2009 PET Review And NOPR Update


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Role of PET in context of 2009 NOPR/NCCN study

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  • Hi. I am Vimal Patel and I will discuss the role of PET scanning in oncology and review the recent NOPR Updates (in the context of the NCCN article)
  • PET or Positron Emission Tomography is a technology where physiologic processes in the body are imaged. PET is not an anatomic image, such as CT or MRI, but structural or anatomic images are generally complimentary and used in conjunction with PET for interpretation.
  • This is a picture of FDG or fluoro-deoxy-glucose. A normal glucose molecule is modified, so that the hydroxyl group in the 2 position is replaced with a fluorine atom. The fluorine atom used is the F-18 isotope, which is a positron emitter.
  • A PET scanner has an array of crystals that detect these two 511 KEV photons simultaneously. As you saw in the previous slide, it is similar in appearance to a CAT scanner. The major difference, from the patient’s point of view, is that prior to scanning, there is an uptake period of 45 to 60 minutes, while the patient is resting in a comfortable recliner chair, and image acquisition can take 30 to 60 minutes. Patients are informed before the study, that the entire procedure will take approximately two hours. The patient typically fasts four hours prior to the study.
  • CMS is the Centers for Medicare and Medicaid Sevices, formerly known as HCFA. In addition to breast cancer, CMS has approved FDG-PET reimbursement for: … Private insurers will reimburse for additional indications.
  • 2009 PET Review And NOPR Update

    1. 1. The Role of PET in Oncology & Review of NCCN/NOPR Study by Vimal T. Patel Senior Sales Consultant
    2. 2. Agenda & Objectives <ul><li>First half => Overview of PET as a procedure </li></ul><ul><li>Second half=> Highlights of NCCN study in context of NOPR & and the impact. </li></ul><ul><li>* PET as a modality from restrictive “tumor” imaging to broad scope of cancer imaging. </li></ul>
    3. 3. “ Cat Scan vs PET Scan”
    4. 4. PET/CT Positron Emission Tomography <ul><li>Images a physiologic process in the body </li></ul><ul><li>Not just anatomy e.g. MRI or CT alone </li></ul>
    5. 5. Radiopharmaceutical (Isotope) 18 FDG 2-deoxy-2-[ 18 F]fluoro-D-glucose FDG Metabolism :
    6. 6. Positron Decay and Annihilation 180 degrees (coincidence imaging)
    7. 7. Patient prep for exam CNMT injects patient w/ FDG Imaged on scanner laying flat on back CNMT monitors patient image acquisition CNMT processes image and transfers/uploads image for MD Patient notified to follow-up w/ referring MD Typical PET Workflow & Procedure 45-60 minutes wait post-injection (uptake)
    8. 8. PET-CT versus PET or CT alone Antoch et al. Radiology 2003 93% 63% 89% Accuracy 94% 77% 94% NPV 89% 50% 80% PPV 94% 59% 89% Specificity 89% 70% 89% Sensitivity PET-CT CT PET
    9. 9. FDG PET Approved CMS Indications (2005) <ul><li>Breast Cancer </li></ul><ul><li>NSCLC </li></ul><ul><li>Colorectal Cancer </li></ul><ul><li>Lymphoma </li></ul><ul><li>Esophageal Cancer </li></ul><ul><li>Melanoma </li></ul><ul><li>Head and Neck Cancer </li></ul><ul><li>Solitary Pulmonary Nodule </li></ul><ul><li>Myocardial Viability </li></ul><ul><li>Refractory Seizure </li></ul>
    10. 10. What is NCCN/NOPR? How do they share our Vision ? Value ? $$$ ?
    11. 11. Nationwide Collaborative Programs National Cancer Center Network (NCCN) and National Oncologic PET Registry (NOPR): Sponsored by Managed by Advisor Endorsed by <ul><li>Chair, Bruce Hillner, MD, Virginia Commonwealth University </li></ul><ul><li>Co-chair, Barry A. Siegel, MD, Washington University </li></ul><ul><li>R. Edward Coleman, MD, Duke University </li></ul><ul><li>Anthony Shields, MD, PhD Wayne State University </li></ul><ul><li>Statistician: Dawei Liu, PhD, Brown University </li></ul><ul><li>Epidemiologist: Ilana Gareen, PhD, Brown University </li></ul>
    12. 12. NOPR background and demographics <ul><li>Initiated on May 2006 => 130,167 patients - data entry completed </li></ul><ul><li>1,891 PET facilities nationwide participating (over 90% of all sites) </li></ul><ul><li>~ 92% patients and 96% referring MDs consented to use of data </li></ul><ul><li>Technology profile - 84% PET/CT ( 71% non-hospital, 76% fixed sites) </li></ul>
    13. 13. Study objective & goal <ul><li>Objective - assess the effect of PET on referring MD’s plan of intended patient management </li></ul><ul><ul><ul><li>across a whole range of cancer indications for PET not covered by CMS </li></ul></ul></ul><ul><ul><ul><li>in relation to cancer-type, indication, performance status, physician’s role in management, and type of PET. </li></ul></ul></ul><ul><li>Goal - acquire data that can be used to evaluate PET in a manner that does not interfere with patient care & minimizes burden to the patient, PET center, and referring physician. </li></ul>
    14. 14. *Excluded Scans done for treatment monitoring Major Cancer Types vs. Incidence (Patients Over Age 65) Cancer Type Total NOPR Scans (2007)* Incidence (CDC 2004) Scans per Incidence (2007) Prostate 3,769 116,659 3.2% Ovary and Adnexa 3,706 9,625 38.5% Pancreas 3,561 21,962 16.2% Bladder 2,665 44,570 6.0% Kidney/Other Urinary Tract 2,623 20,886 12.6% Small Cell Lung 2,390 19,657 12.2% Stomach 2,349 13,048 18.0% Myeloma 1,336 10,194 13.1%
    15. 15. Referring MD requests PET Pre-PET Form PET done PET interpreted & reported Post-PET Form sent, including question for referring MD consent Post-PET Form completed. Claim submitted Ongoing patient management NOPR/NCCN Workflow Ask patient for consent
    16. 16. Takeaways for PET in changing intended Management <ul><li>The average overall change was 38.0% </li></ul><ul><li>Metastatic disease in 54% ; PET findings led to: </li></ul><ul><ul><li>Switch to another therapy in 26% </li></ul></ul><ul><ul><li>Adjust dose or duration of therapy in 17% </li></ul></ul><ul><ul><li>Switch from therapy to observation/supportive care in 6% </li></ul></ul><ul><ul><li>Chemotherapy 82%, chemoRT 12%, RT 6% </li></ul></ul>Hillner et al., J Nucl Med 2008 <ul><li>Utility of PET/CT and diagnostic CT differ </li></ul><ul><li>NO substitute for BIOPSY to establish diagnosis </li></ul><ul><li>MRI still gold standard for Brain studies </li></ul><ul><li>PET not ideal for genatourinary tract </li></ul>
    17. 17. Snapshot of Previous Coverage versus New Framework <ul><li>Initial treatment evaluation, single PET scan will be covered for all cancers with the exception of prostate cancer , breast cancer diagnosis and axillary nodal staging, and melanoma regional nodal staging </li></ul><ul><li>Subsequent treatment , expanded coverage for PET in pre-existing conditions to include treatment monitoring </li></ul><ul><li>New coverage for subsequent treatment evaluation of cervical cancer, ovarian cancer, and myeloma </li></ul>Previous Framework New Framework Dx Staging Restaging Treatment Monitoring Initial Rx Subseq. Rx Breast N/C 1 Cover Cover 1 Cover Colorectal Cover Cover Cover CED Cover Cover Esophagus Cover Cover Cover CED Cover Cover Head Neck Cover Cover Cover CED Cover Cover Lymphoma Cover Cover Cover CED Cover Cover Melanoma Cover 2 Cover CED 2 Cover NSCLC Cover Cover Cover CED Cover Cover Thyroid Cover Cover 3 CED Cover 3
    18. 18. Emerging Applications & Future Directions <ul><li>Biomarkers in clinical trials - FLT </li></ul><ul><li>(thymidine analog imaging cell proliferation ) </li></ul><ul><li>Role of PET in Radiation Treatment Planning </li></ul>
    19. 19. PET from Business Viewpoint Marketing to Radiation Oncologists Marketing to Surgical Oncologists Marketing to Medical Oncologists Marketing to Primary Care MDs <ul><li>PET as tool in managing patient with history of cancer </li></ul><ul><li>Staging & Treatment Planning </li></ul><ul><li>Palliative versus Curative Dose to increase survival </li></ul><ul><li>Identify surgical candidate sooner vs later </li></ul><ul><li>Pre-op for metastatic disease </li></ul><ul><li>PET can empower them to refer patient to Specialist </li></ul><ul><li>Monitor for recurrence & other therapies </li></ul><ul><li>Stage & stratify non-surgical candidate for chemo </li></ul>
    20. 20. <ul><li>Acknowledgements – NOPR, Montefiore MDs </li></ul><ul><li>Questions & Comments </li></ul><ul><li>Wrap-up </li></ul><ul><li>Vimal contact : [email_address] (201)792-7070 </li></ul>Thank you!