© 2006 Cardinal Health. All rights reserved.
Marketing PET’s Role in Marketing PET’s Role in Breast Cancer Management Breast Cancer Management
PET Marketing Forum – Accelerating Practice Growth
September 27, 2006Dr. Patrick Peller
Welcome!
© 2006 Cardinal Health. All rights reserved.
Brought To You By Brought To You By Cardinal HealthCardinal Health
• Part of PET FoundationsSM > comprehensive marketing and education program
• Fourth 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
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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/CT-- Your team
© 2006 Cardinal Health. All rights reserved.
Targeted SpecialistsTargeted Specialists““The Select Seven”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 ReferringWhat Does a ReferringPhysician Want?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 CasesEstimated US Cancer Cases
Source: American Cancer Society, 2006.
Men710,400
Women662,870
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
Prostate 33%
Lung and bronchus 13%
Colon and rectum 10%
Urinary bladder 7%
Melanoma Skin 5%
Non-Hodgkin 4% Lymphoma
Kidney 3%
Leukemia 3%
Oral Cavity 3%
Pancreas 2%
All other sites 17%
© 2006 Cardinal Health. All rights reserved.
What Does a ReferringWhat Does a ReferringPhysician Want?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 CancerBreast Cancerversus Lung Cancerversus Lung Cancer
• Variable and increased FDG in breast tissue
© 2006 Cardinal Health. All rights reserved.
FDG PET in Breast CancerFDG PET in Breast Cancer Normal BreastsNormal Breasts
Premenopausal Postmenopausal
Menopausal HRTPostpartum
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Breast CancerBreast Cancerversus Lung Cancerversus 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 FDG PET in Breast Cancer Primary CancersPrimary Cancers
© 2006 Cardinal Health. All rights reserved.
Breast CancerBreast Cancerversus Lung Cancerversus 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 <100 (versus >2000 in lung cancer)
© 2006 Cardinal Health. All rights reserved.
Breast Cancer and PETBreast Cancer and PET Clinical RolesClinical Roles
• Breast cancer diagnosis
• Breast cancer staging
• Breast cancer restaging
© 2006 Cardinal Health. All rights reserved.
Diagnosing Breast CancerDiagnosing 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 PET in the Diagnosis of Breast CancerDiagnosis of Breast Cancer
Primary size Sensitivity
<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 StagingBreast 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 or T>5cm
Stage IIIA Fixed axillary or int. mammary nodes
Stage IIIB Chest wall involved or Inflammatory
Stage IV Distant metastases
Breast Cancer StagingBreast 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 StagingBreast Cancer Staging
© 2006 Cardinal Health. All rights reserved.
• Multidisciplinary Surgery
Radiotherapy
Chemotherapy
• Issues--where, when and order
Breast Cancer TherapyBreast 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 Approaching the Breast SurgeonSurgeon
Gil-Rendo A, Brit J Surg. 2006; 93:707.
© 2006 Cardinal Health. All rights reserved.
Staging Breast CancerStaging 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 Approaching the Radiation OncologistOncologist
Gil-Rendo A, Brit J Surg. 2006; 93:707.
© 2006 Cardinal Health. All rights reserved.
Staging Breast CancerStaging 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 Approaching the Medical OncologistOncologist
Inoue T J Cancer Res Clin Oncol. 2004; 130:273.
© 2006 Cardinal Health. All rights reserved.
Approaching the Medical Approaching the Medical OncologistOncologist
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 CancerStaging 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 Approaching the Medical OncologistOncologist
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 CancerStaging Breast Cancer
© 2006 Cardinal Health. All rights reserved.
Why stage with PET?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 RestagingBreast Cancer Restaging
• Standard evaluation
• Role of PET and PET-CT
• Physician audience Medical Oncologist
© 2006 Cardinal Health. All rights reserved.
Breast Cancer RestagingBreast 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 CancerRestaging Breast Cancer Detecting RecurrenceDetecting 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 CancerRestaging Breast Cancer Detecting Extent of RecurrenceDetecting Extent of Recurrence
© 2006 Cardinal Health. All rights reserved.
# Sensitivity Specificity
Bender 1997 75 97% 91%
Moon 1998 57 93% 79%
Hathaway 1999 10 100% 100%
Lonneax 1999 28 84% 55%
Sugawara 1999 26 100% 67%
Gimenz 1999 53 84% 100%
Kim 2001 27 94% 80%
PET and Breast CancerPET and Breast CancerRecurrence DetectionRecurrence 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 Approaching the Medical OncologistOncologist
Cachin F J Clin Oncol 2006; 24:3026.
© 2006 Cardinal Health. All rights reserved.
Approaching the Medical Approaching the Medical OncologistOncologist
Cachin F J Clin Oncol 2006; 24:3026.
© 2006 Cardinal Health. All rights reserved.
FDG PET in Breast CancerFDG PET in Breast Cancer Therapy AssessmentTherapy Assessment
Initial
Post therapy
© 2006 Cardinal Health. All rights reserved.
PET Reimbursement in PET Reimbursement in Breast CancerBreast 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 PETBreast Cancer and PET
• Female patients--high tech but high touch, compassionate environment
• Growth opportunities Lead into women’s health—cervical and
ovarian cancer
Scanner and tracer advancements
Radiation therapy planning
New therapeutic agents
© 2006 Cardinal Health. All rights reserved.
What Does a ReferringWhat Does a ReferringPhysician Want?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 ArticlesNew 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. 2006 Jul 1;24(19):3026-31.
• Gil-Rendo A etal. Fluorodeoxyglucose positron emission tomography with sentinel lymph node biopsy for evaluation of axillary involvement in breast cancer. Br J Surg. 2006 Jun;93(6):707-12.
• 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 ArticlesNew 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. 2006 May;13(5):677-84
• 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; 22:1253-9.
© 2006 Cardinal Health. All rights reserved.
Marketing ToolsMarketing Toolsavailable through PET Foundationsavailable 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
www.PETFoundations.com
© 2006 Cardinal Health. All rights reserved.
Marketing PET’s Role in Marketing PET’s Role in Breast Cancer ManagementBreast Cancer Management
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September 27, October 25, November 15