What Is A Nuclear Medicine And Medical Setting?

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2 With nuclear medicine and molecular imaging, physicians can obtain unique insights into a patient s body that allow for a more personalized approach to the evaluation and management of heart disease, cancer and brain disorders. Introduction Each year an estimated 17 million nuclear medicine and molecular imaging procedures are performed in hospitals and medical settings across the United States. With nuclear medicine and molecular imaging, physicians can obtain unique insights into a patient s body that allow for a more personalized approach to the evaluation and management of heart disease, cancer and brain disorders. Yet despite the important implications these procedures can have for patients health, in many states technologists are not required to have or a license to perform these tests. Nuclear medicine and molecular imaging technologists are responsible for performing a wide variety of highly specialized procedures [see What Is Nuclear and Molecular Imaging? p.3]. Conducting these procedures entails, among other responsibilities: preparing and administering radioactive chemical compounds; performing patient imaging procedures using sophisticated radiation-detecting instrumentation; completing computer processing and image enhancemen; analyzing biologic specimens in the laboratory; providing images, data analysis, and patient information to the physician for diagnostic interpretation; and working directly with the patient throughout the procedure. It is essential that technologists perform these scans correctly to ensure that high-quality information is provided to physicians, that patients receive the lowest achievable dose of radiation and that health care costs are minimized. The Society of Nuclear Medicine (SNM) has created this report to bring light to the fact that mandatory, stringent education and standards must be enacted for technologists performing nuclear and molecular imaging scans to ensure excellent patient care, safety, and effectiveness. SNM and the SNM Technologist Section are committed to improving the quality and safety of medical imaging and therapeutic procedures. 2

3 What is Nuclear Medicine and Molecular Imaging? Nuclear medicine is a medical specialty that uses very small amounts of radioactive materials (radiopharmaceuticals) to diagnose, guide management and treat disease. Most nuclear medicine procedures are molecular imaging procedures that use radioactive substances to visualize the molecular processes through which the body functions. This provides physicians with molecular level not only anatomical or structural level data that can help personalize treatment. Nuclear and molecular imaging procedures are safe, painless, and cost-effective; they provide a way for physicians to gather medical information that would otherwise be unavailable, require surgery or necessitate more expensive diagnostic tests. Many times these procedures identify abnormalities very early in the progress of a disease, long before many medical problems are apparent with other diagnostic tests. With nuclear and molecular imaging physicians can determine almost in real-time the effectiveness of a treatment, allowing them to offer patients highly targeted therapies and to ensure that higher doses of medicine are directed more precisely at problem areas. Common nuclear and molecular imaging technologies include: Positron emission tomography (PET) scans: Commonly used in the staging of cancer and evaluation of treatment. Single photon emission computer tomography (SPECT) scans: Used to diagnose brain and heart disease. Magnetic resonance spectroscopy: Used to study metabolic changes in brain tumors, strokes, seizure disorders, Alzheimer s disease, depression and other diseases affecting the brain. Optical imaging: Uses light-producing molecules designed to attach to specific cells to identify cancer cells or brain chemicals. Molecular ultrasound imaging: Uses microbubbles for both imaging and therapy for a wide variety of diseases and disorders, including cancer, heart disease and inflammation. The Need for High-Quality Imaging Much depends on the quality of nuclear and molecular imaging procedures. When performed properly, a molecular imaging scan can provide unique information that allows doctors to better diagnose, guide management of and treat diseases; however, when performed improperly, the resulting scan can be useless. Before the nuclear or molecular imaging procedure takes place, a technologist must determine the appropriate dose of radioactive materials needed to obtain a high-quality imaging scan based on a patient s height, weight and affected part of the body. Based on this information, technologists also calculate the length of time a patient should be scanned. Scan quality is affected by the positioning of the patient and the scanning device. Scanners must be placed over the appropriate body part, with the height and angle of the scanner precisely measured. Based on the body part to be imaged, technologists adjust the controls on the scanner to account for density, detail and contrast. If a scan is performed incorrectly, a poor-quality image may be produced. This can result in the misdiagnosis of disease, delays in treatment and needless anxiety for the patient. If additional testing is required, patients are exposed to an increased amount of radiation. While imaging can be an invaluable tool, the procedures do carry a potential health risk, and radiation can be harmful if administered improperly. 3

4 Reducing Health Care Costs Poor-quality imaging affects not only individual patients but also the U.S. health care system as a whole. Repetition of medical imaging examinations due to improper positioning or poor technique costs the U.S. health care system millions of dollars annually in needless medical bills. According to the Radiologic Sciences of North America journal Radiology, approximately 130 million diagnostic radiology procedures including X-rays, magnetic resonance imaging (MRI), computed tomography (CT) scans and nuclear medicine scans are performed on 30 million Medicare enrollees a year.[i] Approximately $2.4 billion was spent by Medicare on medical imaging in 2006, according to the Government Accountability Office Medicare Part B Imaging Services report.[ii] An estimated four to seven percent of these procedures are repeat procedures due to poor imaging.[iii] Thus, by extrapolation, by ensuring high quality imaging and avoiding repeat scans, the federal government could possibly generate $132 million each year. Figure 1. Cost of Nuclear Medicine and Molecular Imaging (Medicare) Total federal funds per year spent on nuclear medicine and molecular imaging scans $2.4 billion Estimated percentage of all repeated 5.5% medical imaging exams Potential federal funds saved each year by avoiding repeat nuclear medicine and molecular imaging scans $132 million Current Requirements for Nuclear Medicine and Molecular Imaging Technologists Nuclear medicine and molecular imaging technologists are regulated on a state-by-state basis. Certification and on- going registration in nuclear medicine is managed by two national organizations the American Registry of Radiologic Technologists (ARRT) and the Nuclear Medicine Technology Certification Board (NMTCB). To be certified by the ARRT, nuclear medicine technologists must have within the past five successfully completed an educational program that is accredited by a mechanism acceptable to the ARRT. After meeting the ARRT Standard of Ethics, candidates must then pass an ARRT examination, which assesses the knowledge and cognitive skills underlying the intelligent performance of the tasks typically required of staff technologists practicing at entry-level within the discipline. Prospective technologists who graduate from approved nuclear medicine technology programs or meet alternative requirements (e.g., related coursework or clinical experience) are eligible to take the NMTCB examination. Candidates who pass the examination receive. Currently, 30 states, as well as the District of Columbia, have licensure or regulatory provisions for nuclear medicine technologists that require them to be certified by either the ARRT or the NMTCB. The remaining 20 states do not regulate this profession at all. Improving Medical Imaging Across the United States, it is possible that individuals with little or no training are performing sophisticated medical imaging procedures that, if performed improperly, could harm patients and further cost the health care system millions of dollars. To improve the quality of medical imaging, the Consistency, Accuracy, Responsibility and Excellence in Medical Imaging (CARE) bill has been introduced on Capitol Hill. If enacted, this bill would establish minimum education and standards for personnel who perform nuclear medicine and molecular imaging procedures. As a result, institutions that provide medical imaging or radiation therapy to Medicare patients would be required to employ personnel who meet or exceed the standards set by the federal govern- 4

5 Figure 2 Regulatory Provisions for Nuclear Medicine Technologists *List complete as of April 10, 2012 States that regulate nuclear medicine technologists States that do not regulate nuclear medicine technologists ment. The CARE bill is supported by the Alliance for Quality Medical Imaging and Radiation Therapy, a group co-founded by SNM, its Technologist Section and the American Society of Radiologic Technologists in Since then, an additional 20 organizations have joined the alliance; together, the 23 groups represent more than 500,000 health care professionals. These groups include: American Association of Medical Assistants American Association of Medical Dosimetrists American Association of Physicists in Medicine American College of Medical Physics American Registry of Radiologic Technologists American Society of Echocardiography American Society of Radiologic Technologists Association of Educators in Imaging and Radiologic Sciences Association of Vascular and Interventional Radiographers Cardiovascular Credentialing International 5

6 A Technologist s Perspective Ann Marie Alessi, BS, CNMT, NCT, RT(N) SNM Technologist Section President Having worked as a nuclear medicine technologist for over 26, I am fascinated by how much the field has changed. While PET and SPECT are common imaging techniques, modalities like hybrid imaging with PET/MR and optical fluorescence imaging are the new wave of the future. With new technologies upon us every year, it s critical that nuclear medicine and molecular imaging technologists are up to date on the techniques required to appropriately perform the imaging scans. To maintain licensure or, technologists must complete a defined number of continuing education hours each year to keep their skills and knowledge current. Without this education, a technologist may be relying on knowledge that was acquired during his or her initial training, which can quickly become out of date. SNM has several initiatives in place to help technologists remain current on the latest technologies, including continuing education courses, opportunities for advanced education, and publications on new modalities. The society also has a road show in which it travels to its chapters throughout the country promoting the importance of radiation safety. We take keeping our patients safe seriously; that s why it s important for there to be minimum education and standards for technologists. With the enactment of the CARE bill, we can make great progress in ensuring that patients receive the best care possible. Joint Review Committee on Education in Cardiovascular Technology Joint Review Committee of Education in Diagnostic Medical Sonography Joint Review Committee on Education in Radiologic Technology Joint Review Committee on Educational Programs in Nuclear Medicine Technology Medical Dosimetrists Certification Board Nuclear Medicine Technology Certification Board Section for Magnetic Resonance Technologists of the International Society of Magnetic Resonance in Medicine Society for Radiation Oncology Administrators Society for Vascular Ultrasound Society of Diagnostic Medical Sonography Society of Invasive Cardiovascular Professionals Society of Nuclear Medicine Society of Nuclear Medicine Technologist Section The bill is also supported by many consumer and medical organizations such as the American Cancer Society, the Cancer Research Foundation of America, Help Disabled War Veterans, the National Coalition for Cancer Survivorship and others. In June of 2011, the CARE bill (HR 2104) was introduced in the House of Representatives by Rep. Ed Whitfield (R-KY). As of April 13, 2012, it has 89 cosponsors. It is expected that a companion bill will be introduced in the U.S. Senate as well. What Does It All Mean for Patients? Individuals undergoing nuclear and molecular imaging studies should know that even in states that don t have formal requirements, many technologists do hold s and are skilled in their profession. Patients should be encouraged to discuss with their physician what the recommended imaging procedure entails and other pertinent details, as an informed patient is the best patient. Examples of potential questions include: Does my state require licensure for nuclear medicine technologists? Does the facility performing my scan require for nuclear medicine technologists? What type and dose of radiopharmaceutical will I receive as part of my examination? Are there any side effects of the radiopharmaceutical of which I should be aware? Regardless of whether a state has licensure or regulatory provisions, all individuals should contact their Congressional representatives to encourage them to support the CARE bill. References I Radiology 2005; 234: , Sunshine and Bhargavan, Utilization of Radiology Services in the UnitedStates: Levels and Trends in Modalities, Regions and Populations. II US Government Accountability Office. Medicare Part B Imaging Services. June III American Society of Radiologic Technologists. 6

7 Appendix A: Listing of State Requirements State Licensure Requirements* Continuing Reference: Certification Reference: Continuing Education (if different) Education Requirements Alabama None None N/A N/A Alaska None None N/A N/A Arizona Arkansas California examination, NMTCB examination or ARRT examination examination, NMTCB examination or ARRT examination 6 hours of continuing education acquired within the year preceding the date of renewal 5 hours every 5 per scope. There are 4 scopes. This totals 20 hours every 5. Document.asp?inDoc=/ars/32/ htm&title=32&doctype=ars hslicensingregulation/radiationcontrol/pages/radiologiclicensing.aspx cdph8435.pdf Document.asp?inDoc=/ars/32/ htm&title=32&doctype=ars hslicensingregulation/radiationcontrol/pages/radiologiccontinuingeducation.aspx CEC-Renewal.aspx Colorado None None N/A N/A Connecticut None None N/A N/A Delaware Per licensure requirement title16/4000/ 4400/4466.shtml District of Columbia Florida NMTCB or ARRT Per licensure requirement 12 hours every 2 N/A Georgia None None N/A N/A Hawaii NMTCB or ARRT html/radiationsection/radiationsection/pdf/rai.pdf N/A html/radiationsection/radiationsection/pdf/radtechrenewal.pdf Idaho None None N/A N/A Illinois NMTCB or ARRT 091% pdf Indiana NMTCB or ARRT Iowa Kansas Kentucky NMTCB or ARRT DOCS/ pdf 12 hours every year

8 Appendix A: Listing of State Requirements, continued State Licensure Requirements* Continuing Education Requirements Louisiana Maine Maryland Massachusetts Successful completion of NMTCB or ARRT Successful completion of NMTCB or ARRT examination and NMTCB or ARRT examination, or NMTCB or ARRT 20 hours every 2 Reference: Certification htm regs/105cmr125.pdf Reference: Continuing Education (if different) See Radiologic Technology Board of Examiners Michigan None None N/A N/A Minnesota None None N/A N/A Mississippi NMTCB or ARRT pdf Missouri None None N/A N/A Montana None None N/A N/A Nebraska None N/A N/A Nevada None None N/A N/A New Hampshire None None N/A N/A New Jersey, ARRT, or NMTCB examination None New Mexico title20/ htm Ohio 12 hours every 2 New York NMTCB or ARRT 12 hours every year North Carolina None None N/A N/A North Dakota None None N/A N/A CBB73B A4D/Fr72_02.pdf Oklahoma None None N/A N/A Oregon NMTCB or ARRT oar_337/337_010.html Pennsylvania Successful completion of NMTCB or ARRT None Rhode Island NMTCB or ARRT community/state_board_of_medicine/12512/licensure_information/599413#forms pdf/doh/6514.pdf 8

9 Appendix A: Listing of State Requirements, continued State Licensure Requirements* Continuing Education Requirements South Carolina Reference: Certification Final%20Rules%20and%20Procedures%20July% pdf Reference: Continuing Education (if different) South Dakota None None N/A N/A Tennessee None None N/A N/A Texas Successful completion of NMTCB or ARRT Utah Vermont Successful completion of NMTCB or ARRT examination 16 hours every two Virginia None N/A N/A for radiography and radiation therapy Washington None West Virginia D7z97OX0%3d&tabid=338 RLfNioRIE%3d&tabid=322 Wisconsin None None N/A N/A Wyoming NMTCB or ARRT RulesRegsChapter2.pdf *ARRT is the American Registry of Radiologic Technologists NMTCB is the Nuclear Medicine Technology Certification Board 9

10 Appendix B: Glossary of Terms Computed tomography (CT): A medical imaging technique that uses a computer to acquire a volume of x-ray based images, generally reconstructed as two-dimensional or threedimensional pictures of inside the body. These images can be rotated and viewed from any angle. Each CT image is effectively a single slice of anatomy. Contrast agent: A compound or other substance introduced into the body in order to create a difference in the apparent density of various organs and tissues, making it easier to delineate adjacent body tissues and organs. Diagnostic imaging: Imaging that uses technologies such as x-ray, CT, MRI, ultrasound, PET and SPECT to provide physicians with a way to look inside the body without surgery. Diagnostic imaging is considered a non-invasive diagnostic technique, as opposed to a biopsy or exploratory surgery. PET, SPECT and some types of MR imaging also provide information about how certain tissues and organs are functioning. FDG (F-18-fluorodeoxyglucose): A frequently used radiotracer in PET scanning. FDG is a compound in which a radioactive fluoride atom is attached to a molecule of glucose, or sugar. Once in the body, the FDG molecule is absorbed by various tissues. Radiation from the fluorine is used to create pictures of how the radiotracer is distributed within the body. Gamma camera: A specialized camera that is capable of detecting gamma rays the byproduct of a radiotracer, a combination of a radioactive atom, called an isotope, and another substance. The gamma camera creates two-dimensional pictures of the inside of the body from different angles. Hybrid imaging: The combination of the two imaging techniques, such as PET/MRI or PET/CT, that allows information from two different studies to be viewed in a single set of images. Imaging agent: A substance introduced into the body as part of a diagnostic procedure. In nuclear medicine, imaging agents are typically a compound consisting of a drug or a natural substance, such as glucose, and a small amount of radioactive material, which can be detected by an imaging device to produce pictures of the inside of the body. Ionizing radiation: Subatomic particles or electromagnetic waves that are energetic enough to detach electrons from atoms or molecules, a process called ionization. Radiation on the short-wavelength end of the electromagnetic spectrum, such as x-rays and gamma rays are ionizing. Ionizing radiation is produced by radioactive decay, nuclear fusion and particle accelerators. Isotope: Atoms of a single element that have differing masses. Isotopes are either stable or unstable (radioisotope). Radioisotopes are radioactive: they emit particulate (alpha, beta) or electromagnetic (gamma) radiation as they transform or decay into stable isotopes. Magnetic resonance imaging (MRI): A diagnostic scan that uses high-strength magnetic fields rather than radiation. MRI techniques are used primarily to study anatomy, but a special type of MRI scan, functional MRI (fmri), can be used to map blood flow for functional studies. Molecular imaging: An array of non-invasive, diagnostic imaging technologies that can create images of both physical and functional aspects of the living body. It can provide information that would otherwise require surgery or other invasive procedures to obtain. Molecular imaging technologies include traditional nuclear medicine, optical imaging, magnetic resonance spectroscopy, PET and SPECT. Ultrasound, traditionally an anatomical imaging technique, uses microbubbles to create molecular images. Nuclear medicine: The use of very small amounts of radioactive materials (called radiopharmaceuticals or radiotracers) to evaluate molecular, metabolic, physiologic and pathologic conditions of the body for the purposes of diagnosis, therapy and research. Nuclear medicine procedures can often identify abnormalities very early in the progress of a disease 10

11 Appendix B: Glossary of Terms, continued long before many medical problems are apparent with other diagnostic tests. Optical imaging: A molecular imaging procedure in which light-producing molecules designed to attach to specific cells, such as cancer cells or brain chemicals, are injected into the patient s bloodstream. Imaging is then performed using devices that are able to detect these molecules inside the body. The two major types of optical imaging are bioluminescence imaging, which uses a natural chemical such as luciferase, the substance that enables fireflies to glow to trace the movement of certain cells or to identify the location of specific chemical reactions within the body, and fluorescence imaging, which uses proteins that produce light when activated by an external light source such as a laser. Single photo emission computed tomography (SPECT): Imaging that uses a gamma camera to detect radioisotopes that emit high-energy radiation. The gamma camera, which rotates around the patient, works with a computer to create three-dimensional images of the distribution of the tracer in the body. For a complete listing of nuclear medicine and molecular imaging terms, visit Positron emission tomography (PET): A medical imaging technique that uses radiopharmaceuticals that emit positrons (positively charged electrons). A radiopharmaceutical such as FDG is injected into the patient. The fluorine emits positrons, which react with the first electron they come in contact with, annihilating both and producing energy according to Einstein s famous E=MC 2 formula. This energy takes the form of two photons (particles of light) with a very specific energy level that shoot off in opposite directions. When these photon pairs are detected by the PET scanner, the location of the original fluorine atom can be extrapolated. Although positron/electron annihilation is one of the most powerful reactions known to science, the amount of mass involved is so small that the actual energy produced is not harmful to the patient, and the fluorine decays rapidly into harmless oxygen. Radiopharmaceutical: A type of imaging agent used in nuclear medicine, a branch of molecular imaging. It is a compound consisting of a drug and a small amount of radioactive material that localizes in specific organs or areas of the body and can be detected by an imaging device. 11