© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Breast Cancer Management PET Marketing Forum – Accelerating Practice Growth September 27, 2006 Dr. Patrick Peller Welcome!

© 2006 Cardinal Health. All rights reserved. Brought To You By Cardinal Health Part of PET Foundations SM > comprehensive marketing and education program Fourth 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

© 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

© 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/CT-- Your team

© 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

© 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

© 2006 Cardinal Health. All rights reserved. Estimated US Cancer Cases Source: American Cancer Society, Men 710,400 Women 662,870 32%Breast 12%Lung and bronchus 11%Colon and rectum 6%Uterine corpus 4%Non-Hodgkin lymphoma 4%Melanoma Skin 3%Ovary 3%Thyroid 2%Urinary bladder 2%Pancreas 21% All other sites Prostate33% Lung and bronchus13% Colon and rectum10% Urinary bladder7% Melanoma Skin5% Non-Hodgkin 4% Lymphoma Kidney3% Leukemia3% Oral Cavity3% Pancreas2% All other sites 17%

© 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 Breast Cancer Understand where PET/CT is reimbursed in Breast Cancer

© 2006 Cardinal Health. All rights reserved. Breast Cancer versus Lung Cancer Variable and increased FDG in breast tissue

© 2006 Cardinal Health. All rights reserved. FDG PET in Breast Cancer Normal Breasts Premenopausal Postmenopausal Menopausal HRT Postpartum

© 2006 Cardinal Health. All rights reserved. Breast Cancer versus Lung Cancer Variable and increased FDG in breast tissue Lower FDG avidity in breast cancers

© 2006 Cardinal Health. All rights reserved. FDG PET in Breast Cancer Primary Cancers

© 2006 Cardinal Health. All rights reserved. Breast Cancer versus Lung Cancer Variable and increased FDG in breast tissue Lower FDG avidity in breast cancers Late and limited Medicare approval Frequently contested PET reimbursement Far fewer peer reviewed articles 2000 in lung cancer)

© 2006 Cardinal Health. All rights reserved. Breast Cancer and PET Clinical Roles Breast cancer diagnosis Breast cancer staging Breast cancer restaging

© 2006 Cardinal Health. All rights reserved. Diagnosing Breast Cancer History 50 YOF Palpable (barely) mass in left breast; doctor not concerned Dense breasts, mammogram normal PET Findings Hyper-metabolic breast focus in left breast Outcome Surgical resection Stage I breast cancer

© 2006 Cardinal Health. All rights reserved. PET in the Diagnosis of Breast Cancer Primary sizeSensitivity <0.5cm 25% >0.5cm-1.0cm 25% >1.0cm-2.0cm 84% >2.0cm-3.0cm 94% >3.0cm-4.0cm 87% >4.0cm-5.0cm 93% >5.0cm 100% Avril N J Clin Oncol 2000; 18:3495.

© 2006 Cardinal Health. All rights reserved. Breast Cancer Staging Conventional breast cancer staging Role of PET and PET/CT Physician audience Breast Surgeon Radiation Oncologist Medical Oncologist

© 2006 Cardinal Health. All rights reserved. Stage I T< 2cm and no nodal metastases Stage IIA Adds axillary nodes or T>2cm but <5cm Stage IIB Adds axillary nodes to T>2cm but 5cm Stage IIIA Fixed axillary or int. mammary nodes Stage IIIB Chest wall involved or Inflammatory Stage IV Distant metastases Breast Cancer Staging

© 2006 Cardinal Health. All rights reserved. T staging Mammography-overestimates Ultrasound-underestimates MRI-best estimates tumor size N staging Palpation-75% risk if positive Axillary node dissection (ALND) Sentinal node biopsy (SLNB ) M Staging Breast Cancer Staging

© 2006 Cardinal Health. All rights reserved. Multidisciplinary Surgery Radiotherapy Chemotherapy Issues--where, when and order Breast Cancer Therapy

© 2006 Cardinal Health. All rights reserved. PET Impact on Surgical Staging PET high positive predictive value in the axilla (98.4%) PET allows for direct full ALND without need for SLNB PET and surgical staging complementary Approaching the Breast Surgeon Gil-Rendo A, Brit J Surg. 2006; 93:707.

© 2006 Cardinal Health. All rights reserved. Staging Breast Cancer History 53 YOF Left breast cancer PET Findings Hyper-metabolic left breast cancers and axillary nodes Outcome SLNB changed to ALND Chemotherapy Radiotherapy nodes primary

© 2006 Cardinal Health. All rights reserved. PET Impact on Staging PET high positive predictive value for nodal metatases vs. biopsy PET allows for detection of int. mammary node metastasis and synchronous cancers PET provides additional info for radiation treatment planning. Approaching the Radiation Oncologist Gil-Rendo A, Brit J Surg. 2006; 93:707.

© 2006 Cardinal Health. All rights reserved. Staging Breast Cancer History 53 YOF Left breast cancer PET Findings Hypermetabolic left breast cancers and axillary nodes Outcome Axillary node dissection Chemotherapy Radiotherapy Ax. nodes IM node 2nd primary

© 2006 Cardinal Health. All rights reserved. PET Impact on Staging High FDG uptake in breast cancers is assoc. with poorer prognosis PET allows for accurate detection of node metastasis which is and independent risk factor PET positive patients (SUV>4 and +nodes) indicate neoadjuvant chemo Approaching the Medical Oncologist Inoue T J Cancer Res Clin Oncol. 2004; 130:273.

© 2006 Cardinal Health. All rights reserved. Approaching the Medical Oncologist Inoue T J Cancer Res Clin Oncol. 2004; 130:273.

© 2006 Cardinal Health. All rights reserved. History 57 YOF Right breast cancer Elevated tumor markers PET Findings Hyper-metabolic right breast cancer and axillary nodes Outcome Primary chemotherapy Surgery deferred mets primary Staging Breast Cancer

© 2006 Cardinal Health. All rights reserved. PET Impact on M Staging High FDG uptake in distant metastasis allows differentiation of stage III and IV. PET allows for accurate detection of distant metastasis with better specificity Preoperative PET useful in patients at high risk for distant metastasis. Approaching the Medical Oncologist Van der Hoeven J. J Clin Oncol 2004; 22:1253. Port E. Ann Surg Oncol 2006; 13:677.

© 2006 Cardinal Health. All rights reserved. Staging Breast Cancer

© 2006 Cardinal Health. All rights reserved. Why stage with PET? PET provides additional information Best approach to axilla Radiation therapy sites Distant metastasis PET provides prognostic information which can indicate which patients require neoadjuvant chemotherapy

© 2006 Cardinal Health. All rights reserved. Breast Cancer Restaging Standard evaluation Role of PET and PET-CT Physician audience Medical Oncologist

© 2006 Cardinal Health. All rights reserved. Breast Cancer Restaging Physical examination and serum tumor markers every 3-6 months High risk patients get serial Chest CT scans Surgery and radiation therapy leave scarring

© 2006 Cardinal Health. All rights reserved. Restaging Breast Cancer Detecting Recurrence History 57 YOF Breast cancer 5 years ago, primary is gone Presented with elevated markers Mammo negative CT negative Bone scan negative PET Findings Left supraclavicular node uptake Outcome Biopsy proven metastasis XRT & chemotherapy normal GI activity

© 2006 Cardinal Health. All rights reserved. History 49 YOF Breast cancer 7 years ago Presented with elevated markers Asymptomatic PET Findings Numerous skeletal and liver foci Outcome Biopsy proven mets High dose chemotherapy Stem cell replacement Restaging Breast Cancer Detecting Extent of Recurrence

© 2006 Cardinal Health. All rights reserved. # Sensitivity Specificity Bender % 91% Moon % 79% Hathaway %100% Lonneax % 55% Sugawara % 67% Gimenz %100% Kim % 80% PET and Breast Cancer Recurrence Detection

© 2006 Cardinal Health. All rights reserved. PET Impact on Restaging Negative PET following high dose chemo assoc with 24 month survival PET demonstrates response rate twice that of conventional imaging PET powerful and independent predictor of survival Approaching the Medical Oncologist Cachin F J Clin Oncol 2006; 24:3026.

© 2006 Cardinal Health. All rights reserved. Approaching the Medical Oncologist Cachin F J Clin Oncol 2006; 24:3026.

© 2006 Cardinal Health. All rights reserved. FDG PET in Breast Cancer Therapy Assessment Initial Post therapy

© 2006 Cardinal Health. All rights reserved. PET Reimbursement in Breast Cancer Medicare Adjunct to conventional staging Restaging and therapy monitoring Non-Medicare Letter of medical necessity Gather supportive journal articles Be ready to challenge denials

© 2006 Cardinal Health. All rights reserved. Breast Cancer and PET Female patients--high tech but high touch, compassionate environment Growth opportunities Lead into womens healthcervical and ovarian cancer Scanner and tracer advancements Radiation therapy planning New therapeutic agents

© 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 Breast Cancer Understand that PET/CT is reimbursed in Breast Cancer

© 2006 Cardinal Health. All rights reserved. New Articles Cachin F etal. Powerful prognostic stratification by [18F]fluorodeoxyglucose positron emission tomography in patients with metastatic breast cancer treated with high-dose chemotherapy. J Clin Oncol Jul 1;24(19): Gil-Rendo A etal. Fluorodeoxyglucose positron emission tomography with sentinel lymph node biopsy for evaluation of axillary involvement in breast cancer. Br J Surg Jun;93(6): Inoue T etal.Preoperative evaluation of prognosis in breast cancer patients by [F-18]-deoxy-2fluoro-D-glucose positron emission tomography. J Cancer Res Clin Oncol. 2004; 130:273-8.

© 2006 Cardinal Health. All rights reserved. New Articles Port ER etal. 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography scanning affects surgical management in selected patients with high-risk, operable breast carcinoma. Ann Surg Oncol May;13(5): Van der Hoeven J etal. [F-18]-deoxy-2fluoro-D-glucose positron emission tomography in staging of locally advanced breast cancer. J Clin Oncol 2004; 22:

© 2006 Cardinal Health. All rights reserved. Marketing Tools available through PET Foundations PET Perspectives Brochure - from referring physicians viewpoints Case Studies - Staging Restaging and Monitoring Expert Voices Videos – Dynamic tool for sharing referring physicians perspectives

© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Breast 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