The six PET centres (five of them in Gauteng) in South Africa are running into trouble as medical schemes decline to fund this diagnostic procedure.
It’s about money
Because of the cost involved, most medical schemes are very strict about authorising the use of PET scans, except for those members who’ve bought top-end options – and even then, tight criteria exist.
Clare Garner, case manager for Medical Services Organisation (MSO), says PET is “a superb tool in stageing cancer, and correct diagnosis can save on treatment costs in the long run". MSO deals with hospital admissions and permission for specialised radiology for several medical schemes, including MediHelp and GEMS. But, Garner suggests, PET can be inappropriately prescribed. "It costs on average R10 300 per patient to have this scan done,” she says. "There is the risk of this procedure being overprescribed, when a normal MRI (Magnetic Resonance Imaging) scan would do.
"The oncology (cancer) environment is an emotional one and when medical schemes seem reluctant to fund treatment for cancer, it tends to hit the headlines. But most medical schemes have limited funds and decisions should be seen against this background." So strict guidelines exist for authorising a PET-CT scan, including that only oncologists can request the treatment.
Which is all very well, until you or someone close to you is denied access to a scan.
For Health24 readers who have been following Lynn's cancer diary, read her latest update in which a PET-CT scan changed her treatment modality from surgery to chemotherapy.
Though the Radiological Society of South Africa (RSSA) was involved in developing these guidelines, it is challenging the wisdom of some of them. “PET-CT is 15-20% more accurate than other modalities in determining the stage and the extent of a cancer,” says Dr Ralph Posner, who practises from Morningside Medi-Clinic in Johannesburg, and is a member of the RSSA. “Usually, a patient sees an oncologist after a specialist physician makes the initial diagnosis and surgery is performed. If the diagnosing specialist could access PET-CT, he and his patient would benefit enormously. He would be able to make decisions regarding appropriate treatment before surgery or other interventions.”
Dr Jean de Villiers, radiologist and member of the RSSA, confirms that good practice worldwide dictates that the diagnosing physician or operating surgeon can order a PET-CT scan.
What makes PET-CT scans so special?
PET-CT is the only screening modality that uses size, shape, and biological activity to identify cancerous tumours. Other techniques, working on the presumption that cancerous cells are distorted, diagnose cancer based on physical differences between normal organs and cancerous growths.
However, it is not always true that distortion exists. PET-CT works on physical and metabolic differences in cells. A glucose-based isotope is injected. Tumours take up the isotope quicker than normal cells because they have faster biological activity. The isotope allows the tumour to show up on the scan even if the organ is not distorted, according to the RSSA.
The cancers which PET-CT is used for include Hodgkins and non-Hodgkins lymphoma, thyroid, head and neck, breast, stomach, testicular, oesophogael, ovarian, and melanoma.
Technology could be lost
“We are at risk of losing the technology as it is not sustainable at current [usage] levels,” says Posner.
According to the RSSA, South Africa has the correct number of scanners to serve the insured population according to international norms. After two years, these centres are still losing millions every year.
Garner queries the RSSA’s assertions. "Maybe we have too many PET-scanners in the country," she says. "Setting them up and keeping them running is extremely expensive, and one cannot blame these centres for wanting to recoup their costs. But one also has to ask what sort of research was done beforehand. South African medical schemes are under pressure and cut costs where they reasonably can – it's no secret. They have to spread their funds among their members."
Delay 'detrimental to patient'
De Villiers is critical of the processes underlying the current authorisation processes. “In South Africa, a cancer patient and his doctor have to submit the request for PET-CT to a peer review panel and then get medical aid authorisation. This may take up to two to three weeks to complete. This time period is critical if the cancer is malignant. The wait also adds unnecessarily to the patient’s trauma,” he says.
“We understand the concerns of medical scheme administrators that over-utilisation of PET-CT could raise costs,” says Dr Clive Sperryn, president of the RSSA. “However, we only recommend PET-CT for cancer patients. Proper use of PET-CT actually lowers the overall cost of treating cancer by avoiding unnecessary surgery and modifying ineffective treatment. A single PET-CT scan provides the same information as a number of other examinations.”
Much closer co-operation between the funding industry and the PET-CT providers, with an improved approach to ensure the appropriate utilisation of PET-CT, will result in the retention of this world class imageing modality for the South African population, according to the RSSA.
And the clock is ticking. Unless some compromise is reached, this technology will be lost to everyone, even those who can afford it.
(Susan Erasmus, Health24, August 2008)