Medical Imaging in Cancer Care Whitepaper

Medical Imaging in Cancer Care: CHARTING THE PROGRESS How Innovation in Cancer Diagnosis and Treatment Improves Health and Economic Productivity www.medicalimaging.org Prepared By Policy Analysis and Public Affairs 1500 Wilson Boulevard Suite 520 Arlington Virginia 22209 April 2006 www.medicalimaging.org Copyright © US Oncology, Inc. and National Electrical Manufacturers Association (NEMA), 2006 1 Medical Imaging in Cancer Care: CHARTING THE PROGRESS Executive Summary T he New England Journal of Medicine1 calls medical imaging one of the most important medical developments of the past 1,000 years—ranking with such milestones as the discovery of anesthesia and the discovery of antibiotics. The reason: the remarkable power of medical imaging in providing physicians with sight— and insight—about human disease and physiology. This is especially important for cancer, where researchers and physicians are now able to see not just inside the body, but deep within the chaos of cancer cells. Medical imaging is a vital component of the nation’s war on cancer. Medical imaging is a vital component of the nation’s war on cancer. In this role, imaging is used to: I Screen, diagnose, and stage cancer; I Guide cancer treatments; I Determine if a treatment is working; I Monitor cancer recurrence; and I Facilitate medical research, particularly in such critical areas as drug discovery and therapeutic innovation to improve patient care. This paper highlights the many contributions that medical imaging makes in modern, state-of-the-art cancer care, including its role in screening, detection, diagnosis, treatment, and follow-up. Imaging Detects Cancer Early Medical imaging often detects cancer at its most curable stage—and, in many cases, when it is least costly to treat. As such, medical imaging is center-stage in America’s efforts at cancer prevention and early detection. Sometimes this occurs through screening programs to spot cancer early in individuals who otherwise seem perfectly healthy. In many cases, however, imaging is used to detect tumors or other forms of cancer at their early stages when patients go to the doctor with worrisome symptoms. Molecular imaging enables physicians to go even further, detecting disease at the cellular level, before any symptoms or signs are noticeable. 1 “Looking Back on the Millennium in Medicine.” New England Journal of Medicine. 342.1 (2000): 42-49. 2 Medical Imaging in Cancer Care Imaging Enables Less-Invasive Cancer Diagnosis and Treatment Medical imaging enables a range of less-invasive, highly targeted cancer therapies that translate into better and more comfortable care for patients. Because they are less invasive, these treatments mean fewer complications, shorter hospital stays, and, in many cases, no incisions or surgery. Thus, the patient benefits in two ways—better care and more comfortable, convenient care. Imaging Fosters More Effective Management of Cancer Medical imaging has become a key component of comprehensive oncology care. An essential tool in cancer therapy and management, imaging can determine the presence or spread of cancer in addition to visualizing a patient’s response to therapy. Imaging helps ensure that radiation is delivered according to the precise shape of a tumor, thereby killing cancer cells and avoiding substantial damage to sensitive, healthy surrounding tissue. Imaging Fosters Efficiencies And Savings in Cancer Care Medical imaging makes the health care system work more efficiently by fostering greater economy and cost savings. Such savings are often apparent, as when imaging replaces surgery. Other times, however, savings are harder to see, as when imaging allows a patient to recover in half the time. Imaging’s newest frontier, using information technology to superimpose or fuse digital images together, or combine digital images with other clinical and laboratory information, is introducing savings that stretch throughout the health care system. Imaging Keeps Workers Productive Medical imaging in cancer detection and therapy can help keep workers healthy and on the job by avoiding surgery, long recuperation, and disability. Improvements in cancer care and cures, along with the accompanying enhancements in quality of life and functioning, have brought significant economic value. Economists are calculating the economic value of longer life expectancy, better functioning, reduced disability, and greater employee productivity. The economic and clinical gains in cancer care over the past half century are certain to continue if public policy recognizes that: I Medical imaging fosters better health and better cancer outcomes; I Better health brings economic value; I Economic value from better health is clear, real, and quantifiable; and I Innovation in medical technology—an inherently unpredictable and evolutionary process—lies at the heart of such achievements. Without an understanding of productivity improvement and economic output from advances in cancer care, public policy often focuses only on cost. To be sure, costs are a critical and appropriate concern. But addressing them should not overshadow the value that technological innovation brings in making Americans healthier, more able, and more productive. 3 Medical Imaging in Cancer Care: CHARTING THE PROGRESS Introduction I n his Director’s Message prepared for The Nation’s Investment in Cancer Research: A Plan and Budget Proposal for Fiscal Year 2005, National Cancer Institute Director Andrew C. von Eschenbach wrote: In 1971—with the passage of the National Cancer Act—we committed our national will and resources to eliminating cancer. A cure for this complex set of diseases has proven far more elusive than anticipated thirty-three years ago. Yet our persistence and patience have led to increasingly significant dividends. There are now nearly ten million cancer survivors in the United States compared to three million in 1971. Death rates from the four most common cancers—lung, breast, prostate, and colorectal—continue to decline. Over the past decade, Americans have experienced a 7 percent decline in mortality from cancer and hundreds of thousands of lives have been saved….We are making extraordinary progress in cancer research. This progress has opened new avenues to even greater opportunities that will enable us to reach our goal of eliminating the suffering and death due to cancer.2 NCI’s Challenge Goal: Eliminate the suffering and death due to cancer by 2015 With this, von Eschenbach introduced a significant challenge to the nation: eliminate the suffering and death due to cancer by 2015. Achieving that goal, he admitted, would not be easy—demanding commitment, research, and continued medical innovation. A key component in achieving victory, he said, was medical imaging: Cancer research and care are both critically dependent on imaging technologies. Imaging advances are already permitting remarkable accuracy in detecting whether a tumor has invaded vital tissue, grown around blood vessels, or spread to distant organs; allowing physicians to monitor patient progress without the need for biopsies; and allowing precise delivery of various tumor-destroying approaches. With sufficient resources, NCI will build on this momentum by expanding the discovery and development of novel imaging agents, devices, and methods; accelerating the integration of advanced imaging methods into therapeutic clinical trials; speeding the development and clinical testing of image-guided interventions (IGI); and stimulating research on components and systems integration of devices for in vivo molecular sensing.3 2 3 National Cancer Institute. The Nation’s Investment in Cancer Research: A Plan and Budget Proposal for Fiscal Year 2005, October 2003. Ibid. 4 Medical Imaging in Cancer Care Over the past 50 years, medical imaging technologies have contributed significantly to improvements in cancer diagnosis and treatment. One of the biggest challenges is the very nature of cancer itself. Cancer is a constellation of many diseases, which means we are actually fighting—and in many cases winning—multiple wars on numerous battlefields. Over the past 50 years, medical imaging technologies have contributed significantly to improvements in cancer diagnosis and treatment. This is not to suggest that cancer has been conquered. More than one million people will be diagnosed with cancer this year. At least half a million will die from it. There is encouraging news, however. The American Cancer Society reports that the number of cancer survivors has tripled in the last three decades. What these numbers suggest is that millions of people are alive today— conducting healthy, active lives—people who would not have survived even a decade ago. One of America’s most dangerous killers is taking fewer lives than it might have, thanks in no small part, to medical imaging technologies. The contributions of medical imaging to the research, clinical, and economic achievements in cancer care have been widespread and dramatic. 5 Medical Imaging Technologies B efore detailing the clinical contributions of medical imaging in cancer care, it is important to understand the primary imaging technologies and what they do. The following highlights the medical imaging innovations that work daily to improve the health outcomes of cancer patients by enhancing diagnosis and treatment:4, 5 X-Rays X-rays (also called radiographs) are used in cancer diagnosis and typically represent a two-dimensional image. For example, chest radiographs are often used for early cancer detection or to see if cancer has spread to the lungs or other areas in the chest. X-Ray Mammography Mammograms use X-rays to look for tumors or suspicious areas in the breasts. A key benefit of mammography is its ability to identify changes in the breasts before a patient or physician can feel any suspicious abnormalities. Mammograms can be recorded either on conventional film or digitally, using an electronic digital detector. Early detection through mammography has been a major factor in the dramatic decrease in breast cancer mortality. Ultrasound Ultrasound, also called sonography, is an imaging technique in which high-frequency sound waves that cannot be heard by humans are bounced off tissues and internal organs. Their echoes produce a picture called a sonogram. Ultrasound is especially good at imaging soft tissues and distinguishing between solid tumors and fluid-filled cysts. It can help determine how far tumors of the uterus, esophagus, or rectum have spread, and it can help physicians learn whether cancer has spread into blood vessels, especially the liver and pancreas. Ultrasound is also used widely to guide minimally invasive therapies for liver, prostate, and other cancers. Another important use of ultrasound is to evaluate lumps that are hard to see or characterize on a mammogram. Sometimes, ultrasound is used as part of other Mammogram Ultrasound 4 5 Images courtesy of GE Healthcare. National Cancer Institute, Cancer Imaging Program, accessed February 10, 2006 at http://imaging.cancer.gov/imaginginformation/cancerimaging/. 6 Medical Imaging in Cancer Care diagnostic procedures, such as fine needle aspiration (also called needle biopsy) and is routinely used as a guide for determining the exact location of certain tumors treated with radiation therapy. In addition, ultrasound studies ensure that radiation treatments are correctly targeted. Computed Tomography A computed tomography scan (also known as a CT or CAT scan) uses computerintensive reconstruction techniques to create images of the body from X-rays. These are the same type of X-rays used for plain radiographs. However, a radiograph and a CT scan convey different types of information. A CT scanner makes images that are tomographic (cross-sectional) slices of the body (like slices of bread), and the data from a CT scan can be enhanced in several ways to show internal structures more vividly than on plain radiographs. Thus, a physician could not only tell if a tumor is present, but roughly how deep it is in the body. Recent technical advances dramatically improved CT. Called multi-slice or helical (spiral) scanning, which takes continuous pictures in a rapid spiral motion and eliminates gaps between the slices collected, these CT advances improved both speed and readability. Current CT technology allows an entire study to be collected as a single volume of information (known as volumetric CT study). The speed of current computer processors allows the oncologist to reconstruct the “slices” of the patient in any plane requested and use any slice thickness to help build a more definitive diagnosis of the patient’s disease. CT scans are among the most common imaging technologies used in diagnosing cancer, as well as in planning and monitoring cancer treatment; especially in detecting cancer of the liver, pancreas, lungs, and bones. CT is also important in providing information on cancer in the stomach, intestines, and brain. Computed Tomography Magnetic Resonance Imaging Magnetic Resonance Imaging (MRI) uses radio frequency (rf) waves in the presence of a strong magnetic field that passes through the cavity of the MRI machine where the patient lies. These rf waves are used to get tissues to emit radio waves of their own. Different tissues (including tumors) emit a more or less intense signal based on their chemical makeup, so a picture of the body organs can be reconstructed and displayed on a computer screen. Much like CT scans, MRI can produce three-dimensional images of sections of the body, but MRI is often better than CT scans for distinguishing soft tissues. MRI is the standard for imaging brain tumors, as well as for evaluating the status of the tumor and how the patient responds to treatment.6 Additionally, it is often the best method of detecting and characterizing cancer in the head, neck, bones, and muscles.7 Magnetic Resonance Imaging Nuclear Medicine (Planar and SPECT Gamma Imaging, PET) Nuclear imaging uses low doses of radioactive substances to help visualize specific biological processes in the body or in certain types of tissues, such as tumor cells. 6 7 Prados, MD et al. “Primary Central Nervous System Tumors: Advances in Knowledge and Treatment.” CA—A Cancer Journal for Clinicians. 48 (1998): 331-360. American Cancer Society, accessed February 10, 2006 at http://www.cancer.org/docroot/PED/content/PED_2_3X_Imaging_Radiology_Tests.asp?sitearea=PED. CHARTING THE PROGRESS 7 Using special detection equipment, clinicians can trace the radioactive substances to see where and when they concentrate. This means cancer cells can be identified in tissue and bone, thus assisting with more precise and effective treatment. Typically, nuclear medicine studies are among the most sensitive types of studies for determining the presence or spread of cancer. Most routine nuclear medicine studies are performed with compounds that emit gamma rays that are detected by a gamma camera, while SPECT is a specialized form of gamma imaging, and PET utilizes a different kind of radiation detection altogether. Planar Gamma Imaging: A small amount of a radioactive drug is injected into a vein, and—as the cells process the radioactive material—a scanner creates detailed images. One of the most common studies in oncology is bone scanning, which has been used for decades as a highly accurate means to assess whether various cancers, like lung or breast cancer, have spread to the bones. Newer agents used for nuclear oncology imaging include compounds that target specific receptors or proteins on the surface of tumor cells. Some of these agents have evolved into therapeutic agents for certain cancers, and imaging is crucial to those treatments. Also, nuclear techniques are often used to monitor heart function in cancer patients, as some of the common chemotherapy drugs can weaken the heart muscle. Planar Gamma Imaging SPECT Gamma Imaging: Single photon emission computed tomography (SPECT) uses the same type of radioactive tracers as planar gamma imaging, but the gamma cameras are operated in a special way to record data that a computer reconstructs into two- or three-dimensional images. This provides an advantage similar to that of CT— that is, allowing physicians additional precision in detecting and localizing cancer deposits. SPECT is particularly advantageous in cancer studies that image specific receptors or proteins residing on the cell surface of many tumors. For example, a number of radioactively labeled antibodies bind to special proteins called antigens on the tumor surface. These radioactive antibodies concentrate at the site of tumor deposits and can thus be imaged and localized with SPECT. In the future, other cancer-specific molecular imaging SPECT tracers are likely to play a large role in imaging cancer patients. PET: The positron emission tomography (PET) scan is similar to SPECT, but uses different types of radioactive tracers, called positron-emitters, to image biochemical and physiologic processes. For the large majority of oncologic PET studies, the patient is given an injection of a substance that consists of a small amount of a radioactively labeled compound similar to a common sugar, glucose. The radioactive sugar can help in locating a tumor, because cancer cells use glucose more avidly than other tissues in the body. By showing metabolic changes in tissues and tumors, PET scans provide a vital tool in cancer management and therapy.8 For many common tumors, PET is the most accurate single imaging technique for visualizing the spread of tumor or its response to therapy. SPECT Gamma Imaging PET/CT 8 “Imaging Techniques Improve Cancer Detection.” Medical College of Wisconsin, accessed February 10, 2006 at http://healthlink.mcw.edu/article/1031002410.html. 8 9 The Role of Imaging in Cancer Care I n some ways, the role of medical imaging in cancer is something of an anomaly. On the one hand, imaging plays a vital role in detecting and treating virtually all types of cancer, in addition to the critical role it plays in medical research and drug discovery. On the other hand, these contributions, both clinical as well as economic, are often poorly understood or not well recognized. Imaging is Key to Future Cancer Research “The ability to detect, through imaging, the molecular changes associated with a tumor cell will improve our ability to detect and stage tumors, select appropriate treatments, monitor the effectiveness of a treatment, and determine prognosis.” Ellen Feigal, MD Acting Director Division of Cancer Treatment and Diagnosis, NCI Cancer Imaging Informatics Workshop September 25, 2002 This paper will highlight the various roles medical imaging plays in cancer care, ranging from its ability to detect cancer at its early stages to its impact in fostering state-of-the-art management of cancer therapy and follow-up. Among these key characteristics of imaging in cancer care are the following: I Imaging Detects Cancer Early I Imaging Enables Less-Invasive Cancer Diagnosis and Treatment I Imaging Fosters More Effective Management of Cancer I Imaging Fosters Efficiencies and Savings in Cancer Care I Imaging Keeps Workers Productive Imaging Detects Cancer Early Medical imaging often detects cancer at its most curable stage—and, in many cases, when it is least costly to treat. As such, medical imaging is center-stage in America’s efforts at cancer prevention and early detection. Sometimes this occurs through screening programs to spot cancer early in individuals who otherwise seem perfectly healthy. In many cases, however, imaging is used to detect tumors or other forms of cancer at their early stages when patients go to the doctor with worrisome symptoms. Molecular imaging enables physicians to go even further, detecting disease at the cellular level, before any symptoms or signs are noticeable. Mammography Screening Detects Breast Cancer Early More than 200,000 new cases of breast cancer will be diagnosed in the U.S. during the next year—and more than 40,000 patients will die. But there is good news: the mortality rate from breast cancer is dropping—down 16 percent in the last 20 years. Early detection through mammography has been a major factor in the dramatic decrease in breast cancer mortality. In fact, mammography is one of the key factors in early stage detection—some 63 percent of breast cancers are detected at the localized 10 Medical Imaging in Cancer Care stage (as a result of mammography screening) for which the 5-year survival rate is 97.5 percent9. A recent study in the British medical 33 journal, The Lancet,10 reported that 32 the dramatic reduction in the 1531 year mortality rate from breast 30 cancer comes about, in part, 29 through early detection by 28 mammography. 27 Before mammography, women 26 relied upon self-exams, often discovering lumps at later, and 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 more dangerous stages. Although Age-adjusted self exam remains an important Source: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov), Total U.S. (1969tool in early detection, the size of a 2002), National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released palpable lump is much larger and April 2005. Underlying mortality data provided by NCHS (www.cdc.gov/nchs). indicative of further growth than that detectable using imaging. Advances in mammography include increasing speed, precision, comfort, and 9,000 capabilities. Other imaging technologies, such as MRI, ultrasound, and computerassisted diagnosis (CAD)—a kind of computerized double-checking system—are also 8,000 joining in the battle against breast cancer. Studies show that CAD mammography 7,000 systems can increase the detection rate of early breast cancer by one-third.11 6,000 One of the most significant advances in mammography in recent years has been the development of digital mammography. With this technology, images are created 5,000 digitally, rather than on film, offering physicians greater precision, detail, and 4,000 flexibility. The digital nature of the images also fosters greater productivity—including 3,000 the ability to send, store, and retrieve images electronically. With this, physicians can consult with colleagues at distant locations, and underserved areas can gain access to 2,000 world-class radiologists and other physicians. Digital mammography is also a core 1,000 component of electronic health records—electronic files that contain a patient’s medical history. Digital images can now be incorporated into the electronic record, w/o PET Scan with PET Scan allowing physicians to see a patient’s imaging scans while he or she examines the Conventional Work-up patient's medical history. Studies have repeatedly shown the economic and productivity gains from electronic health records. Breast Cancer Mortality, Females, All Ages and Races, 1975–2002 Detecting Disease at the Molecular Level The promise of molecular imaging (i.e., PET imaging), sometimes called the next frontier of diagnostic imaging, is its ability to detect “pre-diseases.” It probes the fundamental biology of disease—that is, changes and abnormalities at the cellular and molecular levels that lead to disease. In most cases, this means identifying the evolution of a disease process, such as cancer, long before signs and symptoms are apparent.12 Patient Time Facility Costs Equipment Supplies Provider Time 0 50 100 150 200 250 300 350 400 American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2005. 2005. Dollars 10 “Effects of Chemotherapy and Hormonal Therapy for Early Breast Cancer on Recurrence and 15-year Survival: An Overview of the Randomised Trials.” Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), The Lancet. 365 (2005): 1687-1717. 11 Destounis, SV et al. “Can Computer-aided Detection with Double Reading of Screening Mammograms Help Decrease the False-Negative Rate? Initial Experience.” Radiology. 232 (2004): 578-584. 12 Weissleder, R and U Mahmood. “Molecular Imaging.” Radiology. 219 (2001): 316-333. 9 Euros Deaths per 100,000 population CHARTING THE PROGRESS 11 Molecular imaging, used to track the growth of cancerous tumors, also can ensure that various therapies treat only the cancer cells, avoiding the toxic effects of treatment on the patient’s healthy tissue. In the future, molecular imaging is expected to aid in identifying the presence of drug-resistant genes enabling clinicians to predetermine which treatment regimens will be most effective within hours or days of initiating treatment. This will help minimize ineffective as well as inappropriate treatments and avoid delays in optimizing a patient’s therapy. There is an additional benefit as well. Eliminating ineffective or inappropriate treatments, treatments that are typically expensive, can save the health care system money. Imaging Enables Less-Invasive Cancer Diagnosis and Treatment Medical imaging enables a range of less-invasive, highly targeted cancer therapies that translate into better and more comfortable care for patients. Because they are less invasive, these treatments mean fewer complications, shorter hospital stays, and, in many cases, no incisions or surgery. Thus, the patient benefits in two ways—better care and more comfortable, convenient care. Bone Tumors: Medical Imaging Reduces Surgery Over the past 50 years, advances in medical imaging have virtually replaced exploratory surgery. Physicians today routinely use medical imaging to diagnose various cancers, including bone tumors. Only a few years ago, patients with suspected cancerous tumors had only one choice to find Image-Guided Percutaneous Biopsy vs. Open Surgical Biopsy in out for sure whether the tumor was Diagnosis of Primary Bone Tumors malignant. They had to undergo Image-Guided Open Surgical exploratory surgery—with long Bone Biopsy Biopsy hospital stays and recuperation time. Procedure Time <1 hour >1 hour Medical imaging has changed Complication Risk 1% 2–20% that. Minimally invasive Treatment Start After Procedure 1 day 10–21 days procedures guided by fluoroscopy, Location Outpatient Inpatient CT, ultrasound, and MRI have Incision/Scar None 2–5 inches virtually replaced open surgical Wound Healing Prompt Delayed biopsy for bone (and other) tumors. Accuracy High High According to researchers, these Source: Jelinek JS et al. “Diagnosis of Primary Bone Tumors with Image-Guided Percutaneous Biopsy: image-based procedures range Experience with 110 Tumors.” Radiology. 223 (2002): 731-737 and “Image-Guided Bone Biopsy: Faster, Easier, Safer,” RSNA, May 28, 2002. from three to seven times more cost-effective than surgical biopsies.13 A 2002 study in Radiology reported that image-guided percutaneous biopsy of bone tumors creates new efficiencies while fostering less-invasive care. Among them: shorter procedure time, fewer infections, fewer complications, and earlier wound healing. Another benefit of the non-surgical approach is an earlier start for therapy: “With definitive diagnosis, therapy can be started the day after core needle biopsy. 13 Jelinek, JS et al. “Diagnosis of Primary Bone Tumors with Image-Guided Percutaneous Biopsy: Experience with 110 Tumors.” Radiology. 223 (2002): 731-737. 12 Medical Imaging in Cancer Care After a surgical approach, a delay of 10 days to 3 weeks is required to allow wound healing and prevention of infection and bleeding.”14 Though savings that result from the substitution of image-based therapies for surgery may seem apparent, they are worth underscoring. Fewer complications mean fewer days in the hospital, less demand on hospital personnel, fewer visits to physicians, and lower costs. Shorter procedure times translate into administrative efficiencies, such as greater availability of surgical suites and staff. From the patient’s perspective, avoiding weeks of recuperation translates into fewer lost work-days, less sick-leave, and a decreased need for caregivers. Medical imaging has become a key component of comprehensive oncology care. Prostate Cancer: Minimally Invasive, Image-Guided Cancer Treatment Improves Outcomes Medical imaging helps oncologists target cancer-killing agents directly to the diseased tissue, even if it lies deep within the body. The results are improved treatment, fewer complications, and—in many cases—longer life. Under the guidance of MRI or ultrasound, physicians can place radioactive material encapsulated in metallic “seeds”—about the size of grains of rice—inside the prostate where the seeds can deliver the radiation dose directly to the cancerous tissue. This minimally invasive procedure, called ultrasound-guided prostate brachytherapy, results in lower complication rates, including chronic side effects such as urinary incontinence and impotence.15,16 There is no need for an incision, sutures, or general anesthesia. Brachytherapy is performed in about an hour using needles to deliver the seeds to their intended place in the tumor, and patients can return to normal activities in a day or two.17 Radical surgery, on the other hand, can require a three to seven day hospitalization and weeks of recovery.18 Other studies also report promising findings: I Some 87 percent of the patients with low-risk disease who received brachytherapy in one study showed no signs of recurrence 10 years later.19 I Another study found that this procedure is equally effective in African-American males whose five-year survival rates from prostate cancer have been lower than those for all races combined.20 Imaging Fosters More Effective Management of Cancer Medical imaging has become a key component of comprehensive oncology care. An essential tool in cancer therapy and management, imaging can determine the presence or spread of cancer in addition to visualizing a patient’s response to therapy. Imaging helps ensure that radiation is delivered according to the precise shape of a tumor, thereby killing cancer cells and avoiding substantial damage to sensitive, healthy surrounding tissue. 14 15 16 17 18 19 20 Ibid. Tempany, CM and BJ McNeil. “Advances in Biomedical Imaging.” Journal of the American Medical Association. 285 (2001): 562-567. “Will Radical Prostatectomy Become Obsolete?” Contemporary Urology. 14i:10 (2002): 75. Ragde, H et al. “Modern Prostate Brachytherapy.” CA—A Cancer Journal for Clinicians. 50.6 (2000): 380-393. WebMD, accessed February 24, 2006 at http://www.webmd.com/hw/prostate_cancer/hw77111.asp. Grimm, PD et al. “10-year Biochemical (PSA) Control of Prostate Cancer with 125-I Brachytherapy.” International Journal of Radiation, Oncology, Biology, and Physics. 52.1 (2001): 31-40. Radiological Society of North America. Brachytherapy and Early Diagnosis: Prostate Cancer Cure Rates Similar for African-American and White Males. December 2002. CHARTING THE PROGRESS 13 The Evolution of Image Guidance in the Treatment of Lung Cancer Planning treatment for patients with cancer relies heavily on imaging. Various types of imaging technologies help establish the stage of the tumor, determine its exact location and contours—as well as its relationship to surrounding organs—and assess how well it responds to treatment.21 The first studies on CT imaging for planning lung cancer treatment appeared more than 20 years ago.22,23 During the early years, treatment relied primarily on 2D techniques that suffered from significant flaws. Among other things, these methods did not account for the large differences between the density of lung tissue and that of other structures in the chest. The result was that physicians were able to develop only a limited understanding of the actual doses received by the tumor. In addition, the lack of information about the effect of a patient's breathing or of the patient's heart beating on the motion of the tumors led physicians to broaden the margins around the radiation target, resulting in irradiation of a large volume of the chest cavity. Since that time, advances in CT, as well as the development of PET scanning, have given physicians more targeted and detailed information. For example, functional PET imaging—which shows where the active cancer is—aids radiation oncologists in designing treatment fields and helping them fully understand the nature and extent of the cancer. If the PET information reveals other sites of disease within the chest—in addition to the original tumor—the treatment plan may call for a palliative course of therapy rather than intensive treatment that would likely only subject the patient to more side effects with little, if any, improved chance of cure. On the other hand, PET is valuable in helping determine whether a mark on a CT scan is a tumor or a collapsed lung. The PET findings can also be superimposed on the CT study to indicate the extent of tumor, yielding a much more accurate description of the tumor for the oncologist to use in targeting treatment. Similarly, the rapidly growing interest in 4D CT for treatment planning will be an essential component in optimizing patient treatment.24 The 4D CT information enables the oncologist to observe the exact tumor position throughout the course of normal breathing. This assists the oncologist in designing a treatment volume that ensures the tumor is encompassed at all times during the breathing cycle. The Evolution of Image Guidance in the Treatment of Prostate Cancer The importance of imaging in guiding therapy can be seen clearly in managing prostate cancer as well. For decades, the nature of the technology forced a great deal of guesswork in targeting radiation therapy to tumors. To identify the location and precisely target the tumor, physicians used some of the X-rays from the radiation treatment beam itself to make an X-ray image. But, as with traditional medical X-ray images, these therapy X-ray images showed primarily the bony anatomy of the patient and not the soft tissues or organs very well. As a result, physicians went to great lengths to correlate the “expected” position of the soft tissue targets (i.e., the prostate gland) to regional bony anatomy that was visible on the X-ray. Although largely successful, this generic approach required oncologists to 21 22 23 24 Planning treatment for patients with cancer relies heavily on imaging. Blomquist, L and MR Torkzad. “Whole Body Imaging with MRI or PET/CT: The Future of Single-Modality Imaging in Oncology?” Journal of American Medical Association. 290.24 (2003): 3248-3249. Lackner, K et al. “Importance of Computed Tomography in Irradiation Planning for the Thoracic Region.” Strahlentherapie. 157.3 (1981): 157-163. McCullough, EC. “Potentials of Computed Tomography in Radiation Therapy Treatment Planning.” Radiology. 129.3 (1978): 765-768. Underberg, RW et al. “Four-Dimensional CT Scans for Treatment Planning in Stereotactic Radiotherapy for Stage I Lung Cancer.” International Journal of Radiation Oncology, Biology and Physics. 60.4 (2004): 1283-1290. 14 Medical Imaging in Cancer Care 33 Deaths per 100,000 population 32 31 30 29 28 27 26 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 Age-adjusted use large treatment fields to compensate for differences between individual patients as well as to account for daily changes in any given patient. Improvements in medical imaging have changed that. Access to imaging technologies like CT, MR, and ultrasound over the last 20 years has given oncologists the resources to plan treatments for their patients, without the limits of traditional X-rays. In the case of prostate cancer, use of ultrasound imaging immediately before beginning treatment has become part of the clinical mainstream because it provides important, volumetric information of the prostate and the regional anatomy near the prostate. Similar use of CT imaging will also yield high-resolution images of the target at the time of treatment. Although still in its first generation of development, the use of CT in this way is expected to become part of standard treatment for a very simple reason: as with ultrasound, PET, and other imaging technologies used in targeting various types of cancer over the past two decades, CT will add yet greater precision in escalating dose to the prostate target while limiting harm from irradiation of surrounding tissue. Average Costs of Conventional Work-up vs. Conventional Work-up Plus PET Scan Costs shown in Euros Imaging Fosters Efficiencies And Savings in Cancer Care Medical imaging makes the health care system work more efficiently by fostering greater economy and cost savings. Such savings are often apparent, as when imaging replaces surgery. Other times, however, savings are harder to see, as when imaging allows a patient to recover in half the time. Imaging’s newest frontier, using information technology to superimpose or fuse digital images together, or combine digital images with other clinical and laboratory information, is introducing savings that stretch throughout the health care system. The clinical gains in the diagnosis and treatment of cancer create another benefit: They offer significant economic gains as well—from the economic value of longer life to the productivity gains of reduced hospitalization. 9,000 8,000 7,000 6,000 Euros I Imaging Tests I Non-invasive tests I PET I Surgery I General Hospital Ward 5,000 4,000 3,000 2,000 1,000 I Intensive Care Ward Imaging Saves Money by Reducing or Eliminating Unnecessary or Inappropriate Care PET scans are able w/o PET Scan with PET Scan to reduce futile operations for lung cancer by 50 percent. While Conventional Work-up avoiding such surgeries obviously benefits patients, a recent Source: Verboom, P et al. “Cost-Effectiveness of FDG-PET in Staging study25 also found that, in doing so, PET scans reduce overall Non-Small Cell Lung Cancer: The PLUS Study.” The European Journal costs. In the group of patients who received a conventional of Nuclear Patient Time Medicine and Molecular Imaging. 30.11 (2003). diagnostic work-up, 41 percent of patients underwent futile operations—in effect, there was nothing that could be done for Facility Costs the patients. In the group that also received PET scans, only 21 percent of the Equipment operations were futile. The reduction translated into one prevented unnecessary surgery for every five PET scans. The average cost of treatment based on a work-up Supplies that included a PET scan, as compared to a conventional diagnostic work-up resulted in a savings of 13 percent. The savings came from reduced costs of surgery, hospital Provider Time stays, and intensive care. 0 50 100 150 25 200 250 300 350 400 Verboom, P et al. “Cost-Effectiveness of FDG-PET in Staging Non-Small Cell Lung Cancer: The PLUS Study.” The Dollars European Journal of Nuclear Medicine and Molecular Imaging. 30.11 (2003). CHARTING THE PROGRESS 15 Ultrasound-Guided Liver Biopsies Reduce Liver Biopsy without Ultrasound and with Ultrasound Complications and InHospital Time Proper diagnosis of most liver diseases requires Liver Biopsy physicians to conduct surgical Biopsy WITHOUT Biopsy WITH biopsy of the liver. Discomfort and Ultrasound Ultrasound pain are common complications, requiring hospitalization in about No Complications No Complications 4 percent of patients.26 But 48% (no cost) 62% (no cost) complications and hospitalization rates drop significantly when Minor Complications Minor Complications physicians use ultrasound to guide 50% ($58/complication) 37% ($58/complication) the biopsy—thus allowing patients to avoid pain and return to their Major Complications Major Complications regular routines sooner. 2% ($5,000/complication) 0.5% ($5,000/complication) Another study found that 62 percent of patients who received Source: Pasha, T et al. “Cost-Effectiveness of Ultrasound-Guided Liver Biopsy.” Hepatology. 27.5 (1998). ultrasound experienced no complications at all versus 48 percent whose biopsy was done without ultrasound.27 About 2 percent of nonultrasound patients were hospitalized—with an average length of stay of 3.5 days, versus 0.5 percent of ultrasound patients. Imaging Keeps Workers Productive Medical imaging in cancer detection and therapy can help keep workers healthy and on the job by avoiding surgery, long recuperation, and disability. Improvements in cancer care and cures, along with the accompanying enhancements in quality of life and functioning, have brought significant economic value. Economists are calculating the economic value of longer life expectancy, better functioning, reduced disability, and greater employee productivity. Keeping Workers Healthy and Productive Creates Economic Value Economist David Bloom, Ph.D., points out that healthy, active workers are essential ingredients in a nation’s economic strength. In Bloom’s words, “Healthier means wealthier.”28 That makes sense especially when the productivity costs of poor health are factored into the equation. In 2004, the overall cost of cancer in the U.S. was $189.8 billion. That figure includes $69.4 billion in direct medical expenses, $16.9 billion for lost worker productivity due to illness and $103.5 billion for lost worker productivity due to premature death.29 26 27 28 29 Lindor, KD et al. “The Role of Ultrasonography and Automatic Needle Biopsy in Outpatient Percutaneous Liver Biopsy.” Hepatology. 23.5 (1996): 1079. Pasha, T et al. “Cost-Effectiveness of Ultrasound-Guided Liver Biopsy.” Hepatology. 27.5 (1998). Also see Lindor, KD et al. “The Role of Ultrasonography and Automatic Needle Biopsy in Outpatient Percutaneous Liver Biopsy.” Hepatology. 23.5 (1996): 1079. “Better Health Boosts GNP Coy P Business Week, p.28, December 3, 2001. ,” , From the Council of State Governments, “Comprehensive Approaches to Cancer Control” based on data from the U.S. Centers for Disease Control and Prevention, American Cancer Society, and National Cancer Institute, 2005. 27 26 16 Medical Imaging Cancer Care 1976 1978 1980 1982 1984 1986 1988 in1990 1992 1994 1996 1998 2000 2002 Age-adjusted Percentage Economic Benefit of Early Detection Here is how better cancer care can lead to better economic outcomes: In addition to saving lives, early breast cancer detection through mammography offers important economic benefits, according to a new study in the American Cancer Society journal, Cancer.30 The study of 1433 cancer survivors found that breast cancer survivors are among the most likely to go back to work or remain on the job several years after treatment. 9,000 The reason, according to the researchers, is that mammography detects breast cancer 8,000 early, when treatments are most effective. 7,000 The study, which explored the impact of various types of cancer on employment, found that 4 out of 5 cancer survivors either continued working or returned to their 6,000 jobs within several years of their treatment. The researchers found that patients with 5,000 breast cancer, cancer of the uterus, melanoma, and thyroid cancer were most likely to 4,000 return to work. The Cancer study underscored a key fact: That returning to work is a significant 3,000 outcome measurement in determining the success of treatment. “For society, the total 2,000 economic burden of cancer is increased by the lost productivity of survivors who quit working, reduce their hours, or 1,000 have disabilities that limit the w/o PET Scan with PET Scan kind of work they can do.” Average Resource Costs for Surgical vs. Conventional Work-up Image-Guided Core Needle Biopsy Imaging Saves Money by Reducing the Costs of I Image-Guided Core Needle Biopsy Patient Time I Surgical Biopsy Individual Treatments or Episodes of Care Similar Facility Costs productivity gains for employees can be seen when imaging is used Equipment to guide breast biopsies. ImageSupplies guided core needle biopsy is a minimally invasive procedure that Provider Time uses ultrasound or mammography images to locate a suspicious lump 0 50 100 150 200 250 300 350 400 Dollars or nodule in the breast. A thin needle is then inserted to remove a Source: Burkhardt, JH and JH Sunshine. “Core-Needle and Surgical Breast Biopsy: Comparison of Three tissue sample. Studies show that Methods of Assessing Cost.” Radiology. 212 (1999): 181-188. this procedure improves productivity and savings. One study31 found that a surgical biopsy—in which the tissue is removed through a surgical incision in the breast—costs two-and-a-half to three times more than the image-guided core needle biopsy ($698 vs. $243). That factors in the costs of the hospital, doctors, nurses, supplies, and the value of the patient’s time away from work. The researchers reported that the average amount of time that patients needed to be away from work was 6.9 hours for core needle biopsy and 13.9 hours for surgical biopsy. Those who underwent the core needle procedure were able to return to their normal activities after 24 hours, on average, while those who underwent surgical biopsy 80 were not able to do so for 48 hours. The study authors noted that if the one million surgical breast biopsies performed 60 annually in the U.S. used the core needle approach, the total savings could be as much as $1.6 billion every year. Euros 40 30 31 20 Short, PM et al. “Employment Pathways in a Large Cohort of Adult Cancer Survivors.” Cancer. 103.6 (2005): 1292-1301. Burkhardt, JH and JH Sunshine. “Core-Needle and Surgical Breast Biopsy: Comparison of Three Methods of Assessing Cost.” Radiology. 212 (1999): 181-188. 17 Major Challenges Remain D espite our many successes, many challenges still exist. One of the primary challenges is that many individuals are not receiving needed cancer care. Some 45 million Americans do not have health insurance—and thus do not have adequate access to care. In addition—regardless of insurance coverage— Americans as a whole often do not receive widely recommended treatments. A 2003 study by the RAND Corporation published in The New England Journal of Medicine concluded that Americans receive only about half of well-established, widely-recommended treatments and medical interventions. The study found that patients with colorectal cancer received 54 percent of recommended care, but just 38 percent of adults were screened for colorectal cancer. Routine tests and appropriate follow-up could prevent 9,600 deaths a year. The study concluded that the deficit between what we know works and what is actually done poses “serious threats to the health and well-being of the U.S. public.”32 Other complex challenges remain, particularly in the area of minority health. The National Cancer Institute reports that “one in four deaths in the U.S. is attributable to cancer, and one in three Americans will eventually develop some form of cancer. Each day, 3400 people in America are diagnosed with cancer and another 1500 die from the disease. But the burden of cancer is too often greater for the poor, ethnic minorities and the uninsured than for the general population.”33 Although everyone is at risk of developing some form of cancer:34 I Overall, African-Americans are more likely to develop cancer than persons of any other racial or ethnic group. I African-American women have lower incidence rates of breast cancer, but experience higher death rates than other women. I Cervical cancer incidence in Hispanic women has been consistently higher at all ages than for other women. I American Indian and Alaska Natives have the poorest survival from all cancers combined in comparison with all other racial and ethnic groups. 32 33 34 McGlynn, EA et al. “The Quality of Health Care Delivered to Adults in the United States.” New England Journal of Medicine. 348.26 (2003): 2635-2645. National Cancer Institute. The Nation’s Investment in Cancer Research: A Plan and Budget Proposal for Fiscal Year 2005. October 2003. From Comprehensive Approaches to Cancer Control, The Council of State Governments, based upon data from the U.S. Centers for Disease Control and Prevention, www.cdc.gov/cancer/minorityawareness/index.htm. 2005. 18 Medical Imaging in Cancer Care Continued Innovation to Meet Continued Demands These challenges necessitate an enlightened public policy that I 2010 Healthy People Objectives I Average recognizes the importance of I Uninsured investment in innovation and in I No usual source of care 80 I In U.S. < 10 years access to needed care. A myopic view, focused only on short-term 60 expenditures, will cost the U.S.— both its citizens as well as its 40 economy—more in the long run. Without an understanding of productivity improvement and 20 economic output from advances in cancer care, public policy often Men Women Pap test within Mammogram within focuses only on cost. To be sure, the last 3 years the last 2 years Colorectal cancer screening within the last in women 25+ in women 40+ costs are a critical and appropriate 5 years in adults 50+ years years of age years of age concern. But addressing them should not overshadow the value Source: www.cdc.gov/cancer/minorityawareness/overview.htm that technological innovation brings in making Americans healthier, more able, and more productive—critical factors particularly in a knowledge-based economy. Greatest Disparities in the Use of Cancer Screening Tests Percentage In fact, the NCI stressed this point in its National Advanced Technologies Initiative for Cancer:35 Our Nation’s economy will almost certainly benefit from the initiative, as the global economy is increasingly being driven by knowledge-based industries including advanced biomedical technologies. In addition, a second, possibly even more powerful, economic stimulus effect will likely accrue. Improved care for cancer and other diseases based on molecularly targeted interventions will eliminate a vast portion of the human and financial loss associated with cancer and other diseases. Current estimates indicate that reducing the death rate from cancer by only 20% would contribute about $10 trillion to the Nation’s economy, more than one year’s gross national product.36 These findings underscore the critical need for public policies that foster medical innovation. The effects of illness and disability from cancer must be minimized so that productive workers can grow the economy and fewer seniors will be sidelined with costly medical needs. The price tag of inaction is high. 35 36 National Cancer Institute. National Advanced Technologies Initiative for Cancer: Harnessing the Full Potential of Advanced Technologies to Eliminate Suffering and Death Due to Cancer. Murphy, K and R Topel (eds). Medical Care Output and Productivity. Chicago, Ill.: University of Chicago Press. 2002. CHARTING THE PROGRESS 19 The economic and clinical gains in cancer care over the past half century will continue—and be available to address the nation’s unmet needs—only if public policy recognizes that: I Medical imaging fosters better health and better cancer outcomes; I Better health brings economic value; I Economic value from better health is clear, real, and quantifiable; and I Innovation in medical technology—an inherently unpredictable and evolutionary process—lies at the heart of such achievements. Cancer can only be eradicated if we continue to chart a public-private path toward eliminating its suffering and death. We have less than a decade to go if we are to successfully meet NCI’s Challenge Goal to the nation. 20 21 Medical Imaging in Cancer Care: CHARTING THE PROGRESS Appendix: Major Advances in Medical Imaging Since 1950 T he war on cancer relies upon many kinds of medical treatments and technologies, but few have had more impact during the past half century than advances in medical imaging. Before development of computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and positron emission tomography (PET), among others, cancer patients had few options for diagnosing and staging cancer other than exploratory surgery and limited radiology exams. During the past 20 years, however, “technical advancements, refinements, and development of noninvasive imaging procedures have substantially improved the quality of medical care, and the care of the patient with cancer in particular,” according to John Hoffman and Anne Menkens of the National Cancer Institute.1 That progress has been seen both in faster, less-invasive diagnosis and easier, less painful, and minimally-invasive, imaging-driven therapies. These interventions provide clinicians with detailed “road maps” that are critical both in planning surgery and radiation therapy.2 Along with the improvements in cancer survival—no small part of which is due to medical imaging—such advances have redefined our fundamental thinking about cancer and how to treat it. And that appears to be just a start. Developments in molecular, cellular, functional, and genetic imaging, particularly in light of the mapping of the human genome, promise a new era of prediction and prevention of disease, not just diagnosis and treatment.3 That medical imaging is a core component of the National Institutes of Health program to accelerate movement of new discoveries and cutting-edge biomedical research from bench to bedside is no surprise. This table captures some of the most important milestones in the emergence of medical imaging as a critical clinical tool in the war on cancer. It explains briefly how each technology works, its impact on improving cancer diagnosis and care, and—for many technologies—“before-and-after” glances at how particular technologies changed the care for patients. The table also identifies the transition of medical imaging from simply diagnosing cancer, to its role in aiding treatment, to its future role in prevention and prediction. The table does not intend to be comprehensive; it attempts simply to highlight some of the medical imaging technologies that have been of great importance. Prepared by www.medicalimaging.org Copyright © US Oncology, Inc. and National Electrical Manufacturers Association (NEMA), 2006 22 Medical Imaging in Cancer Care Era Innovation Nuclear medicine introduced4 Outcome I Originally used to treat cancer of the thyroid and diagnose thyroid disease6 Diagnosing 1950s Uses small amounts of radioactive materials that are attracted to specific bones, tissues, or organs; special cameras create images of the tissue based on the amount of radiation emitted5 X-ray angiography introduced7 I Shows blood flow, vessel constrictions Originally used to help determine the stage of cancer, or the extent of a tumor; now largely replaced by CT and MRI Ultrasound developed in 1959, with high quality images emerging in the ‘70s Uses high-frequency sound waves to show internal tissues and organs I I I Originally used as diagnostic in obstetrics, often used today to guide minimally-invasive therapies for liver, prostate, other cancers Especially good at imaging soft tissues and distinguishing between solid tumors and fluidfilled cysts9 Helps determine how far tumors have proceeded through the wall of the uterus, esophagus, or rectum10 1970s 1960s diagnostic technology13 Nuclear medicine becomes key I Identifies cancer “hot spots” and blood flow to the lungs Routine mammography for breast cancer begins Uses X-rays to identify tumors, often before a lump can be felt I Key factor in dramatic reduction in mortality rates CT (computed tomography) becomes available Uses X-rays from different angles to show the shape, volume, size, and location of a tumor, as well as blood vessels that feed it.18 Produces crisp, detailed pictures of bones and cartilage and precise images of the brain I I Provides better detail, better treatment planning; replaces painful diagnostic procedure that led to nausea, severe headaches19 Permits early diagnosis, tailored treatment for colon, breast, and lung cancer CHARTING THE PROGRESS 23 Then vs. Now I Later used also to identify cancer “hot spots” throughout the body, nuclear imaging has become standard tool for identifying cancer Additional Information I Used today to help surgeons identify blood vessels near a tumor in order to limit blood loss during operation, and to diagnose noncancerous blood vessel diseases8 Doppler ultrasound, which shows blood movement in color, can help physicians learn whether cancer has spread into blood vessels, especially the liver or pancreas11 Reduces costs, improves outcomes in guiding bone tumor biopsies12 Before:…the only imaging options for soft-tissue required use of radiation… Today:…ultrasound provides detail by using harmless soundwaves… Before:…open surgery was required to obtain biopsy of suspicious mass… Today:…ultrasound guides physicians in minimallyinvasive biopsies without surgery, creating savings for patients and hospitals I I I By the ‘70s, most body organs could be imaged, including the liver and spleen; helped pinpoint brain cancer14 Before:…physicians were not able to track the spread of cancerous cells throughout the body… Today:…cancer cells could be identified in tissue and bone, thus assisting with more precise and effective treatment I Best tool to save lives through early detection15 Before:…women relied on self-exams, often discovering lumps at later, and more dangerous, stages… Today:…mammography is one of the key factors in early stage detection…some 63% of breast cancers are detected at the localized stage (as a result of mammography screening), for which the 5-year survival rate is 97.5%16 I In 1974, Betty Ford went on a highly publicized trip touting the importance of breast cancer screening and self-exams. Soon mammograms were recommended on TV—breast cancer is “out of the closet”17 I I Among the most common imaging technologies used in diagnosing and treating cancer, especially in detecting cancer of the liver, pancreas, lungs, and bones20 CT also important in providing information on cancer in stomach, intestines, and brain Before:…patients had to undergo a lengthy and painful procedure in which air was injected into their skulls and they were rotated upside down… Today:…patients experience virtually no pain in receiving scans which can take only seconds I I I I Called “the most significant development in radiology since the discovery of the X-ray”21 Paved the way for MRI22 Credited with saving Secretary James Brady’s life in 1981 after he was shot during the assassination attempt on President Reagan23 NIH pronounces CT scanners “safe, powerful, and cost-effective”24 24 Medical Imaging in Cancer Care Era Innovation PET (positron emission tomography) scanning introduced (1985) Shows cells and tissue functioning Outcome I Improves cancer management and therapy by showing metabolic changes in tumors and tissue25 Reduces futile lung cancer surgeries by 50% Diagnosing Treating 1980s I MRI (magnetic resonance imaging) introduced Uses magnetic fields to detect changes in radio-frequency waves, thus creating images of tissue and body structures I Especially useful in creating images of soft tissue within the body, including the workings of the heart and brain28 Interventional radiology introduced Uses ultrasound, X-ray, and other imaging to guide catheters and miniature tools through blood vessels or other parts of the body to deliver treatment directly to cancer site30 I Image-guided procedures such as shunting, drainages, and stenting have become key therapeutic approaches for different types of cancer therapy Imaging becomes part of standard cancer I Physicians begin substituting imaging for surgery Physicians rely on imaging to detect tumors, guide therapy, and aid in determining stage of disease and helping manage treatment increases Regular mammography screening I Public and private campaigns encourage regular screening I Early diagnosis through mammography a key factor in improvement in 15-year survival rate during the 1990s36 Screening mammography is believed to reduce mortality from breast cancer by 2030% and possibly by as much as 50%37 CHARTING THE PROGRESS 25 Then vs. Now I Reduces unnecessary surgery in pancreatic, esophageal, and gastric cancers Before:…X-rays showed only the outlines of existing structures, reducing the ability to detect tumors early or assess progress in treating them… Today:…physicians use PET images to show biochemical changes in tissue, enabling them to identify cancerous cells before structural changes occur Additional Information I I PET scans “changed the usual expectations of specialists”26 Private health insurers did cover PET procedures—CMS did not until 1995 – because they were impressed by its ability to distinguish between different kinds of heart disease, determine viability of heart tissue in preparation for bypass and transplants, and to identify metastasis cancers27 MRI does to bones what X-rays do to skin—it makes them disappear so physicians can see through them29 I Considered to be the imaging modality of choice for brain tumors Before:…patients underwent painful procedure in which air was injected into the brain… Today:…MRI provides virtually painless diagnosis, with exquisite detail and no patient discomfort I I Peritoneovenous shunting, which improved blood flow, was first used on patients with malignant ascites from liver cancer, then expanded to treat patients with abdominal, breast, genitourinary, and gynecologic cancers31 On Treatment Options: Before:…surgery was the only option for biopsy; and surgery and radiation were the only options for treatment… Today:…interventional radiology allows physicians to do biopsies, provide targeted therapy directly to the cancer, and relieve pain and discomfort – all without surgery32 On Patient Comfort: Before:…recovery from surgery was often long, painful, with many complications… Today:…for many patients interventional radiology means less painful therapy, less difficult and faster recovery, and fewer side effects and complications33 I For kidney cancer patients, surgery is the best chance for cure, but for those patients who cannot tolerate surgery, interventional radiology provides a lessinvasive approach34 I Invasive diagnostic and therapeutic interventions begin to give way to minimallyinvasive imaging procedures Before:…in the 70's, 50% of patients with rare form of tumors in the extremities underwent amputation to prevent spreading… Today:…radiation imaging and chemotherapy are able to control spread in nearly 90% of patients, without amputation35 I I Screening mammography is associated with reduced risk of cancer recurrence38 Breast cancer detected by screening has better prognosis than cancer at similar stage that is detected because of symptoms39 I I In 1989, a coalition of 11 organizations (including American College of Radiology, American Cancer Society, American Medical Association) issued a joint statement urging women to begin mammograms at age 4040 “Breast cancer detection becomes the equivalent of TB-screening crusades of the last quarter of the 20th century”41 26 Medical Imaging in Cancer Care Era Innovation Image-guided breast biopsy introduced Outcome I I Faster recovery, less pain, greater convenience, less cost Reduces costs by 70% compared to surgery; permits patients to return to work in half the time42 Permits faster stereotactic core needle biopsy45 Diagnosing Treating Managing 1990s Digital spot-view developed mammography I Creates digital images that can be used immediately to guide breast biopsies44 MRI use expands I Uses magnetic fields to detect changes in radio-frequency waves, thus creating images of tissue and body structures I I Becomes the standard for imaging brain tumors, as well as for evaluating the status of the tumor and how the patient responds to treatment47 Physicians can often distinguish cancerous from non-cancerous tumors with MRI Best method of detecting cancer in head, neck, brain, bones, muscles48 Brachytherapy for cancer expands I Imaging guides placement of radioactive “seeds” close to the tumor I Reduces open surgeries, hospitalization, and side effects. Can reduce recovery time from weeks to days51 Sometimes in conjunction with other radiation therapy, reduces mortality for cervical, esophageal, prostate, and other cancers52 3-D imaging used widely I Improves mapping of tumor, thus improving planning, targeting of treatment Shows tumor details in three dimensions Spiral CT introduced I Used in some lung cancer tumors, as well as tumors in the liver and pancreas56 Creates images as with standard CT, but rather than creating images of a single slice of the anatomy (like a slice of bread), takes continuous pictures as it rotates around the body55 CHARTING THE PROGRESS 27 Then vs. Now I Ultrasound use increases in helping diagnose breast cancer, especially to distinguish between benign cysts and solid tissue that requires a biopsy43 Additional Information I Shortens examination times, improves patient comfort and convenience46 I I Faster scanning has increased its clinical usefulness -- cardiac and vascular MRI provides good resolution of rapidly moving structures; essential for heart imaging – also allows high-quality, noninvasive peripheral arterial studies49 MRI significantly improves the chance of early breast cancer detection among women who are at high risk; detects twice as many cancers as mammography did in women whose cumulative lifetime risk of breast cancer was 15% or more due to family or genetic predisposition to the disease50 After 10 years, 87% of prostate cancer patients were disease-free53 Before:…radical surgery or weeks of external radiation were the only options for prostate cancer... Today:…brachytherapy guided by ultrasound can be done in outpatient setting, with few side effects, minimal-invasiveness, rapid recovery, and excellent outcomes54 I I 3-D detail allows physicians to increase radiation dose for the tumor, while minimizing radiation on healthy tissue I Multislice CT systems offer 3-D reconstructions and virtual endoscopy – it’s more patient-friendly and more anatomy can be scanned in less time57 28 Medical Imaging in Cancer Care Era Innovation Intensity-modulated radiation therapy developed Uses 3-D images from dozens of CT scans to map the tumor precisely, then targets intense radiation on the tumor while shielding healthy tissue Outcome I I Increases success rate, reduces sideeffects58 Treats many tumors considered untreatable Diagnosing Treating Managing Predicting 2000s CT use for virtual colonoscopy I Accurate, minimally-invasive screening for colon cancer to detect polyps in their earliest and most treatable stages This much less invasive procedure is an accurate, easier, and more convenient screening method than the traditional colonoscopy performed with optical scope62 CAD (computer-aided diagnosis) introduced for cancer detection Uses computer algorithms to “double check” scans read by technicians I CAD systems increase detection rate of early breast cancer by one-third64 PET scanning use expands I Advances in PET scanning improve cancer detection due to PET’s ability to identify chemical changes within cells Medicare expands coverage for use of PET in cervical, colorectal, esophageal, non-small cell lung, and head and neck cancers, as well as lymphoma and melanoma66 PET and CT scanning combined I Allows physicians to observe tumor structure and functioning Helps physicians better understand where the cancer is located, how far it has spread, and what types of treatment are most appropriate; also helps assess impact of treatment69 Studies done on three continents show that CT detects early stage lung cancer72 Key 1999 Cornell study finds that annual helical, low-dose CT scans in 1,000 heavy smokers over age 60 finds four times the cancers that X-ray finds and six times the number of stage I tumors, which are more treatable than later-stage cancer73 CT identifies non-small cell lung cancer I I Major advances in CT equipment and software allows identification of early stage, non-small cell lung cancer Advances include increased speed of CT scans, multi-slice scanners that provide more images with greater detail, and computer programs that “double check” images and help manage the large volume of images created by new scanners71 Molecular and functional imaging introduced Shows functioning of living cells and tissue I I Permits physicians to determine whether cells are healthy or diseased Aids in monitoring impact of treatment Digital mammography New version of traditional film-based mammography allows doctors to magnify and change the contrast of images for a better picture I Digital mammograms found to more accurately detect breast cancer in women under age 50 or perimenopausal and those with dense breasts78 CHARTING THE PROGRESS 29 Then vs. Now I Greater precision facilitates the treatment of a variety of cancers in children59 Before:…prior to 3-D imaging, radiation therapy was applied using “best guess” about the location of a tumor, exposing healthy tissue to increased toxicity…60 Today:…sophisticated imaging allows physicians to pinpoint tumor location and “sculpt” each beam of radiation to deliver high-doses only to the tumor, which kills cancer cells without substantial harm to surrounding, healthy tissue61 I Virtual colonoscopy also identifies medical problems outside the colon, including aneurysms and cancers63 Additional Information I Computer-aided diagnosis in liver lesions lead to 99% accuracy65 I PET improves detection of local and distant metastases in non-small cell lung cancer; becomes key element in diagnosing lung cancer67 Before:…physicians could identify cancer only after it had led to structural changes within the body, such as a tumor… Today:…PET permits physicians to identify malignant cells even before anatomical changes are visible… I “There is now substantial evidence that the use of PET with [FDG-18] can improve the accuracy of cancer staging in a cost-effective manner”68 I Using PET and CT scans combined was far more accurate than using either technique alone in determining the staging of non-small cell lung cancer70 Despite studies, debate continues over whether early detection improves mortality and identifies cancers that would not have been lethal74 I Death of prominent television journalist Peter Jennings in 2005 and activist Dana Reeve in 2006 brought renewed focus to lung cancer detection and treatment “The rapid improvement in resolution and cost of spiral CT has provided a powerful impetus to reconsider the possibilities for achieving safe, economical, and meaningful early lung cancer detection…”75 I I I Key step in identifying changes within cells that signal cancer76, 77 I I Digital mammography offers greater precision and detail in images, the ability for physicians to view images concurrently from different locations and also to transmit, share, and store images electronically Images can be integrated with hospital information technology systems and electronic health records I Over the next 10-15 years, almost all film systems will be replaced by digital X-ray detection, making it easier to enhance images, for practitioners to share files amongst themselves, increase ease of storage and archiving79 30 Medical Imaging in Cancer Care 1 2 Hoffman, JM and AE Menkens. “Molecular Imaging in Cancer: Future Directions and Goals of the National Cancer Institute.” Academic Radiology 2000. 7.10 (2000): 905. Koh, DM et al. “New Horizons in Oncologic Imaging.” New England Journal of Medicine. 348. 25(2003): 24872488. 3 Tempany, CM and BJ McNeil. “Advances in Biomedical Imaging.” Journal of the American Medical Association. 285.5 (2001): 562-567. 4 The Medical & Healthcare Marketplace Guide 2001-2002, 17th Edition. Philadelphia, P .A.: Dorlands Healthcare Information. 2002: 1427. 5 National Cancer Institute, Cancer Imaging Program, accessed February 10, 2006 at http://imaging.cancer.gov/imaginginformation/cancerimaging/page5#. 6 Society of Nuclear Medicine, accessed February 10, 2006 at http://interactive.snm.org/index.cfm?PageID=1110&RPID=3106&FileID=2136. 7 The Medical & Healthcare Marketplace Guide 2001-2002, 17th Edition. Philadelphia, P .A.: Dorlands Healthcare Information. 2002: 1427. 8 American Cancer Society, accessed February 10, 2006 at http://www.cancer.org/docroot/PED/content/PED_2_3X_Imaging_Radiology_Tests.asp?sitearea=PED. 9 Ibid. 10 Ibid. 11 Ibid. 12 Jelinek, JS et al. “Diagnosis of Primary Bone Tumors with Image-Guided Percutaneous Biopsy: Experience with 110 Tumors.” Radiology. 223 (2002): 731-737. Also see “Image-Guided Bone Biopsy: Faster, Easier, Safer.” RSNA Press Release. May 28, 2002. 13 The Medical & Healthcare Marketplace Guide 2001-2002, 17th Edition. Philadelphia, P .A.: Dorlands Healthcare Information. 2002: 1424. 14 Society of Nuclear Medicine, accessed February 10, 2006 at http://interactive.snm.org/index.cfm?PageID=1110&RPID=3106&FileID=2136. 15 Pisano, E. “Issues in Breast Cancer Screening.” Technology in Cancer Research & Treatment. 4.1 (2005): 5-9. 16 American Cancer Society, accessed February 10, 2006 at http://www.cancer.org/downloads/STT/CPED2005v5PWSecured.pdf. 17 Kevles, BH. Naked to the Bone: Medical Imaging in the Twentieth Century. New Brunswick, N.J.: Rutgers University Press. 1998: 256. 18 American Cancer Society, accessed February 10, 2006 at http://www.cancer.org/docroot/PED/content/PED_2_3X_Imaging_Radiology_Tests.asp?sitearea=PED. 19 Leeds, NE and SA Kleffer. “Evolution of Diagnostic Neuroradiology from 1904 to 1999.” Radiology. 217 (2000): 309-318. 20 American Cancer Society, accessed on February 10, 2006 at http://www.cancer.org/docroot/PED/content/PED_2_3X_Imaging_Radiology_Tests.asp?sitearea=PED. 21 Busch, U et al. “Diagnostic Imaging Makes Huge Technological Progress.” Diagnostic Imaging. 2005: 33. 22 Kevles, BH. Naked to the Bone: Medical Imaging in the Twentieth Century. New Brunswick, N.J.: Rutgers University Press. 1998: 187. 23 Ibid., p. 145. 24 Ibid., p. 146. 25”Imaging Techniques Improve Cancer Detection.” Medical College of Wisconsin, accessed February 10, 2006 at http://healthlink.mcw.edu/article/1031002410.html. 26 Kevles, BH. Naked to the Bone: Medical Imaging in the Twentieth Century. New Brunswick, N.J.: Rutgers University Press. 1998: 227. 27 Ibid., p. 211. 28 Ibid., p. 197. 29 Ibid., p. 173. 30 Society of Interventional Radiology, accessed February 10, 2006 at http://www.sirweb.org/patPub/cancer.shtml. 31 Abella, HA. “Interventionalists Offer New Choices For Cancer Therapy.” Diagnostic Imaging. 2005: 44. 32 Society of Interventional Radiology, accessed February 10, 2006 at http://www.sirweb.org/patPub/cancer.shtml. 33 Ibid. 34 Ibid. 35 Cormier, JN and RE Pollack. “Soft Tissue Carcinomas.” CA—A Cancer Journal for Clinicians. 54 (2004): 94-109. 36 ”Effects of Chemotherapy and Hormonal Therapy for Early Breast Cancer on Recurrence and 15-year Survival: An Overview of the Randomised Trials.” Early Breast Cancer Trialists' Collaborative Group (EBCTCG), The Lancet. 365 (2005): 1687-1717. 37 Pisano, E. “Issues in Breast Cancer Screening.” Technology in Cancer Research & Treatment. 4.1 (2005): 5-9. 38 Immomen-Raiha, P et al. “Mammographic Screening Reduces Risk of Breast Carcinoma Recurrence.” Cancer. 103 (2005): 474-482. 39 Shen, Y et al. “Role of Detection Method in Predicting Breast Cancer Survival: Analysis of Randomized Screening Trials.” Journal of National Cancer Institute. 97 (2005): 1195-1203. 40 Kevles, BH. Naked to the Bone: Medical Imaging in the Twentieth Century. New Brunswick, N.J.: Rutgers University Press. 1998: 256. 41 Ibid. 42 Burkhardt, JH and JH Sunshine. “Core-Needle and Surgical Breast Biopsy: Comparison of Three Methods of Assessing Cost.” Radiology. 212 (1999): 181-188. 43 Kevles, BH. Naked to the Bone: Medical Imaging in the Twentieth Century. New Brunswick, N.J.: Rutgers University Press. 1998: 257. 44 Imaginis, the Breast Health Resource, accessed February 10, 2006 at http://imaginis.com/breasthealth/digital_mammo.asp. 45 ”The Value of Investment in Health Care.” MedTAP International, Inc., accessed February 10, 2006 at http://www.medtap.com/Products/HP_FullReport.pdf. 46 Busch, U et al. “Diagnostic Imaging Makes Huge Technological Progress.” Diagnostic Imaging. 2005: 33. CHARTING THE PROGRESS 31 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 Prados, MD et al. “Primary Central Nervous System Tumors: Advances in Knowledge and Treatment.” CA—A Cancer Journal for Clinicians. 48 (1998): 331-360. American Cancer Society, accessed February 10, 2006 at http://www.cancer.org/docroot/PED/content/PED_2_3X_Imaging_Radiology_Tests.asp?sitearea=PED. Busch, U et al. “Diagnostic Imaging Makes Huge Technological Progress.” Diagnostic Imaging. 2005: 33. 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