Challenging Medicare Coverage for PET Imaging

An independent panel commissioned by the Health Care Financing Administration (HCFA) has questioned the value of positron emission tomography (PET) imaging for the diagnosis of breast cancer. HCFA is the federal agency responsible for Medicare administration and coverage.

PET is a specialized imaging technique that was first developed in the 1970s. It involves the injection into a patient of a very small amount of a radioactively labeled natural compound that travels throughout the body and congregates around potentially cancerous tumors. A PET scanner is used to detect emissions from the compound and highlight any suspicious sites.

Currently, Medicare covers PET imaging for a variety of cancers, but not for breast cancer diagnosis.

PET for Breast Cancer

The evaluation of PET for diagnosing breast cancer was conducted by the Blue Cross Blue Shield Technology Evaluation Center. The study focused on the value of PET imaging in four settings:

• Initial diagnosis of breast cancer;
• Initial staging of axillary lymph nodes;
• Detection of locoregional recurrence or distant metastases; and,
• Evaluating response to treatment.

The study concluded that the risk of false-negative results with PET imaging was high and the panel therefore did not recommend its use for the initial diagnosis of breast cancer. Furthermore, for all of the evaluation criteria, the report cited a surprising lack of definitive research data.

"The available body of literature is too sparse to draw conclusions regarding the diagnostic performance of PET," the report warned. It highlighted particular gaps in research regarding PET's ability to determine axillary lymph node metastases, recurrence or metastasis.

"The available evidence is of limited quantity, quality and consistency and is insufficient to permit conclusions about the diagnostic performance of PET in evaluating response to treatment," the report added.

In response to the report, industry representatives sharply disputed the commission's conclusions, noting that PET imaging has already demonstrated its value as a diagnostic tool for breast cancer and that future advances will only serve to improve its utility.

SOURCES:
"FDG Positron Emission Tomography for Evaluating Breast Cancer," Blue Cross Blue Shield Technology Evaluation Center (http://www.hcfa.gov/coverage/download/8bl-gl.pdf)
Health Care Financing Administration (http://www.hcfa.gov)

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