Intended Versus Inferred Treatment After 18F-Fluoride PET Performed for Evaluation of Osseous Metastatic Disease in the National Oncologic PET Registry

Bruce E. Hillner; Lucy Hanna; Rajesh Makineni; Fenghai Duan; Anthony F. Shields; Rathan M. Subramaniam; Ilana Gareen; Barry A. Siegel

doi:10.2967/jnumed.117.205047

Article Figures & Data

Tables

View popup

TABLE 1

Defining the Cohort

NOPR cases (2/6/2011 to 9/30/2014)	n
Total number of cases	32,663
Patient or provider: consent withheld	(4,648)
Patient: no match to social security number	(652)
Patient: age < 65 at time of scan	(1,520)
Indication: cancer of unknown primary origin	(266)
Indication: diagnosis	(1,078)
Indication: suspected progression of osseous metastasis or treatment monitoring	(5,825)
Indication: subsequent scan performed for FOM	(3,283)
Additional evaluation: post–NaF PET plan to image or biopsy	(1,844)
Insurance: Medicare Advantage	(2,184)
Insurance: no claims paid	(566)
No claim found for NaF PET	(899)
Analysis cohort	9,898

View popup

TABLE 2

Profile of NOPR Cohort

	Lung		Prostate		Other
Patient profile, indication, and findings	IS	FOM	IS	FOM	IS	FOM
Number	216	362	2,701	4,749	496	1,374
Age, median 25%–75% quartile (y)	73 (68–77)	74 (69–80)	73 (69–78)	76 (71–82)	75 (69–81)	75 (70–80)
Symptoms, signs, or test results (%)
None	70 (32.4)	43 (11.9)	1,574 (58.3)	732 (15.4)	231 (46.6)	142 (10.3)
Elevated or rising tumor marker or PSA only	^*	^*	724 (26.8)	2,368 (49.9)	^*	77 (5.6)
Pain only	80 (37.0)	213 (58.8)	142 (5.3)	683 (14.4)	165 (33.3)	733 (53.3)
Evidence from other imaging	28 (13.0)	40 (11.0)	117 (4.3)	293 (6.2)	49 (9.9)	145 (10.6)
Multiple	20 (9.3)	43 (11.9)	98 (3.6)	550 (11.6)	24 (4.8)	197 (14.3)
NaF PET findings (%)
Benign or equivocal	139 (64.4)	216 (59.7)	2,198 (81.4)	2,886 (60.8)	391 (78.8)	934 (68.0)
Probable metastases	17 (7.9)	34 (9.4)	164 (6.1)	439 (9.2)	29 (5.8)	108 (7.9)
Definite bone metastases
Unifocal	12 (5.6)	18 (5.0)	36 (1.3)	163 (3.4)	13 (2.6)	46 (3.3)
Multifocal	41 (19.0)	80 (22.1)	227 (8.4)	951 (20.0)	47 (9.5)	206 (15.0)
Diffuse	^*	14 (3.9)	76 (2.8)	310 (6.5)	16 (3.2)	80 (5.8)
Stage, post–NaF PET (%)
Local/NED	60 (27.8)	168 (46.4)	1,974 (73.1)	1,794 (37.8)	288 (58.1)	792 (57.6)
LN+/regional	33 (15.3)	10 (2.8)	81 (3.0)	739 (15.6)	29 (5.8)	49 (3.6)
Single metastases	24 (11.1)	39 (10.8)	134 (5.0)	553 (11.6)	40 (8.1)	123 (9)
Multiple metastases	91 (42.1)	145 (40.1)	393 (14.6)	1,663 (35.0)	111 (22.4)	410 (29.8)
Unknown	^*	^*	119 (4.4)	^*	28 (5.6)	^*
Characteristics from claims
Hospitalized within 180 d after NaF PET (%)	117 (54.2)	157 (43.3)	542 (20.0)	820 (17.2)	187 (37.7)	349 (25.4)
Hospice within 60 d after NaF PET (%)	17 (7.9)	42 (11.6)	^*	60 (1.2)	13 (2.6)	54 (3.9)
Death within 180 d after NaF PET (%)	68 (31.5)	128 (35.3)	47 (1.7)	249 (5.2)	64 (12.9)	168 (12.2)
Medicare Part D claims found (%)	151 (69.9)	223 (61.6)	1,503 (55.6)	2,668 (56.1)	303 (61.0)	848 (61.7)

↵* Cell count < 11.
PSA = prostate-specific antigen; NED= no evidence of disease; LN+ = lymph nodal disease positive.
Data in parentheses are percentages.

View popup

TABLE 3

Concordance of NOPR Post-PET Treatment Plans and Claims-Inferred Care

NOPR treatment plan	Cancer type	Imaging indication	No. of patients	Agreement (%)	95 confidence interval of agreement (%)	Other treatments	No treatment claims
Surgery	Lung	IS	25	19 (76.0)	54.9–90.6	^*	^*
	Other	IS	130	98 (75.4)	67.1–82.5	21 (16.1)	11 (8.5)
	Prostate	IS	506	298 (58.9)	54.5–63.2	183 (36.1)	27 (5.3)
Chemotherapy ± other	Lung	IS	148	120 (81.0)	73.8–87.1	20 (13.5)	^*
	Lung	FOM	136	100 (73.5)	65.3–80.7	12 (8.8)	24 (17.6)
Chemotherapy only	Other	IS	111	77 (69.4)	59.9–77.8	16 (14.4)	18 (16.2)
		FOM	228	154 (67.5)	61.0–73.6	19 (8.3)	55 (24.1)
Radiation	Lung	IS^‡	80	67 (83.7)	73.8–91.1	^*	^*
		FOM^‡	36	26 (72.2)	54.8–85.8	^*	^*
	Other	IS^†	30	24 (80.0)	61.4–92.3	^*	^*
		FOM^†	54	40 (74.0)	60.3–85.0	^*	^*
		FOM^‡	59	36 (61.0)	47.4–73.4	^*	^*
	Prostate	IS^†	729	616 (84.4)	81.7–87.1	75 (10.3)	38 (5.2)
		FOM^†	422	289 (68.4)	63.8–72.9	60 (14.2)	73 (17.3)
ADT only	Prostate	IS	308	265 (86.0)	81.7–89.7	27 (8.8)	16 (5.2)
		FOM	1,088	895 (82.3)	79.9–84.5	36 (3.3)	157 (14.4)
ADT + radiation	Prostate
ADT component		IS	517	418 (80.8)	77.2–84.1	17 (3.3)	15 (2.9)
		FOM	271	205 (75.6)	70.1–80.6	^*	29 (10.7)
Radiation component		IS	517	424 (82.0)	78.4–85.2	17 (3.3)	15 (2.9)
		FOM	271	183 (67.5)	61.6–73.1	^*	29 (10.7)

↵* Cell count < 11.
↵† Radiation component of plans of radiation plus chemotherapy.
↵‡ Radiation therapy only.
Data in parentheses are percentages.

View popup

TABLE 4

Agreement in Post–NaF PET Plans for Scans Obtained for Suspected FOM of Prostate Cancer Stratified by Prior ADT Claims

NOPR treatment plan	Prior ADT	No. of patients	Agreement (%)	95 confidence interval of agreement (%)	Other treatments	No treatment claims
ADT only	Yes	430	389 (90.5)	87.3–93.1	11 (2.6)	30 (6.9)
	No	658	506 (76.9)	73.5–80.1	26 (3.9)	126 (19.3)
Radiation only	Yes	117	86 (73.5)	64.6–81.2	28 (23.9)	^*
	No	305	203 (66.6)	61.0–71.8	34 (11.1)	68 (22.3)
ADT + radiation
ADT component	Yes	83	74 (89.2)	80.4–94.9	^*	^*
	No	188	131 (69.7)	62.6–76.2	^*	^*
Radiation component	Yes	83	63 (75.9)	65.3–84.6	^*	^*
	No	187	120 (63.8)	56.5–70.7	^*	^*
Chemotherapy ± other	Yes	406	208 (51.2)	46.3–56.2	176 (43.3)	22 (5.4)
	No	264	81 (30.7)	25.2–36.6	128 (48.5)	55 (20.8)

↵* Cell count < 11.

View popup

TABLE 5

NOPR Plans for Nontreatment (Watch, Supportive Care, Hospice) and Absence of Treatment Claims Within 60 Days

Cancer type	Imaging indication	No. of patients	Agreement (%)	95 confidence interval of agreement (%)
Lung	IS	24	15 (62.5)	40.6–81.2
Other	IS	113	51 (45.1)	35.8–54.8
Prostate	IS	391	159 (40.7)	35.8–45.7
Lung	FOM	180	136 (75.6)	68.1–81.6
Other	FOM	798	696 (87.2)	84.7–89.5
Prostate	FOM, prior ADT	461	203 (44.1)	39.4–48.7
	FOM, no prior ADT	1,340	1,053 (78.6)	76.3–80.7