ST. LOUIS—As the 2014 Annual Meeting for the Society of Nuclear Medicine and Molecular Imaging (SNMMI) came to a close this year, Molecular Imaging sat down with Barry A. Siegel, MD, professor of radiology and medicine and chief of the nuclear medicine division at Washington University School of Medicine here in St. Louis. Siegel was honored this year with the most prestigious award presented during the meeting: the Benedict Cassen Prize.
The Cassen Prize is offered every other year by the Education and Research Foundation for Nuclear Medicine and Molecular Imaging (ERF) and winners of this award present the SNMMI Cassen lecture. All recipients of the Prize must be a living scientist or physician who has made considerable contributions to the science of nuclear medicine. The title of Siegel’s Cassen Lecture was "What Have We Learned from the National Oncologic PET Registry?"
In addition to this year’s Cassen Prize, Siegel also has received the 2013 Distinguished Clinician Award from Washington University School of Medicine, the 2008 Peter Valk Distinguished Clinical Scientist Award from the Academy of Molecular Imaging and the 2003 Georg Charles de Hevesy Nuclear Pioneer Award for Outstanding Contributions to Nuclear Medicine from the Society of Nuclear Medicine. Siegel worked for several years as associate editor for the Journal of Nuclear Medicine and served on the editorial boards of RSNA News and Clinical and Translational Imaging as well as the European Journal of Nuclear Medicine and Molecular Imaging.
MI: What made you decide to go into the field of nuclear medicine?
It was really serendipitous. I was a sophomore in medical school and we had electives at the end of the year and most of my class was going to go into a lab for six weeks to play with biochemistry and I said I wanted to do something more clinical. I had heard that there was a radiologist who took sophomore students for a short clinical elective and I went into his office with a classmate of mine. He said ‘you’re a half-hour too late, my elective if full,’ but then he said ‘why don’t you go see my new faculty friend, Jim Potchen, who is chief of nuclear medicine, he would love to have some medical students’ and then it all began. I did that elective and a research project that actually got published after just being there for six weeks and it was all really pretty impressive and I was hooked.
MI: Several luminaries in the field have worked under your leadership. What in your opinion makes the Mallinckrodt Institute of Radiology at Washington University a cut above the rest?
It’s been a very forward thinking radiology department at the cutting edge. Being very well capitalized and having good revenue in the golden age of radiology made it easier, but we had a department chairman from the early ‘70s who always wanted to be first on the block. We got maybe the second head CT scanner in the United States, the first full-body body CT scanner, we very early got MR, and the first PET was obviously developed at Washington University. Mike Ter-Pogossian and his colleagues built successive generations of scanners that we used at the university before we started using commercial scanners, and we had the first cyclotron in the United States for biomedical research purposes. It’s been a mix of good basic science and good clinical radiology and nuclear medicine people just trying to push the envelope forward. It made for a very exciting environment. Things have changed a bit. The cash flow isn’t what it used to be in all of radiology and it is harder to go into risky ventures and watch them grow. You can’t do the ‘build it and they will come’ approach anymore. You need better business plans.
MI: What is the next big project or area of research coming up in the future for you?
Currently one of the things that we are most excited about is working with our PET/MR scanner and seeing whether that has important clinical applications.
MI: What are the clinical applications that you are finding?
Well, I must say that I’m agnostic when it comes to PET/MR. It seems like imaging of tumors in the pelvis, imaging of cervical cancers and other GYN cancers and rectal cancers seem to be a real high point. Head and neck cancers seem to be another. In liver tumors where sometimes FDG leaves you a little up in the air, PET/MR really helps you characterize the lesion very well, and pediatric patients of course and young adults who might have many serial imaging studies, but everybody is saying this. The biggest issue is going to be demonstrating that the improved accuracy, ultimately leading to improved outcomes—which will be much harder to prove—is actually worth the difference in cost. For Medicare and Blue Cross to say, ‘we pay you $1,000 for a PET/CT scan and we recognize that PET/MR is better, but more expensive, so we will pay you $3,000 for a PET/MR scan,’ we are a long way before we’ll get anyone to do that and that is a problem.
MI: I have heard different answers to question about whether clinicians can bill separately for PET/MR. Is that true?
The Society of Nuclear Medicine and Molecular Imaging’s guidance says that if you use PET/MR you can use the PET codes to bill for the PET. That is the opinion of both SNMMI and the American College of Radiology. If there is a dedicated body part standard of care, medically necessary request to do a pelvic MR, you bill for that MR code, as well. If you are using the MR for attenuation correction, localization and minimum disease characterization and you decide you are going to start billing for a neck, chest, abdomen and pelvis MR with four separate CPT codes, that is going to be a red flag. It will appear to be billing abuse and I don’t think anybody would accept that the standard two sequences that people get when they just do attenuation correction constitutes a standard of care MRI examination. There are two reasons not to do it. It’s not standard of care and secondly it will almost certainly appear to be up-coding in an effort to milk the system and the insurance companies are going to see the flag and come after it. We have the added problem that some insurance companies are saying that PET/MR is investigational. The FDA didn’t think it was investigational. The insurer’s reason was that PET/MR does not do an adequate job of attenuation correction in bone and therefore it doesn’t work. That was an excuse not to pay.
MI: What were some highlights from your Cassen Lecture this year? What can we take away from the recently released findings of the National Oncologic PET Registry?
The most important thing is to work with third party payers to help them with the kind of information they want rather than jumping up and down and saying, ‘please pay us because we think we deserve it.’ Getting the evidence, of whatever quality you are able to achieve, is a reasonable and important goal. For me cooperation is the most important thing that came out of the NOPR experience. On the other hand, I’ve also learned that what we were able to do at the beginning of coverage with evidence development will no longer fly. Medicare has raised the bar appropriately—I don’t disagree with them, and future coverage with evidence development—trials, registries, cohort studies—whatever you call them, are going to need more accurate and higher quality data and have longer term outcome assessment for patients. Unfortunately that is going to make those trials more expensive and they won’t be able to do what we did. In other words, they won’t be self-funded. Trying to make sure that the amyloid imaging community understands that this is where their coverage with evidence development is going to go presents some communication challenges. It’s not an impossible challenge, but the paradigm shift just needs to be explained.
MI: What is on the horizon for the PET Registry? I know that sodium fluoride bone imaging or NaF NOPR is still in action, but how will the Registry be leveraged for this application?
Really, the only thing that the current national coverage determination allows us to do is sodium fluoride PET and PET/CT for bone metastasis. We actually have broached, in our reconsideration request letter, the concept that sodium fluoride PET for benign bone disease should be considered because frankly it’s just a much better bone scan. There are certain parts of the body that you literally cannot do well with SPECT images: the skull, the skull base, the cervical spine—because the shoulders are in the way and your camera is “miles” away from what you are trying to image, whereas PET, because its resolution is actually best right smack in the center of the field with the big ring and detector far away, is perfect for those parts of the body. There is really good detail for things like the lumbar spine, as well, and so we encourage CMS to at least consider that. We know that the literature is thin and we are hoping that stuff will come in during the comment period that might address it. If you asked me whether I know how to design a registry to go after 35 different benign bone diseases, that would lead to a ‘run don’t walk to the nearest exit response.’ [laughs]