NOPR Revisited
Several years ago a group of U.S. physicians headed by Drs. Siegel, Coleman, Hillner, Shields and others designed a National PET Registry called NOPR (National Oncology PET Registry). This registry was sponsored by the Academy of Molecular Imaging (AMI) and the American College of Radiology (ACR) and was later also supported by other professional organizations such as the Society of Nuclear Medicine (SNM) and Radiological Society of North America (RSNA).
The design and subsequent implementation of NOPR followed a novel concept (“coverage with evidence development”) that mandates the development of evidence prior to CMS (Centers for Medicare & Medicaid Services) reimbursement for services.
In 2005, CMS indicated its intent to establish coverage of PET for all non-covered PET indications in oncology if the provider is participating and the patient is enrolled in one of certain prospective clinical studies (“coverage with evidence development”) such as for instance a prospective registry.
The goal of NOPR was to determine the impact of FDG PET/(CT) imaging on managing those patients whose cancers were not covered by CMS reimbursement.
More than 1,000 academic and private nuclear medicine and radiology facilities participated in the registry. The design was simple and straight forward. Participating sites and referring physicians needed to complete pre-and post PET/(CT) imaging questionnaires specifying the indication for the study and, on the post PET questionnaire, the impact of PET findings on intended patient management.
Several recent publications have summarized the data from the registry. First, the impact of PET on managing cancer patients is similar across all indications and exceeds 30 percent in most. Second, a change in management from treatment to no treatment occurs much more frequently after PET than a switch from no treatment to treatment.
The most recent paper, published in Cancer in January 2009, reports the NOPR results on the impact of PET on intended management when PET is used for treatment monitoring for all cancer types excluding breast cancer (for which treatment monitoring had already been approved for CMS reimbursement).
The primary endpoint of the study was the assessment of PET-based modification of the treatment plan. Close to 10,000 PET scan data sets were analyzed for this study. PET was most frequently used for monitoring the effects of chemotherapy. The most frequent indications included ovarian, lung, prostate, bladder, stomach and colorectal cancer and myeloma. Based on the PET findings, a switch in treatment modality or a modification of the approach was intended in close to 40 percent of the patients. Again, these findings were fairly consistent across all cancer types.
Based on the overall findings, CMS is currently considering a substantial expansion of coverage for PET in cancer. Broad coverage has yet to be achieved. However, the progress has been remarkable thanks to the NOPR visionaries and the organizations that supported their efforts.
More work remains to be done to further broaden the coverage for PET imaging in cancer.
Johannes Czernin, MD
Professor, Molecular & Medical Pharmacology
Director, Nuclear Medicine Clinic, Positron Emission Tomography/Computed Tomography
David Geffen School of Medicine at UCLA, Los Angeles, Calif.
The design and subsequent implementation of NOPR followed a novel concept (“coverage with evidence development”) that mandates the development of evidence prior to CMS (Centers for Medicare & Medicaid Services) reimbursement for services.
In 2005, CMS indicated its intent to establish coverage of PET for all non-covered PET indications in oncology if the provider is participating and the patient is enrolled in one of certain prospective clinical studies (“coverage with evidence development”) such as for instance a prospective registry.
The goal of NOPR was to determine the impact of FDG PET/(CT) imaging on managing those patients whose cancers were not covered by CMS reimbursement.
More than 1,000 academic and private nuclear medicine and radiology facilities participated in the registry. The design was simple and straight forward. Participating sites and referring physicians needed to complete pre-and post PET/(CT) imaging questionnaires specifying the indication for the study and, on the post PET questionnaire, the impact of PET findings on intended patient management.
Several recent publications have summarized the data from the registry. First, the impact of PET on managing cancer patients is similar across all indications and exceeds 30 percent in most. Second, a change in management from treatment to no treatment occurs much more frequently after PET than a switch from no treatment to treatment.
The most recent paper, published in Cancer in January 2009, reports the NOPR results on the impact of PET on intended management when PET is used for treatment monitoring for all cancer types excluding breast cancer (for which treatment monitoring had already been approved for CMS reimbursement).
The primary endpoint of the study was the assessment of PET-based modification of the treatment plan. Close to 10,000 PET scan data sets were analyzed for this study. PET was most frequently used for monitoring the effects of chemotherapy. The most frequent indications included ovarian, lung, prostate, bladder, stomach and colorectal cancer and myeloma. Based on the PET findings, a switch in treatment modality or a modification of the approach was intended in close to 40 percent of the patients. Again, these findings were fairly consistent across all cancer types.
Based on the overall findings, CMS is currently considering a substantial expansion of coverage for PET in cancer. Broad coverage has yet to be achieved. However, the progress has been remarkable thanks to the NOPR visionaries and the organizations that supported their efforts.
More work remains to be done to further broaden the coverage for PET imaging in cancer.
Johannes Czernin, MD
Professor, Molecular & Medical Pharmacology
Director, Nuclear Medicine Clinic, Positron Emission Tomography/Computed Tomography
David Geffen School of Medicine at UCLA, Los Angeles, Calif.