-- by James Brice

It's called the "killer application:" the breakthrough feature of a new technology that makes it indispensable for business, medicine, or just everyday life.

The term entered the English lexicon about 20 years ago when spreadsheet software changed the status of the personal computer from a hobbyist's novelty to mass merchandise. The term also applied to MRI, which debuted at about the same time. MRI's role as a diagnostic tool was secured as soon as neuroradiologists could appreciate its superiority over CT for depicting brain and spinal cord pathology.

Although killer application is an unfortunate term for anything to do with the healing profession, it is precisely what PET needs to promote its acceptance in clinical practice.

The academic radiologists and community-based nuclear physicians who pioneered PET may wonder why everything that has been done thus far to prove PET's clinical value is not sufficient. Against the odds, they have made tremendous progress. In fact, the supporters of this technology have been particularly adept at sensing the political winds and have delivered the appropriate type of outcomes-driven research needed to silence PET's critics and clear the way for reimbursement. Groundbreaking research demonstrates how PET can improve clinical decision-making and pay for itself by reducing the cost of diagnosing and treating metastatic disease.

PET is still justified as an instrument that changes clinical management, however. Because of its superior sensitivity to disease, it helps the oncologist decide when surgical resection will do more harm than good. The cost of performing PET procedures is often justified by saving the insurer the cost of paying for unnecessary surgery and patients the discomfort of surgical recovery in the final weeks of life.

PET practice needs to evolve from the negative mode to a positive one. By positive, we mean applications that have a measurably positive influence on mortality and survival. Radiography achieved this milestone the first time x-rays were used to evaluate a bone fracture. Nuclear medicine was legitimized when it was established as a powerful tool to diagnose pulmonary emboli. Ultrasound became indispensable as soon as its power to evaluate left ventricular function was established.

So it will be with PET. It will become indispensable when the anecdotes of patients whose lives have been saved by PET are statistically validated by multicenter clinical trials. PET's "killer" application must be one that saves lives.

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