confocal microscopy and biopsy volume

[pathbot]

Hey just wanted to get everyone's input on the future of confocal microscopy and other forms of in-vivo microscopy. What are some realistic expectations as to how this technology will be embraced by clinicians and affect anatomic pathologists? From what I hear, it should ideally reduce, but not eliminate, the need for biopsies by allowing more targeted biopsies.

An obvious strength of the technology would be to allow a more rapid diagnosis. However, barriers to implementation appear to be no formal training in this activity by the vast majority of practicing GIs, high cost of implementation, no formal reimbursement, potentially more timely procedures, and more liability for the clinicians.

Yes, some of the big academic centers are working with this, but when do you see this being practiced out in the community, and if so, how do you feel that it would affect your local pathologist in terms of the volume you send him/her. Thanks for your input

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[libertarian]

We just got ours a few months ago and use it pretty regularly. There was a lot at last year's DDW regarding confocal, and I think the push is only going to get stronger. The rep for Cellvizio told me that they were just approved for level 1 CPT coding for confocal endomicroscopy starting Jan 1st, 2013. Medicare will not reimburse the procedure yet, but private insurers are paying a handsome facility fee to the hospital starting Jan 1st. As the trend for physicians has been steadily leaning towards hospital employment, I think hospitals will be more and more interested in the technology, as (I was told) it is the highest reimbursing procedure that gastroenterologists will perform starting Jan 1st. The processor itself is a cool $200K and each probe costs $10K, and you get about 20 uses with each probe, so it is definitely costly.

Will it save us money by reducing the number of biopsies? I highly doubt it. Just like most technology considered the "latest and greatest," all it does it lead to increased costs. Case-in-point: "virtual colonoscopy" with computed tomography. Gastroenterologists were freaking out in the 90's that it would take away from their main revenue stream. Actually, all CT colonoscopy did was INCREASE the number of colonoscopies that gastroenterologists were doing, because now they were finding all sorts of **** (literally) on CT scan, requiring a formal optical colonoscopy. And the colonoscopies were no longer "screening" colonscopies, they were "therapeutic" colonoscopies (which bill higher). So all it did was raise costs, increase business for gastroenterologists, and do nothing to help the patient. Cool technology, huh? (sarcasm...)

Personally, I think confocal endomicroscopy will be accepted as mainstream, and you'll start to see it pop up in community hospitals within the next 5-6 years. It's actually not very difficult to interpret the images with a little practice, and it is cool to tell the patient and their family members that the suspicious lesion is benign or malignant right away, instead of waiting the ridiculous 3-4 days. Which leads me to the my next point/question... any chance pathologists can get results to us a little faster? Say, within 24 hours? I would bet that a lot of centers would hold off on purchasing such expensive equipment if the turn-around on pathology specimens was much faster.

 

[Gastrapathy]

Thats definitely a view from the ivory tower. Confocal has a tiny penetration outside of academics and Mauna Kea is hemorrhaging cash. I think it may keep a small niche. Keep in mind that we've never shown that Barrett's surveillance, for example, makes any difference on survival. NBI has never been shown to be better than a good white light HD exam.

Not a threat to path. The main threat to pathologists is that my group will want to employ you rather than partner with you.

MKEA is the stock ticker on the NSYE Paris. They went public because no big endoscopy company would buy them. They are losing E$3million a quarter and the stock has fallen 50% from its peak.