International Hospitals and Healthcare

TRAVELLING FOR TECH

From advanced remote robotic surgery, gene-editing and cancer-killing nanobots to remote sepsis patient monitoring apps and blockchain enabled cancer screening, the future for medical technologies has never been brighter. Tatum Anderson reports.

Although many of these technologies are in their infancy, innovative technologies are in great demand among international patients. Pete Read, CEO of strategic research and advisory firm Global Growth Markets, said: “In price-agnostic source markets such as China, the Middle East and Russia, accessing technology not available at home is typically the number two reason for travelling overseas for treatment – after gaining access to the latest drugs.” Unsurprisingly, the US is seen as having the most advanced medical technology available to international patients, followed by the UK, Germany and Japan. Singapore is seen as the medtech gold standard within Southeast Asia, for patients from Indonesia and Malaysia, he added. 
So, which technologies are patients travelling for? Establishing that is not as easy as it sounds said Josef Woodman of Patients Beyond Borders: “There’s precious little formal research, so much will be anecdotal.” 
It’s clear that patients travel for cancer treatments. The latest advances are cell-based therapies that use the body’s immune system to target cancer cells. Chimeric Antigen Receptor T cells (CAR-T) are showing great promise in clinical trials for blood cancers such as leukemia and, increasingly, in solid tumors (breast, brain, dermatological), said Edwin McCarthy at City of Hope, California, US. “We are one of the handful of hospitals authorised to administer the first two therapies approved by the US Food and Drug. Numerous other experimental trials are ongoing,” he said. 
According to Jithu Jose, Head of International Business Division of the Middle East and South Asia for Apollo Hospitals Group, patients are travelling for stereotactic radiosurgery or so-called gamma knife or CyberKnife technology, used for highly selective brain radiation therapy. It’s marketed as brain surgery without the knife – using a focused beam of gamma radiation on smaller tumours in the brain.  It’s also offered by world-class providers such as London’s Great Ormond Street Hospital for Children and Tufts Medical Centre in Boston, US. 
But cancer patients are also travelling to India for other specialist innovations. “We handle the highest Oncology inflow of medical travellers to South Asia right from bone marrow transplant (BMT) to Cyberknife,” Jose explained. Robotic surgery has been crucial too. Apollo was the first in India to use Mazor Robots for spine and Da Vinci Robots and its innovations have been driven from the top he said. “We are a three-decade old corporate entity. Our Chairman Dr Prathap C Reddy has reversed the brain drain of doctors from India to a great extent, by getting the best of technology, balancing cost factors and keeping up with globally competent clinical standards,” he said. “We introduced the first cyberknife in South Asia and soon we will commence the first Proton Beam Therapy Center in India.

Proton beam therapy 

Another popular innovation that patients are travelling for is proton beam therapy according to Patients Beyond Borders’ Woodman. “A high number of affluent Chinese lung cancer patients are flooding hospitals in the US, Korea and other destinations due to brutal air pollution in the major cities,” he said. Chinese paediatric patients are also receiving treatments at US hospitals. Many of them are travelling specifically for proton beam therapy, which uses beams of protons (sub-atomic particles) to destroy cancerous cells. It is sold as a treatment that will cause far less damage to surrounding tissue compared to conventional radiotherapy and is in demand for treating cancer in critical areas; such as brain tumours in young children, whose brains are still developing. 
Florida-based UF Health Proton Therapy Institute was one of the first to adopt proton therapy in the US and reckons it is the largest paediatric proton therapy programme worldwide. It has even created a programme for Chinese paediatric patients who visit the US for treatment, including tele-consultations before and after treatment in Florida, Woodman said. In Europe, Germany has become a global centre for proton beam therapy in recent years, with hospitals such as the Friedrichshafen Clinic welcoming hundreds of patients from China, according to Global Growth Markets’ Read. Although not for long, it seems. “More recently, as proton therapy technology has become more widespread in China and globally, demand from international patients is tailing off to some extent,” he said. 

Telemedicine

Telemedicine as a precursor to travel is growing enormously too, said Read. “Many patients are starting off their journeys with a video or teleconsultation – either by video for diagnosis or for a second opinion with a foreign doctor –  and then have follow-up consultations after procedures,” he said. Medical travel facilitators such as Concord CHC in Beijing link patients directly with the hospital. Shanghai startup MediStar Health connects cancer patients with foreign doctors via teleconference and translates records too. 
Hospitals, including India’s Apollo Group, are providing large-scale telemedicine services to patients, and some, such as the Mayo Clinic, provide services to doctors that wish to consult with its specialists for medical opinions. The service is even text-based, to save a third of the time of face-to-face appointments and meetings do not have to be scheduled.
India’s Sri Ramakrishna hospital is participating in Tata Communications’s new Gloheal telemedicine service to offer second opinions to rural patients.” Interestingly, physicians based in Kenya and Rwanda, for example, can also access a diagnosis and a treatment plan. “We give these services at a very affordable cost and general practitioners in these regions use our services due to the non-availability of certain specialities or due to logistics delays and costs incurred by the patient,” said V Ramakrishna, COO of SNR Sons Charitable Trust, which runs the hospital. “All our speciality doctors who are specialised in critical cases and surgeons use this facility and give second opinions. These opinions can also be given on hand-held devices, providing the correct bandwidth is available.” One great advantage of the system is that after the consultation they can either remain at home, or travel knowing that the hospital is familiar with their case. “Any patients travelling to our hospital are treated by the same doctor who has given the telemedicine opinion. Therefore, the patient saves hugely on costs for out-patient services,” he said. 

Dentistry

Some innovations by themselves will not encourage patients to travel. Patients are unlikely to be travelling because their medical records are eventually part of a blockchain. But they will, however, if technologies make travel more convenient. Patients Beyond Borders’ Woodman said that dental clinics and dental departments of hospitals that serve international patients are increasingly deploying CAD/CAM instrumentation, along with in-house laboratories, so they can competitively offer same-day treatments for crowns, veneers, implants and bridges, for example. “This allows travelling patients to save significantly on travel and accommodations costs due to multiple trips to a cross-border facility,” he said.  3D printing is enabling many of these dental services too. 

3D printing 

This kind of personalisation is in great demand. Some hospitals are fitting custom-made 3D bone or joint implants, prosthetics and skin for burns victims. But medical travellers are also accessing surgeons who are using 3D models on which they plan extremely complex surgical procedures. Paediatric surgeons at SickKids in Canada, say 3D models have become vital in the planning of intricate operations on tiny organs for example. “As personalised medicine takes a stronger footing (in large thanks to the advancements in medical tech), procedures and treatments will be increasingly individualised,” asserted Jordan Mills, CEO of MirrorMe3D, a specialist 3D printing company. “You see this happening at a micro-level with 3D printing of medication to individualise dosage levels up what we’re doing, which is helping surgeons with individualised planning for an aesthetic outcome.” Mills’ company works with cosmetic surgeons and reconstruction specialists to create life-sized 3D models of patients’ noses and faces, using scans or photos that are manipulated according to changes requested from their surgeon. Surgeons use models to plan cosmetic procedures, but also in consultation with patients. “Doctors can obtain 3D models ahead of a virtual consult and use it to show the patient potential outcomes,” she said. “Many patients want to see a 3D model of themselves and some feel it helps them better understand what types of changes to expect post-operatively. This makes the model an incredibly important communication tool and often helps patients and surgeons with setting more realistic expectations.”

Artificial intelligence

Another technology that travellers may not specifically travel for, but innovators say may improve their chances, is AI. The hope is that it will be able to diagnose prostate, ovarian, lung and bowel cancer at an early stage and can reduce deaths. Algorithms might detect pneumonia on a chest X-ray or identify a patient at risk of sepsis or acute kidney injury. They might automatically generate a discharge letter that would usually be time consuming to write. 
Today, Moorfields Eye Hospital is using AI to analyse retinal scans, University College London hospitals is utilising it in radiotherapy planning, and Imperial College London in mammography scans. They are collaborating with DeepMind Health, owned by Google’s parent Alphabet, on these projects. AI is also being used by hospitals to help doctors make clinical decisions based on the best available information by keeping up with the enormous scientific papers, guidelines and other important information for them. IBM’s Watson for Health technology – specifically Watson for Oncology (WFO) scours the cloud for medical journal peer-reviewed studies, case studies, newest clinical guidelines from around the world and process them, recommending personalised evidence-based treatments. The system has been used by Bumrungrad International Hospital (BIH) in Thailand, Icon Group in Australia, Grupo Angeles Servicios de Salud in Mexico, Mãe de Deus in Brazil, Taipei Medical University in Taiwan, and three South Korean hospitals.
Nan Chen, Senior Director of R&D and Clinical Data at BIH, has championed the technology. “WFO is one example of the key technologies that will help clinicians harness the increasing amounts of data that is becoming available as both medicine and treatment become more personalised for each individual patient,” he said. “As we treat more than half a million from over 190 countries each year, these technologies are increasingly important to provide the level of care that our patients have come to expect.” 
He added that doctors, sometimes in locations where there are no oncologists – such as BIH-owned hospital in Mongolia – could use clinical WFO decisions confidently. In fact, last year, researchers from BIH and IBM Watson compared decisions made by WFO with oncology specialists at BIH’s Horizon cancer centre and found 81 per cent agreement on retrospective cases (70 per cent for breast, 56 per cent for cervical, 90 per cent for colon, and 94 per cent for rectal cancer for example).
Some hospitals are fitting custom-made 3D bone or joint implants, prosthetics and skin for burns victims. But medical travellers are also accessing surgeons who are using 3D models on which they plan extremely complex surgical procedures
Critics say, however, more independently verified proof that WFO works is required, and less US-focused treatment recommendations. BIH did not respond to requests for comment, although researchers said discordance was largely attributable to BIH oncologists’ preferences, including favouring non-US guidelines for certain cancers, patient preferences, including toxicity, cost and logistic concerns. “Other reasons for non-concordance included recommended US treatment options not available in Thailand,” they said. 
It seems that as innovative technologies race ahead, the rules and public debates on when or whether they are appropriate trail along behind, as does the independent medical evidence establishing whether they work. AI has come in for criticism when it’s at odds with data protection rules. Many monitoring apps have not been peer-reviewed or approved by medical bodies such as the US FDA. And, said Woodman, stem cell applications continue to be oversold to patients everywhere. NHS Choices, a UK science-based health information source, warns that not all overseas clinics providing proton beam therapy do so based on the best available evidence. “They heavily market their services to parents who are understandably desperate to get treatment for their children. Proton beam therapy can be very costly and it is not clear whether all children treated privately abroad are treated appropriately,” it said.  Whether patients travel for appropriate services, therefore, will be up to how much good-quality information, rather than hype, is available.