PET = Personalized Cancer Therapy

Additional reimbursement is great news from CMS for Positron Emission Tomography (PET) and for improved cancer outcomes.  Historically, CMS has only covered a FDG PET study either for the initial diagnosis or a follow-up staging for solid tumors and myeloma.  Because of the high cost of PET, its use has been limited for further follow up staging, an important tool in evaluating the effectiveness of the therapy.  

When I spoke to Claudia Henschke, MD, professor of radiology at Weill Medical College, attending radiologist, chief of the division of Chest Imaging, and chief of the division of Health Care Policy and Technology Assessment at New York Hospital-Cornell Medical Center, New York, NY, she commented on the advantages of PET and stated, “PET is another technology for detecting cancer, but it is usually not effective in detecting very small nodules.  Its primary advantage is in determining an active cancer.” 

Clinical trials support the advantages of using PET technology for determining the effectiveness of a therapy.  One study demonstrated that PET has 95.9% accuracy in restaging cancer for patients after a first-line therapy, revealing that PET is very effective in grading tumors and measuring its tissue response to treatment. 

The drawbacks of PET are high capital costs ($1.6 million plus) and its consumable tracer FDG (18F fluorodeoxyglucose) can range from $200 to over $800 per patient.  This, combined with labor and overhead ($800 to $1,000), leaves little room for positive margins under existing reimbursement practices (APC 308 – $1100 per study).  At a cost of approximately $1,000 per patient, any unreimbursed procedure would put all but the most active programs under a financial strain. 

It doesn’t take a major financial evaluation to determine that additional reimbursement for an imaging study is good news.  Studies have shown that this form of personalized cancer therapy is cost effective.  When a basic round of external radiation therapy starts at $100 and chemo at $200, providers can spend tens of thousands of dollars on cancer treatments that may have a limited effect.  So, any technology that keeps them from wasting time and expense is good news. When CMS offers a financial incentive to practice good medicine, maybe they are trying to say something.