CT vendors end slice wars

January 3, 2008

If we were to believe vendors, radiology would be awash in breakthroughs. But, in reality, industry advances are rare, which is all the more reason to celebrate the events of RSNA 2007.

If we were to believe vendors, radiology would be awash in breakthroughs. But, in reality, industry advances are rare, which is all the more reason to celebrate the events of RSNA 2007.

For the first time since the introduction of quadslice scanners eight years ago, CT users were treated to a true breakthrough, as vendors put an end to the slice wars they had waged for much of the past decade. These wars will be replaced by a cold war of sorts that will be fought over image quality and technological philosophy. The common denominator will be clinical excellence, just as it was at during the last hot war fought by vendors - over ultrasound equipment.

It began with Acuson, a company founded nearly 30 years ago on the belief that ultrasound users would be willing to pay a premium price for scanners, if they delivered premium quality images. Founder Sam Maslak was proven right: The Acuson 128 became widely adopted. Its release in 1983 led Diasonics (now part of GE) and ATL (now part of Philips) to launch crash programs to catch up. This created equipment contests that were usually decided at the high end by the number of channels each system brought to bear. Acuson became the leading vendor in radiology ultrasound.

The number of channels remained the benchmark until, finally, in the late 1980s, engineers reached a point where nothing clinically significant could be gained by adding more channels. Diasonics and ATL caught up to Acuson (now part of Siemens). The three continued to battle through much of the nineties but focused on technologies that improved image quality and extended the clinical value of their scanners.

Like the number of channels in ultrasound, the number of slices in CT will lose relevance with the pending new generation of systems. The first - Toshiba's Aquilion - is scheduled to enter production in summer 2008. Multislice will become a term of the past. Detector rows will serve only as a way of differentiating the earlier generation of CT scanners: 16s, 32s, 40s, and 64s. This transition will be helped by the introduction of a rapidly shuttling focal spot that doubles the slices returned by each row in the detectors being designed in Siemens, GE, and Philips products - though not in Toshiba's.

But CT is no ultrasound. Whereas ultrasound scanners have stayed within or near the price ceiling set by the release of the Acuson 128 - around $250,000 - the slice wars propelled CT far beyond the one-time ceiling of $1 million to twice and now close to triple that mark.

Only Toshiba can talk about the price of its new scanners, as the other vendors' products have not yet received FDA clearance. Talking about price is akin to marketing and a definite no-no if vendors want to stay on the right side of regulators. But given that Siemens, GE, and Philips plan to position their systems against Toshiba's Aquilion One, the prices they set for their products will be in the same ballpark - stratospheric, no matter how you slice it.

And therein lies the unknown. Can the marketplace afford to pay between $2.5 million and $3 million for a single CT scanner? The answer is yes, but not in the way it has been for members of other scanner generations. The latest CT systems will not be sold to every facility regardless of size, at least not anytime in the near future. A new generation of CTs will have to come along to knock down the price. If history is any guide, this will not happen for at least four or five years.

In the meantime, the CT industry and the community it serves will polarize into two camps, much as the MR industry has done. One will focus on a workhorse platform - the 64-slice scanners - which will be the equivalent of the current 1.5T MRs. The second will focus on the superpremium CTs, which will play a role similar to that assigned to 3T.

This latest generation of CTs will be the benchmark for clinical excellence, but not every provider will need them. Clinical studies attesting to the value of 64-slice scanners have only begun to appear. Many more are on the way, establishing their value inside and outside of cardiac applications. Although some 3Ts were adopted by outpatient imaging centers, their sale in this market was snuffed by recent reimbursement cuts. This eliminated any chance that the superpremium CTs will be able to follow in 3T MR's footsteps.

We are entering a new age of CT imaging - one defined by extraordinarily powerful and expensive technologies that create elite centers of care. Ultimately the applications proven at these dizzying heights of performance will find their way to the masses. But more than likely, the applications will migrate to platforms with smaller detectors until, finally, CT matures into a modality much like x-ray, where detector sizes are chosen to match the clinical application. The one-size-fits-all mentality that has characterized CT over the last eight years will become history.

It used to be that bigger was always better. Now better will be determined by clinical need.