Philips – for Russian healthcare

Stop dying of cancer

Olga Vlasova, "Expert" – Country Reviews No. 4-2013

Being equipped with modern diagnostic equipment and its competent use will allow Russia to significantly reduce the mortality of the population from oncological diseases and not only.

The aging of the population and the increase in life expectancy poses a difficult task for European civilization – to provide the population with modern medical care without a dramatic increase in health care costs, which will allow them to maintain their working capacity longer and maintain the quality of life even with serious chronic diseases. The solution of such ambitious tasks goes beyond the most effective public administration and rests on the achievements and developments of world technological leaders. For example, recently the Dutch company Philips and the European Union announced the launch of a program to introduce integrated care and so-called telemedicine. Such a system will provide the majority of chronic patients with effective medical monitoring at home, which will significantly reduce the budget costs of European countries.

For Russia, however, such tasks have not yet become a priority. More pressing issues are on the agenda, for example, timely and effective diagnosis of oncological diseases, which will automatically increase the percentage of successfully cured patients. In Russia, more than half a million cases of cancer are diagnosed annually, while a significant part of them are detected at the third or fourth stages, when treatment rarely leads to a positive result (in the European Union, this is usually the first or second stage). Such a late diagnosis is directly related to the lack of the possibility of studies that allow us to obtain accurate information about the slightest modification of tissues if their malignancy is suspected.

Elena Dizendorf, Medical Director of Philips in Russia and the CIS, told the Expert about how Philips Healthcare could help Russians stop dying from cancer, as well as about other areas of the company's work in Russia.

Almost a panacea– What are the main problem points around which Philips Healthcare is focused in Russia?

– The greatest threat to public health in the world is cardiovascular diseases, and Russia is no exception. The first place among the causes of death in Russia is also occupied by diseases of the cardiovascular system (57 percent). We also supply equipment that is designed for the diagnosis, including early, of these diseases, preparation for treatment, the treatment itself, as well as follow-up of patients and evaluation of the effectiveness of treatment.

The second area of our activity is oncology. In particular, we produce equipment for screening – the primary examination of healthy individuals (for example, screening women to detect early stages of breast cancer). Nuclear medicine (everything related to the use of radioisotopes) is generally one of the most promising areas. It is used both for diagnostic and therapeutic purposes. We produce diagnostic equipment. This includes not only positron emission tomography (PET), but also classical radioisotope diagnostics - single–photon emission computed tomography (SPECT).

– How do these methods differ?

– Different isotopes are used in PET and SPECT. PET is the most modern level of diagnostics, in which ultra–short-lived isotopes are used. Their half-life ranges from a few minutes to several tens of minutes, respectively, isotopes are rapidly excreted without harming the body. The role of isotopes is reduced only to being a marker of those metabolic processes that we want to see. For example, in oncology, it is possible to assess the rate of glucose consumption by cells, tissue hypoxia, and the formation of blood vessels in a tumor. Isotopes help to detect disorders of the body at the molecular level, thereby more accurately diagnose and prescribe effective treatment.

At the same time, Philips is actively developing technologies aimed at reducing the radiation dose of the patient and medical personnel during PET studies. Safety is one of our priorities.

– Where is PET used?

– For example, in cardiology. PET is used for studies of myocardial perfusion. For example, a CT angiography was performed on a patient and they saw that the coronary vessels were narrowed by 50-70 percent. Endovascular surgeons (they are engaged in the treatment of blood vessels. – "Expert") put stents on such a patient. This is a very expensive procedure and not always necessary. If you conduct PET or traditional radioisotope diagnostics before surgery and use it to see how much blood supply to the myocardial muscle is reduced, then in many cases you can see that even with vasoconstriction, blood circulation does not suffer and stenting is not necessary for this patient. This occurs, for example, when the patient has developed circulatory bypasses and the heart copes with vasoconstriction. Thus, a person is saved from unnecessary surgery and unnecessary expenses.

PET can also assess the viability of the myocardium when, for example, a patient wants to undergo coronary artery bypass grafting. With the help of PET, you can see whether there is living tissue in the area of reduced blood circulation of the heart muscle or not – if not, then bypass surgery is not indicated, but other forms of treatment are needed. Finally, thanks to PET after surgery, it is possible to assess how effective coronary artery bypass grafting was.

In addition to cardiology, PET is used in neurology – for the diagnosis of brain tumors, Alzheimer's disease and epilepsy. However, 90 percent of all cases of PET use are oncology. With this procedure, even the smallest metastases in the lymph nodes and distant organs can be detected.

Prevention saves– But in real life, people receive a referral for this kind of research already with specific recommendations and suspicions, when it is very unlikely to find the zero stage of cancer.

– It's true. I know of only one example when PET studies were included in a mass medical examination. Such an experiment was conducted in Japan. Tens of thousands of healthy people were screened with PET, and about one percent of them were found to have malignant tumors in a very early phase.

However, the cost of the procedure – at least $ 1,000 – does not allow it to be used for mass medical examination. In addition, the PET procedure is associated with irradiation of the patient, therefore, preventive screening programs with PET are not accepted in any country. In order for a person to undergo the procedure, certain indications are necessary. For example, PET is used in the case of cancer patients in whom doctors have identified a primary tumor, but cannot find metastases and do not know whether they are present in the body at all. If a patient is undergoing a conventional computed tomography (CT) or magnetic resonance imaging (MRI), then small metastases can easily be missed. And, accordingly, it is inaccurate to determine the stage of cancer and prescribe ineffective treatment. And if you irradiate the primary focus and do not affect the metastases, then there will be no sense from such treatment. The PET procedure finds all the smallest foci – metastases both in the lymph nodes and in distant organs. Thus, it is possible to accurately determine the stage of the disease and prescribe the necessary treatment. I worked as a doctor in Zurich for two years, and the topic of my scientific work was the sharing of PET/CT in the planning of radiation therapy. And it has been proven that if we add PET to the traditional methods of planning radiation therapy (CT), then for more than 70 percent of patients, either the volume, dose, or tactics of irradiation change. So every oncological patient is recommended to undergo PET before prescribing treatment.

– There is a problem with cancer prevention in Russia. Unlike Europe, our cancer is diagnosed mainly at the third or fourth stage. Why is that?

– Firstly, it is the attitude to prevention itself. In the West, it is not neglected – at least because it is expensive to get sick there. In Russia, prevention is overlooked. At the end of 2011, together with a sociological company, we conducted an all-Russian study "Index of Health and Well-being". And it turned out that 37 percent of respondents undergo preventive measures either very rarely or never. 40 percent go to the doctor only in extreme cases. 32 percent diagnose themselves on the advice of family and friends, and the same number – from doctors. In general, only 41 percent of Russians believe that their health depends on themselves (for comparison: in Brazil, 67 percent of respondents think so, in the USA – 60, in India – 57).

Another reason is that in the West, unlike Russia, preventive medicine is very well developed, serious nationwide screening programs. For example, in Germany, all women of a certain age are invited to undergo a mammographic breast examination for free. For those who live in small towns or villages, there are special mobile brigades (each of them can take hundreds of women a day). Then all digital images are sent to the regional center, where doctors look at them and decide who to invite for a second examination, who to appoint additional examinations.

Similar procedures are carried out for lung cancer. And this is not our fluorography, which was done on low-quality equipment, missed a lot of foci of tuberculosis and lung cancer and thereby discredited itself. In Europe, more modern equipment is used, which detects even the smallest foci.

– How much does the screening equipment in Russian hospitals meet the spirit of the times in general?

– Despite all efforts to modernize, the equipment fleet in Russia is still very outdated – from the simplest samples of X-ray diagnostic equipment to MRI and CT systems. There is nothing to say about nuclear medicine at all – radioisotope departments were active in our country until the 1980s, and then the whole system was destroyed. There are still Hungarian gamma cameras manufactured in the 1970s in a number of cities - with low resolution, constantly breaking down. However, many cities do not have this either. In general, in Russia, tomographs (CT, MRI) work for fifteen to twenty years, whereas in the West they change every five to seven years.

There is another problem: a number of hospitals have non-core equipment. The reason is that the tender process for purchasing equipment in Russia does not particularly take into account the needs of doctors, but is decided by officials. And as a result, for example, an MRI in a complete set designed for oncology is delivered to a cardiology clinic, and vice versa. Tenders for the purchase of equipment also do not take into account the need for post-warranty service. As a result, the hospital has no money for service contracts, and in case of equipment failure, several months are spent on holding a tender for spare parts and repairs. All this time the device is idle.

We teach you to read pictures– Many stories are connected with the fact that our doctors do not know how to work with a tomograph.

In Vladikavkaz, for example, there is a tomograph, but there is no one to work on it. When you supply your equipment, do you train the staff at the same time?

– Training is one of the priorities of our company. We have a circle of specialists in clinical training – experienced doctors who have worked on this equipment for more than one year. And after purchasing, for example, a magnetic resonance tomograph, one of them necessarily comes to the buyer and spends a week or two there, depending on the complexity of the equipment. He trains doctors and average medical staff in the skills of work – conducts the so-called application training.

However, our work on training doctors is not limited to this. We regularly conduct extensive educational programs: seminars, schools. Including in the regions, including on-the-job. For example, in the Bakulevsky center we organized a school on CT and MRI of the heart and blood vessels. There were users who worked on our equipment, but had not yet dealt with cardiological problems. Or they wanted to know more about it. They were lectured by leading specialists of the Bakulevsky Center and foreign professors, practical classes were conducted on the examination of patients. Then, at the workstations, the skills of processing the received images, making a diagnosis in difficult cases were practiced.

We try to conduct as many such classes as possible, however, in accordance with the Law on the Basics of Public Health Protection, serious restrictions are imposed on medical equipment manufacturers to interact with doctors.

"Which ones?"

The law, which came into force last year, equalized the rights of pharmaceutical companies and manufacturers of medical equipment. He seriously restricted our access to the medical community. Meanwhile, what we were doing was not illegal, but on the contrary, contributed to the improvement of the educational level of doctors. This includes trips to international congresses: we do not consider it shameful when a doctor who is a user of our equipment, who knows English and is interested in modern diagnostics, goes to an international congress at our expense and listens to lectures by leading specialists. There is no corruption scheme here – after all, he does not make a decision about what equipment a particular medical institution will buy. However, we are now being told that if the doctor does not make a report himself, then his trip cannot be summed up as "research activity" and we have no right to pay for his air ticket and hotel. At the same time, it should be understood that the current level of training of a significant part of our doctors will not allow them to speak at international congresses – their theses will simply not be accepted. To do this, they first need to learn and listen to the world's luminaries – so it turns out to be a vicious circle. Moreover, on the same basis, we cannot pay for the arrival and accommodation in Moscow to doctors from the regions (who also need to study in order not only to read reports, but also to work effectively).

All these restrictions not only do not help the development of doctors, but also contribute to the emergence of "gray" companies that disguise themselves as various funds and circumvent the law through dubious schemes.

– How do you train doctors in the regions in such conditions?

– Well, for example, we have purchased ten workstations equipped with the most modern programs for working on CT, MRI, PET and combined into one system. And we can take these workstations to cities, hold field events on them with the participation of our application specialists and experienced local experts. We often invite foreign lecturers who give lectures at major congresses. But it's not easy with them either. First of all, the above–mentioned law imposes serious restrictions on the invitation of foreign specialists - we need to provide a lot of documents for them, including for paying for their lectures. In addition, we have to provide simultaneous interpretation – unfortunately, there are few doctors in Russia who speak English. Philips has a lot of international educational programs and materials in electronic form in a foreign language, and we have to adapt all this for the Russian reader.

– Anyone who has undergone a tomography understands that the equipment is one thing, and the interpretation is quite another. The person who receives these pictures is not always able to comprehend them. Do you participate in the training of doctors in medical universities? What kind of equipment do these students study on, how modern is it?

– Students study at clinical bases in those medical institutions that are attached to these universities. And they work on the equipment that is there. For example, there is no particular problem in Moscow universities, many clinical bases are equipped with the most modern equipment. In other cities, the situation is not quite simple. Sometimes there is simply nothing to learn from. Not everyone has the opportunity to go to Moscow and St. Petersburg internships.

With regard to the level of training, indeed, doctors of related specialties – neurologists, oncologists – do not know how to read MRI results. However, it is necessary to teach not only them – even those doctors who work on MRI should regularly take advanced training courses and be able to work on new equipment. We are currently negotiating with Sechenov Moscow State Medical University to actively participate in the process of preparing students.

However, we aimed not only at students – Philips intends to train the management staff of the healthcare system as well. In Russia, this is a problem, if someone teaches radiologists in our country, then until recently almost no one was engaged in doctors-managers. And here is MGMU im. Sechenova organized two–year MBA courses for healthcare managers at all levels - from ministers to heads of departments. Our module was also included in this program – last year, together with the American University of Virginia, we conducted a course for these students aimed at improving the efficiency of the medical institution. This is an extremely important point – it is necessary to build the system of work of the X-ray department in such a way that extremely expensive equipment is used to the maximum. This year we are negotiating to repeat the course and bring Dutch specialists from Maastricht University to the audience.

The word belongs to the state– What joint projects do Philips have with Russia in the field of healthcare?

– For example, we cooperate with the Russian company "Electron" in the production of CT scanners. The percentage of localization of production here is quite large – the software is written by "Electron", the interface is in Russian, some of the components are produced by them. In addition, our partner's highly qualified engineers are ready to provide high-quality service.

We have also been cooperating with Rosatom for almost three years. Our cooperation began after a meeting held in April 2010 by President Medvedev in Obninsk with the participation of the Minister of Health Tatyana Golikova. Then the president announced the need to develop nuclear medicine in the country. This was immediately discussed at the highest level, the preparation of the state program for the development of nuclear medicine began, within the framework of which a large amount of equipment was supposed to be purchased. It was then that Philips and Rosatom started a joint project in the field of nuclear medicine. In 2011, within the framework of the St. Petersburg Economic Forum, we signed a memorandum of cooperation and agreed that when the state program unfolds, we will offer our joint products. And although the program has not yet found real outlines, we do not abandon our intentions.

– And why do you need it so much?

– The nuclear industry is generally very capital- and technology-intensive. Creating a PET center from scratch is not an easy task. This includes design work, construction, but the most difficult thing is the organization of the production of PET radiopharmaceuticals. They need to be produced near the center – otherwise they will simply disintegrate during transportation. This also includes clean rooms with a complex ventilation and sewerage system, compliance with radiation safety standards, and training of specialists. All this, taking into account the cost of equipment, costs at least 500 million rubles, and somewhere a billion - depending on the volume of production of drugs, the capacity and number of PET scanners. And it will pay off at least in ten years. That is why no manufacturer will invest here without state guarantees of a minimum state order. We received these guarantees on CT scanners, came to Russia and, together with Electron, localized a sixteen-slice system.

In other areas, everything is much more complicated. In general, there are two factors limiting the development of nuclear medicine, including private medicine (today it is almost all state-owned). First of all, PET tests are not included in mandatory medical insurance, so insurance companies do not pay for such types of diagnostics. The second factor is very serious requirements for the production of radiopharmaceuticals in our country, which are much more stringent compared to the West. So, to use a radiopharmaceutical for clinical purposes, the PET center must first conduct a preclinical phase of testing (on animals), then on healthy volunteers, then collect a huge pile of documents for our authorities - all this takes at least two years. This is after the center is built, the staff is trained (it takes about a year to prepare a radiochemist from a chemist) and the equipment is working. A number of PET centers that have been built cannot be launched precisely because of the difficulty of obtaining licenses from Rostechnadzor. Fortunately, a provision has now been adopted to the law, according to which certain concessions are made to PET centers that make radiopharmaceuticals for themselves, and not for sale. While this law, however, has not entered into force.

All these restrictions have led to the fact that, with a population difference of two times, there are two hundred PET centers in Russia, and hundreds in the USA.

– Where are the Russian PET centers located?

– Those that are already working are located in Moscow, St. Petersburg, Chelyabinsk, Magnitogorsk, Khabarovsk, Voronezh, Khanty-Mansiysk and Tyumen. And according to international standards, at least one PET tomograph is needed per million inhabitants.

– When purchasing expensive equipment in Russia, there were many corruption scandals. Does Philips have its own method of ensuring transparency of purchases?

– One of the most important principles of Philips is doing business in strict accordance with local and international anti-corruption legislation. For example, Philips, whose shares are listed on the New York Stock Exchange, is subject to the FCPA - the US federal law on corrupt practices. And it is observed by the company's divisions around the world, and not only in the United States – otherwise, multimillion-dollar fines may be imposed on the company and it may lose contracts with American budget organizations.

As for tenders in Russia, it should be understood that until recently Philips Healthcare sold its equipment exclusively through distributors, without direct sales. Of course, we exercise control: each distributor goes through a business reputation check procedure, and once a year they are collected and conduct trainings, including on countering corruption. But we decided to go further. The company could not ignore the calls of the Russian leadership to increase the transparency of transactions in the field of medical equipment. And since the Russian market is one of the key ones for us (according to the results of last year, Russia became the fastest growing market for Philips), it was decided to switch to a new business model – onshore. This model involves the import of equipment to Russia by Philips itself and its sale to distributors under local contracts in rubles.

We are confident that onshore will allow us not only to better control the sales process, but also to reduce the price of goods by eliminating the chain of foreign intermediaries. In the future, it will also make it possible to conclude contracts directly with end users. At the same time, the company has no intention of refusing to work through distributors – we strive to continue to successfully cooperate with them throughout Russia, continuing to develop a sales network.

Gevorg Mirzayan took part in the preparation of the material.

Portal "Eternal youth" http://vechnayamolodost.ru17.06.2013