Sara Michael

Interest in clinical applications for PET/MR continues to mount, and now researchers at the University of North Carolina School of Medicine are studying its use for bladder cancer staging.

Researchers at UNC’s Lineberger Comprehensive Cancer Center, Department of Radiology, and Biomedical Research Imaging Center are conducting a pilot study to evaluate PET/MR for staging patients with muscle invasive bladder cancer, which represents about a quarter of bladder cancer patients.

“We are interested in understanding whether PET/MR may be a better modality for detecting lymph node involvement” in these patients, said Matthew Milowsky, MD, principal investigator of bladder cancer staging project and a medical oncologist and associate professor of medicine at UNC Chapel Hill.

Conventional MR and CT are the standard of care, but their accuracy is poor in these cases. The reported sensitivity for detection of lymph node metastases is 50 percent for MR and overall accuracy is 50 percent to 60 percent for CT, Milowsky said. PET/MR might offer better soft tissue characterization and anatomical information plus functional molecular imaging, he said.

Thirty patients with muscle invasive bladder cancer are enrolled in the study. Prior to surgery, each patient undergoes conventional imaging with CT and a PET/MR scan with the Biograph mMR PET/MR system from Siemens Healthcare. The pathology from the standard of care lymph node dissection is used as the gold standard to evaluate the accuracy of PET/MR. “We will be able to see whether or not we can predict the presence of lymph node involvement,” Milowsky said.

Although it’s too early in the study to speculate on whether PET/MR is a better modality, Milowsky said “that’s the hypothesis and we are excited.”

Arif Sheikh, MD, assistant professor of radiology, nuclear medicine, at UNC, noted a growing interest in understanding the molecular characteristics of cancer, as well as finding the extent of the cancer. Though PET and MR each have their shortcomings, the combined modality may offer enough information to improve sensitivity and specificity, he said. “This is a marriage of the best two strengths in imaging to stage the patient with bladder cancer.”

The Biograph mMR PET/MR system received FDA approval in 2011, and researchers and clinicians continue to build data to demonstrate PET/MR’s advantages. Because it’s a new technology, the benefits have yet to be fully proven in bladder cancer, Milowsky said.

The technology is being reimbursed for both the PET and MRI portions when each exam is medically necessary and clinically indicated. In the case of bladder cancer, this pertains to the use of PET and MR during pretreatment staging.

A challenge for UNC with the new modality is the lack of cross-trained technologists, according to Weili Lin, PhD, director of the Biomedical Research Imaging Center, who is leading the implementation and current research. Training for the PET and MR technologists - which includes adjusting the work flow and learning the software - took some time. For the interpreting physicians, new software must be used to view the studies due to  complexities that are not experienced with traditional PET/CT imaging or even with the fusion of PET and MRI studies. This training will continue to be refined once the needs become more clearly defined, researchers said.

Joseph K.T. Lee, MD, a radiology professor in abdominal imaging and former chair of the department of radiology at UNC, credited his institution’s organization and team approach for making the program run smoothly. Every research project is led either by a clinician or a radiologist, said Lee, “and we have nuclear medicine physicians and radiologists and technologists working together. Without this organized team approach, there would be no way we could advance a new modality like PET/MR systematically.”

Milowsky agreed. “Any good medicine we know these days is characterized by a multidisciplinary effort. I think UNC has done a tremendous job in fostering a culture of collaboration and collegiality.”

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The timely and reliable delivery of critical test results has become a major priority for radiologists. Without effective systems in place, delayed communication could threaten patient safety and physician efficiency.

Recognizing this, Maimonides Medical Center implemented a critical test result management (CTRM) system four years ago. The system, a Nuance product, has dramatically improved the radiology department’s workflow, said Mark Flyer, MD, CIIP.

“The concern was… getting these results to the right person and making sure patients don’t fall through the cracks,” Flyer said in an interview at this year’s 

 where he presented about their use of this system. “We saw an opportunity to improve on patient care and communication, making sure that critical results are communicated efficiently, quickly and to the right person.”

The facility learned quite a few lessons along the way - one major one being that physicians across the board preferred physician-to-physician communication of results. In a survey conducted by the hospital, physicians noted their concern with the automated system was that lack of direct interaction.

“We in radiology have tried to back track a little and always put out the call first to the doctor,” Flyer said.

But when that direct contact isn’t possible, this system allowed them to effectively relay that information, he noted. The system has improved productivity by making it easier to convey the results. Hospital officials also made tweaks to the system to make it more flexible and tailored to specific physicians’ schedules and preferred contact methods.

Above all, the system has brought physicians a heightened understanding of the need for communication, Flyer said.

“Our job is not done once we issue a report and make a finding,” he said. “Our job is half done. The other half entails making sure that information gets into the hands of the person that has to act on it, so the patient will be the ultimate beneficiary of this.”

Videos

VIDEO: Mark Flyer, MD, CIIP, of Maimonides Medical Center, shares the experiences and lessons learned when his facility implemented a critical test results management system.

Tips for Implementing a Critical Test Results System

Radiology services have been a target of federal reimbursement cuts for the last several years. And most of these cuts, said 

, president of the American College of Radiology, are not based in logic.

These reimbursement policies represent a common thread between radiologists and radiation oncologists, said Blumberg, himself a radiation oncologist at and a practicing radiation oncologist at Radiation Oncology HealthCare PA and vice chair of the Department of Radiation Oncology at Greater Baltimore Medical Center.

“Though some may think there is a world of difference between the practice of radiology and radiation oncology, the truth of the matter is, the biggest challenge facing both subspecialties is really the government and the reimbursement polices being instituted by CMS and their constant efforts to reduce expenditures,” he said.

Blumberg was elected to his new post in May and recently sat down with Diagnostic Imaging to discuss the challenges facing radiologists and radiation oncologists.

The industry’s greatest fight right now, he said is to encourage CMS to adopt a computerized decision support system. This would allow for more appropriate image ordering, Blumberg said, which would result in savings, rather than cutting from radiologist reimbursement.

When it comes to bridging the gap between radiologists and radiation oncologists, Blumberg noted that the challenges the two groups are facing have a lot more commonalities than differences.

“It’s time to circle the wagons,” he said. “There needs to be an agreement that this should be a major goal.”

VIDEO: ACR president Albert Blumberg, MD, discusses CMS’s reimbursement cuts and the shared challenges of radiologists and radiation oncologists.

ACR President Blumberg on Reimbursement Cuts, Industry Goals

The radiology department at Hackensack University Medical Center has always been committed to patient safety and quality of care. But now they have a unique distinction to prove it.

The Bergen County, NJ, facility was recently recognized by the American College of Radiology as one of the first two 

This distinction, also awarded to the Mount Desert Island Hospital in Bar Harbor, Maine, shows the medical center went above and beyond accreditation, proving high quality in areas such as personnel, equipment specifications, outcomes measurement and quality control systems, safety policies, utilization reviews, facility management and patient outcomes. The center was also evaluated in service, availability of imaging and radiologists, and image interpretation and quality.

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. “This says we feel a great deal of responsibility for that.”

Agress and Jason Kreitner, MHA, RT, (R)(T), FACHE, administrator of clinical services at Hackensack, convened a multidisciplinary team to review the ACR standards set in the application. Together, that team tackled each area to ensure they met the requirements, he said. It turned out the medical center was already following most of the standards, and a few areas needed attention.

For example, the team upgraded and formalized many of their policies and procedures, such as those documenting communication with referring physicians. They also clarified some job descriptions, and spent time formalizing their education and marketing of radiation safety to patients and referrers.

Agress noted a few elements that make Hackensack unique, including that they have 24-7 coverage by onsite attending physicians, rather than outsourced radiologists or residents and fellows. That makes the radiology department available for consultation at any time, he said, and allows for faster turnaround times.[[{"type":"media","view_mode":"media_crop","fid":"14194","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1973456998479","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"709","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Jason Kreitner, MHA, RT, (R)(T), FACHE","typeof":"foaf:Image"}}]]

Now, with this Center of Excellence distinction, the facility can show to patients and referring physicians that they are taking that extra step, Agress said. “We are really a high-level imaging center [and] we care a great deal about our patients and the quality of what we are doing.”

The 25-page application can be a bit overwhelming, officials said, but it’s worth the effort. And Kreitner has already received calls from other facilities asking how they achieved this recognition and what the process was like.

“This exemplifies to our patients and physicians in our community that quality is paramount,” he said, “and demonstrates that we made the investment in ensuring we deliver the highest possible care to our patients.”

Podcasts

Hackensack University Medical Center has earned ACR’s distinction as one of the first two Diagnostic Imaging Centers of Excellence. Here’s how they did it.

Sara Michael

Articles

PET/MR for Bladder Cancer: UNC Investigates

Tips for Implementing a Critical Test Results System

ACR President Blumberg on Reimbursement Cuts, Industry Goals

What It Takes To Be an Imaging Center of Excellence