Begin with a National NET Multidisciplinary Meeting
NETs are uncommon, heterogeneous tumors requiring complex individualized management
strategies. Treatment planning for people with NETs in multidisciplinary meetings
(MDMs; also known as tumor boards) is evidence-based, improves outcomes, and can lead
to altered management in up to 61% of cases.[5] NET MDMs are therefore the foundation for clinical care including selection of patients
for PRRT.
The NZ NET MDM was designed at national clinical meetings in 2012 and 2014. The meetings
were led by a small team of medical specialists and scientists who began the “NETwork!”
research project, which combined NET outcome measurement, epidemiology, tissue collection,
genomics, and clinical care. The academic component provided energy, partial salary
support for a clinical lead, rigor in planning, and attracted like-minded clinicians
working together to understand NETs.
Initially, MDMs in four to six sites were planned across the country. Due to limited
administrative and funding support, a single NET MDM was established in one center,
which gradually opened to national referrals, ensuring that any clinician/patient
in NZ has access to expert multidisciplinary advice.
The structure has since evolved to a core group of regularly attending specialists
in nuclear medicine (NM), oncology, endocrinology, pathology, radiology, surgery,
and NET clinical nursing. There is an ongoing process to recruit other specialists
including gastroenterologists, cardiologists, radiation oncologists, and dieticians
to regularly attend; currently, these specialists are individually invited to attend
if a case requires their input.To evaluate the impact that the NET MDM had on clinical
management an internal retrospective audit of the first 103 cases was performed. Three
attending specialists retrospectively and independently compared patients' medical
records to MDM recommendations. The results showed significant clinical impact: diagnosis
changed in 17%, the World Health Organization grading in 14%, and radiological staging
in 25%. Patient management changed in 50%, avoiding surgery in 9%, chemotherapy in
3%, and shifting to observation in 8%. MDM recommendations were followed in 74% of
cases.
Subsequently, the frequency of meetings increased from monthly to weekly, with funding
secured for a coordinator (2017), online pro forma (2018), and Zoom video platform
(2019). The online format allowed expert clinicians from multiple centers to join
the MDM team. The national NET MDM unified NZ NET specialists. Increasing case volume
enhanced experience and improved the quality of recommendations. The meeting is currently
the sole point for PRRT referral.
Maturation of the Service
Since establishment, the service has been in a constant state of refinement and evolution
to ensure robustness and quality of care. Six key areas of improvement were:
Infrastructure: Auckland Hospital was able to meet the national[9]
[10] and international[12] standards for the safe delivery of radionuclide therapies including radiation protection,
storage, and disposal thereof. Dedicated lead lined shielding rooms originally used
for administration of high-dose iodine-131 (I-131) were repurposed for administration
of Lu-177 dotatate. Initially, only two of the four dedicated lead lined shielding
rooms in the hospital were available for use. In July 2022, following the approval
of an additional business case, a third room was made available for use to increase
patient throughput.
When the service was first established, patients were admitted to the treatment rooms
for the night following their PRRT infusion for monitoring of secretory crises or
pain flare. As a newly introduced service, for a group of patients who had often been
waiting with extensive NET disease, the treating team prioritized patient safety to
ensure they could manage any potential adverse events. Over time, as the team gained
experience and confidence in the safety profile of PRRT, the treatment protocol evolved.
Patients who remained stable postinfusion are now discharged the same day (the vast
majority), while those requiring admission are accommodated within the adjacent medical
oncology ward. This transition optimizes admission and staffing resources.
A further challenge encountered during the establishment of the service was the lack
of a specific protocol for the admission of radioactive patients to the intensive
care unit (ICU). Additionally, intensive care teams had not received basic training
on how to safely manage radioactive patients in an acute setting. Recognizing the
importance of addressing these gaps, significant effort was dedicated to education,
training, and collaboration with critical care teams. This involved developing a structured
protocol to guide emergency response teams in safely managing radioactive patients
on the ward and ensuring a clear framework for the admission of radioactive patients
to the ICU. Importantly, this protocol was designed not only for PRRT patients but
also for those receiving high-dose metaiodobenzylguanidine (MIBG) therapy, ensuring
a standardized approach to the acute management of all radioactive patients requiring
intensive care.
Staffing: To expand treatment capacity and advance service development and training, an additional
NM specialist with expertise in theranostics was recruited in 2022. This specialist
is accredited by the Joint Training Committee of the Australasian Colleges of Radiology
and Internal Medicine and is a fellow of the Australasian Association of Nuclear Medicine
Specialists, meeting Australasian and international criteria for performing theranostics,
as well as for training and supervision.[13] Alongside the NM specialist, a medical officer in NM with an MBChB qualification
was also recruited to support service delivery. Recruiting medical officers in NM
is vital, given the ongoing shortage of theranostics-skilled NM specialists not only
in NZ but also globally[14] and in particular developing countries.[15] While the medical officer collaborates closely with the specialist, the overall
responsibility for patient care and service development remains with the NM specialist.
The onsite theranostics treatment team now consists of three NM specialists, one medical
officer, four NM medical imaging technologists (NM MITs), two medical oncologists,
one endocrinologist, two NET clinical nurse specialists, and one medical physicist.
Training: Auckland City Hospital, a tertiary center, received accreditation for NM training,
including theranostics, in 2024 by the joint training committee of the Australasian
Colleges of Radiology and Internal Medicine. The facility currently meets the criteria
to be classified as a Category 1: Basic clinical Theranostics Training Center.[13]
Theranostics has always been within the scope of practice for NM MITs in NZ; however,
their role has traditionally been limited, working alongside NM specialists, oncologists,
and license holders. With advancements in theranostics, NM MITs now play a significantly
larger role, necessitating further skill development in this specialized field. To
address this, the University of Auckland has introduced a 12-week theranostics course,
covering key areas such as imaging and quantification, dosimetry, theranostics services
and roles, the establishment of theranostics services, radiation safety and protection,
and clinical applications. This course, launching in July 2025, is fully online and
forms a compulsory component of the Nuclear Medicine Postgraduate Diploma in Health
Sciences. Additionally, it is available as a Certificate of Proficiency, for registered
MITs as an independent course for Continuing Professional Development. Integrating
dedicated theranostics training within the NM MITs current scope of practice is essential
in this rapidly advancing field. This initiative positions NM MITs to adopt leading
practice standards and take on a more comprehensive role in the delivery of theranostic
therapies.[16]
Course link:
https://courseoutline.auckland.ac.nz/dco/course/MEDIMAGE/729/1255
Ongoing professional development: Ongoing professional development is essential to ensure a high-quality, evolving
PRRT service. To support this, short teaching sessions have been integrated into the
weekly PRRT planning meetings, with teaching responsibilities rotating between NM,
medical oncology, and endocrinology. This structured approach reinforces proficiency
in patient care, medical knowledge, interpersonal skills, practice-based learning,
professionalism, and ethical behavior, ensuring a well-rounded, multidisciplinary
learning environment.
Beyond internal training, close collaboration with expert centers remains a priority,
allowing the team to learn through discussing problem cases and by adapting treatment
protocols. Annual attendance at key NET-specific educational and research conferences,
such as ENETS and CommNETS, is strongly supported, along with participation in specific
theranostics conferences and preceptorships. This promotes continuous professional
development and the acquisition of new competencies, ensuring that the entire team
remains skilled and up to date.
By fostering a strong culture of ongoing learning and collaboration, the service aims
to continuously improve patient care and optimize treatment outcomes.[13]
The extended period without PRRT access prior to 2019 created a backlog and a surge
in referrals that exceeded the estimated 30 patients per year. This “bow wave” saw
referral numbers approximately double expectation for the first 4 years, specifically
51 in 2021, 59 in 2022, 64 in 2023, and 22 by June 2024. This puts significant pressure
on the PRRT waitlist. The service gradually increased capacity treating three patients
per fortnight, expanding to six in July 2022, and then eight in July 2023. In addition,
the initial patients had more advanced disease with higher risk of secretory crisis
needing support from medical oncology and endocrinology. The “bow wave” is now settling
at 4 years after service initiation and patients are now being treated within the
ideal time frames ([Fig. 4]).
Fig. 4 Time between referral and treatment commencement by priority (A). Clinical priority scoring system (B).
A clinical priority scoring system with treatment time frames ([Fig. 4]) was introduced in 2022 to replace the “first referred, first treated” system. This
was done to improve equity and safety of patient care. Treatment time frames also
offered a trackable metric for audits, ensuring that patients are prioritized based
on clinical risk and treated within a designated time frame, regardless of ethnicity
or geographical location.
At the inception of the service, PRRT referrals were submitted via email, printed
as hardcopies, and stored in a physical folder in a filing cabinet. These referrals
were processed on a “first referred first serve” basis with no digital record of the
patient information provided. In April 2022, the implementation of a central digital
referral system introduced an electronic patient data capture method process. This
transition enabled all patients to have digital summaries of their referral information
and allowed for priority placement on an electronic waitlist. The digital summaries
are easily accessible throughout the patient's PRRT treatment and are continuously
updated to include blood test and imaging results performed during treatment. This
has significantly improved the accuracy of tracking and monitoring patients and will
be an important data source for our national PRRT database, which is currently being
established.
[Fig. 4] depicts the “bow wave” and its gradual resolution, achieved by an incremental increase
in capacity and working through the backlog of patients at the time-of-service initiation.
Accurate waitlist data capture was only possible after implementing digital methods
for data management, and so data are shown from June 2022.
Initial insufficient administrative support led to communication breakdowns and inappropriately
shifted administrative duties to clinical staff, especially NET Clinical Nurse Specialists
(CNSs). Securing full-time administrative support significantly improved communication
between the service, referring clinicians, and patients and has enabled NET CNSs to
focus on coordinating and delivering clinical care.
All patients receive comprehensive support throughout their PRRT journey. Prior to
the first specialist assessment (FSA), the team proactively identifies potential barriers
to treatment, such as limited social support, low health literacy, financial hardship,
or psychological challenges (e.g., anxiety related to scans or treatment). Recognizing
that such factors can impact treatment access and adherence, the service works closely
with local hospitals and community networks to provide tailored assistance. This includes
food and petrol vouchers, transport support, and additional appointments as needed,
ensuring patients remain engaged in their care. Strong relationships with local lead
health care providers (initiated through the NET MDM) across the country allow the
team to optimally utilize local resources and ensure that patients receive individualized
and closely coordinated care.
In recognition of the ongoing health inequities experienced by NZ people of Māori
ancestry, and with the aim of delivering gold-standard, culturally responsive care,
the PRRT service has introduced dedicated cultural support for Māori patients. One
of Auckland City Hospital's Kaumātua (respected elder) plays a pivotal role in engaging
with Māori patients, providing cultural connection, support, and karakia (prayer)
during both the FSA and on the ward before treatment. A kaumātua is an acknowledged
leader and guardian of traditional knowledge, genealogy, and cultural customs. Through
whakawhanaungatanga—a process of relationship-building based on shared ancestry, friendships,
and interests—Māori patients are welcomed into the service in a way that aligns with
Te Ao Māori (the Māori worldview). This culturally grounded approach fosters a sense
of belonging, trust, and emotional well-being, ensuring Māori patients feel valued,
respected, and fully supported throughout their PRRT journey.
