PET/CT Value: Rocky Mountain Cancer Centers

Transcription

1 PET/CT Value: Rocky Mountain Cancer Centers Glenn Balasky Executive Director Rocky Mountain Cancer Centers CANM/CAMRT Joint Conference March 22, 2018 Vancouver, British Columbia

2 Disclaimers I do NOT have a financial interest, arrangement, or affiliation with any commercial organization that may have a direct or indirect interest in the subject matter of my presentation. I had nothing to do with the outcome of the final Women s hockey game in the recent Winter Olympics

3 Goals of Presentation Share the Rocky Mountain Cancer Center overview of how we provide PET/CT and related diagnostic imaging services to cancer patients Describe Clinical Utility and Perspective of U.S. based physicians towards imaging in Oncology Share some of the challenges and benefits of PET/CT imaging for oncology the United States Time for questions and answers

4 Leading the Way in Cancer Care 17 Locations across the Front Range RMCC sees nearly 10,000 new cancer patients per year or over half of the patients in Colorado In 2015, completed over 160,000 patient visits

5 Full Spectrum of Cancer Care Services Medical Oncology Radiation Oncology Gynecologic Oncology NET Center of Excellence Cancer Surgery Chemotherapy Diagnostic Imaging Laboratory Services Genetic Counseling Supportive Care

6 Cancer Care Continuum

7 RMCC Expertise 54 Physicians and 29 Advance Practice Providers Integrative Approach to Cancer Care Delivery Delivery of leading Edge Clinical Trials Long term use of Oncology Specific EHR Evidence Based Guidelines/Pathways Progressive relationships with Payers Partnership oriented approach with All Hospital Systems and other Partners Progressive management through USOncology relationship

8 Oncology PET Imaging Milestones 1998 CMS coverage of FDG PET for 5 indications 2002 Breast ca covered 2003 PET married CT 2006 National Oncologic PET Registry (Greatly expanded reimbursable indications for PET) 2009 NOPR for NaF bone scans May 2016 FDA approval of Axumin for prostate cancer June 2016 FDA approval of Ga 68 Dotatate for NETs (Octreoscan 1994) 8

9 Goal of Imaging in Oncology To find functional and anatomic disease and therefore define the nature and extent of disease to appropriately stage patients for appropriate treatment: IV Chemotherapy Radiation Oral Chemotherapy Surgery Palliative care Monitor the effectiveness of treatment Surveillance to monitor for cancer reoccurrence 9

10 RMCC Diagnostic Imaging Mobile 6 locations Fixed PET/CT and 4 locations Fixed 3 locations RT 5 locations CT since 1998 PET since 2000 PET/CT

11 PET =18FluoroDeoxyGlucose F18 Cyclotron produced T1/2 of 110 minutes Method of action - Glucose uptake in malignant tumors due to their increased metabolism

12 FDG PET/CT

13 18FDG PET Initial Staging / 4 months into treatment 4 months later

14 PET = 68Ga DOTATATE (NETSPOT) Ga68 generator produced T1/2 of 68 minutes Method of action - NETSPOT is a somatostatin analog that is attracted to Somatostatin receptors over-expressed in neuroendocrine tumors (NETs)

15 Title 15

16 Octreoscan Poor Image Quality Ga68 Dotatate Higher Image Quality 16

17 Coming Soon Arrived in February 18F Axumin Axumin (fluciclovine F 18) Injection Indication 1 Axumin (fluciclovine F 18) injection is indicated for positron emission tomography (PET) imaging in men with suspected prostate cancer recurrence based on elevated blood prostate specific antigen (PSA) levels following prior treatment. Patient is injected and scan is started immediately completing the test in ~45 minutes. 17

18 RMCC Radiotherapies 18 Y90 Zevalin (beta) for NHL as an option to Rituxan 1 dose is administered Very specific criteria Ra223 Xofigo (alpha) for Bone metastasis in prostate cancer 6 doses administered, 1 every 4 weeks Lu177 Lutathera (PRRT) (Beta) for NETS Recently Approved FDA Expanded Access Program RMCC selected to enroll 10+ patients 4 doses administered, 1 every 8 weeks Requires coordinating with infusion team for amino acid infusion to protect kidneys from high radiation dose

19 RMCC History and Metrics Rocky Mountain Cancer Centers Imaging Volume (Projected) PET/CT CT

20 Imaging Volume Notes RMCC treats almost 10,000 new cancer patients per year RMCC follows about 30,000 existing cancer patients and survivors per year Providing ~ 2 scans for every new cancer patient or.25 scans per total number of cancer patients Growth in utilization increases with more new cancer patients, improved cancer survivorship, and new isotopes (Gallium and Auxim)

21 Goal of Imaging in Oncology To find functional and anatomic disease and therefore define the nature and extent of disease to appropriately stage patients for appropriate treatment: IV Chemotherapy Radiation Oral Chemotherapy Surgery Palliative care Monitor the effectiveness of treatment Surveillance to monitor for cancer reoccurrence 21

22 Challenges in the U.S. System Medicare (>65 years old) limit of 3 PET/CT scans per patient for a unique diagnosis Private payers have created burdensome authorization systems to garner approval for CT and PET/CT scans Physicians subject to Peer to Peer reviews with private payer medical directors but in the end >99% of physician requests are approved Some private payers are slow to approve newer imaging modalities Firm diagnostic imaging guidelines for cancer patients are not in place in the U.S. No Certificate of Need requirements in most states in the U.S. so hospitals and other medical practices can implement PET/CT services Image access to other providers is improving with image sharing tools that can provide access in a complicated environment with multiple PACs systems

23 Benefits of Oncology Imaging Specificity of new agents like Auxim and Gallium provide better quality diagnosis for Prostate Cancer and Neuroendicrine Tumors High cost medications (~$10,000 per month) support the use of advanced imaging to assure effectiveness of treatment and curtail use of ineffective treatments Patients and physicians alike have strong desire for measurable status of disease and/or treatment effectiveness is high For a private payer, the cost of PET/CT in a medical practice is about 1/3 the cost in a hospital ($1800 versus $5000 or more) RMCC participates in several value based programs with the payers were we have incentives to keep the total cost of cancer care down when and where possible Convenient access to imaging encourages long-term surveillance

24 It Takes a Team 24

25 Questions and Answers with Audience

26 Thank You! Glenn Balasky Executive Director 26