FDG-PET AND TREATMENT RESPONSE: EARLIER IS BETTER, ACCORDING TO STUDY

A new study by physicians at the Weill Medical College of Cornell University and the New York Presbyterian Hospital, New York, indicates that FDG-PET results from the first cycle of treatment can better predict progression-free survival in patients with aggressive non-Hodgkin's lymphoma or Hodgkin's disease than can PET scans performed at the end of treatment.

The study, published in the August issue of the Journal of Nuclear Medicine, reported on 23 patients who received PET scans before and after one cycle of treatment, and also at the end of chemotherapy. According to the study's findings, PET was accurate 87% of the time after one cycle, but only 70% after completion of chemotherapy. The ability to detect FDG and disease was also higher after one cycle, at 82% versus 45.5%, and 90% of patients with positive results after one cycle experienced disease relapse (see Figure) while 85% who had negative findings after one cycle remained in remission.

Figure. Published in the August Journal of Nuclear Medicine, the images show a 35-year-old man with Hodgkin's disease who underwent F-FDG PET before (A), after first cycle of (B), and at completion of (C) chemotherapy. The pretherapy image (A) shows radiotracer uptake in the anterior mediastinum. Image B shows residual disease in the right anterior mediastinum, while image C shows no evidence of residual lymphoma in corresponding regions at completion of chemotherapy. The disease relapsed in the patient's mediastinum after a progression-free survival of 6 months.

In a commentary accompanying the published study, Val Lowe, MD, and Gregory Wiseman, MD, of the Department of Radiology at the Mayo Clinic, Rochester, Minn, took issue with elements of the study's findings. For example, they expressed concerns over the size and makeup of the study group, suggesting that the study's focus on different diseases being treated differently at different points in the subjects' treatments made it difficult to make valid comparisons. The commentary also contends that the use of the less sensitive gamma camera coincidence imaging, rather than a dedicated, full-ring PET scanner, could have affected the study's results as they relate to end-of-cycle findings of disease.

But study coauthor Lale Kostakoglu, MD, Division of Nuclear Medicine, Department of Radiology, defends both the study's methodology and its results. "They have viable points, yet we disagree with them and stand by our findings," she says. "Ultimately, what they are missing is the heart of our study: that you can get answers long before an entire 6-month treatment cycle is complete."

Kostakoglu also says the group is planning an additional study this fall focusing on advanced Hodgkin's disease.

In Lieu of Surgery, Radiation Therapy Suffices as Rectal Cancer Treatment

A study in the September issue of the International Journal of Radiation Oncology, Biology and Physics reports that radiation therapy alone is an adequate treatment for some patients with rectal cancer.

While surgery is still the most common treatment for rectal cancer, the study says that therapy alone is a suitable treatment for patients who are not surgery candidates, owing to their poor physical condition or to their lack of consent to surgery and its possible side effects.

The study, conducted by a team of physicians led by Jean-Pierre Gerard, MD, of the Centre Antoine-Lacassagne, Paris, looked at 63 rectal cancer patients between 1986 and 1998. The patients had to have T2-T3, N0-N1, M0 adenocarcinoma of the middle or lower rectum involving less than two thirds of the circumference. The radiation therapy began with contact x-rays, and was followed by external beam radiation therapy with a concomitant boost. After a 4-6 week interval, an iridium implant delivered a completion dose to the tumor, with no chemotherapy administered.

Results showed that the primary local tumor control rate was 63%, and the 5-year  survival rate was 64.4%. For patients under 80 years old, the survival rate was 79%. Good anorectal function was maintained in 92% of living patients. The T stage was a strong prognosis factor, with a 5-year overall survival rate of 84%, and 53% for T2 and T3 lesions in patients under 80 years old.

BI-RADS TRAINING IMPROVES MAMMOGRAPHY READS

A study published in the September issue of Radiology reports that training in the Breast Imaging Reporting and Data System (BI-RADS) resulted in the participants' greater consensus with experienced mammographers in the recognition of suspicious features and biopsy recommendations. Berg et al also concluded that training in BI-RADS feature analysis and assessment resulted in improved consistency in lesion description.

The study, conducted by radiologists at  the University of Maryland, Baltimore; the University of Massachusetts, Worcester; Indiana University, Indianapolis; the Medical College of Wisconsin, Milwaukee; the University of California, Los Angeles; and the American College of Radiology, Reston, Va; used a test set of mammograms consisting of 54 lesions, made up of 28 masses and 26 microcalcifications.

Breast imagers and mammogram-interpreting physicians reviewed mammograms, while observer performance before and after training was measured by way of agreement with consensus description and assessments, rate of biopsy of malignant and benign lesions, and areas under receiver operating characteristic curves. In addition, performance was measured for 11 participants 2-3 months following training.

Participants showed improved agreement with consensus feature analysis for mass margins and/or symmetries, with a pretrained generalized mean of agreement (k value) of 0.36 and a post-training generalized k value of 0.41. Similar improvement was seen for description of calcification morphology, with no improvement seen in describing calcification distribution. Final assessments were more consistent after training, with a pretraining k value of 0.31, compared with 0.45 after training.

In addition, the study showed that the mean biopsy rate for malignant lesions improved from 73% before training to 88% after training, with little increase in mean biopsy rate of benign lesions. For the group of participants with delayed follow-up, no significant decline in post-training results was seen. The authors also concluded that trainees showed improved rates of recommending biopsy for malignant lesions over a 2-3 month period.

INSURER DISCLOSURE OF FEES ON THE RISE

With insurers in Georgia now under state orders to disclose fee schedules to physicians, and similar regulations likely in California and Texas, it looks as though fewer physicians will complain about health insurance contracts that do not specify what providers will be paid for a given health care procedure, according to an article in the electronic newsletter MD Practice Alert.

In a late-May judgement against Blue Cross Blue Shield of Georgia, the Fulton County, Georgia, state court ordered those companies to publish fee schedules and methods for calculating payments. Insurers were ordered to mail out that required information to 19,000 physicians in the state.

At press time, Texas insurers were awaiting a final regulation that would similarly require insurers to disclose payment policies. In addition, the California Department of Managed Health Care is expected to pass a similar regulation sometime this fall.

RADIOLOGY TRENDS IDENTIFIED

US Radiology Partners, Irving, Tex, has released the findings of its 2002 Survey of Radiologists. While the sample surveyed is small (240 responses), the results provide a snapshot of some of the pressures shaping radiology at the outset of the 21st century.

Among the trends and other data revealed from the survey: staffing was ranked the top priority/concern facing radiologists in the next 12 months, followed by declining reimbursement, and upgrading/transitioning to digital/PACS.

Other findings: 78% surveyed saw an increase in imaging volume in the past year; 70% are using teleradiology; and 71% said their groups/practices offer 24-hour physician/radiologist coverage.

House Committee Takes Up Medical Malpractice Bill

The US House Energy and Commerce Committee is currently studying a bill that would limit damage awards and attorney fees in medical malpractice lawsuits, according to a report by Reuters Health.

The "Help Efficient Accessible, Low-Cost, Timely Health Care," or HEALTH Act, recently approved by the Judiciary Panel, would limit the time allowed for filing alleged malpractice suits to 3 years. It would also put a cap on noneconomic damages, awarded for pain and suffering, at $250,000, and a cap on punitive damages, awarded to punish egregious wrongdoing, at the greater of twice the amount awarded for direct economic losses or $250,000.

In addition, the bill would also limit attorney fees on a sliding scale, limiting lawyers to no more than 15% of awards above $600,000.

The HEALTH Act, sponsored by Representative James Greenwood (R-Pa), is intended to protect patients' access to care by addressing increasing medical malpractice insurance premiums. Greenwood has said that without federal legislation to help address rising claims, liability insurers will continue leaving markets, while physicians are forced out of medicine altogether.

Prior to approving the bill, the Committee defeated more than 12 amendments brought by Democrats, including a proposal to eliminate the 3-year limit on filing malpractice suits.

Although the measure is likely to pass the House sometime in late September, prospects are not good in the Senate, which killed a similar proposal in July. In that case, a less-sweeping amendment was defeated by Senate Democrats, who criticized it as pro-HMO, pro-drug company, and pro-insurance company.