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© 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!
© 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
• 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
© 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 and/or 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 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%
© 2006 Cardinal Health. All rights reserved.
Lung CancerLung Cancer
• First and best reimbursed PET indication
• Pulmonary nodule/density
• Lung cancer staging
• Lung cancer restaging
© 2006 Cardinal Health. All rights reserved.
Pulmonary NodulePulmonary Nodule
• Standard evaluation
• Role of PET and PET/CT
• Physician audience
• Pulmonologist
• Internist
• Interventional Radiologist
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
Diagnostic Evaluation of a Diagnostic Evaluation of a Lung NoduleLung Nodule
• Risk stratification
• PET or PET/CT
• Tissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy
© 2006 Cardinal Health. All rights reserved.
Diagnostic Evaluation of a Diagnostic Evaluation of a Lung NoduleLung Nodule
• Risk stratification
• PET or PET/CT
• Tissue sample: FNA, needle bx, bronchoscopy, VATS, thoracotomy
• OR “watchful waiting” serial CT scans
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
• 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
© 2006 Cardinal Health. All rights reserved.
Bronchoscopy and PET for Bronchoscopy and PET for Pulmonary NodulesPulmonary Nodules
Chhajed P. Chest 2005; 128:3558.
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
Management Strategies for Management Strategies for Pulmonary NodulesPulmonary Nodules
Gould Ann Intern Med. 2003;138:725.
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© 2006 Cardinal Health. All rights reserved.
Educational ToolsEducational Tools
• Overview brochure• Clinical
• Technical
• Emotional
• Case studies• Patient brochures
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
Lung Cancer StagingLung Cancer Staging
• Conventional NSCLC staging
• Role of PET and PET/CT
• Physician audience Pulmonologist
Thoracic Surgeon
Radiation Oncologist
© 2006 Cardinal Health. All rights reserved.
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
Lung Cancer StagingLung Cancer Staging
© 2006 Cardinal Health. All rights reserved.
Lung Cancer StagingLung Cancer Staging
Mediastinoscopy
Bronchoscopy Chamberlain
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
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.
Approaching the PulmonologistApproaching the Pulmonologist
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
• 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
© 2006 Cardinal Health. All rights reserved.
Tumor Volume DelineatedTumor Volume DelineatedWith PET-CT With PET-CT
Steenbakkers R. Int J Radiat Oncol Biol Phys. 2006;64:435.
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
Lung Cancer RestagingLung Cancer Restaging
• Standard evaluation
• Role of PET and PET/CT
• Physician audience
Pulmonologist
Medical Oncologist
© 2006 Cardinal Health. All rights reserved.
Lung Cancer RestagingLung Cancer Restaging
• Serial Chest CT scans every 3-6 months• Surgery and radiation therapy leave
scarring
© 2006 Cardinal Health. All rights reserved.
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
© 2006 Cardinal Health. All rights reserved.
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%
Approaching the PulmonologistApproaching the Pulmonologist
Bury Eur Respir J 1999;14:1374.
© 2006 Cardinal Health. All rights reserved.
• 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
© 2006 Cardinal Health. All rights reserved.
Neoadjuvant Chemotherapy in Neoadjuvant Chemotherapy in NSCLCNSCLC
Pöttgen Clin Cancer Res 2006;12:97.
SUV decline ≤50%
SUV decline >50%
© 2006 Cardinal Health. All rights reserved.
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
Pöttgen Clin Cancer Res 2006;12:97.
© 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 that PET/CT is reimbursed in Lung Cancer
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
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.
© 2006 Cardinal Health. All rights reserved.
Marketing PET’s Role in Marketing PET’s Role in Lung Cancer ManagementLung Cancer Management
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