Molecular Imaging Insight - May 2008 - (Page 9) tumor to combination therapies, often including radiotherapy, for regional disease and to systemic therapies for disseminated cancer, this ability can have a major impact on patient management. Economies of scale One of the major impediments to the wider application of PET has been the perception of its high cost. In many regards, this has been due to self-fulfilling policy! Because of high scan costs, access to funding was restricted in many parts of the world and consequently relatively few scans were referred. This, in turn, stifled sale of PET scanners and the number of scans performed per scanner. Fast-forward to 2007 and we now have many hundreds of PET/CT scanners being delivered each year by each of the major manufacturers, efficiently manufactured and benefiting from continual quality and design improvement. The large installed base allows a larger spare-parts inventory to be available and more effective use of maintenance engineers, decreasing servicing costs. On the operational side, regional cyclotrons are producing and distributing FDG in bulk—allowing a marked reduction in the unit dose cost. The advent of PET/CT has allowed the acquisition time for typical whole-body scans from more than one hour to less than 30 minutes. This, in turn, has allowed higher throughput and hence, greater amortization of capital equipment costs, more productive use of staff, and more efficient use of FDG, which can rapidly decay during the scanning of preceding patients. In 1996-1997, my facility performed slightly more than 700 scans on a single scanner; whereas in 20062007, we have performed more than 4,500 scans on two PET/CT scanners. The quality of these scans has improved dramatically and the real cost of scans has decreased. Nevertheless, it needs to be understood that scan costs are critically dependent on practice models and that if throughput is constrained by bureaucratic or logistical constraints, or the production and use of FDG from a cyclotron is inefficient, then PET will remain substantially more expensive than competing diagnostic modalities used in cancer evaluation. sues. Furthermore, a move away from cheap older-style cytotoxics to targeted therapies has substantially increased chemotherapy costs. Moreover, the days of single modality therapies are rapidly passing, if not already gone. Most patients will now receive adjuvant chemotherapy or radiotherapy in addition to “curative” surgery. Radiotherapy is often used in combination with chemotherapy and, more recently, with biological-targeting agents. Monoclonal antibodies and small molecule tyrosine kinase inhibitors are being added to more conventional chemotherapeutic agents in the hope of improving progression-free and overall survival, but are massively increasing the cost of treatment. Despite this explosion in therapeutic options and hugely burgeoning costs, reductions in cancer mortality have been disappointing. In 2004, more than 557,000 people died of cancer in the In a prospective series of patients being considered for curative chemoradiotherapy, my group in Australia demonstrated that FDG-PET altered management in more than 50 percent of cases. Importantly, approximately 25 percent of patients were found to have distant metastases that had not been recognized on conventional staging. Rodney J. Hicks, MD, FRACP Professor, Department of Medicine, the University of Melbourne, Director, Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia PET in perspective However, the unit cost of PET scans is not the critical issue in justifying the wider use of this technology. Cancer care is amongst the most expensive areas of therapeutics. The surgery involved is often complex and may require major tissue reconstruction. No longer is surgery confined to those with local disease, with major hepatic and lung resections being increasingly performed for patients presumed to have limited, and therefore resectable, metastatic disease. Radiotherapy also is becoming increasingly complex and expensive to deliver due to advancements aimed at better confining dose to disease sites and sparing toxicity in normal tisMolecularImaging.net United States, but this number was reduced by a bare 3,000 or so compared with the year before. The total cost of cancer care in 2004 was $72.1 billion (U.S.), an increase of 75 percent compared with expenditures in 1995. These costs exclude the cost of screening programs and don’t reflect the societal costs, which have been estimated to be in excess of $190 billion in the same year. These ever-expanding health costs are clearly not sustainable with an aging population. So, why should it even be considered that an expensive test such as FDG-PET could be added to existing costs? Well, let us consider lung cancer, the most common cause of cancer mortality. This disease costs approximately $9.6 billion in 2004 in the U.S. Medicare payments alone cost $24,700 per patient in the first year of diagnosis, ignoring out-of-pocket expenses, which may add in excess of 10 percent to this. Assuming that the majority of these costs represent attempted curative treatments in the approximately 75 percent of patients who don’t already have clear evidence of metastatic disease at presentation, the scope for more accurate diagnosis to impact health expenditure can clearly be appreciated if one considers the incremental diagnostic value of FDG-PET in published series. May 2008 | Molecular Imaging Insight http://MolecularImaging.net
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