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

© 2006 Cardinal Health. All rights reserved.

Marketing PET’s Role in Marketing PET’s Role in Lung Cancer Management Lung Cancer Management

PET Marketing Forum – Accelerating Practice Growth

May 17, 2006Dr. Patrick Peller

Welcome!


Brought To You By Brought To You By Cardinal HealthCardinal Health

• Part of PET FoundationsSM > comprehensive marketing and education program

• Third of a 6-part Series

• Recorded presentation and PowerPoint available on www.PETFoundations.com > Market Your PET Center > Marketing Forum page

• Exclusive benefit to Cardinal Health PET customers


Dr. Patrick J. PellerDr. 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


What Does a ReferringWhat Does a ReferringPhysician Want?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


Targeted SpecialistsTargeted Specialists““The Select Seven”The Select Seven”

Medical

Medical Oncologists

Pulmonologists

Gastroenterologists

Surgical

Oncologic Surgeons

Thoracic Surgeons

Colorectal Surgeons

Radiation Oncologists




• 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


Estimated US Cancer DeathsEstimated US Cancer Deaths

Source: American Cancer Society, 2006.

Men295,280

Women275,000

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 bronchus 31%

Prostate 10%

Colon and rectum 10%

Pancreas 5%

Leukemia 4%

Esophagus 4%

Liver and intrahepatic 3%bile duct

Non-Hodgkin 3% Lymphoma

Urinary bladder 3%

Kidney 3%

All other sites 24%


Lung CancerLung Cancer

• First and best reimbursed PET indication

• Pulmonary nodule/density

• Lung cancer staging

• Lung cancer restaging


Pulmonary NodulePulmonary Nodule

• Standard evaluation

• Role of PET and PET/CT

• Physician audience

• Pulmonologist

• Internist

• Interventional Radiologist


Diagnostic Evaluation of a Lung Diagnostic Evaluation of a Lung NoduleNodule

• 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


PET Evaluation of a Lung PET Evaluation of a Lung NoduleNodule

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


Diagnostic Evaluation of a Diagnostic Evaluation of a Lung NoduleLung Nodule

• Risk stratification

• PET or PET/CT



Diagnostic Evaluation of a Diagnostic Evaluation of a Lung NoduleLung Nodule

• Risk stratification

• PET or PET/CT


• OR “watchful waiting” serial CT scans


PET for Diagnosis of PET for Diagnosis of Pulmonary NodulesPulmonary 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; 285:914-924.


PET Evaluation of a Lung PET Evaluation of a Lung NoduleNodule

History • 62 YOF• Pulmonary nodule on CXR • Anti-coagulation

PET Findings• No abnormality

Outcome• No change on CXR for 2 years


• 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 PulmonologistApproaching the Pulmonologist


Bronchoscopy and PET for Bronchoscopy and PET for Pulmonary NodulesPulmonary Nodules

Chhajed P. Chest 2005; 128:3558.


Approaching the GeneralistApproaching 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


Management Strategies for Management Strategies for Pulmonary NodulesPulmonary 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.


Management Strategies for Management Strategies for Pulmonary NodulesPulmonary Nodules

Gould Ann Intern Med. 2003;138:725.

*

*


Educational ToolsEducational Tools

• Overview brochure• Clinical

• Technical

• Emotional

• Case studies• Patient brochures


Approaching the Approaching the Interventional RadiologistInterventional Radiologist

• Difficult patient: anticoagulation, nodule location, severe COPD

• Prior biopsy nondiagnostic

• Multiple abnormalities: Best choice

• CT suggests advanced disease


PET in Pulmonary NodulesPET 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.


PET Evaluation of Pulmonary PET Evaluation of Pulmonary NodulesNodules

. Patients Sensitivity Specificity

14 studies 1078 97% 77%

Lowe 1997 197 96% 77%

Multicenter 89 98% 69%

MRP 112 98% 60%

Lowe V et al Radiology 1997; 202:435.

Lowe V et al J Clin Onc 1998; 16:1075.


Lung Cancer StagingLung Cancer Staging

• Conventional NSCLC staging


• Physician audience Pulmonologist

Thoracic Surgeon

Radiation Oncologist


Stage I No nodal metastases and totally

resectable

Stage II Adds hilar nodes or resectablechest wall involvement

Stage IIIA Extensive mediastinal nodes

Stage IIIB Distant nodal metastasis

Stage IV Distant metastases




Mediastinoscopy

Bronchoscopy Chamberlain


Preoperative Staging with PETPreoperative Staging with PET

PET versus CT--Mediastinal Nodes

Sensitivity Specificity

CT 75% 66%

16% 20%

PET 91% 86%

Pieterman N Engl J Med 2000; 343:254-61.


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.



Extra-thoracic StagingExtra-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


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 Approaching the Thoracic SurgeonSurgeon

Vesselle J Thorac Cardiovasc Surg 2002; 124:511.


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 Approaching the Thoracic SurgeonSurgeon


More Accurate Guided BiopsyMore 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


• 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/CT’s 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 Approaching the Radiation OncologistOncologist


Tumor Volume DelineatedTumor Volume DelineatedWith PET-CT With PET-CT

Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.


Lung CancerLung Cancer Staging of the MediastinumStaging of the Mediastinum

.. Patients Sensitivity Specificity PET CT PET CT

9 studies 488 88% 63% 93% 73%

Pieterman 102 91% 75% 86% 66%

Kiernan 94 88% 64% 86% 94%

MRP 158 90% 68% 86% 66%

Pieterman et al NEJM 2000; 343:254.

Kiernan et al S. Med. J. 2002, 95:1168.


Lung Cancer RestagingLung Cancer Restaging

• Standard evaluation


• Physician audience

Pulmonologist

Medical Oncologist


Lung Cancer RestagingLung Cancer Restaging

• Serial Chest CT scans every 3-6 months• Surgery and radiation therapy leave

scarring


Detecting Lung Cancer Detecting Lung Cancer RecurrenceRecurrence

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


Non-Small Cell Lung Cancer

• 126 patients; stage I-IIIB

• Histopathology or clinical progression

• PET and CT every 6 months

PET CTSensitivity 100% 71%Specificity 92% 95%


Bury Eur Respir J 1999;14:1374.


• 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 Approaching the Medical OncologistOncologist


Neoadjuvant Chemotherapy in Neoadjuvant Chemotherapy in NSCLCNSCLC


SUV decline ≤50%

SUV decline >50%


Neoadjuvant Chemotherapy in Neoadjuvant Chemotherapy in NSCLCNSCLC

• 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





• 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


New ArticlesNew 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.


New ArticlesNew 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.


Marketing PET’s Role in Marketing PET’s Role in Lung Cancer ManagementLung Cancer Management

How Did You Like This Session?How Did You Like This Session?

Please Fill Out The Polling Questions Please Fill Out The Polling Questions Before You LeaveBefore You Leave

Thank You!Thank You!

Mark Your Calendars For The Fall Series!

September 27, October 25, November 15

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

Documents

cardinal health pet

pet evaluation

lung cancer slide

practice pet

fdg pet

pet neg

pet andor petct

thoracotomy slide