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Diagnostic imaging

Ontario to finally fund PET exams

TORONTO – After studying the effectiveness of Positron Emission Tomography (PET) scanning for seven years, the government of Ontario announced it will start reimbursing specialists for conducting PET exams this fall. However, the funding will be made only for certain types of medical conditions, where the province says PET scans have been proven to be clinically effective.

The government didn’t announce how much money it is investing in the expensive scans, which can cost in the neighbourhood of $2,000 per study. It didn’t say, moreover, how many scans it expected to be covered in the future.

PET scanning is used around the world as a highly effective means of diagnosing cancers and heart problems, and is also used for surgical planning and follow-up. Specialists in Ontario have been clamouring for the government to start funding the modality for years; they have been even more vocal since the shutdown of the nuclear reactor at Chalk River, Ontario, has resulted in a shortage of medical isotopes for standard nuclear medicine procedures.

PET scanning also requires radioisotopes, but they are not produced by nuclear reactors. Instead, they are created in cyclotrons.

PET technology is said to produce more sensitive results than conventional nuclear medicine for many types of testing. It can be used as substitute for many but not all of the tests conducted in traditional nuclear medicine scanners.

PET scanning can provide information on both the location and the extent of the metabolic activity of abnormal tissues, such as cancer, and it has the potential to identify the areas of abnormal metabolic activity that is not always found through the use of MRIs or CT scans.

For the services that will be insured, PET is useful in determining the stage or extent of some cancers to aid in treatment decisions. PET has also been determined to be useful in making treatment decisions in certain advanced heart conditions.

By October 2009, insured PET scans will be performed in Ottawa, London, Toronto, Hamilton and Thunder Bay.

Ontario has established one of the largest PET infrastructures in Canada, with 10 PET scanners at nine centres. However, the scanners have mostly been used for research purposes.

“[This] announcement is a step in the right direction and will benefit cancer and cardiac patients who meet the clinically proven indications for PET scans. In addition, the OANM looks forward to working with government in order to appropriately increase PET access for those patients requiring this procedure in the future,” said Dr. Christopher O'Brien, President, Ontario Association of Nuclear Medicine (OANM).

The government has made amendments to regulations under the Health Insurance Act to include PET scans under the Ontario Health Insurance Plan for patients with the following evidence-based health indications:

Cancer
• Solitary Pulmonary Nodule (SPN): for which a diagnosis could not be established by a needle biopsy due to unsuccessful attempted needle biopsy; the SPN is inaccessible to needle biopsy; or the existence of a contra-indication to the use of needle biopsy.

• Thyroid cancer: where recurrent or persistent disease is suspected on the basis of an elevated and/or rising thyroglobulin but standard imaging studies are negative or equivocal.

• Germ cell tumours: where recurrent disease is suspected on the basis of elevated tumour marker(s) – (beta human chorionic gonadotrophin (HCG) and/or alpha fetoprotein) and standard imaging tests are negative, or a mass persists after primary treatment for seminoma when curative surgical resection is being considered.

• Colorectal cancer: where recurrent disease is suspected on the basis of an elevated and/or rising carcinoembryronic antigen (CEA) level(s) during follow-up after surgical resection but standard imaging tests are negative or equivocal.

• Lymphoma: for the evaluation of residual mass(es) following chemotherapy in a patient with Hodgkin's or non-Hodgkin's lymphoma when further potentially curative therapy (such as radiation or stem cell transplantation) is being considered; or for the assessment of response in early stage Hodgkin's lymphoma following two (2) or three (3) cycles of chemotherapy when the chemotherapy is being considered as the definitive single modality therapy. Non-small cell lung cancer: where curative surgical resection is being considered based on negative standard imaging tests.

• Clinical stage III non-small cell lung cancer: that is being considered for potentially curative combined modality therapy with radical radiotherapy and chemotherapy.

• Limited disease small cell lung cancer: for evaluation and staging where combined modality therapy with chemotherapy and radiotherapy is being considered.

Cardiac
• Myocardial viability assessment in a patient suitable for a cardiac revascularization procedure or cardiac transplantation with ischemic left ventricular dysfunction (left ventricular ejection fraction of 35% or less);

• and prior myocardial viability or stress imaging assessment with another modality (i.e. SPECT using thallium, MIBI or dobutamine stress echocardiography) has been equivocal for viability or demonstrated insufficient viable myocardium.

Ongoing Clinical Trials
The Ministry has been evaluating how best to use PET to improve decision making for cancer and cardiac treatment through ongoing clinical trials conducted by the Ontario Clinical Oncology Group. These trials are resulting in high quality and internationally recognized evidence of improved patient outcomes. Recommendations for insuring PET for the nine indicators have been made on the basis of evaluation studies completed to date.

Positron Emission Tomography (PET) Scanning
PET scanning is a nuclear medicine diagnostic imaging exam. PET scanning can provide information on both the location and the extent of the metabolic activity of abnormal tissues such as cancer and it has the potential to identify areas of abnormal metabolic activity before anatomical changes can be detected by MRIs or CT scans. For the services that will be insured, PET is useful in determining the stage or extent of some cancers to aid in treatment decisions. PET has also been determined to be useful in making treatment decisions in certain advance heart conditions.

A patient undergoing a PET scan is given a radiopharmaceutical, which is injected into a vein. The radiopharmaceutical eventually gathers in the organ or area of the body being examined where it gives off energy in the form of gamma rays.

The PET scanner is a large machine with a round, doughnut shaped hole in the middle – similar to a CT scan unit. The scanner has multiple rings of detectors that measure the absorption of the radiopharmaceutical in a person's body. The scanner produces an image based on the energy given off by the different amounts of radiopharmaceutical absorbed by different cells in the body (i.e. cancer calls may absorb more radiopharmaceutical than normal tissue).

The PET scanner works with a computer to create two- and three-dimensional images of the structure and function of organs and tissues. It can help determine how well organs and tissues are functioning by measuring such things as blood flow, oxygen use and sugar (glucose) metabolism.PET Locations

PET scans are available at the following hospital sites:

• University Health Network (Princess Margaret Hospital)

• Sunnybrook Regional Cancer Centre

• Hamilton Health Sciences Centre

• St. Joseph's Healthcare (Hamilton)

• London Health Sciences Centre

• St. Joseph's Health Care London

• The Ottawa Hospital

• The Ottawa Heart Institute.

PET scanning will be available at the Thunder Bay Regional Health Sciences Centre in the fall of 2009.

Posted July 30/09.

 

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