PET Scans for Follow-Ups

Costly overuse is not supported by patient outcomes.

All of healthcare looks to reduce costs, secure profits, and identify leaks along the care continuum. With cancer care being one of the most costly efforts, there may be multiple opportunities to preserve quality care and realize important savings.

Researchers at the University of Michigan (UM) Medical School and Dartmouth-Hitchcock have conducted a study leading them to believe that one such area is unnecessary and costly overuse of PET scan imaging for lung cancer and esophageal cancer follow-up.

The traditional rationale is once a patient has gone through lung cancer treatment, it is urgent to catch any recurring cancer quickly. However, PET scans are not the recommended primary way of monitoring for a possible recurrence; rather, they are more appropriately used as a backup to other types of scans, according to information provided by the University of Michigan.

The university also noted, “PET scans are not expensive and powerful. They let doctors see increased activity by cells inside the body, including fast-growing cancer cells, and can do so early. Many cancer patients receive PET scans as part of diagnosis, to see how advanced their cancer is, and how it’s responding to treatment. But the scans are not recommended as the first option to monitor for recurrence. In fact, it’s one of the few imaging tools for which Medicare imposes limits – currently three follow-up PET scans per person, even when doctors only order them after spotting something on a CT scan or other medical image.”

Despite this limit, the investigators found widespread use of PETs for follow-ups among Medicare data for more than 100,000 lung and esophageal cancer patients between 2000 and 2011. The results of the study were published in The Journal of the National Cancer Institute.

Variations in Frequency


Mark Healey, MD, a surgical resident and research fellow at UM Department of Surgery, told ADVANCE:

“We found high overall use of PET as a primary study for recurrence, with substantial hospital-based variation in the use of PET. Some hospitals used it eight times more often than others. Despite this, there was not a significant difference in survival for patients across high and low PET-use hospitals.”


No matter how often PET scans were used, results were the same: Patients who went to a low PET-use hospital for follow-up were just as likely to survive two years as those who went to a high PET-use hospital.

With findings that clearly suggest patient outcomes are not improved with greater use of PET, Healey suggested, “Physicians should avoid ordering these studies in asymptomatic patients who have already been treated for their cancer, unless it is to follow up on a suspicious finding on a lower-cost scan, such as CT.”

While some hospitals use PETs inappropriately, the researchers also found on the whole that patients rarely reach the three-PET limit set by Medicare. “Our work shows that almost no one reaches the three-PET threshold,” Healey explained. “But, with many thousands of patients getting one or two scans across the whole country, this is still a very large number, with very high costs. If the intention of the policy is to curb overuse, this doesn’t seem to be a very effective method, and CMS should reevaluate how it structures its limits.”

Healey and colleagues have found the same effect in pancreatic cancer, which has been reported earlier. They hope their findings will help providers of all kinds understand the best use of PET scanning in cancer care, and patients as well.

“Following evidence-based guidelines for clinical follow-up is the way to go,” said Healey. “Don’t order PET in asymptomatic patients. And I would tell patients if they are not having symptoms and are doing well, there’s no reason to seek out this scan.”

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