Presentation on theme: "Marketing PET’s Role in Lung Cancer Management"— Presentation transcript:
1Marketing PET’s Role in Lung Cancer Management Welcome!Marketing PET’s Role in Lung Cancer ManagementPET Marketing Forum – Accelerating Practice GrowthMay 17, 2006Dr. Patrick Peller
2Brought To You By Cardinal Health Part of PET FoundationsSM > comprehensive marketing and education programThird of a 6-part SeriesRecorded presentation and PowerPoint available on > Market Your PET Center > Marketing Forum pageExclusive benefit to Cardinal Health PET customers
3Dr. Patrick J. Peller Over 15 years of PET experience Read over 15,000 clinical PET scansMRP team member3 marketing reps, 15+ staffMRP Volume > 500 PET/CTs per month
4What Does a Referring Physician Want? Quality PET/CT imagingPET/CT the easy wayEasy to order, promptly reported, has easy to understand results and provides a specific answerReliable and expert source of answers on PET and/or PET/CT-- Your team
6What Does a Referring Physician Want? Quality PET/CT imagingPET/CT the easy wayReliable and expert source of answers on PET/CTUnderstand clinical uses for PET/CT in Lung CancerUnderstand where PET/CT is reimbursed in Lung Cancer
7Estimated US Cancer Deaths Men 295,280Women 275,000Lung and bronchus 31%Prostate 10%Colon and rectum 10%Pancreas 5%Leukemia 4%Esophagus 4%Liver and intrahepatic 3% bile ductNon-Hodgkin % LymphomaUrinary bladder 3%Kidney 3%All other sites %27% Lung and bronchus15% Breast10% Colon and rectum6% Ovary6% Pancreas4% Leukemia3% Non-Hodgkin lymphoma3% Uterine corpus2% Multiple myeloma2% Brain/ONS22% All other sitesLung 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.
8Lung Cancer First and best reimbursed PET indication Pulmonary nodule/densityLung cancer stagingLung cancer restaging
9Pulmonary Nodule Standard evaluation Role of PET and PET/CT Physician audiencePulmonologistInternistInterventional Radiologist
10Diagnostic Evaluation of a Lung Nodule Risk stratificationPatient: smoker, >70yr, hx of CaCT nodule: spiculated, growth, calcifications, >3cmRisk of biopsy or surg complicationsTissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomyOR “watchful waiting” serial CT scans
11PET Evaluation of a Lung Nodule History45 YOMPulmonary nodule on CXRBiopsy (several) negativePET FindingsHyper-metabolic focusNo metastasesOutcomeSurgical resection, stage I squamous cell carcinoma20% 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.
12Diagnostic Evaluation of a Lung Nodule Risk stratificationPET or PET/CTTissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy
13Diagnostic Evaluation of a Lung Nodule Risk stratificationPET or PET/CTTissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomyOR “watchful waiting” serial CT scans
14PET for Diagnosis of Pulmonary Nodules Meta-analysis--40 published studies1474 focal lung lesions (≥1cm)FDG PET compared to histologyHigh sensitivity (96.8%) and intermediate specificity (77.8%)High negative predictive value 97.6%Gould JAMA 2001; 285:
15PET Evaluation of a Lung Nodule History62 YOFPulmonary nodule on CXRAnti-coagulationPET FindingsNo abnormalityOutcomeNo change on CXR for 2 years
16Approaching the Pulmonologist Bronchoscopy and PET are complementaryPET greater sensitivity (94% sens, 70% spec)Bronch provides tissue diagnosis (53% of pts)If nodule >1cm and BOTH Bronch and PET neg--benign noduleChhajed P. Chest 2005; 128:3558.
17Bronchoscopy and PET for Pulmonary Nodules Chhajed P. Chest 2005; 128:3558.
18Approaching the Generalist Must defeat 3 myths:PET is used only by specialistsPET is too technical for me to understandPET does not have a role in my practicePET provides a management strategy for the evaluation of pulmonary nodules
19Management Strategies for Pulmonary Nodules Risk stratification approachPatient chance of lung cancerCT chance of lung cancerSurgical complication riskPET especially useful when patient risk and CT results divergePET for patients intolerant of “watchful waiting”Gould Ann Intern Med. 2003;138:725.
20Management Strategies for Pulmonary Nodules **Gould Ann Intern Med. 2003;138:725.
22Approaching the Interventional Radiologist Difficult patient: anticoagulation, nodule location, severe COPDPrior biopsy nondiagnosticMultiple abnormalities: Best choiceCT suggests advanced disease
23PET in Pulmonary Nodules Prospective evaluation of 40 patients15 biopsy not possible25 biopsy results not helpful24 cancers--23 detected by PETSensitivity 96%; Specificity 81%Negative predictive value 93%Pitman MJA 2001; 175:303.
24PET Evaluation of Pulmonary Nodules Patients Sensitivity Specificity14 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.
25Lung Cancer Staging Conventional NSCLC staging Role of PET and PET/CT Physician audiencePulmonologistThoracic SurgeonRadiation Oncologist
26Lung Cancer Staging Stage I No nodal metastases and totally resectableStage II Adds hilar nodes or resectablechest wall involvementStage IIIA Extensive mediastinal nodesStage IIIB Distant nodal metastasisStage IV Distant metastases
27Lung Cancer StagingMediastinoscopyChamberlainBronchoscopy
28Preoperative Staging with PET PET versus CT--Mediastinal NodesSensitivity SpecificityCT 75% 66%16% %PET 91% 86%Pieterman N Engl J Med 2000; 343:
29Approaching the Pulmonologist PET/CT Staging of NSCLCT stage 88% acc (≥23% better)N stage 81% acc (≥21% better)PET-CT faster and more certainIntegrated PET/CT provided additional info in 41% of ptsLardinois N Engl J Med 2003; 348:2500.
30Extra-thoracic Staging History61 YOMSmokerKnown lung cancer, stage I, small cm noduleBone scan negativePET FindingsPrimary and distant metastasis in right femurOutcomeBiopsy proved bone metastasisChemotherapy and XRTIn 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)
31Approaching the Thoracic Surgeon PET Impact on Surgical StagingPET directed staging away from customary in 25% of patientsPET allows for directed and sensitive surgical stagingPET and surgical staging complementary and together more accurateVesselle J Thorac Cardiovasc Surg 2002; 124:511.
32Approaching the Thoracic Surgeon Staging Accuracy in NSCLCPET/CT better predicts stage I and IIPET/CT shows T and N statusN1 accuracy 90%, N2 accuracy 96%Cerfolio R. Ann Thorac Surg. 2004; 78:1017.
33More Accurate Guided Biopsy CT shows LUL mass consistent with Lung Cancer and no nodal metastasesPET shows right paratracheal uptake suggesting nodal metastasisPET/CT shows metastasis to normal sized right paratracheal nodeProven by surgical biopsy
34Approaching 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. atelectasisPET/CT’s greatest impact--showing nodal involvementPET/CT reduces variability between rad oncologistsSteenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.
35Tumor Volume Delineated With PET-CT Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.
36Lung Cancer Staging of the Mediastinum Patients Sensitivity SpecificityPET CT PET CT9 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.
37Lung Cancer Restaging Standard evaluation Role of PET and PET/CT Physician audiencePulmonologistMedical Oncologist
38Lung Cancer Restaging Serial Chest CT scans every 3-6 months Surgery and radiation therapy leave scarring
39Detecting Lung Cancer Recurrence History49 YOMLung cancer resected 6 months earlierPrior stage I lesionCT post resection showed some changes and scarringPET FindingsSmall hyper-metabolic focusOutcomeRecurrent cancer resectedXRTThis 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.
40Approaching the Pulmonologist Non-Small Cell Lung Cancer126 patients; stage I-IIIBHistopathology or clinical progressionPET and CT every 6 monthsPET CTSensitivity 100% 71%Specificity 92% 95%PET was compared to biopsy (histopathology) or follow-up (clinical progression)Bury Eur Respir J 1999;14:1374.
41Approaching the Medical Oncologist Advanced stage NSCLC receiving neoadjuvant chemotherapy 12wksPET/CT before and after therapyMeasured SUV decline in tumor and dominant nodeCompared to histology of surgical specimenPöttgen Clin Cancer Res 2006;12:97.
42Neoadjuvant Chemotherapy in NSCLC SUV decline ≤50%SUV decline >50%Pöttgen Clin Cancer Res 2006;12:97.
43Neoadjuvant Chemotherapy in NSCLC Drop in SUV >50%-- 40% of pts disease free at 36 monthsPET/CT could predict response and avoid unsuccessful resectionsPET/CT improves clinical management of NSCLC ptsPöttgen Clin Cancer Res 2006;12:97.
44What Does a Referring Physician Want? Quality PET/CT imagingPET/CT the easy wayReliable and expert source of answers on PET/CTUnderstand clinical uses for PET/CT in Lung CancerUnderstand that PET/CT is reimbursed in Lung Cancer
45New ArticlesBunyaviroch 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.
46New ArticlesChhajed 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.
47Marketing PET’s Role in Lung Cancer Management How Did You Like This Session? Please Fill Out The Polling Questions Before You Leave Thank You!Mark Your Calendars For The Fall Series!September 27, October 25, November 15