FDG-PET changes management for one in three cancer patients

Preliminary results from more than 20,000 patients in the National Oncologic PET Registry found that referring physicians changed their intended clinical management for more than one-third of cancer patients based on findings from FDG-PET.

The NOPR was devised to confirm that FDG-PET is as efficacious in clinical practice as it appeared to be from clinical trials that preceded the decision of the Centers for Medicare and Medicaid Services in 2005 to conditionally grant reimbursement for most applications for cancer diagnosis, staging, and treatment monitoring. The requirement for a registry, managed by the American College of Radiology Imaging Network, was written in Medicare's coverage determination to measure FDG-PET's influence on clinical decision-making.

The first year of data compiled by the NOPR suggest that using FDG-PET as a cancer imaging tool for all types of malignancies makes sense, said coauthor Dr. Barry A. Siegel, director of nuclear medicine at the Mallinckrodt Institute of Radiology and cochair of the NOPR working group.

"Medicare should, when given the opportunity to look at these data formally, strongly consider opening up the coverage to include either all cancers or most cancers," he said.

Siegel was part of a team of eight investigators who gathered the data under the lead of Dr. Bruce E. Hillner, associate chair of internal medicine at Virginia Commonwealth University.

Hillner and colleagues reviewed 22,975 cases entered in the registry from May 8, 2006 to May 7, 2007. The most common cancer types in the registry were prostate, ovary and uterine adnexa, pancreas, bladder, kidney and other urinary tract malignancies, unknown primary, stomach, small cell lung, other uterine, and liver/intrahepatic bile duct.

The investigators found that more than one-third of patients who underwent FDG-PET for one of the cancer types included in the registry had a major change in intended management, including treatment selection. Hillner described the initial results at the 2007 RSNA meeting.

On average, physicians changed their management in 36% of cases based on PET results. For 28% of the cases, FDG-PET led the referring physician to shift from nontreatment to treatment. For 8%, the imaging results led the physician to decide against treatment.

In 48% of patients whose pre-PET plan was treatment, the post-PET plan changed from curative to palliative intent. In patients switching from nontreatment to treatment after PET, the revised treatment goal was nearly equally divided between curative and palliative intent in cases of cancer diagnosis or initial staging. In cases of restaging, suspected recurrence, or treatment monitoring, however, a palliative goal was at least twice as common.

Researchers expressed satisfaction that NOPR results are consistent with prior published literature for covered cancers and expect that CMS will consider the data in a positive way, Siegel said.

"We hope CMS shares our belief that these data go a long way toward demonstrating that it would be appropriate to cover additional cancers," he said. "The registry has exceeded our expectations."

For more information from the Diagnostic Imaging archives:

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PET registry warns providers against paying referring physicians for surveys

PET registry boosts coverage outlook for rare cancers