1. Marketing PET’s Role in Lung Cancer Management
Welcome!
Marketing PET’s Role in Lung Cancer Management
PET Marketing Forum – Accelerating Practice Growth
May 17, 2006
Dr. Patrick Peller

2. Brought To You By Cardinal Health
Part of PET FoundationsSM > comprehensive marketing and education program
Third of a 6-part Series
Recorded presentation and PowerPoint available on > Market Your PET Center > Marketing Forum page
Exclusive benefit to Cardinal Health PET customers

3. Dr. Patrick J. Peller Over 15 years of PET experience
Read over 15,000 clinical PET scans
MRP team member
3 marketing reps, 15+ staff
MRP Volume > 500 PET/CTs per month

4. What Does a Referring Physician Want?
Quality PET/CT imaging
PET/CT the easy way
Easy to order, promptly reported, has easy to understand results and provides a specific answer
Reliable and expert source of answers on PET and/or PET/CT-- Your team

5. Targeted Specialists “The Select Seven”
Medical
Medical Oncologists
Pulmonologists
Gastroenterologists
Surgical
Oncologic Surgeons
Thoracic Surgeons
Colorectal Surgeons
Radiation Oncologists

6. What Does a Referring Physician Want?
Quality PET/CT imaging
PET/CT the easy way
Reliable and expert source of answers on PET/CT
Understand clinical uses for PET/CT in Lung Cancer
Understand where PET/CT is reimbursed in Lung Cancer

7. Estimated US Cancer Deaths
Men 295,280
Women 275,000
Lung and bronchus 31%
Prostate 10%
Colon and rectum 10%
Pancreas 5%
Leukemia 4%
Esophagus 4%
Liver and intrahepatic 3% bile duct
Non-Hodgkin % Lymphoma
Urinary bladder 3%
Kidney 3%
All other sites %
27% Lung and bronchus
15% Breast
10% Colon and rectum
6% Ovary
6% Pancreas
4% Leukemia
3% Non-Hodgkin lymphoma
3% Uterine corpus
2% Multiple myeloma
2% Brain/ONS
22% All other sites
Lung cancer is the most common fatal cancer in men (31%), followed by prostate cancer (10%), and colon & rectum cancer (10%). In women, lung (27%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death.
Source: American Cancer Society, 2006.

8. Lung Cancer First and best reimbursed PET indication
Pulmonary nodule/density
Lung cancer staging
Lung cancer restaging

9. Pulmonary Nodule Standard evaluation Role of PET and PET/CT
Physician audience
Pulmonologist
Internist
Interventional Radiologist

10. Diagnostic Evaluation of a Lung Nodule
Risk stratification
Patient: smoker, >70yr, hx of Ca
CT nodule: spiculated, growth, calcifications, >3cm
Risk of biopsy or surg complications
Tissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy
OR “watchful waiting” serial CT scans

11. PET Evaluation of a Lung Nodule
History
45 YOM
Pulmonary nodule on CXR
Biopsy (several) negative
PET Findings
Hyper-metabolic focus
No metastases
Outcome
Surgical resection, stage I squamous cell carcinoma
20% of all biopsies come back non-diagnostic due to sampling of too few cells.
Sampling this suspicious nodule in the lung is difficult. The biopsy needle is trying to “stab a marble in a bowl of jello.”
The nodule can move when you try to take a sample.
It can be hard to penetrate to collect cells.

12. Diagnostic Evaluation of a Lung Nodule
Risk stratification
PET or PET/CT
Tissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy

13. Diagnostic Evaluation of a Lung Nodule
Risk stratification
PET or PET/CT
Tissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy
OR “watchful waiting” serial CT scans

14. PET for Diagnosis of Pulmonary Nodules
Meta-analysis--40 published studies
1474 focal lung lesions (≥1cm)
FDG PET compared to histology
High sensitivity (96.8%) and intermediate specificity (77.8%)
High negative predictive value 97.6%
Gould JAMA 2001; 285:

15. PET Evaluation of a Lung Nodule
History
62 YOF
Pulmonary nodule on CXR
Anti-coagulation
PET Findings
No abnormality
Outcome
No change on CXR for 2 years

16. Approaching the Pulmonologist
Bronchoscopy and PET are complementary
PET greater sensitivity (94% sens, 70% spec)
Bronch provides tissue diagnosis (53% of pts)
If nodule >1cm and BOTH Bronch and PET neg--benign nodule
Chhajed P. Chest 2005; 128:3558.

17. Bronchoscopy and PET for Pulmonary Nodules
Chhajed P. Chest 2005; 128:3558.

18. Approaching the Generalist
Must defeat 3 myths:
PET is used only by specialists
PET is too technical for me to understand
PET does not have a role in my practice
PET provides a management strategy for the evaluation of pulmonary nodules

19. Management Strategies for Pulmonary Nodules
Risk stratification approach
Patient chance of lung cancer
CT chance of lung cancer
Surgical complication risk
PET especially useful when patient risk and CT results diverge
PET for patients intolerant of “watchful waiting”
Gould Ann Intern Med. 2003;138:725.

20. Management Strategies for Pulmonary Nodules* *
Gould Ann Intern Med. 2003;138:725.

21. Educational Tools Overview brochure Case studies Patient brochures
Clinical
Technical
Emotional
Case studies
Patient brochures

22. Approaching the Interventional Radiologist
Difficult patient: anticoagulation, nodule location, severe COPD
Prior biopsy nondiagnostic
Multiple abnormalities: Best choice
CT suggests advanced disease

23. PET in Pulmonary Nodules
Prospective evaluation of 40 patients
15 biopsy not possible
25 biopsy results not helpful
24 cancers--23 detected by PET
Sensitivity 96%; Specificity 81%
Negative predictive value 93%
Pitman MJA 2001; 175:303.

24. PET Evaluation of Pulmonary Nodules
Patients Sensitivity Specificity
14 studies % 77%
Lowe % 77%
Multicenter % %
MRP % 60%
Lowe V et al Radiology 1997; 202:435.
Lowe V et al J Clin Onc 1998; 16:1075.

25. Lung Cancer Staging Conventional NSCLC staging Role of PET and PET/CT
Physician audience
Pulmonologist
Thoracic Surgeon
Radiation Oncologist

26. Lung Cancer Staging Stage I No nodal metastases and totally
resectable
Stage II Adds hilar nodes or resectable
chest wall involvement
Stage IIIA Extensive mediastinal nodes
Stage IIIB Distant nodal metastasis
Stage IV Distant metastases

27. Lung Cancer Staging
Mediastinoscopy
Chamberlain
Bronchoscopy

28. Preoperative Staging with PET
PET versus CT--Mediastinal Nodes
Sensitivity Specificity
CT 75% 66%
16% %
PET 91% 86%
Pieterman N Engl J Med 2000; 343:

29. Approaching the Pulmonologist
PET/CT Staging of NSCLC
T stage 88% acc (≥23% better)
N stage 81% acc (≥21% better)
PET-CT faster and more certain
Integrated PET/CT provided additional info in 41% of pts
Lardinois N Engl J Med 2003; 348:2500.

30. Extra-thoracic Staging
History
61 YOM
Smoker
Known lung cancer, stage I, small cm nodule
Bone scan negative
PET Findings
Primary and distant metastasis in right femur
Outcome
Biopsy proved bone metastasis
Chemotherapy and XRT
In this case, the CT missed the single focus in poroximal of the right humorus because the CT stops at the adrenal gland (top of the kidneys)

31. Approaching the Thoracic Surgeon
PET Impact on Surgical Staging
PET directed staging away from customary in 25% of patients
PET allows for directed and sensitive surgical staging
PET and surgical staging complementary and together more accurate
Vesselle J Thorac Cardiovasc Surg 2002; 124:511.

32. Approaching the Thoracic Surgeon
Staging Accuracy in NSCLC
PET/CT better predicts stage I and II
PET/CT shows T and N status
N1 accuracy 90%, N2 accuracy 96%
Cerfolio R. Ann Thorac Surg. 2004; 78:1017.

33. More Accurate Guided Biopsy
CT shows LUL mass consistent with Lung Cancer and no nodal metastases
PET shows right paratracheal uptake suggesting nodal metastasis
PET/CT shows metastasis to normal sized right paratracheal node
Proven by surgical biopsy

34. Approaching the Radiation Oncologist
Safe delivery of high dose of radiation to tumors require a high level of geometric accuracy.
PET/CT allows differentiation of tumor from nontumor, e.g. atelectasis
PET/CT’s greatest impact--showing nodal involvement
PET/CT reduces variability between rad oncologists
Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.

35. Tumor Volume Delineated With PET-CT
Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.

36. Lung Cancer Staging of the Mediastinum
Patients Sensitivity Specificity
PET CT PET CT
9 studies % 63% % 73%
Pieterman % 75% % 66%
Kiernan % 64% % 94%
MRP % 68% % 66%
Pieterman et al NEJM 2000; 343:254.
Kiernan et al S. Med. J. 2002, 95:1168.

37. Lung Cancer Restaging Standard evaluation Role of PET and PET/CT
Physician audience
Pulmonologist
Medical Oncologist

38. Lung Cancer Restaging Serial Chest CT scans every 3-6 months
Surgery and radiation therapy leave scarring

39. Detecting Lung Cancer Recurrence
History
49 YOM
Lung cancer resected 6 months earlier
Prior stage I lesion
CT post resection showed some changes and scarring
PET Findings
Small hyper-metabolic focus
Outcome
Recurrent cancer resected
XRT
This patient wanted to be really sure he was cured. He insisted on PET. Only PET found the residual disease.
It is advised to wait 3-4 weeks following surgery to avoid false reads, however scarring is generally easily recognized.

40. Approaching the Pulmonologist
Non-Small Cell Lung Cancer
126 patients; stage I-IIIB
Histopathology or clinical progression
PET and CT every 6 months
PET CT
Sensitivity 100% 71%
Specificity 92% 95%
PET was compared to biopsy (histopathology) or follow-up (clinical progression)
Bury Eur Respir J 1999;14:1374.

41. Approaching the Medical Oncologist
Advanced stage NSCLC receiving neoadjuvant chemotherapy 12wks
PET/CT before and after therapy
Measured SUV decline in tumor and dominant node
Compared to histology of surgical specimen
Pöttgen Clin Cancer Res 2006;12:97.

42. Neoadjuvant Chemotherapy in NSCLC
SUV decline ≤50%
SUV decline >50%
Pöttgen Clin Cancer Res 2006;12:97.

43. Neoadjuvant Chemotherapy in NSCLC
Drop in SUV >50%-- 40% of pts disease free at 36 months
PET/CT could predict response and avoid unsuccessful resections
PET/CT improves clinical management of NSCLC pts
Pöttgen Clin Cancer Res 2006;12:97.

44. What Does a Referring Physician Want?
Quality PET/CT imaging
PET/CT the easy way
Reliable and expert source of answers on PET/CT
Understand clinical uses for PET/CT in Lung Cancer
Understand that PET/CT is reimbursed in Lung Cancer

45. New Articles
Bunyaviroch T. Coleman E. PET evaluation of lung cancer. J Nucl Med 2006;47:451.
Lardinois D. etal. Staging of non-small cell lung cancer with integrated positron emission tomography and computed tomography. N Engl J Med 2003; 348:2500.
Pöttgen C. etal. Value of 18fluoro-2-deoxy-glucose positron emission tomography/computed tomography in non-small cell lung cancer for prediction of pathologic response and time to relapse after neoadjuvant chemotherapy. Clin Cancer Res 2006;12:97.
Gould M. etal. Cost-effectiveness of alternative management strategies for patients with solitary pulmonary nodules. Ann Intern Med. 2003;138:725.

46. New Articles
Chhajed P. etal. Combining bronchoscopy and positron emission tomography for the diagnosis of the small pulmonary nodule ≤3cm. Chest 2005; 128:3558.
Steenbakkers R. etal. Reduction of observer variation using matched CT-PET for lung cancer delineation: a three dimensional analysis. Int J Radiat Oncol Biol Phys. 2006;64:435.
Cerfolio R. etal. The accuracy of integrated PET- CT compared with dedicated PET alone for staging of patients with nonsmall cell lung cancer. Ann Thorac Surg. 2004; 78:1017.

47. Marketing PET’s Role in Lung Cancer Management
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