Great Expectations: PET/CT Delivers

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More than five years after PET/CT technology thrust open the door to clinical molecular imaging, the technology is now proving its clinical worth. As the National Oncologic PET Registry (NOPR) releases data collected over the last two years, the value of PET/CT in oncology patient management is clear.

The NOPR, designed to examine the role of PET in management of cancers not currently eligible for Medicare coverage, points to the value of PET/CT imaging. “Based on the data, we can expect PET/CT results to change patient management in about 35 percent of cases,” states Chaitanya Divgi, MD, chief of nuclear medicine and clinical molecular imaging at the University of Pennsylvania Health System in Philadelphia. If the Centers for Medicare & Medicaid Services (CMS) accept the data, PET/CT access should improve, says Todd Blodgett, MD, chief of cancer imaging at University of Pittsburgh Medical Center (UPMC) in Pennsylvania.

PET/CT is spreading it wings beyond oncology, too. The hybrid modality is a boon to cardiac imaging, providing a solid option for an array of cardiovascular imaging needs. This month, Health Imaging & IT visits a trio of experts to learn more about molecular imaging’s premiere modality.

Oncology imaging: Removing barriers, new frontiers

Oncology imaging is the major growth area for PET/CT imaging. The publication of NOPR data could open the door to applications in scores of additional cancers. “NOPR applies to staging and re-staging of any malignancy currently not covered by Medicare or a third-party payor,” explains Blodgett. The significance is tremendous because the lack of reimbursement has limited PET/CT imaging.

Although reimbursement policies vary by state, in many cases payors do not reimburse for PET/CT without a previous diagnostic CT study. If the CT results are normal, it can be difficult to persuade an oncologist to order a PET study. Reimbursement woes cross paths with a second barrier—physician education. 

“Even in the United States where PET/CT systems are ubiquitous, PET/CT is underutilized because many physicians think CT is the gold standard. But CT often misses lesions that are detected with PET or PET/CT,” notes Blodgett. If the CT is abnormal, the oncologist may use the CT for decision-making; however, baseline PET/CT studies are critical and can change the overall approach to patient management. Take, for example, lung cancer patients. “There is no low-risk lung cancer. A patient should not be referred to surgery if occult metastatic disease is present,” says Blodgett. And PET/CT, rather than CT, is the best means to locate occult disease.

“The reimbursement paradigm needs to be reversed,” states Divgi, with simultaneous PET/CT serving as the gold standard for staging and treatment efficacy monitoring. As the reimbursement climate changes, PET/CT providers and radiologists need to address other barriers to more widespread use of PET/CT imaging. “It’s critical for radiologists to interact with our oncology colleagues to make sure they understand the appropriate role of PET/CT,” continues Divgi. In other words, radiologists need to make time to attend tumor boards and multi-disciplinary conferences, where they can educate colleagues about the value of PET/CT imaging. Another key piece of the puzzle is the clinically relevant report. The report should describe areas of increased uptake and SUV and include clinical interpretations that can guide cancer patient management.

On the oncology horizon

Treatment efficacy monitoring or response to therapy could be the next major PET/CT application. “It appears that physicians should be able to predict whether or not a therapy is working earlier with PET/CT than with CT alone,” explains Blodgett. Currently, PET/CT is approved only for therapeutic monitoring of breast cancer patients. “As more therapeutic options become available for different types of cancer, it’s important to employ PET/CT imaging for therapeutic monitoring,” continues Blodgett. That’s because physicians can switch a patient’s therapy if the PET/CT data show that the patient is not responding to the first-line therapy.

Divgi of the University of Pennsylvania Health Center believes treatment efficacy monitoring could see significant growth in the next few years. Currently, Divgi’s department completes about 16 PET/CT studies daily on its Philips Healthcare Gemini Time of Flight PET/CT scanner. About 20 percent of studies are staging studies, another 20 percent are ordered