small objects sharper and more conspicuous is a huge win for paediatric imaging, since children have smaller internal or- gans, vasculature, and other struc- tures,’ said Brady. He said DLR is making a difference by enabling low noise and low dose imaging in CT. For IR, the consensus was that dose reduction should be limited to 15–30% to preserve low-contrast detectability. But Brady pointed out that initial phantom and patient observer studies in DLR have shown accept- able dose reduction between 44–83% for both low- and high- contrast object detectability tasks. Ultrasound for abdominal emergencies A second element of the Canon webinar saw paediatric radiologist Dr Elisa Aguirre from Hospital 12 de Octubre in Madrid, Spain, out- line how abdominal symptoms are the most common reason for pae- diatric emergency department vi- sits, with ultrasonography usually the first line and main technique in Dr Samuel Brady Dr Samuel Brady is Chief of the Clinical Medical Physics Section in the Department of Radiology, Cincin- nati Children’s Hospital Medical Center and Associate Professor of Radiology, University of Cincinnati. As a medical physicist, his primary experience lies in developing and maintaining protocols for imaging ef- ficacy and safety with a particular in- terest in dose-minimization for CT imaging techniques. enabling the diagnosis. She ex- plained how Doppler ultrasound and microvascular imaging can add relevant information in paediatric abdominal emergencies. ■ Report: Mark Nicholls EUROPEAN HOSPITAL Vol 33 Issue 3/24

6 Joint action ONCOLOGY A pan-European effort to tackle cancer and NCDs This February, the Norwegian In- stitute of Public Health officially launched the “Joint Action on cancer and other non-com- municable disease prevention project” (JA PreventNCD). In the four-year-initiative, 22 mem-ber states of the European Union (EU) plus Iceland, Norway and the Ukraine have joined forces to combat the increasing burden of non-communicable diseases (NCDs) across national borders. The Norwegian Directorate of Health leads the project and its Professor Knut-Inge Klepp, scien- tific coordinator of the project, em- phasizes the need for the collabor- ative approach: ‘The pandemic has underscored the importance of cross-border cooperation in ad- dressing health crises. NCDs, while slower in their progression, repre- sent a significant health crisis that requires coordinated action.’ Investing in prevention Given the fact that a large propor- tion of NCD-related deaths are avoidable and expenditures on prevention stand only at around 3% of national health budgets in the EU, this initiative is a worth- while endeavour. It has a total budget of €95.5 million, of which the EU funds €76.4 million within the framework of its EU4Health programme. The EU contribution represents 20% of the EU‘s total health budget. Linda Granlund, project coordinator and head of the Public Health and Prevention Division at the Norwegian Direc- the torate of Health said on the project launch in Oslo: ‘Cancer and other NCDs constitute a large pro- portion of the total burden of disease in Europe. NCDs can be pre- vented, and sadly we have not managed to tackle chal- lenges in an effec- tive coor- dinated way up until now. This project represents a paradigm shift, with 20% of health budgets dedicated to prevention - a symbol of Europe‘s evolving approach to health.’ and A framework for addres- sing common risk factors At the core of JA PreventNCD is its commitment to unify efforts, reduce fragmentation and avoid duplication when it comes to re- ducing cases of NCDs. The project wants to establish a holistic ap- proach to prevention amongst the participating countries whilst ad- dressing the common underlying risk factors both on a personal and societal level. To do so, the initi- ative combines a healthcare fo- cused agenda with other topics like taxation and regulation in ad- dition to a healthy living environ- ment. It also aims to strengthen national authorities across different levels to implement measures to promote health such as raising co- herence in policies addressing risk factors and social inclusion. Fur- thermore, it foresees to assess the effects of prevention strategies with the help of rigorous evalu- ation processes to optimize them. A key goal of the initiative is to tackle social inequalities in view of their contribution to NCD risks. A core instrument for the project is the establishment of a robust Euro- pean infrastructure for monitoring NCD-related health determinants such as inactivity, unhealthy diet, overweight and obesity as well as harm to alcohol con- sumption. related The medical agenda The medical agenda of JA Pre- ventNCD incorporates efforts to advance the early detec- tion of people at risk, in- cluding the use of gen- etic profiling. Prof Dr Katharina Anke Bergmann, Lead Personalised Ge- nomics, Deputy Director Institut for Human Gen- etics at Hannover Medical School, which takes part in the project on the German side, emphasis the role of genetic profiling for the prevention of NCDs. In her view, genetics will be increas- ingly essential for early diagnoses and prevention: ‘As part of the “Joint Action Prevent NCD”, we will develop new inter- disciplinary care pathways in the area of genetic (cancer) predisposi- tion in the European context in order to ensure structured, re- source-adapted care systems and thus detect (cancer) diseases ear- lier, treat them better or ideally prevent them.’ The project also in- vestigates more patient-centered interventions, integrated care path- ways and eHealth solutions. As part of its monitoring agenda, JA PreventNCD has the goal to im- prove data capture management and will use AI-based algorithms for analysis and modelling pur- poses. Prof Dr Lars Schaade, Presi- dent of the German Robert Koch Institute (RKI), which is also a stakeholder in the initiative, ex- plains: ‘One of the main tasks will be to systematically collect and col- late relevant health data. The RKI will contribute such “data for ac- tion” from its own and inter- national studies and projects in order to strengthen the prevention of major common diseases, pro- mote health equity and promote health and well-being for all people.’ AI will be an invaluable tool to drive the prevention agenda There is a strong momentum in healthcare systems to shift towards a prevention-centered approach to avoid suffering as well as render healthcare delivery more sustain- able. Technological and medical progress have made it possible to jointly analyse individuals’ genetic information and the gathered medical, lifestyle and environment- al data to gain new insights into human health. The algorithms used for analysing those data and mod- elling health scenarios are based on artificial intelligence (AI). The project’s collaborative ap- proach resembles in many aspects the UK’s largest ever research pro- ject Our Future Health (see our re- port on page 12). Both put the no- tion of prevention rather than curation at their core and will help to enable a paradigm shift in how we view health. ■ Report: Cornelia Wels-Maug Cancer care in Europe: alarming gaps remain former Ulrika Årehed Kågström, Presi- dent-elect of the Union for Inter- national Cancer Control (UICC), and UICC Board Members Nick Grant and Cris- tiana Fonseca offer their insights and solutions to the widening gaps in preventing and surviving cancer in Sweden, the UK, Portugal and Europe more widely. for people living Europe accounts for about 20% of the global cancer incidence and mortality, with about four million new cancer cases recorded in 2020 and an estimated 1.9 million people who died from cancer. Yet even in countries in Europe, such as Sweden, the UK and Portu- gal, which have a tradition of ro- bust healthcare, disparities exist in the risks of developing cancer, hav- ing it detected early and success- fully treated. These disparities are a result of inequitable access to re- liable information, screening, diag- nostics, treatment and care services due to where people live, their economic status, level of edu- cation, ethnicity, age, physical and mental capabilities, age, gender and gender norms, sexual orien- tation and other socioeconomic factors. Ulrika Årehed Kågström, Secretary- General of the Swedish Cancer So- ciety and President-elect of UICC, explains: “For people with low so- cioeconomic status, the risk of dying from cancer in Sweden is no- tably higher compared to those who belong to more privileged groups. People with higher edu- cation generally spend more time with healthcare professionals to ask questions when seeking care than those with only primary school education, who are more likely to refrain from care-seeking in the first place. Socioeconomic status can also influence the de- gree to which a cancer patient is likely to follow through on treat- ment.” Nick Grant, Executive Director of Strategy and Philanthropy at Cancer Research UK and former UICC Board Member, says that, in the UK, limited progress has been made in addressing inequities in the past ten years. These have even worsened since the Covid-19 pan- demic. “Life expectancy has stalled, and the gaps in life expectancy be- tween the most and least under- privileged areas has widened. Many of the causes lie not in the health system itself, but in the broader environment – which makes it harder for some groups to live a healthy life. Smoking ac- counts for half the difference in life expectancy between the lowest and highest income groups in Eng- land. Bold action to reduce smok- ing rates – such as the legislation proposed by the UK Government to raise the age of sale of tobacco products – can help create a heal- thier society for all,” says Nick Grant. Cristiana Fonseca, Health Edu- cation and Capacity Building Head of Department at the Portuguese League Against Cancer – Northern Branch, says about the situation in her country that “while there are national screening programmes for their cancers, various im- plementation and attendance rates vary across regions, and invest- ment in research and treatment has improved cancer prognosis, but disparities persist in resource dis- tribution and management prac- tices in different regions and in- stitutions.” Ms also highlights inconsistencies in strat- egies to address environmental and other risk factors for cancer. Fonseca As modifiable behavioural factors contribute to over 40% of all cancer deaths, UICC’s World Cancer Day 2024 Equity Report emphasises overall that implementing cost- efficient and evidence-based pre- vention measures, such as limiting the marketing, sales and con- sumption of tobacco, alcohol and unhealthy foods that can lead to overweight and obesity, are crucial to reducing health inequity and the cancer burden. Cristiana Fonseca further recom- mends “multisectoral policies tar- geting modifiable determinants of cancer, prioritise equitable access to treatments, and continuously monitor and reduce inequalities, especially for specific groups such as migrants and those not fluent in the country’s official language.” treatment and care Screening programmes, the early detection of cancer and access to timely for people who develop cancer – re- gardless of their ability to pay – are also vital. The chances of treating cancer successfully are generally higher the earlier it is diagnosed. Dr Cary Adams, CEO of UICC, says, “Where you live, how much money you make, your age, your health, your gender, who you love or the colour of your skin shouldn’t dic- tate whether you have access to cancer care. But the sad reality is, it does. That’s why UICC’s Equity Re- port is so crucial – it shines a light on the obstacles people face in get- ting the care they need, and sug- gests strategies to help overcome them.” ■ Source: Union for International Cancer Control EUROPEAN HOSPITAL Vol 33 Issue 3/24

8 WOMEN’S HEALTH New measures to assess fracture risk in older women Osteoporosis and menopause: new insights Bone fractures caused by osteo- porosis are a common major glo- bal health risk. The International Osteoporosis Foundation (IOF) reports that one in three women over the age of 50 will sustain a potentially life-threatening fra- gility fracture in their remaining lifetimes. Over 25.5 million women have os- teoporosis, according to 2019 IOF estimated statistics. At least 23.8 million European Union (EU) resi- dents are at high risk of osteopo- rotic fractures. Currently, the an- nual cost of osteoporosis-related fractures in Europe alone is esti- mated to be more than €56 billion for its population. Early diagnosis and proactive treatment to keep bones healthy, including pre- scription medication and lifestyle changes, has the potential to sig- nificantly reduce this risk and its fi- nancial burden. Yet osteoporosis and osteopenia are among the most undiagnosed and untreated medical conditions, not only in Europe, but throughout the world. Governments and healthcare providers need to pre- pare for a skyrocketing number of cases, due in great part to an in- creasingly aging population, with Europe alone facing an estimated 25% increase in osteoporotic frac- tures between 2019 and 2034. Finding a public health strategy In February 2023, the World Health Organization (WHO) and the Euro- pean Society for Clinical and Econ- omic Aspects of Osteoporosis, Os- teoarthritis and Musculoskeletal Disease (ESCEO) signed an agree- ment to develop a strategic road- map on bone health and aging, ad- for a public health vocating strategy to prevent fractures among older people. This com- plements the IOF’s 2021 initiative to create an interactive Scorecard for Osteoporosis Europe (SCORE) recording the burden of disease, policy framework, service in public of Korea have validated a hypothesis that oral health is corre- lated with FRAX scores. Their study, published in Scientific Re- ports, is based on national survey data from over 2,300 Korean women over age 65 years. It statis- tically demonstrates that there are significant relationships between the number of teeth missing and FRAX 10-year probabilities of hip fracture risk. The researchers from Kangbuk Samsung Hospital in Seoul and Ajou University School of Medicine in Gyeonggi-Do explain that ‘losing teeth […] may lead to chewing dif- ficulty, contributing to changes in food selection, malnutrition, and low bone and muscle mass. Good oral health influences the quality of life in a myriad way, including social communi- cations, self-esteem, resilience, and adequate nutritional intake. As the tooth number in the elderly is an indicator of physical, mental, and social well-being, it can be con- sidered as a potential parameter of fracture risk in the elder popu- lation.’ They advocate that dentists become aware of this association. interactions, Another study by researchers at Shanghai General Hospital in China of over 1,200 post-menopau- sal women who sustained an os- teoporotic bone fracture focused on the correlation between BMD and bone metabolic markers and levels of bone reabsorption. Bones consist primarily of calcium phos- phate, a mineral compound that hardens the skeletal framework and type-1 collagen, a protein net- work that gives bone its tensile strength and framework. Bone marker testing helps determine if the rate of bone resorption is in- creasing, suggesting a potential bone disorder. Bone loss occurs when bone resorption occurs faster than the rate of bone formation. The women included 1,008 who had sustained a single fracture and m o c . e b o d a . k c o t s – i k z t i l u a K n a i t s a b e S © strength of a hip. However, the cost of a BMD is prohibitive to many, and there are not enough DEXA scanners to meet global needs. A free-of-charge Fracture Risk As- sessment Tool (FRAX), created in 2008 by researchers at the Univer- sity of Sheffield, calculates the ab- solute risk of fracture in 10 years independent of BMD assessment. This algorithm analyzes the clinical risk factors of age, current smok- ing, alcohol consumption, rheuma- toid arthritis, family history of hip fracture, previous fragility frac- tures, and use of glucocorticoids. New research from Asia Current research studies are focus- ing on different indicators of frac- ture risk. A multi-institutional group of researchers from the Re- 231 who had a second fracture. The fracture sites included verte- brae, hip, pelvis, ankle, distal fore- arm and proximal humerus. None were caused by violent, high- energy impacts, bone metastases, or bone weakening from drug use. Lead investigators Li You, MD, Xiaonan Zhu and colleagues deter- mined that the higher the levels of the bone markers serum CTX and osteocalcin, which indicate bone resorption, the lower the BMD score. BMD scores were sig- nificantly lower for women who sustained second fractures than women who only sustained one. The that women with high body mass index (BMI) and those not receiving anti- osteoporosis treatment were also at higher risk of sustaining a second fracture. researchers reported This fact is reinforced by the Brazi- lian Society of Rheumatology’s published endorsement of fracture risk assessment in the Revista da Associacao Medica Brasileira. The article states that almost nine mil- lion fractures annually occur worldwide due to osteoporosis, one occurring every three seconds. Additionally, if a person has al- ready sustained an osteoporotic fracture, the risk of a second in- creases by 86%. The Chinese researchers point out in menopause that although DEXA scans provide good estimates of bone tissue loss, the time elapsing between scans may be a period of high bone loss. Also, DEXA scans do not directly reflect bone meta- bolic status. They suggest that ’early recognition of the correlation between BMD and bone metabolic markers can better prevent further bone loss in women with post- menopausal fractures and thus re- duce the risks of later fracture.’ ■ Report: Cynthia E. Keen provision, and service update of 29 EU countries. and assess A bone mineral density (BMD) test is the best method to diagnose os- teoporosis bone strength. A dual-energy X-ray ab- sorptiometry scan (DEXA), the most common and most versatile test, not only assesses bone strength, but also can provide a vertebral fracture assessment (VFA) to detect previously unrecognized spine fracture, a trabecular bone score (TBS) that assesses internal structure of bones in the spine at a microscopic level, full-length femur imaging to recognize thickening of the thigh bone that could lead to a stress fracture, and a hip structural analysis (HSA) to assess how the size, shape, and confirmation of the hip bones can influence Interdisciplinary senology: which imaging modality at which time Interdisciplinary collaboration between gynaecologists, radi- ologists, pathologists and breast care nurses following a pal- pation finding makes a decisive contribution to the success of further breast cancer treatment. This was the consensus among the speakers at the Annual Con- gress of the German Society of Senology in Dresden. The ex- perts ex- planations of which imaging is best for which patient. provided clear PD Dr Susanne Wienbeck, a specialist in radiology at St. Josef- Stift Bremen, made it clear that and both mammography so- nography are first choice methods for clarifying the next steps after an initial palpation finding. Which of the imaging procedures should be used depends largely on age: ‘Patients under 40 should always have a clinical ultrasound scan first,’ emphasised Wienbeck. ‘If the result for example a cyst or fibroadenoma, no further clarification is necess- ary,’ she continued. ‘In the case of suspicious or unclear findings with a low risk, a sonographic punch biopsy should be performed. Ad- vanced imaging such as mam- mography, followed by an open or clearly benign, is percutaneous biopsy, is only rec- ommended for high-risk findings.’ recommends R0 resection as the primary goal Things are different however for patients over 40. Here, the radi- ologist mam- mography as a first step, followed by extended imaging if there are multiple or unclear findings. In ad- dition to the palpation diagnosis, suspicious skin changes, histologi- cally confirmed lesions or unilat- eral mastodynia are also indi- cations for a mammogram. tomy rates. ‘However, this has been proven not to be the case,’ said PD Dr Heike Preibsch, Senior Phys- ician at the University Hospital of Tübingen. ‘Current studies further show that preoperative MRI re- duces the number of resections in breast-conserving surgery.’ The ex- pert explained that not only pa- tients with dense breasts would benefit from this, but that the ad- vantage applies across all entities, stages and risk constellations. ‘Our ultimate goal should always be pri- mary R0 resection.’ audience to the importance of comprehensive communication of findings. ‘Discussing further diag- nostics and the intended markings is essential, as is intraoperative as- sessment. All professional groups involved should be included in order to be able to describe their point of view,’ said Maier. Further, presentation to the tumour board is also absolutely essential, both pre- and post-operatively. ■ Article: Sonja Buske Pre-operative MRI has long been suspected of increasing mastec- Dr Anna Marie Maier from LMU Klinikum Munich sensitised the EUROPEAN HOSPITAL Vol 33 Issue 3/24

10 WOMEN’S HEALTH Oxford debate at senology congress DCIS: pros and cons of radiotherapy Prof Dr Christoph Mundhenke is Chief Physician of the Clinic for Gynaecology and Obstetrics at Klini- kum Bayreuth GmbH. He previously worked at the University Medical Centre Schleswig-Holstein in Kiel. The 49-year-old specialist in gynae- cology and obstetrics is a proven ex- pert in the field of gynaecological oncology. Prof Dr Stefanie Corradini is Dep- uty Director of the Clinic and Poly- clinic for Radiation Therapy at the LMU Hospital Munich since 2023. Her clinical and scientific focus is on gynaecological tumours and breast carcinomas, MR-guided radiotherapy (MR-Linac) and image-guided radi- ation therapy procedures with sur- face scanners. Prof Dr Bernd Gerber is Director of the University Women’s Hospital at Klinikum Südstadt in Rostock. His focus is on gynaecological oncology, where he has established gentler op- erations for patients with breast cancer and thus set new treatment standards in oncology. Prof. Gerber also investigates pregnancy-related diseases (gestosis). Prof Volker Budach is a radiologist and radiation therapist at the private practice RadioOnkologie in Berlin. Previously, he was clinical director of the Department of Radiooncology at the Charité as well as Past President of the German Society of Radiation Oncology (DEGRO). His scientific and clinical focus includes the treatment of head and neck tumours, sarcomas and breast cancer. m o c . e b o d a . k c o t s – o d u t s n a e c O y M © i · ing, calibration and external vali- dation is necessary, as well as level 1B evidence.’ DCIS does not equal cancer At the end of the session, the speakers and their audience agreed that DCIS is often overtreated, and radiation therapy does not have a beneficial impact on overall sur- vival. Good communication with the patient was seen as crucial. Furthermore, the universal con- sensus was that the term “carcino- ma” should be removed from the condition’s name, to not cause un- necessary affected women. ■ alarm for Article: Sonja Buske NEWS ∙ REPORTS ∙ INTERVIEWS ∙ VIDEOS ∙ SOCIAL MEDIA K e p u p - - d a e n h e l a e s n e w s f r m h s p i a l - r e l a e d f i e l d s ! a l Subscribe to our bi-weekly newsletter and conveniently receive selected medical articles and background information. For more information, visit healthcare-in-europe.com EUROPEAN HOSPITAL Vol 33 Issue 3/24 Radiologists and gynaecologists entered a veritable bout during the Oxford debate at the 43rd annual congress of the German Senologic Society in Dresden. Controversy was sparked by the question of whether all patients with a ductal carcinoma in situ (DCIS) should undergo radio- therapy. Kicking off the debate, Prof Dr Christoph Mundhenke expressed his bewilderment that the necessity of radiotherapy was called into question in the first place: ‘Data evidence is excellent and strongly in favour of radiotherapy for all pa- tients,’ the expert from Klinikum Bayreuth argued. This was in refer- ence to a large 2010 meta-analysis, covering four clinical studies with more than 3,700 patients over a 10-year follow-up. ‘This work high- lights the benefits of adjuvant radiotherapy after breast-conserv- ing DCIS treatment. Occurrence of ipsilateral events was cut in half – not only in high-risk patients, but also in older women, who are con- stantly debated to be excluded from radiotherapy because of their age,’ he added. Pro: ‘virtually overwhelming’ evi- dence in favour of radiotherapy Another meta-analysis from 2015, also covering a 10-year follow-up, even included more than 9,000 pa- tients from 26 clinical studies. This research pointed to statistically sig- nificant benefits of post-operative radiotherapy, both for DCIS pa- tients and those with invasive re- currence, Mundhenke elaborated. ‘After breast-conserving surgery, the risk for local recurrence was at 25%. Combined with post-op radio- therapy, this number was reduced to just 14%.’ While this evidence was ‘virtually overwhelming’, he conceded that in certain cases, other factors, such as the patients’ age, their life expectancy and will to treatment, should also be in- cluded. s n o i t a c i f i c l a c o r c i m m a r g o m m a M , n h c r a m J : e c r u o s e g a m I ) 0 . 3 A S - Y B C C ( s l i a t e d , O L M , u t i s n i a m o n i c r a c n i On this mammogram, microcalcifications can be seen as white dots, a typical sign for DCIS. This last aspect was taken as a cue by Prof Dr Stefanie Corradini to launch into her counterargument. The perspective of the patients should not be ignored, the radi- ation oncologist from LMU Klini- kum Munich appealed to her col- leagues. ‘A DCIS diagnosis can be very disheartening. Even though it is just a pre-cancerous stage with a good prognosis, it is treated like early invasive breast cancer. This can be life-changing for these women, who are often haunted by the fear of facing recurrence or an actually invasive form of cancer for years,’ Corradini stressed. ‘We have to do everything in our power to prevent recurrence in DCIS.’ For the radiation therapist, the ques- tion was therefore not about how, rather than if irradiation should be performed. She argued that an in- dividualised therapy, with adapted fraction and dose regiments as well as reduced irradiation volume was the way to go. Con: no survival advantage Prof Dr Bernd Gerbers from Klini- kum Südstadt in Rostock saw things differently. He could see neither a survival advantage nor meaningful impact on distant meta- stases in DCIS radiotherapy, and therefore advocated the adequate treatment of recurrence. ‘Surgical therapies have become better and safer. With the help of mam- mography, the fringes of micro- lesions are clearly visible, so that surgery can be performed con- fidently within safe borders,’ the gynaecologist argued. ‘There are even considerations to drop sur- gery entirely, in favour of a watch- and-wait approach followed by conservative treatment. In case of recurrence, irradiation is still an option.’ private practice Promising molecular biomarkers Also in opposition of radiotherapy was Prof Dr Volker Budach, from the Radio- Onkologie – at least for low-risk patients with decreased local recur- rence rates. In high-risk patients, however, radiotherapy is an ab- solute necessity, he suggested. He pointed out the great potential of molecular biomarkers: ‘Most clini- cal studies do not yet use molecu- lar biomarkers for DCIS therapy de-escalation,’ Budach explained. ‘Today, there are three individua- lized molecular biomarker tests, which make it possible to predict whether a patient will develop local recurrence, after breast- conserving surgery with or without adjuvant radiotherapy. To assess the clinical validity of these biom- arkers, thorough predictive modell-

12 UK research project “Our Future Health”: Shifting from curative to preventive care RESEARCH In the face of increasing longev- ity and the rise of chronic dis- eases in later life, shifting from curative to preventive care will become vital for healthcare sys- tems as they primarily focus on treating symptomatic individuals in the late stages of diseases. The UK’s National Institute for Health and Care Research, for example, predicts that by 2035, 67.8% of those aged 65 will have at least two serious conditions or im- pairments, up from 54% in 2015. Sir John Bell, former Regius Profes- sor of Medicine at Oxford Univer- sity, concludes that as the burden of chronic diseases is escalating, health address underlying pathologies rather than focus primarily on managing late- stage diseases: ‘Before you know it, the health system is overwhelmed by late-stage disease that is very, very difficult to manage.’ systems must The key challenge lies in address- ing the underlying pathologies be- fore they manifest as symptoms. Bell emphasizes the need to transi- tion healthcare from a broad, reac- tive approach to a targeted, preven- tive one. This shift, he argues, not only enhances individuals‘ quality of life but also alleviates financial strains on healthcare systems. that At the Economist Impact event “Fu- ture of Health 2023 Europe” in Oc- tober 2023, Bell proposed a pre- vention agenda identifies high-risk individuals and inter- venes with behavioural changes that delay either the onset of a dis- ease or make it obsolete: ‘Right now, we treat people at high costs three months before they die. However, identifying and treating chronic diseases before they show symptoms, increases the efficacy of therapies,’ explains Bell. m o c . e b o d a . k c o t s – o d u t s a h w r e m e e D © i He proposes a targeted approach, concentrating resources on popu- lations at risk rather than adopting a broad strategy. ‘What you need to do is concentrate your resources on the people who are going to suffer from a disease rather than the whole population,’ he says. ‘Up until recently, we haven’t really been able to do that, because we have had to do everything to every- body, which is massively ineffic- ient. However, developments in the last five to ten years such as large- scale epidemiology as well as mol- ecular tools such as biomarkers and genome sequencing have paved the way for a more pre- ventative approach to healthcare.’ Based on the results of genome se- quencing, polygenic risk scores can establish a measure of an indi- vidual’s risk to develop a specific medical condition due to one’s genes. Combining polygenic risk scores with other factors that in- fluence disease risk allows for a more accurate estimation of how likely a person is to develop a spe- cific disease than considering either alone. The algorithms used for calculating those likelihoods are based on artificial intelligence (AI). All of these approaches com- plement traditional measures like blood pressure and cholesterol le- vels and offer a gamut of tools for a prevention-centered healthcare de- livery. Paradigm shift: Putting preventative healthcare into action The UK’s Our Future Health pro- gramme, which Bell chairs, exemp- lifies the paradigm shift to a pre- vention-centered healthcare approach. The goal is to revol- utionize healthcare by combining genetic analysis with lifestyle data, providing into human health on an unprecedented scale. The study aims to explore the po- tential uses of genetic risk scores in health screening, facilitating the development of new ways to ident- ify diseases before they become symptomatic as well as to improve health outcomes and life quality. insights The project targets to recruit five million volunteers by 2025 and col- lect comprehensive data on their genetics, health, and lifestyle to understand the factors influencing health conditions. The initial focus of the study lies on cancer, Alz- heimer’s, heart disease, arthritis, diabetes and stroke. Our Future Health, which is the UK’s largest ever health research programme, also wishes to showcase that col- lecting these data inexpensively can significantly impact health out- comes. ‘Now you can tell people at the age of 25 that they are in the top 5% of risk for cardiovascular disease, so they need to pay at- tention to it,’ says Bell. Although invitations to sign up for the programme were sent out in- itially to households in West York- shire, West Midlands, Greater Man- chester and Greater London, any resident in the UK above 18 can partake. The first volunteer signed up on July 12th, 2022, and by Janu- ary 19th, 2024, the number of par- ticipants had grown to 1,163,710 with about 3,000 new people join- ing daily. Volunteers’ data will be de-identified and held in “trusted research environments” that meet strict security criteria. An access board, including inde- pendent experts and members of the public, will ensure the re- sources are only used for health re- search in the public interest. ‘When we started Our Future Health, we set out to create a health research programme on a scale never seen before anywhere in the world. Hit- ting one million volunteers over the last year is a truly remarkable achievement and means we’re now rapidly turning that ambition into reality,’ Bell concludes. Our Future Health is run by a char- ity of the same name and is sup- ported by the UK government to- gether with the NHS. It is set up as a public private partnership with partners from the industry as well as disease-related charities, both groups bringing their expertise in discovering and developing new prevention and treatment methods to the table. A third of its £239 mil- lion budget is financed from UK Research and Innovation with the remaining funds coming from lead- ing life sciences companies and charities. Although initial recruit- ment of volunteers is planned to be concluded by end-2025, they will remain enrolled for life unless they decide otherwise, making for a long outlook of the programme. ■ Report: Cornelia Wels-Maug Prof Sir John Bell Prof Sir John Bell is President of the Ellison Institute of Technology (EIT) Oxford. A former Regius Profes- sor of Medicine at the University of Oxford, he has made significant con- tributions to the UK’s life sciences endeavours, and his research has contributed significantly to the understanding of immune activation in a range of autoimmune diseases. Climate change brings new diseases to Europe – using AI to prepare It is possible to forecast how dif- ferent infectious diseases will spread across Europe in relation to global warming. This is done by using artificial intelligence and mathematical modelling of changing travel patterns and dis- ease effects such as expected case fatalities of novel out- breaks. eases are next in line to reach many countries in Europe as the climate changes and we also travel more. Through access to tech- nology and data-driven forecasts, there is room to make decisions about capacity in healthcare and measures to curb the spread,“ says Zia Farooq, doctoral student at Umeå University. In this way, it will be possible to take countermeasures and build up preparedness. This is shown in a new doctoral thesis at Umeå Uni- versity, Sweden. „It will become in- creasingly important to predict how and where infectious diseases will spread. Several serious dis- In his thesis at the Department of Public Health and Clinical Medi- cine, Zia Farooq shows models that, by combining different types of data with artificial intelligence and mathematical modelling can predict the spread of infectious dis- eases. One example is the disease West Nile fever. The spread of this viral disease via host animals is partly driven by climate change with rising temperatures, longer springs and drier winters. The thesis shows that the forecast model that Zia Farooq and the re- search group he is part of would have been able to predict with good precision the latest and un- usually large outbreak of West Nile fever in Europe in 2018. The methodology is based on ap- plications of AI and machine learn- ing algorithms that process disease occurrence data with climate and environmental, sociodemographic and trading data. Another viral disease that is trans- mitted via mosquitoes is dengue fever. It can cause high fever, se- vere pain and life-threatening sequelae. Previously considered a tropical disease, it is now spread- ing in Europe, mainly as a result of increased travelling and climate change. Zia Farooq shows that im- ports of dengue virus through in- fected travellers during the five- year period 2015–2019 increased by 588% compared to 20 years ear- lier. Effective imports require the presence of certain mosquito species that can carry dengue be- tween humans, which is realized by increasing average temperatures in Europe. The fact that dengue fever can spread in this way means that human travel patterns are im- portant in general for also other similar diseases, such as Zika fever, yellow fever and chikungunya. to escape „Of course, it is important to re- duce emissions and thus limit cli- mate change. But we may not en- tirely be able this problem as climate change is al- ready happening. This is why it‘s important to have tools to be pre- pared to face the challenges of cli- mate sensitive and emergent infec- tious diseases,“ says Zia Farooq. ■ Source: Umeå University EUROPEAN HOSPITAL Vol 33 Issue 3/24