© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Breast Cancer Management PET...

Marketing PET’s Role in Marketing PET’s Role in Breast Cancer Management Breast Cancer Management

PET Marketing Forum – Accelerating Practice Growth

September 27, 2006Dr. Patrick Peller

Welcome!

Brought To You By Brought To You By Cardinal HealthCardinal Health

• Part of PET FoundationsSM > comprehensive marketing and education program

• Fourth of a 6-part Series

• Recorded presentation and PowerPoint available on www.PETFoundations.com > Market Your PET Center > Marketing Forum page

• Exclusive benefit to Cardinal Health PET customers

Dr. Patrick J. PellerDr. Patrick J. Peller

• Over 15 years of PET experience

• Read over 15,000 clinical PET scans

• MRP team member

3 marketing reps, 15+ staff

• MRP Volume > 500 PET/CTs per month

What Does a ReferringWhat Does a ReferringPhysician Want?Physician Want?

• Quality PET/CT imaging

• PET/CT the easy way Easy to order, promptly reported, has easy to understand

results and provides a specific answer

• Reliable and expert source of answers on PET/CT-- Your team

Targeted SpecialistsTargeted Specialists““The Select Seven”The Select Seven”

Medical

Medical Oncologists

Pulmonologists

Gastroenterologists

Surgical

Oncologic Surgeons

Thoracic Surgeons

Colorectal Surgeons

Radiation Oncologists

• PET/CT the easy way

• Reliable and expert source of answers on PET/CT

• Understand clinical uses for PET/CT in Lung Cancer

• Understand where PET/CT is reimbursed in Lung Cancer

Estimated US Cancer CasesEstimated US Cancer Cases

Source: American Cancer Society, 2006.

Men710,400

Women662,870

32% Breast

12% Lung and bronchus

11% Colon and rectum

6% Uterine corpus

4% Non-Hodgkin lymphoma

4% Melanoma Skin

3% Ovary

3% Thyroid

2% Urinary bladder

2% Pancreas

21% All other sites

Prostate 33%

Lung and bronchus 13%

Colon and rectum 10%

Urinary bladder 7%

Melanoma Skin 5%

Non-Hodgkin 4% Lymphoma

Kidney 3%

Leukemia 3%

Oral Cavity 3%

Pancreas 2%

All other sites 17%

• Understand clinical uses for PET/CT in Breast Cancer

• Understand where PET/CT is reimbursed in Breast Cancer

Breast CancerBreast Cancerversus Lung Cancerversus Lung Cancer

• Variable and increased FDG in breast tissue

FDG PET in Breast CancerFDG PET in Breast Cancer Normal BreastsNormal Breasts

Premenopausal Postmenopausal

Menopausal HRTPostpartum

• Lower FDG avidity in breast cancers

FDG PET in Breast Cancer FDG PET in Breast Cancer Primary CancersPrimary Cancers

• Lower FDG avidity in breast cancers

• Late and limited Medicare approval

• Frequently contested PET reimbursement

• Far fewer peer reviewed articles <100 (versus >2000 in lung cancer)

Breast Cancer and PETBreast Cancer and PET Clinical RolesClinical Roles

• Breast cancer diagnosis

• Breast cancer staging

• Breast cancer restaging

Diagnosing Breast CancerDiagnosing Breast Cancer

History • 50 YOF• Palpable (barely) mass in left

breast; doctor not concerned• Dense breasts, mammogram

normal

PET Findings• Hyper-metabolic breast focus

in left breast

Outcome • Surgical resection• Stage I breast cancer

PET in the PET in the Diagnosis of Breast CancerDiagnosis of Breast Cancer

Primary size Sensitivity

<0.5cm 25%

>0.5cm-1.0cm 25%

>1.0cm-2.0cm 84%

>2.0cm-3.0cm 94%

>3.0cm-4.0cm 87%

>4.0cm-5.0cm 93%

>5.0cm 100%Avril N J Clin Oncol 2000; 18:3495.

Breast Cancer StagingBreast Cancer Staging

• Conventional breast cancer staging

• Role of PET and PET/CT

• Physician audience Breast Surgeon

Radiation Oncologist

Medical Oncologist

Stage I T< 2cm and no nodal metastases

Stage IIA Adds axillary nodes or T>2cm but

Stage IIB Adds axillary nodes to T>2cm but

<5cm or T>5cm

Stage IIIA Fixed axillary or int. mammary nodes

Stage IIIB Chest wall involved or Inflammatory

Stage IV Distant metastases

• T staging Mammography-overestimates Ultrasound-underestimates MRI-best estimates tumor size

• N staging Palpation-75% risk if positive Axillary node dissection (ALND) Sentinal node biopsy (SLNB)

• M Staging

• Multidisciplinary Surgery

Radiotherapy

Chemotherapy

• Issues--where, when and order

Breast Cancer TherapyBreast Cancer Therapy

PET Impact on Surgical Staging

• PET high positive predictive value in the axilla (98.4%)

• PET allows for direct full ALND without need for SLNB

• PET and surgical staging complementary

Approaching the Breast Approaching the Breast SurgeonSurgeon

Gil-Rendo A, Brit J Surg. 2006; 93:707.

Staging Breast CancerStaging Breast Cancer

History • 53 YOF• Left breast cancer

PET Findings• Hyper-metabolic left breast

cancers and axillary nodes

Outcome • SLNB changed to ALND• Chemotherapy• Radiotherapy

primary

PET Impact on Staging

• PET high positive predictive value for nodal metatases vs. biopsy

• PET allows for detection of int. mammary node metastasis and synchronous cancers

• PET provides additional info for radiation treatment planning.

Approaching the Radiation Approaching the Radiation OncologistOncologist

Gil-Rendo A, Brit J Surg. 2006; 93:707.

History • 53 YOF• Left breast cancer

PET Findings• Hypermetabolic left

breast cancers and axillary nodes

Outcome • Axillary node

dissection• Chemotherapy• Radiotherapy

Ax. nodes

IM node

2nd primary

PET Impact on Staging

• High FDG uptake in breast cancers is assoc. with poorer prognosis

• PET allows for accurate detection of node metastasis which is and independent risk factor

• PET positive patients (SUV>4 and +nodes) indicate neoadjuvant chemo

Approaching the Medical Approaching the Medical OncologistOncologist

Inoue T J Cancer Res Clin Oncol. 2004; 130:273.

History • 57 YOF• Right breast cancer• Elevated tumor markers

PET Findings• Hyper-metabolic right

breast cancer and axillary nodes

Outcome • Primary chemotherapy• Surgery deferred

primary

PET Impact on M Staging

• High FDG uptake in distant metastasis allows differentiation of stage III and IV.

• PET allows for accurate detection of distant metastasis with better specificity

• Preoperative PET useful in patients at high risk for distant metastasis .

Van der Hoeven J. J Clin Oncol 2004; 22:1253.

Port E. Ann Surg Oncol 2006; 13:677.

Why stage with PET?Why stage with PET?

• PET provides additional information

Best approach to axilla

Radiation therapy sites

Distant metastasis

• PET provides prognostic information which can indicate which patients require neoadjuvant chemotherapy

Breast Cancer RestagingBreast Cancer Restaging

• Standard evaluation

• Role of PET and PET-CT

• Physician audience Medical Oncologist

Breast Cancer RestagingBreast Cancer Restaging

• Physical examination and serum tumor markers every 3-6 months

• High risk patients get serial Chest CT scans

• Surgery and radiation therapy leave scarring

Restaging Breast CancerRestaging Breast Cancer Detecting RecurrenceDetecting Recurrence

History • 57 YOF • Breast cancer 5 years ago, primary

is gone• Presented with elevated markers• Mammo negative• CT negative• Bone scan negative

PET Findings• Left supraclavicular node uptake

Outcome • Biopsy proven metastasis• XRT & chemotherapy

normal GI

activity

History • 49 YOF• Breast cancer 7 years ago• Presented with elevated

markers• Asymptomatic

PET Findings• Numerous skeletal and liver

Outcome • Biopsy proven mets• High dose chemotherapy• Stem cell replacement

Restaging Breast CancerRestaging Breast Cancer Detecting Extent of RecurrenceDetecting Extent of Recurrence

# Sensitivity Specificity

Bender 1997 75 97% 91%

Moon 1998 57 93% 79%

Hathaway 1999 10 100% 100%

Lonneax 1999 28 84% 55%

Sugawara 1999 26 100% 67%

Gimenz 1999 53 84% 100%

Kim 2001 27 94% 80%

PET and Breast CancerPET and Breast CancerRecurrence DetectionRecurrence Detection

PET Impact on Restaging

• Negative PET following high dose chemo assoc with 24 month survival

• PET demonstrates response rate twice that of conventional imaging

• PET powerful and independent predictor of survival

Cachin F J Clin Oncol 2006; 24:3026.

FDG PET in Breast CancerFDG PET in Breast Cancer Therapy AssessmentTherapy Assessment

Initial

Post therapy

PET Reimbursement in PET Reimbursement in Breast CancerBreast Cancer

• Medicare Adjunct to conventional staging Restaging and therapy monitoring

• Non-Medicare Letter of medical necessity Gather supportive journal articles Be ready to challenge denials

Breast Cancer and PETBreast Cancer and PET

• Female patients--high tech but high touch, compassionate environment

• Growth opportunities Lead into women’s health—cervical and

ovarian cancer

Scanner and tracer advancements

Radiation therapy planning

New therapeutic agents

• Understand clinical uses for PET/CT in Breast Cancer

• Understand that PET/CT is reimbursed in Breast Cancer

New ArticlesNew Articles

• Cachin F etal. Powerful prognostic stratification by [18F]fluorodeoxyglucose positron emission tomography in patients with metastatic breast cancer treated with high-dose chemotherapy. J Clin Oncol. 2006 Jul 1;24(19):3026-31.

• Gil-Rendo A etal. Fluorodeoxyglucose positron emission tomography with sentinel lymph node biopsy for evaluation of axillary involvement in breast cancer. Br J Surg. 2006 Jun;93(6):707-12.

• Inoue T etal.Preoperative evaluation of prognosis in breast cancer patients by [F-18]-deoxy-2fluoro-D-glucose positron emission tomography. J Cancer Res Clin Oncol. 2004; 130:273-8.

New ArticlesNew Articles

• Port ER etal. 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography scanning affects surgical management in selected patients with high-risk, operable breast carcinoma. Ann Surg Oncol. 2006 May;13(5):677-84

• Van der Hoeven J etal. [F-18]-deoxy-2fluoro-D-glucose positron emission tomography in staging of locally advanced breast cancer. J Clin Oncol 2004; 22:1253-9.

Marketing ToolsMarketing Toolsavailable through PET Foundationsavailable through PET Foundations

• PET Perspectives Brochure - from referring physicians viewpoints

• Case Studies -

Staging

Restaging and Monitoring

• Expert Voices Videos – Dynamic tool for sharing referring physicians’ perspectives

www.PETFoundations.com

Marketing PET’s Role in Marketing PET’s Role in Breast Cancer ManagementBreast Cancer Management

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Please Fill Out The Polling Questions Please Fill Out The Polling Questions Before You LeaveBefore You Leave

Thank You!Thank You!

Mark Your Calendars For The Fall Series!

September 27, October 25, November 15

© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Breast Cancer Management PET...

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