EXECUTIVE SUMMARY Context and Policy Issues In 2008, approximately 166,400 new cases of cancer were diagnosed in Canada.
Radiological imaging modalities, including positron emission tomography (PET), are used in the diagnosis, staging, assessment of treatment response, and monitoring of recurrence of cancers. PET is a modality that is used to provide a three-dimensional image of functional changes in the body. PET can be used to track the deposition of radioactive molecules to sites in the body. The most common radioactive tracer is 2-[18F] Fluoro-2-deoxy- D-glucose (FDG). FDG is a glucose analogue that accumulates in tissues with high metabolic activity, such as tumour tissue. In addition to its use in cancer diagnosis, PET is commonly used to determine the stage or extent of disease for various types of cancers. The approach to treating the cancer will depend on the stage. Therefore, accurate information about diagnosis and staging is critical for planning the most appropriate treatment strategy. PET is also used to assess how a person is responding to treatment during or at the end of the treatment, and to monitor if the cancer has recurred after treatment. The use of PET is on the rise, and the number of possible indications for PET use is increasing. Access to PET varies across Canada. With an increasing number of Canadians being diagnosed with cancer each year, there is a need to review the evidence on the clinical effectiveness of PET for oncologic conditions compared with other imaging modalities including computed tomography (CT) and magnetic resonance imaging (MRI). Research Questions 1. What is the clinical effectiveness of positron emission tomography (PET) in oncology compared to computed tomography (CT) and magnetic resonance imaging (MRI) when used as an adjunct to CT or MRI? 2. What are the indications for PET use in oncology? Methods Published literature was obtained by crosssearching PubMed, MEDLINE, and Embase on the OVID search system between 2007 and December 4, 2008. Parallel searches were performed on The Cochrane Library (Issue 4, 2008), and the University of York’s Centre for Reviews and Dissemination (CRD) databases. Results were limited to English language publications only. Filters were applied to limit the retrieval to systematic reviews, health technology assessments (HTAs), meta-analyses, and guidelines. The websites of HTA and related agencies were searched, as were specialized databases such as those of the National Institute for Health and Clinical Excellence (NICE), ECRI Institute, and EuroScan. The Google search engine was used to search for information on the Internet. Two independent reviewers screened articles for selection. This report was peer-reviewed by two clinical experts. Summary of Findings Three HTAs were identified in our literature search. The first HTA assessed the clinical Positron Emission Tomography (PET) in Oncology: A Systematic Review of Clinical Effectiveness and Indications for Use v effectiveness of PET in breast, colorectal, head and neck, lung, lymphoma, melanoma, esophageal, and thyroid cancers. The use of FDG-PET for diagnosis, staging or restaging, and monitoring recurrence and treatment for each cancer type was evaluated. The authors concluded that the highest quality evidence on the clinical effectiveness of PET was in the detection of distant metastases, staging or restaging of colorectal cancer, detection of solitary pulmonary nodules, staging of non-small cell lung cancer (NSCLC), and restaging of Hodgkin disease. The second HTA reviewed the use of PET in monitoring the treatment response among women with breast cancer. The evidence suggested that PET may be useful in the identification of patients with advanced breast cancer who are not responding to neoadjuvant treatment and patients with metastatic disease who are responding to treatment. The third HTA examined the use of PET for monitoring the response to treatment of Hodgkin disease and non-Hodgkin lymphomas (NHLs). The authors concluded that a positive PET scan (specific uptake of FDG) during the monitoring of treatment of response is predictive of death or disease progression. Ten systematic reviews and three metaanalyses were indentified in our literature search. Overall, the systematic reviews and meta-analyses concluded that PET had the highest accuracy for the detection of cancers originating in the lung, pancreas, head and neck region, and cancers of unknown primary origin. PET was effective in the staging or restaging of breast cancer, colorectal cancer, esophageal cancer, head and neck cancer, lung cancer, lymphoma, and melanoma. The systematic reviews and meta-analyses described the clinical effectiveness of PET for the detection of lymphoma, residual or recurrent breast cancer, colorectal cancer, head and neck cancer, and thyroid cancer. PET was not |
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