© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Breast Cancer Management PET Marketing Forum – Accelerating Practice Growth September

© 2006 Cardinal Health. All rights reserved.

Marketing PET’s Role in Marketing PET’s Role in Breast Cancer Management Breast Cancer Management

PET Marketing Forum – Accelerating Practice Growth

September 27, 2006Dr. Patrick Peller

Welcome!


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• Part of PET FoundationsSM > comprehensive marketing and education program

• Fourth of a 6-part Series

• Recorded presentation and PowerPoint available on www.PETFoundations.com > Market Your PET Center > Marketing Forum page

• Exclusive benefit to Cardinal Health PET customers


Dr. Patrick J. PellerDr. Patrick J. Peller

• Over 15 years of PET experience

• Read over 15,000 clinical PET scans

• MRP team member

3 marketing reps, 15+ staff

• MRP Volume > 500 PET/CTs per month


What Does a ReferringWhat Does a ReferringPhysician Want?Physician Want?

• Quality PET/CT imaging

• PET/CT the easy way Easy to order, promptly reported, has easy to understand

results and provides a specific answer

• Reliable and expert source of answers on PET/CT-- Your team


Targeted SpecialistsTargeted Specialists““The Select Seven”The Select Seven”

Medical

Medical Oncologists

Pulmonologists

Gastroenterologists

Surgical

Oncologic Surgeons

Thoracic Surgeons

Colorectal Surgeons

Radiation Oncologists




• PET/CT the easy way

• Reliable and expert source of answers on PET/CT

• Understand clinical uses for PET/CT in Lung Cancer

• Understand where PET/CT is reimbursed in Lung Cancer


Estimated US Cancer CasesEstimated US Cancer Cases

Source: American Cancer Society, 2006.

Men710,400

Women662,870

32% Breast

12% Lung and bronchus

11% Colon and rectum

6% Uterine corpus

4% Non-Hodgkin lymphoma

4% Melanoma Skin

3% Ovary

3% Thyroid

2% Urinary bladder

2% Pancreas

21% All other sites

Prostate 33%

Lung and bronchus 13%

Colon and rectum 10%

Urinary bladder 7%

Melanoma Skin 5%

Non-Hodgkin 4% Lymphoma

Kidney 3%

Leukemia 3%

Oral Cavity 3%

Pancreas 2%

All other sites 17%






• Understand clinical uses for PET/CT in Breast Cancer

• Understand where PET/CT is reimbursed in Breast Cancer


Breast CancerBreast Cancerversus Lung Cancerversus Lung Cancer

• Variable and increased FDG in breast tissue


FDG PET in Breast CancerFDG PET in Breast Cancer Normal BreastsNormal Breasts

Premenopausal Postmenopausal

Menopausal HRTPostpartum




• Lower FDG avidity in breast cancers


FDG PET in Breast Cancer FDG PET in Breast Cancer Primary CancersPrimary Cancers




• Lower FDG avidity in breast cancers

• Late and limited Medicare approval

• Frequently contested PET reimbursement

• Far fewer peer reviewed articles <100 (versus >2000 in lung cancer)


Breast Cancer and PETBreast Cancer and PET Clinical RolesClinical Roles

• Breast cancer diagnosis

• Breast cancer staging

• Breast cancer restaging


Diagnosing Breast CancerDiagnosing Breast Cancer

History • 50 YOF• Palpable (barely) mass in left

breast; doctor not concerned• Dense breasts, mammogram

normal

PET Findings• Hyper-metabolic breast focus

in left breast

Outcome • Surgical resection• Stage I breast cancer


PET in the PET in the Diagnosis of Breast CancerDiagnosis of Breast Cancer

Primary size Sensitivity

<0.5cm 25%

>0.5cm-1.0cm 25%

>1.0cm-2.0cm 84%

>2.0cm-3.0cm 94%

>3.0cm-4.0cm 87%

>4.0cm-5.0cm 93%

>5.0cm 100%Avril N J Clin Oncol 2000; 18:3495.


Breast Cancer StagingBreast Cancer Staging

• Conventional breast cancer staging

• Role of PET and PET/CT

• Physician audience Breast Surgeon

Radiation Oncologist

Medical Oncologist


Stage I T< 2cm and no nodal metastases

Stage IIA Adds axillary nodes or T>2cm but

<5cm

Stage IIB Adds axillary nodes to T>2cm but

<5cm or T>5cm

Stage IIIA Fixed axillary or int. mammary nodes

Stage IIIB Chest wall involved or Inflammatory

Stage IV Distant metastases



• T staging Mammography-overestimates Ultrasound-underestimates MRI-best estimates tumor size

• N staging Palpation-75% risk if positive Axillary node dissection (ALND) Sentinal node biopsy (SLNB)

• M Staging



• Multidisciplinary Surgery

Radiotherapy

Chemotherapy

• Issues--where, when and order

Breast Cancer TherapyBreast Cancer Therapy


PET Impact on Surgical Staging

• PET high positive predictive value in the axilla (98.4%)

• PET allows for direct full ALND without need for SLNB

• PET and surgical staging complementary

Approaching the Breast Approaching the Breast SurgeonSurgeon

Gil-Rendo A, Brit J Surg. 2006; 93:707.


Staging Breast CancerStaging Breast Cancer

History • 53 YOF• Left breast cancer

PET Findings• Hyper-metabolic left breast

cancers and axillary nodes

Outcome • SLNB changed to ALND• Chemotherapy• Radiotherapy

nodes

primary


PET Impact on Staging

• PET high positive predictive value for nodal metatases vs. biopsy

• PET allows for detection of int. mammary node metastasis and synchronous cancers

• PET provides additional info for radiation treatment planning.

Approaching the Radiation Approaching the Radiation OncologistOncologist

Gil-Rendo A, Brit J Surg. 2006; 93:707.



History • 53 YOF• Left breast cancer

PET Findings• Hypermetabolic left

breast cancers and axillary nodes

Outcome • Axillary node

dissection• Chemotherapy• Radiotherapy

Ax. nodes

IM node

2nd primary


PET Impact on Staging

• High FDG uptake in breast cancers is assoc. with poorer prognosis

• PET allows for accurate detection of node metastasis which is and independent risk factor

• PET positive patients (SUV>4 and +nodes) indicate neoadjuvant chemo

Approaching the Medical Approaching the Medical OncologistOncologist

Inoue T J Cancer Res Clin Oncol. 2004; 130:273.



Inoue T J Cancer Res Clin Oncol. 2004; 130:273.


History • 57 YOF• Right breast cancer• Elevated tumor markers

PET Findings• Hyper-metabolic right

breast cancer and axillary nodes

Outcome • Primary chemotherapy• Surgery deferred

mets

primary



PET Impact on M Staging

• High FDG uptake in distant metastasis allows differentiation of stage III and IV.

• PET allows for accurate detection of distant metastasis with better specificity

• Preoperative PET useful in patients at high risk for distant metastasis .


Van der Hoeven J. J Clin Oncol 2004; 22:1253.

Port E. Ann Surg Oncol 2006; 13:677.




Why stage with PET?Why stage with PET?

• PET provides additional information

Best approach to axilla

Radiation therapy sites

Distant metastasis

• PET provides prognostic information which can indicate which patients require neoadjuvant chemotherapy


Breast Cancer RestagingBreast Cancer Restaging

• Standard evaluation

• Role of PET and PET-CT

• Physician audience Medical Oncologist


Breast Cancer RestagingBreast Cancer Restaging

• Physical examination and serum tumor markers every 3-6 months

• High risk patients get serial Chest CT scans

• Surgery and radiation therapy leave scarring


Restaging Breast CancerRestaging Breast Cancer Detecting RecurrenceDetecting Recurrence

History • 57 YOF • Breast cancer 5 years ago, primary

is gone• Presented with elevated markers• Mammo negative• CT negative• Bone scan negative

PET Findings• Left supraclavicular node uptake

Outcome • Biopsy proven metastasis• XRT & chemotherapy

normal GI

activity


History • 49 YOF• Breast cancer 7 years ago• Presented with elevated

markers• Asymptomatic

PET Findings• Numerous skeletal and liver

foci

Outcome • Biopsy proven mets• High dose chemotherapy• Stem cell replacement

Restaging Breast CancerRestaging Breast Cancer Detecting Extent of RecurrenceDetecting Extent of Recurrence


# Sensitivity Specificity

Bender 1997 75 97% 91%

Moon 1998 57 93% 79%

Hathaway 1999 10 100% 100%

Lonneax 1999 28 84% 55%

Sugawara 1999 26 100% 67%

Gimenz 1999 53 84% 100%

Kim 2001 27 94% 80%

PET and Breast CancerPET and Breast CancerRecurrence DetectionRecurrence Detection


PET Impact on Restaging

• Negative PET following high dose chemo assoc with 24 month survival

• PET demonstrates response rate twice that of conventional imaging

• PET powerful and independent predictor of survival


Cachin F J Clin Oncol 2006; 24:3026.



Cachin F J Clin Oncol 2006; 24:3026.


FDG PET in Breast CancerFDG PET in Breast Cancer Therapy AssessmentTherapy Assessment

Initial

Post therapy


PET Reimbursement in PET Reimbursement in Breast CancerBreast Cancer

• Medicare Adjunct to conventional staging Restaging and therapy monitoring

• Non-Medicare Letter of medical necessity Gather supportive journal articles Be ready to challenge denials


Breast Cancer and PETBreast Cancer and PET

• Female patients--high tech but high touch, compassionate environment

• Growth opportunities Lead into women’s health—cervical and

ovarian cancer

Scanner and tracer advancements

Radiation therapy planning

New therapeutic agents






• Understand clinical uses for PET/CT in Breast Cancer

• Understand that PET/CT is reimbursed in Breast Cancer


New ArticlesNew Articles

• Cachin F etal. Powerful prognostic stratification by [18F]fluorodeoxyglucose positron emission tomography in patients with metastatic breast cancer treated with high-dose chemotherapy. J Clin Oncol. 2006 Jul 1;24(19):3026-31.

• Gil-Rendo A etal. Fluorodeoxyglucose positron emission tomography with sentinel lymph node biopsy for evaluation of axillary involvement in breast cancer. Br J Surg. 2006 Jun;93(6):707-12.

• Inoue T etal.Preoperative evaluation of prognosis in breast cancer patients by [F-18]-deoxy-2fluoro-D-glucose positron emission tomography. J Cancer Res Clin Oncol. 2004; 130:273-8.


New ArticlesNew Articles

• Port ER etal. 18F-2-fluoro-2-deoxy-D-glucose positron emission tomography scanning affects surgical management in selected patients with high-risk, operable breast carcinoma. Ann Surg Oncol. 2006 May;13(5):677-84

• Van der Hoeven J etal. [F-18]-deoxy-2fluoro-D-glucose positron emission tomography in staging of locally advanced breast cancer. J Clin Oncol 2004; 22:1253-9.


Marketing ToolsMarketing Toolsavailable through PET Foundationsavailable through PET Foundations

• PET Perspectives Brochure - from referring physicians viewpoints

• Case Studies -

Staging

Restaging and Monitoring

• Expert Voices Videos – Dynamic tool for sharing referring physicians’ perspectives

www.PETFoundations.com


Marketing PET’s Role in Marketing PET’s Role in Breast Cancer ManagementBreast Cancer Management

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September 27, October 25, November 15

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© 2006 Cardinal Health. All rights reserved. Marketing PETs Role in Breast Cancer Management PET Marketing Forum – Accelerating Practice Growth September