Molecular Imaging Insight - September 2007 - (Page 4) tases. In diseases where the management options extend from surgery for local 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. 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 Economies of scale with local disease, with major hepatic and lung resections One of the major impediments to the wider application being increasingly performed for patients presumed to of PET has been the perception of its high cost. In many have limited, and therefore resectable, metastatic disease. regards, this has been due to self-fulfilling policy! Because Radiotherapy also is becoming increasingly complex of high scan costs, access to funding was restricted in and expensive to deliver due to advancements aimed at many parts of the world and consequently relatively few better confining dose to disease sites and sparing toxicity scans were referred. This, in turn, stifled sale of PET scanin normal tissues. Furthermore, a move away from cheap ners and the number of scans performed per scanner. older-style cytotoxics to targeted therapies has substanFast-forward to 2007 and we now have many hundreds tially increased chemotherapy costs. Moreover, the days of of PET/CT scanners being delivered each year by each of single modality therapies are rapidly passing, if not already the major manufacturers, efficiently manufactured and gone. Most patients will now receive adjuvant chemotherbenefiting from continual quality and design improveapy or radiotherapy in addition to “curative” surgery. Radiotherapy is often used in combination with chemotherapy and, more recently, with biological-targetIn a prospective series of patients being ing agents. Monoclonal antibodies and considered for curative chemoradiotherapy, small molecule tyrosine kinase inhibimy group in Australia demonstrated that tors are being added to more conventional chemotherapeutic agents in the FDG-PET altered management in more hope of improving progression-free than 50 percent of cases. Importantly, and overall survival, but are massively approximately 25 percent of patients were increasing the cost of treatment. found to have distant metastases that had not Despite this explosion in therapeutic options and hugely burgeoning been recognized on conventional staging. costs, reductions in cancer mortalRodney J. Hicks, MD, FRACP Professor, Department of Medicine, the University of Melbourne, Director, Centre for ity have been disappointing. In 2004, Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia more than 557,000 people died of cancer in the United States, but this numment. The large installed base allows a larger spare-parts ber was reduced by a bare 3,000 or so compared with the inventory to be available and more effective use of mainyear before. tenance engineers, decreasing servicing costs. The total cost of cancer care in 2004 was $72.1 billion On the operational side, regional cyclotrons are pro(U.S.), an increase of 75 percent compared with expenducing and distributing FDG in bulk—allowing a marked ditures in 1995. These costs exclude the cost of screenreduction in the unit dose cost. The advent of PET/CT has ing programs and don’t reflect the societal costs, which allowed the acquisition time for typical whole-body scans have been estimated to be in excess of $190 billion in the from more than one hour to less than 30 minutes. This, in same year. These ever-expanding health costs are clearly turn, has allowed higher throughput and hence, greater not sustainable with an aging population. So, why should amortization of capital equipment costs, more productive it even be considered that an expensive test such as FDGuse of staff, and more efficient use of FDG, which can rapPET could be added to existing costs? idly decay during the scanning of preceding patients. Well, let us consider lung cancer, the most common In 1996-1997, my facility performed slightly more than cause of cancer mortality. This disease costs approxi700 scans on a single scanner; whereas in 2006-2007, we mately $9.6 billion in 2004 in the U.S. Medicare payments have performed more than 4,500 scans on two PET/CT alone cost $24,700 per patient in the first year of diagnosis, ignoring out-of-pocket expenses, which may add in scanners. The quality of these scans has improved draexcess of 10 percent to this. matically and the real cost of scans has decreased. Assuming that the majority of these costs represent Nevertheless, it needs to be understood that scan costs attempted curative treatments in the approximately 75 are critically dependent on practice models and that if percent of patients who don’t already have clear evidence throughput is constrained by bureaucratic or logistical of metastatic disease at presentation, the scope for more constraints, or the production and use of FDG from a accurate diagnosis to impact health expenditure can cyclotron is inefficient, then PET will remain substantialclearly be appreciated if one considers the incremental ly more expensive than competing diagnostic modalities diagnostic value of FDG-PET in published series. used in cancer evaluation. Molecular Imaging Insight September 2007
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