HCFA expands Medicare coverage for PET cancer diagnosis

In a sweeping move, the Health Care Financing Administration has expanded PET coverage for the diagnosis of six types of cancer and has left the door open for further expansion. The action, announced Dec. 15, is scheduled to take effect July 1.

This is the first time HCFA has set a national coverage policy that allows physicians to judge how best to use PET to improve the care of their patients. With this move HCFA appears to have finally embraced PET's ability to address the biochemical foundation of cancer pathology, handing the PET community a key victory in its long battle for bureaucratic recognition.

"This marks a significant advancement in the recognition of PET as a technology originating from the revolutionary changes occurring in biology and biotechnology that are changing the world we live in," said Dr. Michael E. Phelps, chairman of the department of molecular and medical pharmacology at UCLA. "The importance of this is self-evident when you consider that disease is a biological process and it is these very processes that PET examines. With this (move), HCFA is also recognizing that the merging of biology and medicine is changing our understanding, diagnosis, and treatment of disease."

PET coverage for cancer had previously been granted under relatively constrained indications. For example, coverage was allowed in the staging of non-small cell lung carcinoma (NSCLC). Now, NSCLS is covered for diagnostic and recurrence purposes as well as for staging.

Other cancers now covered include colorectal, lymphoma, esophageal, melanoma, and some head and neck malignancies. Myocardial viability and refractory seizures, both outside the realm of oncology, were also approved.

Among those expected to benefit the most from HCFA's decision are the elderly, said Dr. Val Lowe, president of the Academy of Molecular Imaging.

"Giving seniors additional access to this important new diagnostic test for these cancer indications and cardiovascular disease will mean the difference between life and death for some," he said. "For others, it will have a direct impact on improving their treatment and their quality of life."

Carrying the praise a step further was Dr. Edward Coleman, vice-chairman of radiology at Duke University.

"The expanded PET coverage is also cost-effective for the healthcare system, since it can reduce the number of tests needed to diagnose, stage, and track a disease, and it can prevent unnecessary and less effective procedures and treatment," he said.

HCFA's action came amid predictions that the number of PET scanners in use will triple within five years and that the number of PET procedures could pass the one million mark during the same period. This optimism had been based primarily on the ability of PET to deliver on its promise of clinical accuracy. The modality has demonstrated near-perfect sensitivity in scanning for lung cancer, a leading cause of death among the elderly; specificity for the disease also has been high. Additionally, PET often proves superior to CT in staging for metastatic lung cancer.

Most disease states have a molecular basis. PET often detects these molecular errors before other imaging modalities can see anatomical changes, resulting in earlier and more effective clinical intervention.

In clinical practice today, PET is being used to improve the diagnosis and treatment of patients with many different cancers. Looking to the future, PET may hold significant potential for breast cancer scanning, or positron emission mammography. Another potential application is earlier detection of ovarian cancer, one of the most difficult cancers to diagnose before the disease reaches an advanced stage.