One of the most active clinical PET programs in the country is located at Albert Einstein College of Medicine and Montefiore Medical Center in New York City. Dr. M. Donald Blaufox, chairman of nuclear medicine there, has moved PET into the outpatient setting, where he thinks it has the greatest potential for growth and clinical development.
In an interview with Diagnostic Imaging, Blaufox discussed issues shaping clinical PET that he believes are changing perceptions as well as future applications of the modality.
DI: Outpatient PET facilities used to be the exception rather than the rule. What’s happened to account for this change?
Blaufox: Until a few years ago, Medicare was not reimbursing for PET studies, and that was a major limitation on the development of outpatient PET facilities. Given that situation, facilities had to be primarily based in institutions where research support and other sources of funding could keep them going. A large number of indications are now approved by Medicare, and the number will continue to increase. The potential for outpatient PET facilities is much improved, and that’s where the growth in the field will be. In fact, a large number of PET centers are being set up around the country. A lot of practicing radiologists are starting to buy PET machines. I believe PET has rather limited in-hospital application.
DI: What are the key factors that determine whether a PET facility makes economic sense or not?
Blaufox: There are two ways to go. You need two to three PET procedures a day to be economically viable-to reach break-even. If you can envision 10, 15, or 20 cases a week, then certainly that’s enough to invest in PET. If you can’t foresee that many cases, you can share. Several companies with mobile PET machines spend two days a week at one hospital and three days at another, depending upon patient volume. That kind of joint venture makes sense if you need PET imaging and don’t have ready access to a fixed PET facility nearby.
The decision is determined by your particular patient population and how many PET studies that population will generate. In a general hospital, the primary driving force will be the oncology service. You can estimate your ability to support a PET facility by looking at how busy your therapists are. If you have a neurology institute, you might be able to support a fixed PET facility. Check with your cardiologists and see how much they want to do PET studies. If you can’t come up with 10 or 15 cases a week, you probably should consider a mobile PET arrangement.
DI: What clinical areas contribute to your overall total of PET studies?
Blaufox: If we perceive a study to be clinically indicated, we’ll do it. For instance, we’ll do studies of patients with ovarian carcinoma. Many private insurers will reimburse for procedures that Medicare doesn’t necessarily cover, but obviously Medicare drives the use of PET because it has the dominant share of patients studied. But we will do a study any time it is clinically indicated and can provide a useful role.
DI: To what extent do clinical services other than oncology contribute to your study volume?
Blaufox: In neurology we image a modest number of patients who have intractable epilepsy and are surgical candidates. There will be tremendous growth in the clinical application of PET in the brain because of the development of potential compounds that could be useful in psychiatric disorders, Alzheimer’s disease, and other abnormalities. Brain imaging is probably now in a lull before the major growth starts, I estimate, in the next five to 10 years.
In cardiology, we see a small number of patients in whom there are questions about the viability of myocardium-whether the muscle is still salvageable. Some centers do a lot of perfusion studies, but we don’t do any myocardial perfusion with PET, since our cardiologists are not enthusiastic about it. Right now, this is a limited growth area because the agents that compete with PET for assessing myocardial viability and myocardial perfusion are pretty good, and the advantage of the PET study is small.
DI: What improvements in PET technology have contributed to better image quality?
Blaufox: Each year the cameras get better. New detectors are being developed, and the software continues to improve. Correction of attenuation remains a problem with PET, but the technology is still evolving. We are looking at continued improvement in PET hardware and software over the next several years.
DI: What impact will the new combination of PET and CT scanners have on the use of PET?
Blaufox: I am not enthusiastic about the combination machines. Although it is nice to be able to look at a superimposed CT and PET image, no one has ever shown that there is any improvement in diagnostic accuracy, as compared with putting a CT image on a viewbox and then looking at the PET image. If you look at CT and PET images separately and then correlate them, you get all the information you need; if you superimpose the images, you get a little better anatomic localization, but the true clinical usefulness of that has yet to be proven. On the other hand, you are taking an expensive machine and making it very expensive.
DI: Do you foresee other trends in the clinical application of PET or in the technology itself?
Blaufox: The primary focus of PET will remain in the three clinical areas that have contributed most of the volume up to this point: oncology, brain disease, and cardiac disease. These are the clinical areas that have the greatest clinical need for PET. Does PET have a potential role in infection? Perhaps. There have been scattered pieces of work here and there, but you never know. There was once a lot of enthusiasm for PET in the kidney, but no one has come up with any practical, useful application of PET in the kidney.
Nuclear medicine has always been a slave to the compounds. Tomorrow, someone could put fluorine-18 or carbon-11 on a new compound, and a whole new world of diagnosis could open up. It’s very hard to predict, but I can say that the opportunities are gigantic.
© 2001 CMP Media, LLC.
6/1/01, Issue # 2306, page P16.
