Positron Emission Tomography (PET) scans have become a cornerstone in modern oncology over the last two decades. Initially a highly specialized imaging tool found in select academic centers, PET technology is now widely accessible and crucial for evaluating and managing patients with suspected or confirmed cancer. This expansion hasn’t been arbitrary; each step in PET scan adoption and insurance coverage, particularly by entities like the Centers for Medicare and Medicaid Services (CMS), has been grounded in solid evidence demonstrating PET’s clinical value in oncology. CMS’s recent decisions to approve PET for initial and subsequent evaluations of almost all solid tumors underscore this evidence-based progression, largely influenced by data from the National Oncologic PET Registry and other significant research.
However, a common misconception persists: PET scans are frequently perceived as prohibitively expensive. While PET is categorized as an “advanced” imaging test, a closer look at the costs reveals a more nuanced picture. When you consider the cumulative charges for multiple contrast-enhanced CT scans covering the neck, chest, abdomen, and pelvis – procedures often used for comprehensive cancer staging – the cost of a PET scan can be surprisingly comparable. Similarly, at many healthcare facilities, the price points for MRI and PET scans are often quite similar. Factors like reduced scanner costs and the widespread availability of PET radiopharmaceuticals, primarily fluorodeoxyglucose (FDG), have contributed to aligning the overall costs of PET imaging with other sophisticated imaging modalities.
To truly understand the financial implications, it’s essential to consider the cost-effectiveness of PET scans, not just the initial price tag. Although research is still growing, several peer-reviewed studies have investigated PET’s cost-effectiveness in various cancer scenarios. A landmark study, the PLUS trial from the Netherlands, explored the value of adding FDG-PET to the standard pre-surgical assessment for early-stage lung cancer patients, compared to conventional workup alone. In this study, “conventional workup” meant imaging aligned with standard clinical guidelines. The findings were striking: in the group receiving only conventional workup, a significant 41% of thoracotomies (surgical chest incisions) proved to be unnecessary or “futile.” Conversely, in patients evaluated with FDG-PET in addition to the conventional approach, the futile thoracotomy rate dropped dramatically to just 21%. The researchers concluded that the initial investment in PET imaging was not only justified but actually resulted in cost savings of approximately €1,289 per patient, primarily by preventing the costs associated with unproductive surgeries.
A more recent investigation into advanced gastric cancer reached similar conclusions about the economic benefits of PET scans. Patients with locally advanced gastric cancer underwent FDG-PET/CT scans in addition to standard diagnostic procedures like CT scans, endoscopic ultrasound, and laparoscopy. The PET/CT scans detected previously unsuspected metastatic disease in 10% of these patients, including spread to bones, liver, and lymph nodes. By identifying these cases and averting unnecessary surgeries and their associated complications, the estimated cost saving per patient was substantial, around $13,000. While more research is always beneficial to broaden our understanding across different cancers and clinical situations, these studies and others already in the medical literature build a strong case for the cost-effectiveness of PET scans.
In clinical practice, decisions about utilizing PET scans are ongoing and require careful consideration. While guidelines and insurance policies often present a binary view (covered vs. not covered, recommended vs. not recommended), the actual utility of PET in specific clinical scenarios exists on a spectrum of probability. For instance, in cases of clinically early-stage breast cancer without any indications of distant spread, the likelihood of PET revealing unexpected findings that would alter treatment is low. However, it’s not zero; a small percentage of such patients might indeed have hidden metastatic disease that PET can detect, leading to crucial changes in management. Conversely, in situations like inflammatory breast cancer with palpable axillary lymph nodes, the statistical probability of distant disease is higher. Yet, even in high-likelihood scenarios, PET’s value is never absolute. Coverage decisions and clinical algorithms are developed based on these probabilities, but they inherently might limit an oncologist’s ability to make individualized decisions about PET usage based on a comprehensive understanding of each patient’s unique situation and all available clinical evidence.
In conclusion, PET scanning has undeniably proven itself as a valuable asset in the diagnosis, staging, and overall management of cancer patients. The expanding range of PET scan applications has been supported by evidence-based research published in peer-reviewed journals, demonstrating its clinical utility and cost-effectiveness. While there are still areas where further research is needed, particularly concerning targeted therapies and less common tumors, PET has clearly demonstrated its worth and, in certain clinical contexts, can contribute to reducing overall healthcare costs by preventing unnecessary and ineffective interventions.
References:
- Hillner BE, Siegel BA, Liu D, et al. Relationship between cancer type and impact of PET and PET/CT on intended management: findings of the National Oncologic PET Registry. J Nucl Med. 2008;49:1928-35.
- Verboom P, van Tinteren H, Hoekstra OS, et al. Cost-effectiveness of FDG-PET in staging non-small cell lung cancer: the PLUS study. Eur J Nucl Med Mol Imaging. 2003;30:1444-9.
- Smyth E, Schöder H, Strong VE, et al. A prospective evaluation of the utility of 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography and computed tomography in staging locally advanced gastric cancer. Cancer. 2012;118:5481-8.
