You too have started experiencing a rising PSA after your treatment. No problem, you figure that like your friend you will be able to use one of these advanced radiopharmaceutical scans and then be able to target your cancer.
You are distressed to learn that the scan is no longer available. Facilities stopped performing this expensive scan when insurance reimbursement stopped covering the real cost of it.
Opening Music
Just imagine this: one year ago your friend told you that he had been treated for prostate cancer and recently his PSA had started to rise signaling that he had a prostate cancer recurrence.
His doctor arranged for him to have an advanced diagnostic radiopharmaceutical scan that specifically showed the location of the recurrence.
Fortunately for him, the scan showed that he had only one small area where the cancer had returned. He then was able to have this one single spot of cancer targeted for treatment.
Since his PSA was still only at 0.50, without this more sensitive diagnostic scan, there was a good chance that he would have been unable to locate the specific location of his cancer. Your friend avoided the need to have blind, hit or miss, possibly systemic, treatments that could have missed the cancer completely, but still caused him many unnecessary side effects.
Fast forward to next year and you too have started experiencing a rising PSA after your treatment. No problem, you figure that like your friend you will be able to use one of these advanced radiopharmaceutical scans and then be able to target your cancer.
You are distressed to learn that the scan is no longer available. Facilities stopped performing this expensive scan when insurance reimbursement stopped covering the real cost of it.
Unfortunately, this could be reality in the near future.
We are starting to run into insurance reimbursement issues that could easily prevent you from being able to have this type of advanced scan!
The advanced scans that have been developed and that have received approval need to have adequate reimbursement levels from Medicare and Medicaid so that we can continue to afford access to these life changing procedures. The problem is that the current reimbursement system only allows a reasonable reimbursement for three years, after which the actual, full direct cost of the scan will not be covered!
This looming problem about losing reimbursement at adequate levels can and must be resolved.
Why this is important?
Diagnostic radiopharmaceuticals, and other advanced screening procedures, such as PET scans, are an essential part of the process we need to help us and our treatment teams develop our best treatment pathways.
We patients deserve to have the best care and radiopharmaceutical imaging holds the promise to be able to deliver this level of care.
Radiopharmaceutical imaging allows us, along with our medical team, to make the best possible treatment decisions, by allowing us to have precise information about our cancer, and full access to targeted interventions most likely to be helpful.
These advanced scans will also keep us informed about our treatment’s effectiveness, more so than the other types of tests scans available.
I know, from my own personal experience with 5 primary cancers, that making treatment decisions involves balancing the things that are most important to me, especially the chance of gaining some life extension while also maintaining my Quality of Life.
I want to know as much about my cancer, so that I can make the best possible decisions as I move along my treatment pathway.
Without access to radiopharmaceutical imaging, patients like me, and my doctors cannot understand the true nature of my disease and we cannot make the best decisions about my treatment protocols.
We label cancers by the organ from which they originate, like breast, prostate or colon cancer. These labels don’t tell us about our cancer, other than the organ in which it originated.
We need to know a lot more about our cancer so that we can make sound, intelligent decisions about what might be an appropriate treatment, whether a treatment we are using is effective, and even if we need any treatment at all.
Knowing the organ from which our cancer originated doesn’t tell us enough, but using radiopharmaceuticals like PET imaging allows us to more accurately diagnose a cancer at an earlier stage, so that the potential treatments will be more effective in eliminating or controlling that cancer.
Once the cancer has been diagnosed, these organ labels still don’t tell us about the treatment options and which of these options would be most effective for our cancer. PET imaging contributes important information, that allows us to make better treatment decisions, which could also include helping us to avoid overtreatment, which can unnecessarily affect our quality of life and require an additional and unnecessary drain on our personal resources and on our economy.
Using radiopharmaceuticals like PET imaging helps us gain a more accurate understanding of our specific, individual cancer and can give us the information we need to better know what treatments make sense for us at that moment.
Understanding our individual cancer allows us and our doctor to weigh our goals and preferences and create a treatment path that will accommodate these goals, including both life extension and quality of life.
Once we have made treatment decisions, we will need to constantly monitor the treatment’s effectiveness. PET imaging is one of the best tools we have available that allows us to have a real time measure of our treatment’s effectiveness.
For example, PET imaging often plays a vital role in knowing when to stay the course with a treatment or to move on to another treatment. PET allows an almost real time measure of our treatment’s efficacy, because the tumor is more likely to be visualized and be able to be monitored.
Since most cancers have a limited number of FDA approved treatments, and many of these treatments have a limited effective life, we need to monitor whether or how well a treatment is working to decide if we should stay with that treatment, or move on to another.
Given the limited number of approved treatments, we need to “wring out” as much as we can from each treatment before moving on to another treatment. PET imaging can help us get the full bang for the buck from our treatment.
On the other hand, continuing to use ineffective treatments, because we cannot accurately measure its effectiveness, provides an unnecessary opportunity for the cancer to progress, making further treatments less effective and possibly causing us unnecessary pain and suffering.
Cancer treatments are often very expensive, and the cost of using treatments that are not effective or have stopped working is also an economic waste.
Since most cancer treatments come with significant side effects, it is indefensible to subject a patient to these side effects if the treatment is not going to help. There should never be a need to inflict a treatment side effect on a person without accomplishing cancer control.
Using ineffective treatments not only wastes the money spent on the treatment itself, it also causes unnecessary negative side effects on the patient’s quality of life.
Not only do inappropriate and ineffective treatments create a huge burden on our own life, it also creates a huge burden on our families, on our spouses, our partners, and on our children. It also unnecessarily costs the economy when treatments that don’t work are continued.
PET imaging is one of our best tools to measure a treatments’ ongoing effectiveness. PET can help us know when to move on to another treatment, and when we should continue with a treatment that is still working.
Having PET imaging available for all cancer patients will have a direct and positive effect on patients and will also have a positive ripple effect on our families, friends and the general economy.
The fundamental need for supporting reimbursement of radiopharmaceuticals extends well beyond cancer patients. It includes patients suffering with many other medical issues, including heart disease and neurologic disorders to name a few.
We must find a way to ensure that radiopharmaceutical scans will be available to all patients who would benefit when they need them. The benefits that radiopharmaceutical scans provide far outweighs their cost.
These benefits include better diagnoses, better treatment choices, and follow-up decision making, and additional treatment options.
If you remember, your friend whom I mentioned in the opening of this podcast was covered by insurance; if it he had not been covered it would have cost him many thousands of dollars to have the scan. Without the insurance coverage he probably could not have afforded the scan and probably would have had to utilize an untargeted type of therapy which might have missed the cancer and still caused him side effects that he would need to live with for the rest of his life.
The good news is that these advanced diagnostic radiopharmaceutical scans are currently covered by CMS, the Medicaid/Medicare system. The bad news is that they are covered only for a period of three years after their approval by the FDA.
Under current regulations referred to as a Pass Through, after the three years, the reimbursement schedule changes and the reimbursement rate is reduced so that even the cost to make the contrast material used in the scan is not completely paid for. This means that each scan performed costs more money than is reimbursed by insurance.
The end result is that hospitals and doctors will stop using these scans; they can’t afford to lose money on each scan.
Cancer ABCs is fighting this issue. Please join us in getting CMS to change the Pass Through policy. Let us know that you are willing to add your voice to our voice. Send us an email at info@CancerABCs.org and we will loop you into the fight.
This has been Joel T Nowak for Cancer ABCs.
