PET Scan Use in Follow-up Care for Lung and Esophageal Cancer Shows Wide Variation Between Hospitals, No Impact on Survival

Key Points

  • More than 22% of lung cancer patients and 31% of esophageal cancer patients had at least one PET scan to look for a cancer recurrence during follow-up without first having a CT scan or other imaging.
  • Hospitals varied widely in how often they used this approach, from nearly never at some to a majority of the time in others. Some hospitals used it eight times more often than others.
  • Patients who went to a high–PET-use hospital for lung cancer follow-up were just as likely to survive 2 years as those who went to a low–PET-use hospital.

A new study suggests that one approach to watching for a cancer's return is being inappropriately used at many hospitals and isn't helping patients survive longer. The findings are published by Healy et al in the Journal of the National Cancer Institute. The study looked at how often survivors of lung and esophageal cancer went through positron-emission tomography (PET) scanning as the primary way of monitoring their condition, instead of as a backstop to other kinds of scans.

PET scans are expensive but potentially powerful. They let doctors see increased activity by cells inside the body—including fast-growing cancer cells—and can do so early. Many cancer patients receive PET scans as part of diagnosis, to see how advanced their cancer is and to see how it is responding to treatment.

However, PET scans aren't recommended as the first option for long-term monitoring to watch for recurrence. In fact, it's one of the few imaging tools for which the Medicare system imposes limits—currently, three follow-up PET scans per person, even when doctors only order them after spotting something on a computed tomography (CT) scan or other medical image.

Despite this, the researchers from the University of Michigan Medical School and Dartmouth-Hitchcock found widespread use when they looked at Medicare data for more than 100,000 lung and esophageal cancer patients who had cancer in the mid-2000s and follow-up care through 2011.

Key Findings

More than 22% of lung cancer patients and 31% of esophageal cancer patients studied had at least one PET scan to look for a cancer recurrence during follow-up without first having a CT scan or other imaging. Hospitals varied widely in how often they used this approach, from nearly never at some to a majority of the time in others. Some hospitals used it eight times more often than others.

No matter how often they used it, the result was the same: Patients who went to a high–PET-use hospital for their lung cancer follow-up were just as likely to survive 2 years as those who went to a low–PET-use hospital.

Study Implications

“PET scanning is a great technology and very effective, but using it in this way doesn't seem to make any difference for these cancers that have a relatively poor prognosis,” said Mark Healy, MD, a surgical resident and research fellow in the University of Michigan Department of Surgery and member of the Center for Health Outcomes & Policy. “The appropriate use of PET scanning in follow-up care for lung and esophageal cancer is after findings on lower-cost imaging options.” National guidelines call for this type of use, but the new findings suggest they are not being followed.

In addition, said Dr. Healy, “Our work shows that almost no one is getting to the three-scan limit set by Medicare. But with many thousands of patients getting one or two scans across the whole country, this is still a very large number, with very high costs. If the intention of the policy is to curb overuse, this doesn't seem to be a very effective method, and the agency should reevaluate how it structures its limits.”

Better coordination between radiologists and the physicians who care for cancer patients after their treatment might also improve appropriateness, Dr. Healy commented.

Dr. Healy and senior author Sandra L. Wong, MD, MS, Chair of Surgery at Dartmouth-Hitchcock and a former U-M researcher, used Surveillance, Epidemiology, and End Results (SEER) and Medicare-linked data to perform the study. They hope their findings will help providers of all kinds understand the best use of PET scanning in cancer care, and patients as well.

“Following evidence-based guidelines for clinical follow-up is the way to go. Don't order PET in asymptomatic patients,” concluded Dr. Healy. “And for patients, if you are not having symptoms and you're doing well, there's no reason to seek out this scan.”

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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