Access to PET/CT

Key findings

In 2015, 143 integrated positron emission tomography-computed tomography (PET/CT) scans per 1000 total cancer incidence were performed in Ontario. The volume of PET/CT scans performed has steadily increased since 2011, although significant regional variation continues to exist across Ontario. This variation is likely driven by differences in referral patterns among physicians and their awareness of the PET/CT program.

There also are differences in the use of PET/CT scans by disease site. For example, while eighty-one percent of non-small cell lung cancer (NSCLC) patients received a PET/CT scan prior to radical treatment, there is a gap for emerging uses of PET/CT scans (such as in the staging of aggressive lymphoma) as physician practice shifts to include PET/CT.

With point-in-time sample data, self-reported by the PET/CT centres, wait times are typically less than 10 days in Ontario, with the monthly median ranging from 3 to 10 days. Despite an increase in scanning volume, PET/CT wait times have remained consistent over time.

Measure	Desired Direction	As of this Report
PET/CT scan utilization
Percentage of NSCLC patients who had PET/CT scan prior to radical treatment
Percentage of esophageal patients who had PET/CT scan prior to radical treatment
Median number of business days between referral date and first available appointment (point-in-time sampling)
See Methodology and Approach to find out how the ratings are calculated.

What are PET/CT scans?

• Medical imaging, such as CT scans and magnetic resonance imaging (MRI), is routinely used to provide information about anatomical structures within the body. This information is used to diagnose illnesses (such as cancer) and make decisions about treatment.
• PET scans are a type of nuclear medicine imaging exam. A PET scan provides pictures of what is happening inside the body at the molecular and cellular level; in some situations, it has the potential to identify areas of disease (such as cancer) before other imaging techniques. PET imaging is typically performed on a combined PET/CT scanner to help localize the information from the PET scan to the patient’s anatomy.
• PET/CT imaging has clinical utility (i.e. the results may affect how a patient is managed) for some cancers as well as other conditions (such as cardiovascular disease and epilepsy).

PET/CT scanning in Ontario

• PET Scans Ontario, which is operated by Cancer Care Ontario, collaborates with the Ministry of Health and Long-Term Care to coordinate PET/CT scan services and to ensure access to PET/CT services that are supported by evidence. This evidence-based approach ensures that patients receive the right test at the right time; this, in turn, helps to avoid the use of tests that are not of clinical benefit to the patient. The program also aims to improve transparency, accountability and equity for PET/CT scan services across Ontario.
• In Ontario, patients can receive a PET/CT scan through 4 streams of access¹:
  • services insured under the Ontario Health Insurance Plan (OHIP), where there is sufficient evidence that a PET/CT scan will benefit the patient and that it has advantages over other testing tools;
  • the Ontario PET Registry, which makes PET/CT scans available to patients in cases where there is some evidence to support the benefit of PET/CT scanning, but where additional evidence is needed before funding through OHIP can be recommended;
  • provincial clinical trials, which determine whether a PET/CT scan improves patient management or outcomes when there is little (or no) published evidence; and
  • the Ontario PET Access Program, which considers physician requests on a case-by-case basis in instances where patients may benefit from a PET/CT scan but do not meet the eligibility criteria under one of the other categories.
• In Ontario, a PET/CT scan is recommended only in situations where (according to available evidence) it improves patient care and outcomes. The primary use of PET/CT scans in the province is for certain cancers, but some PET/CT scanning is performed for cardiology and other emerging areas.
• To ensure patients are receiving their PET/CT scan in a timely fashion, PET Scans Ontario tracks wait times for the 12 PET/CT centres in the province (see Figure 1 for locations).

What do the results show?

The number of PET/CT scans performed continues to increase, but regional variations persist (Figure 2).

• Overall PET/CT utilization is being reported per 1000 total cancer incidence, which helps account for different rates of cancer diagnoses between regions. Although PET/CT scanning is not used for all cancers, it does play a role for many common cancers (e.g. lung and colorectal cancers, and lymphoma) and thus reflects true differences in regional use with the best accuracy.
• The number of PET/CT scans across the province in 2015 increased relative to the previous year. The number of completed cancer-related PET/CT scans per 1000 total cancer incidence increased from 92 in 2011 to 143 in 2015, which may be a result of an increase in awareness of both the availability of PET/CT scanning and its utility in some clinical scenarios.
• Differences in utilization are likely in part related to physician referral patterns and their awareness of the PET/CT program.
• PET/CT centre location relative to patient Local Health Integration Network (LHIN) of residence does not appear to be a primary driver of the variation: utilization rates are, in some cases, comparable or higher for LHINs that do not have a PET/CT scanner than for those that do.
• Cancer Care Ontario has continued to provide support to the regional PET/CT centres through education and support for quality improvement initiatives.

PET/CT scans prior to radical treatment for Non-Small Cell Lung Cancer (NSCLC) (Figure 3).

• Cancer Care Ontario measures access to PET/CT scans across the province generally, and for lung (NSCLC), esophageal and lymphoma cancers specifically.
• In 2015, 81% of NSCLC patients had a PET/CT scan prior to radical treatment, which continues to remain relatively consistent since 2012 (79%).
• It is worth noting that some regions without local access to PET/CT scanners actually had higher performance for this metric than regions that do. Thus, it is likely that reasons for regional performance are multifaceted, potentially including both proximity to a PET/CT scanner and local referral patterns or practice.
• The Canadian Partnership Against Cancer’s 2015 Cancer System Performance Report measured the percentage of all NSCLC patients who received a PET scan (versus the indicator in this section, which measures only the percentage who had a PET scan prior to radical treatment). Compared to 5 other provinces, Ontario had the highest percentage of all NSCLC patients who received a PET scan at 38%².

PET/CT scan prior to radical treatment for esophageal cancers (Figures 4 and 5)

• In 2015, 72% of patients received a PET/CT scan prior to radical treatment for esophageal cancer.
• The highest percentage of performed PET/CT scans was reported in 2014 with a rate of 83%. Overall, the percentage has remained relatively stable over the years (2011-2015).
• There is some regional variation among the Local Health Integration Network (LHIN) of patient residence. However, given the low incidence of esophageal cancer, it is unclear whether this variation is significant or a result of low numbers.

PET/CT use for the staging of aggressive lymphoma is far from reaching the Cancer Care Ontario range of 50% to 65% (Figure 6)

• In May 2013, PET Scans Ontario launched a Registry to assess the impact of PET/CT scans on the management of patients with early stage aggressive lymphoma. The goal was to strengthen preliminary evidence of clinical utility determined through a systematic evidentiary review³.
• In August 2014, international guidance was released recommending PET/CT scans for the staging of aggressive lymphomas⁴.
• In 2015, 14% of patients who fit the criteria for PET/CT scan for staging aggressive lymphoma received the scan, which was below Cancer Care Ontario’s range of 50% to 65%.
• Since launch of the PET Registry, the rate of PET/CT scans for lymphoma staging has continually improved, increasing sharply from the time of the release of international guidance (data not shown). It is expected that uptake will continue towards the clinically recommended rate over time.

On average, wait times are typically less than 2 weeks (10 business days) at each PET/CT centre (Figure 7).

• The monthly median wait time across all centres from 2011 to 2016 ranged from 3 to 10 business days.
• In previous years, the PET/CT centres reporting the maximum wait times varied from month to month (no consistent outliers were present). Some PET/CT centres have recently experienced increased demand for services, which has led to consistently longer wait times for these locations.
• The volume of PET/CT scans performed in Ontario for all oncology and non-oncology indications has increased year over year, with 6,995 scans in 2011, 8,223 in 2012, 10,355 in 2013, 11,854 in 2014, 12,893 in 2015 and 14,200 in 2016. The data, however, show that median wait times have not been significantly affected.

Why is this important for patient care?

• PET/CT scanning typically occurs at a decision point for a patient’s treatment. For example, in patients with NSCLC, a PET/CT scan helps to determine whether radical treatment (i.e. treatment with curative intent) is appropriate. If it is determined not to be beneficial, then the patient is prevented from undergoing a significant procedure and the associated recovery.
• PET/CT scan utilization provides a way of assessing whether patients are receiving an appropriate scan as part of their care. The regional data can be used to identify where physician outreach and education may improve equity of use.
• A PET/CT scan is one part of the diagnostic phase of the patient journey, since patients typically have a number of tests before treatment. The time a patient waits for a PET/CT scan contributes to the overall time between diagnosis and treatment. By monitoring wait times, we can ensure access to PET/CT scans is timely and that any delay is minimal.

How does Ontario compare with other jurisdictions?

• Jurisdictions have taken different approaches to the introduction, use and monitoring of PET/CT scans. As a result, differences in utilization cannot be interpreted as differences in appropriate care.
  • The 2015 Canadian Agency for Drugs and Technologies in Health (CADTH) report on the publicly funded uses of PET scans in Canada provides provincial-level information regarding annual volumes, PET/CT locations and indications across Canada⁵.
  • A 2004 survey of 14 members of the International Networks of Agencies for Health Technology Assessment (INAHTA) identified the number of PET scanners per million ranging from 0.25 in the Netherlands to 1.26 in Belgium. Australia had 0.65 per million, the United States had 0.83 and Canada had 0.39⁶.
    • The Canadian Partnership Against Cancer’s 2011 Cancer System Performance Report showed data that identified significant variability across Canada in the availability and use of PET scanners. Quebec reported the maximum availability, while some provinces, including Prince Edward Island, did not have a PET scanner⁷.
    • The Canadian Partnership Against Cancer’s 2015 Cancer System Performance Report showed the percentage of NSCLC patients who received a PET scan. Compared to 5 other provinces, Ontario had the highest percentage of patients at 38%².
  • The Organisation for Economic Co-operation and Development (OECD) presented data on the number of PET scanners available per thousand population for several countries, including Canada. Of those reporting data for 2014 (the most recent year for Canada), Korea had the highest number of PET scans per thousand population (7.6), with Denmark (6.9) and Israel (5.8) having the second and third highest, respectively⁸.

Find out more

• For more information about PET/CT scans and the provincial program, visit the PET Scans Ontario website.
• To read the evidence around the use of PET/CT scans, see the Program in Evidence-Based Care (PEBC) Six-Month Monitoring Reports and Recommendation Reports
• Oversight for the PET Scans Ontario program is through Cancer Care Ontario’s Cancer Imaging Program. Other areas of focus for the Cancer Imaging Program include the appropriateness of cancer imaging use, timely access, development of an imaging community of practice and synoptic radiology reporting. Find out more about the Cancer Imaging Program.
• Ontario also reports wait times for CT and MRI scans for all disease types. Find reports through the Ontario Ministry of Health and Long-Term Care.

View Notes

1. Cancer Care Ontario [Internet]. Toronto: Cancer Care Ontario. PET scans Ontario: PET scanner primer; [cited 2016 Feb 24]. Available from: www.PETscansontario.ca.
2. Canadian Partnership Against Cancer. The 2015 cancer system performance report [Internet]. Toronto: Canadian Partnership against Cancer; 2015 [cited 2016 Feb 23]. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/
   the_2015_cancer_system_performance_report_en.pdf.
3. Kouroukis CT, Cheung M, Sussan J, Hodgson D, Freeman M and Kellett S. The Clinical Utility of Positron Emission Tomography in the Diagnosis, Staging, and Clinical Management of Patients with Lymphoma: Recommendation Report. [Internet]. Toronto: Cancer Care Ontario; 2015 [cited 2016 Mar 1]. Available from: https://cancercare.on.ca/common/pages/UserFile.aspx?fileId=334671.
4. Barrington S, Mikhael NG, Kostakoglu L, Meignan M, Hutchings M, Müeller SP, et al. Role of imaging in the staging and response assessment of lymphoma: consensus of the International Conference on Malignant Lymphomas Imaging Working Group. J Clin Oncol. 2014; 32(27):3048–3058.
5. CADTH [Internet]. Canadian Agency for Drugs and Technologies in Health; c2016. Positron emission tomography in Canada 2015; 2015 Sep 29 [cited 2016 Mar 3]. Available from: https://www.cadth.ca/positron-emission-tomography-canada-2015.
6. Hastings J, Adams EJ. Joint project of the international network of agencies for health technology assessment—Part 1: survey results on diffusion, assessment, and clinical use of positron emission tomography. Int J Technol Assess. 2006; 22(2):143–148.
7. Canadian Partnership Against Cancer. The 2011 cancer system performance report [Internet]. Toronto: Canadian Partnership against Cancer; 2011 [cited 2016 Feb 24]. Available from: http://www.cancerview.ca/idc/groups/public/documents/webcontent/
   2011_system_performance_rep.pdf.
8. OECD.Stat [Internet]. The Organisation for Economic Co-operation and Development (OECD); c2016. Health status; 2017 Feb 8 [cited 2017 Feb 8]. Available from: http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.