Building Awareness: Spreading the Word on Molecular Imaging
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Outside the molecular imaging community, awareness and understanding of what molecular imaging offers is not as clear cut as one might think for a wide cross-section of specialists, such as neurosurgeons, cardiologists and even oncologists, as well as for patients. An SNM (Society of Nuclear Medicine) survey of approximately 9,500 referring physicians conducted in June 2008 revealed that the most important factors influencing PET/CT referrals were the quality of PET/CT imaging and that the reports answered the clinical questions physicians were seeking. The most important factor impeding referrals was the lack of or incomplete insurance coverage; the second most importance impeding factor was that clinical indications of PET/CT were unclear.
The onus is now on molecular imaging specialists to build the awareness of molecular imaging’s proven efficacy for referring physicians so that they refer the right patient for the right molecular imaging exam and to simply build awareness of how molecular imaging can enable more personalized medicine and treatment for patients. The right treatment starts with ordering the right exam. But how does the molecular imaging community educate the specialist and referring physician community?
Bridging the gap between science and practice
To build awareness, it might not be a question of the value of molecular imaging, but perhaps a question of how best to incorporate it into daily practice, especially when facing a restrictive economic and reimbursement climate, says Homer Macapinlac, MD, professor and chair of the department of nuclear medicine at the University of Texas M.D. Anderson Center in Houston.
“I think the referring physicians in the rest of the community, although aware of the benefit of PET/CT or molecular imaging, are not quite sure sometimes of how to use it in daily practice,” he says. Part of the uncertainty, at least in relation to cancer, is due in part perhaps to the lack of incorporation of the use of PET/CT clearly in the guidelines provided by the National Comprehensive Cancer Network (NCCN). Macapinlac says that it is incorporated in some, but not all of the guidelines, and speculates that this is due to the lack of outcomes benefits for molecular imaging in some areas of oncology.
“So there is this lack of data in some cancers, or perhaps even the lack of perception of the benefit provided by PET/CT in terms of outcomes,” he adds. However, with the release of data from the National Oncology PET Registry (NOPR), the role of molecular imaging, specifically PET, in relation to health outcomes has shown that the information obtained from a PET scan changed the treatment plans for cancer patients, such as changing chemotherapy agents, modes of treatment, or the current dose or duration of therapy.
Regulatory and economic hurdles
Spreading the word is challenging, in light of today’s tough economic climate and reimbursement environment. The Centers for Medicare & Medicaid Services (CMS) is currently seeking comments on its proposed decision memo on NOPR issued in January, which removes a significant part of the coverage with evidence development (CED) requirement for PET scans in cancer, designating one PET scan to guide the initial treatment strategy, but limiting the CED for subsequent treatment strategies.
“Speculation, being the way it is, makes us fear that there will be further restrictions on utilization due to the economic realities surrounding us at the moment,” says Robert Atcher, PhD, president of SNM. “The NOPR data need to be further reviewed to see the outcome of the effect of PET imaging on these various types of tumors because if the data prove that the modality is worthwhile, it could further enhance our position of using the imaging modality in terms of assessing the status of these patients.”
Atcher says that clarity will be helpful in terms for CMS in issuing its guidance, as well as a unified voice of guidance to referring physicians and, more importantly, to interpreting physicians for future utilization.
Meanwhile, some call for more studies like NOPR, as well as multi-center studies with well-defined inclusion criteria, to help spread the word about molecular imaging and potentially, move the specialty beyond its restrictive reimbursement binds.
“Frankly, in the current [poor] economic climate, any test you do costs money,” says Heiko Schoder, MD, director of PET imaging at Memorial Sloan-Kettering Cancer Center. “To demonstrate the benefits of molecular imaging convincingly, we will need to document exactly how and when molecular imaging can influence patient management, and how it can be deployed in a cost-effective manner.”
Education is key
The ability to determine the outcomes from cost-effective imaging that will allow better treatment is crucial, and the education of referring physicians and patients is fundamental in the dissemination of molecular imaging modalities across these patient types.
Clearly, education is the key. Macapinlac suggests educating referring physicians on the NCCN guidelines to keep them informed on appropriate usage. While the imaging world “gets it” about molecular imaging, other specialties and patients do not know in which patient and which stage of the disease it should be employed.
However, Schoder says it’s important to not overstate the case for molecular imaging. “We need to be clear regarding when molecular imaging is not able to provide all the answers. Otherwise, expectations among patients and physicians will be sky-high, and a single false-positive or false-negative molecular test will disappoint them to such a degree that they may stop ordering tests altogether,” he notes.
As the population ages, and as healthcare continues to overcome some of the obstacles of cardiovascular disease as well as cancer, one needs to keep in mind the degenerative diseases or neurological disorders that become more prevalent.
“Within the advances in the study of the dementias and hopefully the onset of very effective therapy, one looks forward to utilizing the developing molecular imaging techniques for assessment because it may provide us with the method of not only identifying patients susceptible to these disorders, but also may provide a method of evaluating response to the therapies,” Macapinlac says.
“We need to educate referring physicians on the power of molecular imaging to provide physiological information; educate patients on how molecular imaging can change their treatment; and educate payors and regulators on the economic viability and health outcome benefits of molecular imaging,” Atcher says.
Furthermore, molecular imaging specialists need to provide uniformity in terms of providing a clinically relevant report, to allow comparability and better utilization by answering the clinically relevant questions in a structured and more standardized way.
Atcher says that the real challenge lies in making a compelling case for the appropriate expansion of molecular imaging utilization and effectively showing its advantages for personalized medicine. “We’ve got to make a case now for the molecular imaging studies that we perform so that those in regulatory and reimbursement [leadership] roles understand the economic and health outcome benefits so they don’t get shoved aside in the search for cost savings in healthcare,” he concludes.