K:\07 Health Support Ser\Specialist & Screening\NMCNs & NMDNs\Commissioning\MDICN\PET \Mins Author: Miss Miriam Remally

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1 National Services Division Minutes Area 062 Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone Fax Subject: PET Working Group Date of Meeting: 19 September 2014 File ref: K:\07 Health Support Ser\Specialist & Screening\NMCNs & NMDNs\Commissioning\MDICN\PET \Mins Author: Miss Miriam Remally Attendees Mrs Deirdre Evans, Director, National Services Division, NSS (Chair) Prof. Mateo Zanda, Dept. of Biomedical Physics & Bioengineering, Aberdeen Prof. Peter Sharp, Dept. of Biomedical Physics & Bioengineering, Aberdeen (outgoing Chair) Dr Annemarie Sinclair, Lead Clinician, Scottish Clinical Imaging Network (SCIN) and Clinical Director, Diagnostics Directorate, NHS Greater Glasgow and Clyde Dr Fergus McKiddie, (VC) PET Physicist, Nuclear Medicine Department, NHS Grampian Mr Graham Dunn, Financial Controller, Scottish Government Health & Social Care Directorates Dr Glen Gardiner, PET Physicist, NHS Tayside Mr Steven Evans, Radiology Manager, NHS Lothian Dr Alison Fletcher PET Physicist, NHS Lothian Dr Alan Denison (VC) Honorary Consultant Radiologist, Clinical Lead, Nuclear Medicine/PET, NHS Grampian Dr Dilip Patel, Consultant Radiologist, NHS Lothian Ms Aileen MacLennan, Director of Diagnostics Directorate, NHS Greater Glasgow and Clyde Secretariat Mrs Alexandra Speirs, Network Manager, National Clinical Imaging Network, NSD Miss Miriam Remally, Programme Support Officer, NSD Apologies Dr Jean Wright, Assistant General Manager for Diagnostic Imaging, NHS GG&C Ms Liz Porterfield, Head, Strategic Planning/Clinical Priorities Team, SGHSCD Dr Sai Han, Consultant Radiologist NHS GG&C Dr Gerry Gillen, NHS Grampian Dr Rodger Staff, NHS Grampian Dr Rachael Joyce, NHS Grampian 1. Welcome & Introduction Mrs Evans welcomed everyone to the meeting and set the context. Responsibility for oversight of PET-CT scanning in NHS Scotland had been transferred from the Scottish Government to the Scottish Clinical Imaging Network (SCIN), supported by the National Network Management Service (NNMS) in National Services Division (NSD). This meeting was the first of the re-formed PET Working Group which had not met since

2 Professor Sharp explained that the PET-CT Working Group had been established to: Develop protocols to inform clinical decision making on the use of PET-CT Publish and monitor information on adherence to PET-CT protocols in Scotland Examine the evidence for the use of PET-CT in new indications Audit the provision of PET-CT in Scotland. It was agreed that this remit remained appropriate. 2. Round table update NHS Grampian had 1 PET-CT scanner that was to be replaced in 2 weeks time, this could involve up to 12 weeks of down time. NHS Tayside had agreed to provide scanning in Dundee to maintain patient care through the period of equipment replacement. Dr Gardiner asked for clarification from NHS Grampian on the number of patients likely to be referred. Dr McKiddie agreed to provide numbers. NHS Grampian planned to restrict the period without a PET-CT service to approximately 10 days, which was similar to the routine Christmas downtime period. The new scanner was due to be operational the last week in December Dr Denison and Dr McKiddie expressed their gratitude to NSS Health Facilities Scotland colleagues for assisting in the procurement of the new machine in NHS Grampian. Dr Denison would communicate with cancer networks to see where there was a risk of waiting time breaches so that he could carefully manage expectations and inform Dr Gardiner. The department had been working with MDT colleagues to change referral patterns and ensure MDT decisions happened when required. NHS Grampian was self-sufficient in tracer production. Professor Zander informed the group that the Aberdeen University would be replacing their cyclotron in October NHS GG&C had 2 PET-CT scanners which were 7 years old; NHS GGC also produced their own tracers. NHS Lothian had 1 PET CT scanner. The scanner is owned by NHS Lothian. The University of Edinburgh contribute to 30% of the revenue costs, which enables them to have 30% of the available scan time. There was a joint University and NHS research programme and inhouse production of FGD, and non FDG isotopes. Dr Patel informed the group that one scanner was sufficient for NHS Lothian s requirements, but NHS Lothian would want to replace their existing scanner in the next four years. NHS Tayside: had 1 PET-CT scanner which was jointly owned by the health board and the University. NHS Tayside did not produce its own tracers; the tracers that used were bought privately. Scottish Government: Mr Graham Dunn explained that the financial arrangements for PET CT scanning across Scotland involved SGHSCD top slicing funds from all NHS Boards with contributions based on the NRAC formula. This money was held centrally by SGHSCD. At the end of the financial year an adjustment was made to the financial allocations of the 4 Boards providing PET-CT based on forecast activity outturn. The total spend in 2013/14 allocated to PET CT was 6.5million nationally. 2

3 Scottish Clinical Imaging Network (SCIN): Dr Anne Marie Sinclair reported that the last meeting of the SCIN steering group took place at the end of August. The network had agreed its work plan for 2014/15 and as part of network being refreshed and reinvigorated, agreed to a change of name from the Managed Diagnostic Imaging Clinical Network (MDICN) to the Scottish Clinical Imaging Network (SCIN). Discussion The following points were made in discussion: Mrs McLelland asked if national funding would be provided for replacement cyclotrons when they came to the end of their working life. Mr Graham Dunn said he would talk to his Scottish Government Colleagues to find out the answer. Action: Mr Graham Dunn Dr Sinclair asked whether any non-fgd tracers were used in Scotland. Professor Zanda and Professor Sharp confirmed that Aberdeen was using these in funded clinical trials. Members commented that carbon 11 demand for prostate was rising. Professor Zanda suggested that Erigal Ltd could supply tracers. Edinburgh produced F18 fluoride in house. Mrs Evans clarified that national procurement was used for replacing PET machines in Scotland. Professor Sharp advised that some centres have shared machines with university (NHSL and NHSG), shared according to research time. Where boards had ownership it was appropriate to procure nationally. 3. Review of previous minutes / matters arising Paper 1 Minutes of meeting held on 16 th Aug 2012 Paper 2 Minutes of meeting held on Nov 2012 Both sets of minutes were approved as accurate records. Dr Patel reported on progress in relation to PET-CT scanning for epilepsy in adults and children. He advised that work stalled because of a neurosurgery vacancy but was planned to start again. Mrs Evans commented that paediatric epilepsy surgery was a designated national specialist service and that paediatric patients were referred to London for scans. Numbers were very low and, the Group considered there were not enough referrals in Scotland to justify setting up a specialist service. Dr Gardiner advised that in NHS Tayside, two scans had been carried out and the images were interpreted and read in London by NHS file transfer. 4. How are PET protocols applied? What conditions warrant the use of PET/ CT? Paper 5: PET statement of best practice and clinical protocols-letter. Paper 6: PET statement of best practice and current protocols V1 Professor Sharp commented that PET-CT was regarded as an integrated multi-site service for Scotland and a range of 6 protocols had been developed to ensure consistency and effective use. The existing protocols covered cancers in which there was evidence of effectiveness, and it was accepted when the protocols were set up that there would always be some additional other categories in which PET-CT scanning might be used. Paper 5 was 3

4 a response to concern for creeping developments which needed protocols. The recent audit had reported that half of referrals did not meet protocols. Professor Sharp commented that there was a need for a protocol or guidance on melanoma. Dr Patel considered that the guidelines did not factor in the number of cancer patients needing repeat scans. PET-CT services receive multiple referrals for the same patient e.g. lung cancer. Patients with recurrence needed several scans. He advised that a revision of protocols in Scotland should take into account the Royal College of Pathology (RCPath) specifications which were used widely in England. There were currently six cancers covered by Scottish protocols, but the RCPath guidance included over twenty indicators for PET-CT. There was a general discussion around gate keeping access to PET-CT scanning. Dr Denison commented that there was a daily onslaught of referrals and, in the absence of protocols in many critical areas, it takes energy to agree the need (or otherwise) for PET-CT with referring clinicians. Mrs McLelland commented that PET-CT does not come under access targets. In NHS GGC, it took ten days for the patient to be scanned and reported. Transparency was needed on the volumes of scanning in cancer patients by tumour site and what other indicators were receiving PET-CT. In discussion it was agreed that robust data collection on current activity was required in order to inform future protocols. A key role of the Group was to develop and maintain guidelines / protocols for Scotland; and to monitor whether protocols were consistently applied in Scotland. Professor Sharp highlighted that in 2013/14, 11/12% of PET-CT activity was in the others category. The group looked at the summary activity spreadsheet showing returns from health boards. It was agreed that information needed to be captured on all of the indications recommended by the RCPath rather than on just the 6 cancers covered by the Scottish protocols. It was agreed that the spreadsheet should be extended to include the 20+ indications; and recirculated for centres to complete in future months. Action: NSD to check excel spreadsheet and extend it to capture information on all PET indications in the RCPath guidance. 5. Draft Sarcoma PET/CT protocols Paper 7: PET Sarcoma protocols 5 th Draft 19 th February 2014 Members discussed the draft sarcoma protocol and Mrs McLelland advised that, before recommending any extension in the range of conditions for which PET-CT was provided in Scotland, the group must ensure there was enough capacity to take this on. The cost was increasing every year. If capacity was at a maximum, more could not be taken on. Mrs McLelland advised that the group needed accurate information on current capacity before the Group recommended an extension to the list of indications for PET-CT. Mrs Evans commented that the recent audit suggested that only half of the current PET-CT scans undertaken in Scotland fitted with protocols on effective use, and only 24% resulted in a change in clinical management. This implied that there was considerable room for improving effectiveness by targeting PET-CT scans on proven effective indications. A reduction in scanning in areas which had no impact on clinical decisions could release capacity for new proven effective indications. The sarcoma workload was reported in the draft protocol to be small and there appeared to be evidence of effectiveness. 4

5 Professor Sharp commented that an accurate picture of current activity could not be shown until there was a breakdown in the indications scanned in the others category. It could be that the sarcoma workload was already being scanned but classed and reported as other. Dr Patel advised that he was in the process of doing an audit classifying scans recorded as others. Discussion reinforced the earlier agreement that the group needed information on what was currently included in returns under the other heading. The Group noted that the draft sarcoma protocol was incomplete and that the section on paediatric sarcoma was missing. It was agreed that NSD should ask the author to complete and resubmit the draft. The group agreed that they were happy to keep sarcoma on the agenda. Dr Patel advised that he was happy to share clinical study results. Action: Mrs Speirs 6. F18 Choline PET for prostate cancer melanoma Paper 8: Current status of choline-pet and prostate cancer (Trends in Urology and Men s Health, May/June 2014). Paper 9: Evidenced Based Indications for the use of PET-CT in the UK 2013 Dr Sinclair commented that prostate cancer affected a significant part of the male population in Scotland. Dr Patel advised that there were potential benefits in using F18 choline PET-CT scanning in prostate cancer. Due to the fact that this group had not met for 2 years and had not been available to discuss nationally the use of F18 Choline in prostate cancer, NHS Lothian had submitted a business case to get this locally funded. Dr Patel informed everyone that the indications for a patient to receive a scan in the local proposal were constrained within tight criteria. A discussion followed regarding the implications of providing this service this in one part of Scotland as opposed nationally, and the group recognised the importance of equity of access for all patients. In view of the work that NHS Lothian had undertaken and the fact that NHS Lothian planned to produce F18 which they could supply to other Scottish centres, the group agreed that NHS Lothian should carry forward an F-18 choline pilot. It successful, this could be rolled out to other centres. Action: NHS Lothian agreed that they would explore developing a national protocol and feed back their findings and results to the group [Post meeting note: Since this discussion NHS Scotland has learnt that Professor Leung (NHS GG&C) is currently working with a nuclear physicist to set this up in Glasgow. The scan will be used for two patient cohorts (1) high risk prostate cancer before they undergo radical surgery, (2) selected patients for salvage cryotherapy.] 5

6 7. PET- CT for paraneoplastic neurological syndrome and for pyrexia of unknown origin (head and neck)? Dr Denison sought guidance from the working group on the use of PET-CT for head and neck paraneoplastic syndrome. Head and neck cancer specialists had been pressing for patients to receive PET-CT scans as routine follow up for head and neck cancers, although this was not an indication approved in the PET-CT guidelines. In the absence of the PET-CT Working Group meeting, Dr Denison and his head and neck colleagues had decided to seek advice from the Scottish Health Technology Group. Dr Sinclair advised the group that she is a member of the national group that decides on Key Performance Indicators in head and neck cancers because this was her personal specialism. She informed the group that follow up of head and neck cancers should be undertaken with a CT scan, and PET-CT scanning is not appropriate. This advice was echoed by Dr Patel. The working group agreed that its formal guidance is that CT scanning, rather than PET-CT scanning, was good practice in the follow up of head and neck cancers. Action: Dr Dennison will contact The Scottish Health and Technology group and inform them not to follow up his referral. 8. PET Audit Paper 10: PET/CT Audit Summary of Findings presented to the DSG (3 rd April 2014) Paper 11: DSG (14)12 PET CT Audit Executive Summary Paper 12: The West of Scotland Cancer Surveillance Unit: National Audit Report on the use of PET/CT scanners in Scotland, May The group agreed that the data that had been collected was interesting but had limited validity due to the methods used in the audit. The group considered that it was important to monitor clinical efficacy of PET-CT scanning, and agreed to undertake further work to decide on appropriate key performance indicators for prospective data collection to inform future audit. Dr Sinclair commented that it was important to have discussion with board management regarding any decisions to changes in PET-CT scanning. Action: To place performance indicators on future agendas. Action: SCIN will hold a PET CT Audit workshop which will assist this group to decide on KPIs and data collection. 9. PET CT health board returns Paper 14: Excel spread sheet PET /CT Health Board returns Mrs Evans led a discussion on the health board returns spreadsheet for 2013/14. She informed the group that there was some missing data in 2013/14. The group agreed that all the data that was provided by Health Boards needed to be submitted in the same format to support comparative analysis. Future returns would increase the range of what was collected as reported above. Action Mrs Speirs 6

7 10. AOB Professor Sharp announced his retirement from the group. Everyone thanked him for the work that he had done for the Scotland wide PET service. A discussion ensued regarding who would be best placed to carry on chairing this group and it was agreed that Mrs Evans should chair this group. 11. Date of next meeting The group agreed that it would be useful to meet every four months and a date in January will be circulated. 7