Why we built Surat's first digital PET/CT — and priced it like a conventional one

For four years at Gujarat Imaging Centre in Ahmedabad I reported PET/CT on two kinds of scanner: a conventional photomultiplier-based system, and a modern digital one. Same patients, same referring oncologists, same reporting standards. The only variable was the machine.

That is an unusual position to be in, and it settled a question I might otherwise have argued about theoretically for years.

What the difference looked like in practice

Not dramatic, most days. Both machines answered the common questions perfectly well. A 3 cm lung mass with a bulky mediastinal node looks like a 3 cm lung mass with a bulky mediastinal node on anything.

The difference showed up at the margins — and the margins are where treatment decisions are actually made.

A 6 mm node next to the aorta that I could call involved with confidence, instead of hedging. A solitary vertebral focus in a man with a PSA of 0.6, where the alternative report would have been "no evidence of disease". A peritoneal deposit in a woman whose CT had been called equivocal for four months.

Every one of those is a treatment plan that changes. Not a nicer picture — a different operation, or no operation, or radiotherapy to a target that would otherwise have been missed.

I also noticed something less measurable. On the digital system I wrote the word "indeterminate" less often. Anyone who reports scans knows the discomfort of that word: it is honest, and it hands the anxiety back to the patient and their doctor for another three months.

The other half: what the patient experiences

Reporting doctors talk about resolution and sensitivity. Patients experience something else entirely.

A whole-body acquisition of about fifteen minutes instead of twenty-five to thirty does not sound like a revolution until you have watched a woman with bone metastases try to lie still on a hard table. Or a breathless patient with a lung primary. Or a frightened seven-year-old.

Halving that time rescues studies that would otherwise be degraded by movement, and it spares people a genuinely difficult half hour at the worst point in their year.

The lower injected dose matters most for the patients nobody thinks about at the time of the first scan: the ones who will have six or eight more over the following two years.

Why Surat

South Gujarat has a large population and good oncologists. What it did not have was a digital PET/CT. Patients who wanted one travelled to Ahmedabad or Mumbai — a day of travel, a night in a strange city, a family member taking leave from work, and a return trip to collect films.

For a well patient that is an inconvenience. For someone three cycles into chemotherapy it is a real barrier, and barriers to imaging turn into delayed staging and delayed treatment.

Surat did not need another PET/CT. It needed one that was not a generation behind.

The price decision

Here is the part I want to be plain about, because it was a deliberate choice and not a slogan.

A digital scanner costs considerably more to buy than a conventional one. The ordinary way to recover that is a price premium — position it as the premium scan, charge accordingly, and accept that some patients will choose the cheaper option elsewhere.

We decided against that, and priced our digital PET/CT at the same level as conventional PET/CT in Surat.

The reasoning was simple. If the advantage of a better scanner only reaches patients who can afford a premium, it is not really an advance in cancer care — it is a luxury product. And the patients who benefit most from a sharper scan are frequently the ones least able to pay extra for it.

The economics work through volume rather than margin. That is a slower way to run a diagnostic centre and it requires the machine to stay busy. So far, it has.

What the machine does not fix

I would rather say this myself than have it said about us.

A scanner does not read a scan. A superb machine reporting through someone without oncology subspecialty training will produce worse outcomes than a modest machine read by an experienced onco-radiologist. Every technical advantage described above is potential; it is realised only in the reporting.

That is why the reporting standards mattered as much to us as the equipment: structured templates, standardised response criteria — RECIST 1.1, PERCIST, Deauville, mRECIST, Choi, RANO — used consistently so that a scan here can be compared against a scan done anywhere, and a weekly tumour board where the images are discussed with the surgeons and oncologists rather than posted to them.

Nor does a scanner fix communication. A patient who leaves holding a report they cannot read has not been served, however good the images are. We keep time for people to come back and have their scan explained to them, with the images on screen, in Gujarati if that is easier. It is not a service line and we do not charge for it.

What comes next

Imaging is only half of molecular medicine. The same molecules that find disease can carry a therapeutic isotope and treat it.

We are commissioning a dual-head gamma camera and a radionuclide therapy suite so that Lu-177 PSMA therapy for advanced prostate cancer, PRRT for neuroendocrine tumours and I-131 therapy for thyroid cancer can be delivered here rather than in another city. Scan with gallium-68, confirm the target lights up, treat with lutetium-177 attached to the same molecule.

See it, then treat exactly what you saw. That is where this is going, and it is why Prismaa was built the way it was.

— Dr. Keyur Mandaliya, Founder & Managing Director