Heavy PETting

[deleted4401]

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Every breast patient is getting a PET-CT now. It's getting out of hand. Pre-treatment. Post-treatment. It started off with the locally advanced/metastatic patients, which sort of makes sense. Then they started with the stage I-II patients, even with gentle reminders that it isn't necessary. I've asked at tumor board for them to be more judicious. I even dictate "Patient got a PET-CT, but I have no idea why". Then it started creeping into the DCIS patients. THE DCIS PATIENTS! Are you kidding me? There is no chance they have distant disease and there is no way it adds any value. The cake was last week. The surgeon ordered it on a patient with ... ADH! ADH! Are you freakin' kidding me?

I'm just so wound up. Yesterday, my stage one follow-up had a PET-CT ordered about 9 months after treatment. About to see a follow-up that had male breast cancer, and just saw that he had a PET-CT. What in the world is going on? Is this a local thing or are you guys seeing it, too? Why is insurance covering this?

 

[medgator]

It's definitely way more prevalent in the community than what I saw in training. Really, outside of a stage III patient (and maybe a triple-neg/sympomatic stage I/II), I really don't see the point.

DCIS ---- wow talk about an inappropriate use of resources. How are the DCIS/ADH indications even getting an approval for a PET?

Honestly, it's crap like this that make a lifetime patient limit on PET/CTs a real possibility since some of our colleagues can't seem to regulate themselves.

 

[Gfunk6]

They'll go back to the ordering physician and the ordering physician will stop harming patients.

And then the ordering physician will never refer you a patient again and/or try to smear your reputation in the community.

It is never black and white in private practice unfortunately.

I do agree that PET/CTs for the indications that Simul cited are outrageous and absolutely unnecessary. What to do about it is the difficult question. Sometimes a public "shaming" or "correction" (depending on your relationship with the MD in question) at the next Tumor Board may help.

 

[deleted4401]

Yeah, I'm keeping the patient out of it. My partners and I bring it up at every breast tumor board at that hospital. They just smile and tease me about it. Seriously. They mention they ordered it, and then say something like "But, Dr. SimulD wouldn't have ordered that..." Once, they found an enlarged mildly active lymph node in the axilla, so they skipped the SLN and went right to dissection. 0/12 nodes positive. The breast MRI is another thing that is driving me nuts. Everyone is getting it for every patient now. At least there is some debate about that, but indiscriminately ordering it on everyone - I don't get it.

People complain about government involvement in medicine and ObamaCare, but the problem really lies in the hands of physicians. For this simple community hospital alone, probably 50-100 unnecessary PET-CTs a year. At $6k a pop, that's $300k-$600k in savings alone. The problem is the price of the scan is higher than what it costs to do it, so the hospital profits. The insurer pays and then passes the costs down the line as higher premiums. Pisses me off, because the same docs are the ones that complain that government and third parties are "restricting" their practice.

 

[RadOncDoc21]

I'm surprised their insurance hasn't stepped in yet. Usually I hear from them the moment any sort of imaging is mentioned and have to verify using NCCN guidelines or saying 7 times that the patient has cancer. Also, is there a possibility these doctors are getting some financial incentive from ordering these PETs?

 

[Gfunk6]

. . . so what is really gained with the PET?

I hate to say it but the answer is $.

 

[Neuronix]

We have practices in the area that re-PET after every single cycle of chemo. We're not talking very sensitive cancers like lymphoma either--NSCLC/SCLC, breast, etc... Chemo choice is always what's most expensive. Of course PET/CT is obtained for every cancer type and stage as part of initial workup.

It's not like it's just medical oncology of course... There's one rad onc group in the area that does a prostate MRI and U/S every year after radiation treatment no matter what the PSA/physical exam shows. Of course initial treatment with them includes brachy, beam, and hormones for even very low risk prostate cancer.


I personally am a fan of the PET/CT for initial stage IIIA or higher for breast. Though the sensitivity/specificity I believe is the same as CT C/A/P w/ bone scan. It comes down to the IGBO cases where the bone scan failed to pick up a lytic bone met outside (or even within) the CT area that you would have found on PET/CT. Or a lymph node is borderline size criteria by CT so the PET helps you decide where to treat or helps you decide to treat or not treat a patient. Does that justify the added cost for PET/CT? Meh, probably not. My understanding of cost difference is something like under $1000 for bone scan/CT vs. $3000 for PET/CT. Then again we don't treat for local control in metastatic breast other than short course palliative for pain/skin lesions/edema/etc. They go to chemo alone.

but indiscriminately ordering [breast MRI] on everyone - I don't get it.

I've seen some breast surgeons do that. It does not improve outcomes, but it does do one thing. Pre-op MRI increases mastectomy + reconstruction rate. Patients get freaked out when the breasts are found to have other little questionable nodules that need additional biopsy work. So then they want the breast(s) off.

 

[deleted4401]

Agree with PET-CT for stage III and above.

What is IGBO?

PET-CT price is 11k and reimbursement is about 6k with most insurers. I think 3k is something I only see at imaging centers where the expectation is cash. Plus, the fusions at those places tend to be turrible. People suck. Correspondingly, they suck because of the way we (and the whole system) get paid and because of the 3rd party insurers who pay the cost but don't reflect it until premiums go up. As I've harped on, fee for service drives this nonsense. No one can give me one good argument why I'm wrong, FFS drives ordering of tests, excessive treatments, and invasive follow up. Why else would smart people go against national guidelines? The whole system is rigged. Someone give me a reason why a board trained physician would order a pet-ct in early stage breast cancer if FFS and 3rd part insurers didn't exist?

 

[BraggPeak]

How do you guys use PET for post treatment in lung? I've seen many people now ordering them 6 weeks post treatment for sbrt or definitive as it is prognostic. But it really doesn't change management...just curious what all of you do.

 

[medgator]

How do you guys use PET for post treatment in lung? I've seen many people now ordering them 6 weeks post treatment for sbrt or definitive as it is prognostic. But it really doesn't change management...just curious what all of you do.

I do it at 3 months. It's nice to let post therapy inflammation settle down imo. Six weeks seems too early

 

[medgator]

i agree, majority of time it's ordered because people are just not thinking, FFS, and all of the reasons you've mentioned above. Sometimes, however, the patient (or their high maintenance family) demands the test.
PT: "well my friend/sister/dogsitter had breast cancer and she had a PET. Why aren't you ordering one?"
MD: Explains why.
PT: "I'm too stupid to understand that. Order the PET. "
MD: Explains again.
PT: "Order the PET"
MD: *gives in*

This is probably the minority of time, but it does happen. No great excuse for it, but I can certainly understand how it would happen.

It happens more than you think. I've had triple-negative Stage I patients who read up on breast CA on the "internet" tell me that they want a PET/CT because "triple-negative" is bad and can spread aggressively, even in stage I. I can't really argue with them against it

 

[RadOncDoc21]

It happens more than you think. I've had triple-negative Stage I patients who read up on breast CA on the "internet" tell me that they want a PET/CT because "triple-negative" is bad and can spread aggressively, even in stage I. I can't really argue with them against it

I had this happen a couple of times with patients and their family members in many disease sites despite repetitive counseling.

 

[Brim]

Agree with PET-CT for stage III and above.

What is IGBO?

I had to look this one up on Wikipedia:
http://en.wikipedia.org/wiki/IGBO

Now you know.

 

[Gfunk6]

Now you know.

 

[Neuronix]

What is IGBO?

IGBO = I Got Burned Once

I do it at 3 months. It's nice to let post therapy inflammation settle down imo. Six weeks seems too early

We only follow up with CT of the thorax. PET/CT or other additional imaging only if concerning findings on CT.

I had to look this one up on Wikipedia:
http://en.wikipedia.org/wiki/IGBO

Now you know.

 

[Reaganite]

It's all about money! Where I work, there is a very strong marketing private imaging facility that has an incredibly nice owner and marketer. They simply coax people into ordering pets because honestly people like them so much on a personal level. and hell it can't hurt to be absolutely sure there aren't any Mets even in dcis right? (That's how the pitch starts...)

 

[Palex80]

Concerning PET after SBRT for lung cancer:
I would only do it in cases where you are not sure if there's progression or not. Surely "it's nice to have one", but "nice to have one" isn't evidence based. Normal follow up for lung cancer after SBRT should be CT only. If you see progression of the lesion or suspicious lymph nodes, you can order a PET then, but there's no reason to do a PET in all patients at a certain pre-defined time frame.
I am a strong opponent of PET at 3 months after SBRT. That's exactly the time frame, where you see inflammation and PET can be (borderline) positive in cases of inflammation too.
Do not forget: We reach 95% local control rate with SBRT in stage I NSCLC. Personally I have never seen a local progression at 3 months after SBRT in several hundred patients treated so far.


PET in breast cancer can be quite valuable for staging in stage II/III breast cancer, especially in patients going into neoadjuvant chemo. I have seen dozens patients being totally inadequately staged prior to chemo, leading to total confusion as to what irradiate later on.


I wonder why PET is so expensive in the US. In Europe you get a FDG-PET-CT for roughly 1500 US dollars nowadays.

 

[ramsesthenice]

First, Simul needs some recognition for his great thread title.

Second, as someone with only experience in academics one real problem (particularly when I was in medicine) with US medicine is doctors have no idea what things actually do cost. Maybe a relative sense, but there is no way to offer a patient a test and then look up how much it costs. I always feel stupid when a patient asks exactly that, the most reasonable question for the situation, and I can honestly say I don't know and I don't know who does.

 

[Ursus Martimus]

I'm not so sure what the resolution of this was but something I got a few months back:
A recently proposed decision memorandum from the Centers for Medicare and Medicaid Services (CMS) regarding positron emission tomography (PET) imaging threatens to severely curtail the ability to order follow-up PET scans for subsequent cancer treatment planning. It is estimated that this policy would preclude CMS coverage of up to 50% of the PET cases performed at community based cancer centers. Take action now (links below include suggestions for comments and a link to submit your comments) in order to pressure CMS to reverse this drastic proposal!

CMS plans to reverse course and cover a maximum of only TWO PET scans for the lifetime of each oncology patient; one for initial treatment strategy and one performed for subsequent treatment strategy. In the past, CMS has not placed limits on the number of scans that can be performed for subsequent treatment strategy, as needed for potential changes in patient management, restaging after therapy, assessment of suspected recurrence, etc. CMS does leave open the possibility for the local carriers to pay for additional subsequent treatment strategy PET scans, with approval on a “tumor-by-tumor” or even "case-by-case” basis. However, getting approval for each of those "case-by-case" scans is likely to be very cumbersome, if not impossible.

CMS did agree to lift the CED requirement for FDG-PET for most of the remaining tumors (note that coverage for NaF PET still remains under CED). Notably, CMS excluded prostate cancer from this new coverage, and now proposes that FDG-PET for prostate carcinoma be nationally "noncovered," meaning that prostate cancer would not be covered either outside or inside of those participating in the National Oncologic PET Registry (NOPR).

For community based oncologists who have utilized PET scans for assessing efficacy of therapy, deciding when a new therapy should be instituted, assessing new or persistent abnormalities seen on CT or MRI, assessing the significance of rising tumor markers, or delineating suspected recurrences earlier than is possible with other imaging modalities, this will create a major void in your ability to manage patients.

While this proposal would immediately affect only payment through Medicare, it is likely that private payers will quickly adopt any CMS-recommended limitations in PET coverage. The US Oncology Network has had success in the past in educating CMS on similar PET coverage decisions but it will require your practice to ACT NOW and submit comments utilizing the links below.

 

[Ursus Martimus]

CMS Releases Final Decision on FDG-PET

Late afternoon on June 11, The Center for Medicare and Medicaid Services released a final rule on F-fluorodeoxyglucose PET and PET/CT imaging (FDG-PET) in solid tumors. Similar to the proposed rule, the final rule ends the requirement for coverage with evidence development (CED) for FDG-PET. Additionally, CMS determined that three FDG-PET subsequent management scans will be covered for the lifetime of the patient. Coverage of any additional FDG-PET scans will be determined by a local Medicare Administrative Contractors.

As you may recall, the March 13 initial proposed rule CMS planned to cover a maximum of one FDG-PET subsequent scan for the lifetime of a patient, which was estimated to preclude CMS coverage of up to 50% of the FDG-PET cases preformed at community based cancer centers. The US Oncology Network submitted comments opposing that proposal on April 12, 2013.

 

[medgator]

CMS Releases Final Decision on FDG-PET

Late afternoon on June 11, The Center for Medicare and Medicaid Services released a final rule on F-fluorodeoxyglucose PET and PET/CT imaging (FDG-PET) in solid tumors. Similar to the proposed rule, the final rule ends the requirement for coverage with evidence development (CED) for FDG-PET. Additionally, CMS determined that three FDG-PET subsequent management scans will be covered for the lifetime of the patient. Coverage of any additional FDG-PET scans will be determined by a local Medicare Administrative Contractors.

As you may recall, the March 13 initial proposed rule CMS planned to cover a maximum of one FDG-PET subsequent scan for the lifetime of a patient, which was estimated to preclude CMS coverage of up to 50% of the FDG-PET cases preformed at community based cancer centers. The US Oncology Network submitted comments opposing that proposal on April 12, 2013.

3 scans as a maximum seems reasonable enough to me for most of the cases I see. Pre-treatment staging and 1-2 scans for post-treatment surveillance, basically.

 

[deleted4401]

When doctors misbehave, they get pissed that the government wants to restrict them in any way. Think about it. For majority of breast - 0 scans. For majority of prostate - 0 scans. For lung - 1 at staging, and 0 after (based on NCCN, you can get one, but it's just prognostic - doesn't change outcome). For colorectal - 1 at diagnosis. For lymphomas, 1 before tx and 1 after. For head and neck, 1 before and 1 after. Same with cervical.

I see so many patients who have like 10 of them. People don't want to do physical exams, nor do they understand that finding something on PET doesn't change the outcome (read up on lag time bias!!!). Doctors are so blind to the fact that they are the leading driver of medical costs. It's not the insureres, its not litigation, it's not drug costs, it's not Obamacare. It's the doctor's pen. It's ordering Erbitux instead of cisplatin. It's treating a bone met to 40 Gy in 16 Fx. It's using CBCT for brain cases where you are just matching to bone anyway. It's doing excisional biopsies for breast abnormalities instead of core biopsies, thereby allowing for 2 billable surgeries. It's getting PSAs on 85 year old men and then referring them to urology and rad-onc. That's what's crushing the system.

Thanks. I have to give credit to the name of the thread to whom it's due - the legendary medical oncologist, Dr. Barry Lembersky, who quietly seethed and uttered harsh cursh words about PET scans back in 2007.

 

[Gfunk6]

CMS to the rescue!

Starting today, for Medicare patients, PET/CT for initial staging of non-metastatic breast cancer is no longer covered. For the "money" chart look at the end of the webpage, right before the bibliography.

Furthermore, PET/CTs have been limited to three per patient after "initial anti-tumor treatment." Additional PET/CTs have to be pre-authorized by your regional CMS rep. This clause has been left (deliberately?) ambiguous. Can you get three more PET/CTs after a salvage chemo? Or not?

 

[medgator]

Starting today, for Medicare patients, PET/CT for initial staging of non-metastatic breast cancer is no longer covered.

That seems a bit overly broad. Are you sure?

Per your link:

Initial Anti-Tumor Treatment Strategy Nationally Covered Indications Effective June 11, 2013

CMS continues to nationally cover FDG PET imaging for the initial anti-tumor treatment strategy for male and female breast cancer only when used in staging distant metastasis.

Breast: Nationally non-covered for initial diagnosis and/or staging of axillary lymph nodes. Nationally covered for initial staging of metastatic disease. All other indications for initial anti-tumor treatment strategy for breast cancer are nationally covered.

So basically, tell them on your order form you're ruling out mets, not trying to stage the axilla. Seems appropriate to me.

 

[Gfunk6]

So basically, tell them on your order form you're ruling out mets, not trying to stage the axilla. Seems appropriate to me.

Good point. We have a meeting with a CMS rep to 'clarify' some of these issues next week. In general, it seems CMS likes to keep these things deliberately vague on the one hand to give themselves leeway and on the other hand to avoid a physician riot if guidelines are "hard."

Maybe surgeons in Simul's neck of the woods will start writing orders for "R breast ADH, r/o mets?"

 

[Gfunk6]

I see so many patients who have like 10 of them. People don't want to do physical exams, nor do they understand that finding something on PET doesn't change the outcome (read up on lag time bias!!!). Doctors are so blind to the fact that they are the leading driver of medical costs. It's not the insureres, its not litigation, it's not drug costs, it's not Obamacare. It's the doctor's pen. It's ordering Erbitux instead of cisplatin. It's treating a bone met to 40 Gy in 16 Fx. It's using CBCT for brain cases where you are just matching to bone anyway. It's doing excisional biopsies for breast abnormalities instead of core biopsies, thereby allowing for 2 billable surgeries. It's getting PSAs on 85 year old men and then referring them to urology and rad-onc. That's what's crushing the system.

I see a future for you as a CMS auditor . . . 🙂

 

[deleted4401]

I would love that job.
-"Dr. No"

 

[medgator]

it's not drug costs

That's debatable. Wasn't it brought up at ASTRO a few years ago that all of the spending on red blood cell support factors like Procrit was equivalent to what was spent on radiation therapy that year?

Even more when you consider newer targeted therapies costing 4-5 figures a month that are taken for several months at a time yielding a few months of OS or PFS benefit.

 

[deleted4401]

And who orders the Procrit? Certainly isn't the drug-maker or the patient or the insurer. The amount of EPO that was being ordered in the late 90s (with no evidence) was incredible! And who had to have restrictions to indications for Procrit to bring down costs instead of making that decision without being coerced?

 

[seper]

PET for DCIS "staging" is a new low of overutilization.

 

[Palex80]

When doctors misbehave, they get pissed that the government wants to restrict them in any way. Think about it. For majority of breast - 0 scans. For majority of prostate - 0 scans. For lung - 1 at staging, and 0 after (based on NCCN, you can get one, but it's just prognostic - doesn't change outcome). For colorectal - 1 at diagnosis. For lymphomas, 1 before tx and 1 after. For head and neck, 1 before and 1 after. Same with cervical.

I see so many patients who have like 10 of them. People don't want to do physical exams, nor do they understand that finding something on PET doesn't change the outcome (read up on lag time bias!!!). Doctors are so blind to the fact that they are the leading driver of medical costs. It's not the insureres, its not litigation, it's not drug costs, it's not Obamacare. It's the doctor's pen. It's ordering Erbitux instead of cisplatin. It's treating a bone met to 40 Gy in 16 Fx. It's using CBCT for brain cases where you are just matching to bone anyway. It's doing excisional biopsies for breast abnormalities instead of core biopsies, thereby allowing for 2 billable surgeries. It's getting PSAs on 85 year old men and then referring them to urology and rad-onc. That's what's crushing the system.

Thanks. I have to give credit to the name of the thread to whom it's due - the legendary medical oncologist, Dr. Barry Lembersky, who quietly seethed and uttered harsh cursh words about PET scans back in 2007.

Best post in this thread. Thank you SimulD.

 

[Gfunk6]

Clarifications from CMS:

1. Pts have a lifetime limit of three PET/CTs per diagnosis.
2. For locally advanced cervical, breast, and melanoma malignancies you can get an initial staging PET/CT ONLY if you have clinical or laboratory data to support mets (e.g. bone pain, elevated LDH). You cannot order a PET/CT for advanced stage disease simply because there is a "high possibility of mets" without some objective evidence.

You may continue to order CT C/A/P w/ contrast after PET/CT limit is reached, though the reimbursement for this is less.