Setting up a Gallium-68 service at Barts

St Bartholomew’s Hospital, also known as Barts, is a large hospital that delivers care to over 2.5 million people in London, UK.¹ Prior to 2019, the hospital only had basic radiopharmacy facilities – with no scope to provide therapies or isotope labelling – and relied on radioisotopes from other locations.² This limited the type of radioisotopes Barts could offer, and the type of medical scans and treatments that could be carried out there.¹ Barts was unable to provide positron emission tomography (PET) scans with Gallium-68, which are used for the imaging of neuroendocrine tumours, prostate cancer and pancreatic cancers (as well as being under investigation for many more applications).³ Gallium-68 takes 68 minutes to decay, and this short half-life means it can only be manufactured close to where PET scans are carried out.⁴

Experts at Barts Cancer Institute developed a business case for the need for a Gallium-68 generator, which led to the Institute being awarded a grant of just under £550,000 (about USD$690,000) from Barts Charity.⁵ The funding was part of a larger £4.5 million funding package to expand the Barts Cancer Institute’s research abilities.² As part of the application, Barts recognised that the whole system would need to adapt to successfully integrate a Gallium-68 service into practice. The grant funding was used to provide infrastructure and workforce, in collaboration with Barts Health NHS Trust.² Funding was used for services including:⁶

• Two Gallium generators
• New shielding (the equipment used to protect from exposure to radiation)
• Endotoxin machine (used to make sure the substances being injected are free from toxins)⁷
• A postdoctoral student to help set up and run the radiopharmacy (the place where radioisotopesare mixed) as part of the service.

Implementation of the service was supported by a collaborative management approach; all radiopharmacy staff members were actively engaged to develop and grow the service.⁸

The service now successfully provides care to people with a variety of cancers. It is unique in NHS England, as the Gallium-68 is able to offer a wide range of nuclear medicine services within one unit.⁸ The service has also expanded its workforce; it now has four radiopharmacists, up from one prior to the service starting, and many radiopharmacy technicians and scientists, as well as the clinical staff.⁸

In addition to offering routine oncology scans, the on-site Gallium-68 generators have allowed Barts to screen people for suitability for radioligand therapy, which has enabled the site to efficiently deliver care to a higher number of people with cancer. Barts has also been able to participate in clinical trials for the imaging and treatment of prostate cancer, which was a core principle and requisite for Barts Charity funding.^{6 9} The generators have also allowed Barts to provide patients from seven other hospitals with Gallium-68.⁸ The service is on track to provide over 100 people with Gallium by the end of 2023 – a large increase from 44 people in 2020.¹⁰

The success of the service, including high staff retention and novel training in radioisotopes training and production, has spurred Barts to further invest in a new single positron computerised tomography (SPECT) scanner.¹⁰ This has lower radiation doses than the existing scanners and is expected to double the number of scans the service can provide.¹¹

Following on from the success of the clinical trials for prostate cancer, trials for the use of radiopharmaceuticals to treat endocrine cancers is due to begin in March 2024.¹⁰

The setting up of the Gallium-68 facility demonstrates that using a systems approach is vital to ensure the proper integration of new services into healthcare. To implement the service, Barts planned for and secured funding for all aspects of infrastructure, as well as the time and workforce needed. Barts’s proactive involvement in clinical trials will support ongoing data collection, which can be built up in provision of evidence-based care.

Using a systems approach also highlights the importance of a collaborative, engaged workforce to create an effective service that provides high-quality care.⁸ The attention to workforce retention and development is key to ensuring health systems are ready to integrate and sustain new services.

Establishing the Gallium-68 service has helped to set a precedent for the NHS business case for radioligand therapy. It demonstrates that an investment in workforce and infrastructure can increase service capacity, improve patient experience and facilitate the involvement in clinical research – both internally and externally.