In last week’s blog, “How to Be Safer as You Live Longer,” I cited the value of annual PET/CT as a screening tool to monitor low-level myeloma, detect hidden infection or early second cancer. This prompted one reader to comment that “Medicare and supplemental insurance companies will not yet cover the cost of the procedure as a screening tool” and to ask for some “practical help” to obtain coverage.
I am acutely aware of the situation regarding imaging for myeloma. I testified to CMS/Medicare to obtain ANY coverage for myeloma and related diseases. We negotiated for an initial pilot study, the results of which were accepted. However, on a more recent review, the number of allowable scans was severely threatened—which we also protested based upon data. The data were accepted, but only one routine follow-up scan was allowed without a request from the doctor.
An accepted part of the plan was that doctors had to request further scans, which would not be covered automatically. BUT, upon request, scans are very frequently covered. Italian data documents the clear role in the post-transplant monitoring: Nanni et al.: ASH 2014 and in the Journal of Clinical Oncology. A positive scan indicates a different risk category and a need for additional testing and intervention.
Indications for scans are 1) new disease or recurrence; 2) low-level disease which is technically “non-secretory”—scans needed for follow-up; and 3) concern about infection or second cancer (SPM). Then a scan is justified and reimbursed.
So, it is the doctor who has to be more assertive on behalf of the patient. This type of request is frequently accepted on the first contact from the doctor, and if not, with a follow-up explanation. The key point is that other, more expensive tests would be required if PET/ CT or other imaging is not done.
A key recent paper is the IMWG updated diagnostic criteria published November 2014 in The Lancet Oncology (first author Dr. Vincent Rajkumar), which documents the central role of imaging. This is also explained in the JCO MRI paper and editorial by Dr. Morie Gertz published in February 2015.
The International Myeloma Working Group (IMWG) is currently working on PET/CT guidelines, as well as whole-body low-dose CT guidelines. So, more and more information is becoming available to support the need for both PET and CT—even PET plus MRI, for which there are new combined machines being evaluated at several centers, including Mayo Clinic in Rochester, Minnesota, which has one of the first PET/MRI machines. Through the IMWG we are standardizing the reading of the PET component of the scans to give exact cutoff values (called SUV: standardized uptake values) for what is positive versus negative, which will be especially helpful for broader use and applications.
It will be increasingly recognized that imaging is a powerful and precise technology which can help patients and be very cost effective within the total health care delivery budget.
I hope this information is helpful. As always, informed patients are their own best advocates!
Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.