Current Status of Theranostics in West Asia: A Country-based Surveillance Study

Introduction

The West Asia region is a dynamic and vital area encompassing countries with diverse levels of economic development, including high-income (Qatar, Saudi Arabia), middle-income (Jordan, Turkey), and low-income countries (Yemen and Syria) [1]. Politically, the region exhibits significant variability, housing both areas under current conflict and those experiencing political stability [2].

As observed globally, the prevalence and mortality impact of non-communicable diseases (NCDs) have recently surged, with more than 50% of annual deaths attributed to these etiologies [3]. Theranostic services represent a crucial and innovative approach to addressing NCDs through diagnostic and therapeutic applications, underscoring the promise of this expanding field [4]. Following the discovery of radioactive iodine in the 1940s by Dr. Saul Hertz, a transformative therapeutic and diagnostic agent was developed, introducing an innovative theranostic concept for thyrotoxicosis and differentiated thyroid cancer [5]. The practice of theranostics, implemented with radioiodine as a prototype, commenced early in the West Asia region, with countries such as Iraq, Kuwait, Pakistan, and Iran beginning to explore and implement theranostics as early as 1955 [6–8].

Currently, a number of West Asian countries offer theranostic services and have established independent training programs to enhance the practice and quality of care [6, 9]. Amidst the current upsurge of NCDs, rise of subregional conflicts, and increased investment in theranostics [2, 3, 10], a group of experts from the West Asia collaborated to examine the current status of theranostics in this surveillance study.

Materials and Methods

Results

A group of theranostic experts from West Asia responded to the online survey, resulting in the inclusion of 15 countries in our analysis. The surveyed region is home to approximately 620 million people, with a median age of 29 years (Fig. 1). Nine countries (60%) have an annual GDP exceeding $200 billion, while the remaining countries have a GDP below this threshold. At the time of surveillance, only Yemen lacked theranostic services on a country-wide basis. The remaining 14 countries offered active theranostic services locally through a total of 452 centers, staffed by 1,426 theranostic physicians across the surveyed region. However, the region exhibited significant heterogeneity in the distribution of theranostic centers (Table 1, Summary statistics). Country-based subregional analysis of theranostic service coverage in administrative units revealed that most countries (12 out of 14; 86%) had coverage gaps in major cities, provinces, and emirates. Only Kuwait and Iran achieved 100% coverage, with theranostic centers available in all governmental administrative units (Table 1, Key criteria).

Discussion

This surveillance study aimed to identify potential strengths, opportunities, and current obstacles to optimal theranostic practice across 15 West Asian countries. At the time of our surveillance study, Yemen was the only West Asian country devoid of any theranostic services, a problem that has persisted due to ongoing conflicts, financial instability, and political unrest [2]. A deeper level of subregional analysis was employed to further characterize and observe theranostic distribution across administrative governmental units in each surveyed country. Coverage gaps in major cities, provinces, and emirates are currently present. With the exception of Iran and Kuwait, citizens of Yemen and those residing in major cities and subregions within other West Asian countries still lack access to theranostic services and are forced to travel outside their area of residence to obtain this vital service. Overall analysis of the region unveiled some mutual challenges facing the region, stemming from a lack of adequate research reactors and radiopharmacist coverage, which are primary requisites for establishing independent theranostic centers [4].

The establishment of theranostic centers in the region faces numerous challenges, including regulatory hurdles, supply chain issues, and securing insurance and reimbursement [10]. These factors necessitate dedicated administrative capabilities and sufficient workforce density for proper theranostic establishment [14]. While some countries grapple with these issues, others encounter different barriers to theranostic implementation, such as the perception of nuclear medicine primarily as a diagnostic service, limiting its integration into therapeutic practices [15].

Our study highlighted important observations regarding the financial and political impact on theranostics. While differences exist between stable and unstable subgroups based on financial and political status, the disparity was more pronounced in terms of manpower for politically unstable regions, while predominantly affecting infrastructure in financially constrained areas. This underscores the complex interplay between theranostics, financial resources, and political stability. Countries affected by recent and ongoing conflicts often struggle to retain healthcare professionals who may feel insecure amidst political instability [16]. Conversely, countries with limited financial resources may possess the knowledge and desire among their staff but lack the capability to develop and progress into prosperous theranostic services due to budgetary constraints [17].

With that being said, regional and subregional disparities in theranostic services may offer opportunities for growth and collaboration. Advanced nations can serve as anchor points for emerging nuclear medicine professionals from neighboring countries, potentially catalyzing the development of nuclear medicine and theranostics in underserved areas [18]. Enhancing communication and collaboration among West Asian countries under the umbrella of national and international organizations can significantly improve the level and scope of care provided. Country-based collaboration is evident in 66% of surveyed nations, facilitated by the ongoing support and activities of their national nuclear medicine societies. These societies are instrumental in shaping the future of theranostic practice within each country, fostering collaborative networks with neighboring and distant nations, and exploring potential areas for skill acquisition and practices that align with their objectives. Establishing nuclear medicine societies in the remaining countries is crucial, as it can enhance collaboration and create opportunities for multi-level support [19].

At present, only nine countries provide local training programs for theranostic applications. A total of six Arab countries within West Asia are currently devoid of local theranostic training programs. Nevertheless, training opportunities abroad in remote and neighboring countries remain accessible. A notable example is Jordan’s significant contribution in offering theranostic training programs for numerous Arab countries, particularly neighboring Iraq and Palestine [9]. The recent establishment of the Arab Board of Nuclear Medicine represents a promising development for many Arab countries currently lacking training programs, as it has the potential to address the pressing need for theranosticians in the region [20].

While this study revealed higher rates of theranostic availability, workforce density, and infrastructure in countries with GDP exceeding $200 billion, financial constraints should not deter interest in promoting theranostics. Recent simulation studies have demonstrated a clear investment case with estimated returns of $12 for each dollar invested, encouraging policymakers to invest in and promote theranostic services [21]. This evidence, coupled with the high rates of population growth and large youth demographics in the West Asia, may create opportunities for theranostic services to thrive and expand beyond current barriers, thereby addressing observed disparities.

In light of the previously mentioned opportunities, the incorporation of innovative therapeutic agents is expected to significantly enhance growth and productivity within the field of theranostics in the region over the coming years [4, 10]. The advent of FAPI theranostics, Terbium radioisotopes, and CXCR4 theranostics in West Asian countries presents promising avenues for the advancement of personalized medicine and the enhancement of patient outcomes [22–25]. These novel agents possess the potential to transform cancer diagnosis and therapy by facilitating precise targeting of tumor cells while minimizing side effects in comparison to conventional therapeutic agents.

Although this study provides a comprehensive analysis of theranostics in the West Asia region, several limitations warrant consideration. The investigation did not include all geographical areas traditionally associated with the West Asia, potentially introducing selection bias. Furthermore, the current analysis lacks perspectives on critical aspects related to quality control measures, theranostic center capacities, and center-specific analytical approaches. Notwithstanding these limitations, this research represents the inaugural study specifically designed to provide an updated perspective on current challenges and barriers to theranostic practice in the West Asia region.

Conclusion

The practice of theranostics in the West Asia reflects a complex landscape characterized by significant subregional discrepancies. Our observations indicate pronounced financial, political, and theranostic care inequalities in the region. However, these disparities can serve as a potent impetus for transformation through strategic collaborations across the region. Establishing partnerships between nations with advanced capabilities and those that lack adequate nuclear medicine infrastructure is not merely beneficial but essential for progress. This collaborative framework has the potential to advance theranostic development, significantly improving both the availability and quality of healthcare services. As these alliances are fostered, they will pave the way for a new era in healthcare within the West Asia, wherein cutting-edge theranostic solutions will be made accessible to all, thereby fundamentally altering patient treatment modalities and outcomes across this diverse region.

Authors Contribution

Akram Al-Ibraheem, Ahmed Saad Abdlkadir, Batool Albalooshi, and Maryam Alkuwari participated in data acquisition and manuscript revision. Akram Al-Ibraheem, Ahmed Saad Abdlkadir, Dyab Al Mahariq, and Khalsa Al-Nabhani participated in initial drafting of the manuscript. Akram Al-Ibraheem, Ahmed Saad Abdlkadir, Abdullah Alqarni, Mohammed Al-Rowaily, Murat Fani Bozkurt, and Habibollah Dadgar participated in the study conception and design. Akram Al-Ibraheem, and Ahmed Saad Abdlkadir prepared the figures and conducted relevant analyses. Akram Al-Ibraheem, Ahmed Saad Abdlkadir, Abdulredha Esmail, Shazia Fatima, Mohamad Haidar, Aysar Khalaf, Fairoz Mohammed, Fuad Novruzov, and Majdi Zein reviewed the final content of the manuscript. All authors read and approved the final manuscript.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Data Availability

The current study data are available from the corresponding author on reasonable request.

Declarations