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© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Lung Cancer Management PET Marketing Forum – Accelerating Practice Growth May 17, 2006.

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Presentation on theme: "© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Lung Cancer Management PET Marketing Forum – Accelerating Practice Growth May 17, 2006."— Presentation transcript:

1 © 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Lung Cancer Management PET Marketing Forum – Accelerating Practice Growth May 17, 2006 Dr. Patrick Peller Welcome!

2 © 2006 Cardinal Health. All rights reserved. Brought To You By Cardinal Health Part of PET Foundations SM > comprehensive marketing and education program Third of a 6-part Series Recorded presentation and PowerPoint available on > Market Your PET Center > Marketing Forum pagewww.PETFoundations.com Exclusive benefit to Cardinal Health PET customers

3 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. Targeted Specialists The Select Seven Medical Medical Oncologists Pulmonologists Gastroenterologists Surgical Oncologic Surgeons Thoracic Surgeons Colorectal Surgeons Radiation Oncologists

6 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. Estimated US Cancer Deaths Source: American Cancer Society, Men 295,280 Women 275,000 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 and bronchus31% Prostate10% Colon and rectum10% Pancreas5% Leukemia4% Esophagus4% Liver and intrahepatic3% bile duct Non-Hodgkin 3% Lymphoma Urinary bladder3% Kidney3% All other sites 24%

8 © 2006 Cardinal Health. All rights reserved. Lung Cancer First and best reimbursed PET indication Pulmonary nodule/density Lung cancer staging Lung cancer restaging

9 © 2006 Cardinal Health. All rights reserved. Pulmonary Nodule Standard evaluation Role of PET and PET/CT Physician audience Pulmonologist Internist Interventional Radiologist

10 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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

12 © 2006 Cardinal Health. All rights reserved. Diagnostic Evaluation of a Lung Nodule Risk stratification PET or PET/CT Tissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy

13 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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. Approaching the Pulmonologist

17 © 2006 Cardinal Health. All rights reserved. Bronchoscopy and PET for Pulmonary Nodules Chhajed P. Chest 2005; 128:3558.

18 © 2006 Cardinal Health. All rights reserved. Approaching the Generalist Must defeat 3 myths: 1.PET is used only by specialists 2.PET is too technical for me to understand 3.PET does not have a role in my practice PET provides a management strategy for the evaluation of pulmonary nodules

19 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. Management Strategies for Pulmonary Nodules Gould Ann Intern Med. 2003;138:725. * *

21 © 2006 Cardinal Health. All rights reserved. Educational Tools Overview brochure Clinical Technical Emotional Case studies Patient brochures

22 © 2006 Cardinal Health. All rights reserved. Approaching the Interventional Radiologist Difficult patient: anticoagulation, nodule location, severe COPD Prior biopsy nondiagnostic Multiple abnormalities: Best choice CT suggests advanced disease

23 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. PET Evaluation of Pulmonary Nodules. Patients Sensitivity Specificity 14 studies107897%77% Lowe %77% Multicenter 89 98% 69% MRP 11298%60% Lowe V et al Radiology 1997; 202:435. Lowe V et al J Clin Onc 1998; 16:1075.

25 © 2006 Cardinal Health. All rights reserved. Lung Cancer Staging Conventional NSCLC staging Role of PET and PET/CT Physician audience Pulmonologist Thoracic Surgeon Radiation Oncologist

26 © 2006 Cardinal Health. All rights reserved. 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 Lung Cancer Staging

27 © 2006 Cardinal Health. All rights reserved. Lung Cancer Staging Mediastinoscopy Bronchoscopy Chamberlain

28 © 2006 Cardinal Health. All rights reserved. Preoperative Staging with PET PET versus CT--Mediastinal Nodes Sensitivity Specificity CT 75%66% 16% 20% PET 91%86% Pieterman N Engl J Med 2000; 343:

29 © 2006 Cardinal Health. All rights reserved. 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. Approaching the Pulmonologist

30 © 2006 Cardinal Health. All rights reserved. Extra-thoracic Staging History 61 YOM Smoker Known lung cancer, stage I, small 1 cm nodule Bone scan negative PET Findings Primary and distant metastasis in right femur Outcome Biopsy proved bone metastasis Chemotherapy and XRT

31 © 2006 Cardinal Health. All rights reserved. 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 Approaching the Thoracic Surgeon Vesselle J Thorac Cardiovasc Surg 2002; 124:511.

32 © 2006 Cardinal Health. All rights reserved. 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. Approaching the Thoracic Surgeon

33 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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/CTs greatest impact--showing nodal involvement PET/CT reduces variability between rad oncologists Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435. Approaching the Radiation Oncologist

35 © 2006 Cardinal Health. All rights reserved. Tumor Volume Delineated With PET-CT Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.

36 © 2006 Cardinal Health. All rights reserved. Lung Cancer Staging of the Mediastinum.. Patients Sensitivity Specificity PET CT PET CT 9 studies % 63% 93% 73% Pieterman % 75% 86% 66 % Kiernan 94 88% 64% 86% 94% MRP % 68% 86% 66% Pieterman et al NEJM 2000; 343:254. Kiernan et al S. Med. J. 2002, 95:1168.

37 © 2006 Cardinal Health. All rights reserved. Lung Cancer Restaging Standard evaluation Role of PET and PET/CT Physician audience Pulmonologist Medical Oncologist

38 © 2006 Cardinal Health. All rights reserved. Lung Cancer Restaging Serial Chest CT scans every 3-6 months Surgery and radiation therapy leave scarring

39 © 2006 Cardinal Health. All rights reserved. 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

40 © 2006 Cardinal Health. All rights reserved. Non-Small Cell Lung Cancer 126 patients; stage I-IIIB Histopathology or clinical progression PET and CT every 6 months PETCT Sensitivity 100%71% Specificity 92%95% Approaching the Pulmonologist Bury Eur Respir J 1999;14:1374.

41 © 2006 Cardinal Health. All rights reserved. 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. Approaching the Medical Oncologist

42 © 2006 Cardinal Health. All rights reserved. Neoadjuvant Chemotherapy in NSCLC Pöttgen Clin Cancer Res 2006;12:97. SUV decline 50% SUV decline >50%

43 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. 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 © 2006 Cardinal Health. All rights reserved. Marketing PETs 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


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