National Services Division Area 062 Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Telephone 0131 275 6575 Fax 0131 275 7614 www.nsd.scot.nhs.uk Scottish Clinical Imaging Network - PET-CT Group Minutes of meeting on 4 December 2015 PET-CT 2015-03 File ref: 07 Health Support Ser\Specialist & Screening\NMCNs & NMDNs\Networks\NMDN SCIN\Groups\SCIN PET CT\Mins\2015\2015-12-04 Author: Mr Liam Anderson Attendees: Mrs Deirdre Evans Dr Dilip Patel Dr Alison Fletcher Dr Prasad Guntur Dr Glen Gardiner Prof. Mateo Zanda Dr Fergus McKiddie Secretariat: Mrs Alexandra Speirs Mr Liam Anderson Apologies: Prof Alan Denison Dr Anne Marie Sinclair Ms Aileen MacLennan Dr Gerry Gillen Dr Sai Han Dr Emma Rammage Mr Stephen Evans Dr Jean Wright Dr Rachel Joyce Dr Rodger Staff Mr Graham Dunn Mrs Dawn Barrie Mr John Davidson Director, National Specialist & Screening Services Directorate, NHS National Services Scotland (Chair) Consultant Radiologist, NHS Lothian PET Physicist, NHS Lothian Consultant Radiologist, NHS Tayside PET Physicist, NHS Tayside Dept of Biomedical Physics & Bioengineering, Aberdeen PET Physicist, Nuclear Medicine Department, NHS Grampian Network Manager, NNMS, NSS Programme Support Officer, NNMS, NSS Honorary Consultant Radiologist, Clinical Lead, Nuclear Medicine/PET, NHS Grampian Lead Clinician, Scottish Clinical Imaging Network (SCIN) and Clinical Director, Diagnostics Directorate, NHS Greater Glasgow and Clyde Director of Diagnostics Directorate, NHS GGC Nuclear Medicine & PET CT, NHS Greater Glasgow & Clyde Consultant Radiologist, NHS Greater Glasgow & Clyde Consultant Radiologist, NHS Grampian Radiology Manager, NHS Lothian Assistant General Manager for Diagnostic Imaging, NHS Greater Glasgow & Clyde Radiographer, NHS Grampian Physicist, NHS Grampian Financial Controller, Scottish Government Health & Social Care Directorates Lead Clinical Technologist, NHS Tayside Consultant Physician, NHS Tayside 1
1. Welcome, Introductions and apologies Mrs Deirdre Evans welcomed everyone to the meeting and noted apologies as above. 2. Minute of meeting held on 15 May 2015 (PET-CT 2015/17) The minutes were approved as a correct record of the previous meeting. 3. Matters Arising and action tracker Mrs Evans invited updates on three ongoing actions on the action tracker: PET-CT centres that use cyclotrons to provide information on the tracers used and how many scans were FDG and non FDG. Representatives of each PET-CT centre agreed to provide an update. Action: PET-CT Centres PET-CT centres had previously agreed they would begin to collect information on the NHS Board of residence of patients scanned; the site in which the PET-CT was carried out; and the indications that warranted a PET-CT. Dr Fergus Mckidie advised that he was due to start collating this data for NHS Grampian. Dr Dilip Patel and Dr Alison Fletcher advised that the capture of data had not yet started. It was agreed that an aggregation of patient resident data should be ready for April/May 2016 and this report should be presented to the PET-CT group annually. Action: PET-CT Centres PET-CT centres were to assess the impact in their centre of extending the range of indications to include all those in the Royal College guidelines. Representatives from NHS Lothian and Tayside advised that they would not be able to meet the demand. Representatives from NHS Grampian advised that the feeling locally was that PET- CT scans for many of the other indications were already being carried out and there was scope to cope with all of the indications. The main issue would be dividing time available between each indication. The updates below were provided on matters arising listed on the agenda: 3.1 NHS Lothian F18 Choline PET for Prostate Cancer Dr Patel informed the group that the F18 Choline PET for Prostate Cancer Pilot began in June 2015. Since the pilot began, 13 patients had been scanned, 70% of these patients had presented with recurring disease that had been originally diagnosed by a scanned biopsy. Following their diagnosis, patients were able to receive effective targeted treatment. Dr Patel shared with the group that the pilot received referrals from the NHS Lothian Urology MDT. In addition to NHS Lothian patients being accepted into the pilot, patients from NHS Borders and NHS Dumfries and Galloway had also been seen in the pilot due to the patient geographical location that NHS Lothian served. Dr Patel concluded by informing the group that the F18 Choline PET for Prostate Cancer Pilot had the capacity to accept referrals from further afield. Dr McKiddie reminded the group that NHS Grampian was currently producing Carbon 11 onsite, and would able to provide F18 Choline to other sites until 2016. The group 2
noted that it would be advantageous to patients if F18 Choline could be transported to the other PET-CT sites, however, staff who wished to use F18 Choline staff needed to attend a two day training course to become accredited. Mrs Evans queried whether there was a Scottish clinical protocol place to support F18 Choline scanning. The group noted that there was no clinical protocol. Dr Patel agreed that he would share the results of the NHS Lothian F18 Choline pilot to enable the group to consider the evidence for the scan to become nationally funded indication to the next PET-CT meeting. Mrs Evans agreed to contact Dr Anne Marie Sinclair (SCIN lead Clinician) regarding the possibility of adopting F18 Choline PET for Prostate Cancer as a national indication. Since there were two Scottish PET-CT centres that were offering this scan it was agreed that if it became a nationally funded indication, it would be charged as a recharge rather than as a cross charge. Mrs Evans informed the group that, since the pilot had commenced, there had been no referrals to NHS England. Action: Dr Patel 3.2 The development of new tracers Professor Matteo Zanda informed the group that NHS Grampian will be increasing their portfolio of tracers in 2016. The following F-18 tracers will be available for clinical use which may replace non-transportable C-11-tracers that have a shorter half life. 18F-FMISO (fluoromisonidazole). Application: tumour hypoxia. Status: clinical research. This will be the second hypoxia tracer available in Aberdeen following the introduction of 18F-FAZA in 2015, currently used in two clinical studies on oesophageal cancer and colorectal cancer. This tracer is transportable. 18F-FLT (fluorothymidine). Application: cell proliferation in solid tumours, including brain and breast cancer. Status: clinical research. Transportable Yes. Comments: it could replace the use of non-transportable 11C-methionine, currently used in Aberdeen for gliomas, 11C-choline and 11C-acetate for some indications. 18F-FEC (fluoroethylcholine). Application: lipid metabolism mostly in prostate cancer. Status: included in 2013 UK indications for clinical practice. Transportable: yes. Comments: it can be used as an alternative to non-transportable 11C-choline. 11F-FEC (fluoroethyltyrosine). Application: amino-acid metabolism and protein synthesis in solid tumours, including brain and head&neck cancer. Status: clinical research. Transportable: yes. Comments: it can be used as an alternative to nontransportable 11C-methionine. Professor Matteo Zanda informed the group that the new clinical evidence regarding the tracers was available in the Neuro-Oncology Advance Access paper published June 30, 2015. Dr Prasad Guntar advised that NHS Tayside did not have any current activity in the development of new tracers. NHS Lothian representatives agreed to provide an update. [Post meeting Note Dr Gerry Gillen NHS Greater Glasgow and Clyde provided an update on the development in Glasgow. The new GE 710 PET-CT scanner was installed in March 2015 and has been operational since then. NHS Greater Glasgow and Clyde continue to deal with a very heavy routine clinical workload and are approaching the capacity limit for two 3
scanners. A third PET-CT scanner would be required to deal with the projected demand. Dr Gillen advised they were currently contributing to 19 clinical trials in Oncology and 2 in Alzheimer s research.] 3.3 Feedback from NHS Lothian- Procurement of PET-CT scanner Dr Patel advised that there were a number of issues regarding procurement of the new scanner at the Royal Infirmary of Edinburgh. The installation of a new research PET-MRI Scanner was expected to impede the installation of a PET-CT scanner, and there might be an impact on sustaining routine service due to a requirement for an application through the Scottish Environment Protection Agency (SEPA). Dr Patel informed the group that NHS Lothian was exploring the provision of an alternative interim service if required. Dr Patel was waiting to receive guidance from NHS Lothian management. Once he received feedback from NHS Lothian he would inform the National Network Management Service (NNMS). Mrs Evans said that, once NNMS had received Dr Patel s update, she would discuss this issue with the Scottish Government. It was considered that leverage from the Scottish Government would aid in processing an application through the Scottish Environment Protection Agency (SEPA). Dr Patel agreed to provide a written update. Action: Dr Patel 4. Review of PET-CT activity stats Mrs Evans provided the group with the data that the NNMS had been collecting on behalf of the SCIN PET-CT group. The members were shown a graphical representation of a forecast based on data that had been collected between April and August 2015. Mrs Evans said that a more robust projection could be established after an up-to-date data set had been received from NHS Greater Glasgow & Clyde from the period of September and November 2015. The group noted that the dominant activity for PET-CT use was for lung cancer. The group discussed how the data which was presented in the others category needed revision before it could be accurately assessed. Mr Anderson agreed to collate and amend new aggregate data and circulate round the PET-CT group for an accuracy assessment. Action: Mr Anderson The graphs presented prompted a discussion on Vasculitis. Colleagues from NHS Lothian informed the group that they had a Vasculitis protocol and would only use PET-CT scanning as a problem solving tool, not routinely, in this indication. NHS Tayside colleagues - Dr Prasad Guntur and Dr Glen Gardiner - informed the group that they were currently in the process of assessing the clinical indications from the past two years in order to ascertain and identify whether the use of PET-CT could be justified in determining if PET-CT made a difference in the treatment outcome of vasculitis. If it was identified that the use of PET-CT did not make a difference in the diagnosis or treatment of vasculitis, then NHS Grampian would be in a stronger position to inform their clinical colleagues that there is no benefit in providing a PET-CT if the patients first diagnosis was accurate without the PET-CT scan. Dr McKiddie advised that the graph was an accurate representation of what NHS Grampian was experiencing. Action: Dr Gardiner to provide evidence for the next meeting 5. Review of indications for PET-CT in Scotland 4
The 6 protocols developed in NHS Scotland were slightly different from the ones which were being used in NHS England for the same indications. Following the last PET-CT Review of Indications Group, Mrs Evans had contacted colleagues in NHS England to seek information to benchmark the Scottish service against. Ms McCulloch, Lead Commissioner of PET-CT services in NHS England, had reported that in England there was a standard national service specification and clinical commissioning policy for PET-CT scanning. The contract was with Alliance Medical and the contract was managed by one Regional NHS England team on behalf of them all. There were 11 local commissioning hub teams in total, but all used the standard national documentation. Ms McCulloch agreed to forward information on the total information of PET-CT scans across NHS England, but did not have a breakdown into individual indications. She had information which broke it down into cancer and other indications, and latest reports indicated that other indications accounted for 3% of the total. Ms McCulloch was keen to ensure that the Scottish PET-CT Review of Indications Group could become a UK Group and would commission work jointly on the evidence for say, 2 non cancer indications and 2 cancer indications, in order to get a proper assessment of the evidence for PET-CT benefit. It was agreed that the Clinical Reference Group chair, Professor Wong, and Ms McCulloch, would be invited to join the Scottish Group and that the aim of joint work would be to ensure that future commissioning would be evidence based. In England the financial cost had risen from 40m- 50m to 80m- 90m, and there had not yet been any clear evidence of benefit in relation to 5 year survival. NHS England was concerned that an expenditure of around 90m needed to be justified in terms of clear clinical benefit. It was agreed that the ROI group should commission work to gain in-depth evidence, but the PET-CT group considered that a joint meeting should be established to make the decisions on which indications to explore in collaboration. It was agreed that Joint meeting of the PET- CT and PET-CT ROI Groups should be held in April 2016. Action: Mr Anderson 6. Report from each PET-CT centre, including research being undertaken Each site provided an update: 6.1 Dundee Currently NHS Tayside provided a NHS PET list 3 days per week with 6 patients per day. The centre received 1, occasionally 2, deliveries of FDG tracer from Alliance Medical s dispensary. NHS Tayside had three technicians and, as they were not yet at capacity, they had the ability to expand if there was a need for expansion. Recent experience has been an increase in activity averaging a 6% rise in numbers year on year; expected to reach 800 next year. Current research involved a study looking at FGFR dysregulated tumours using FDG. There were also several trials due to start 2015/16 on the 3T MRI scanner for Dementia and Alzheimers. There were PET sub-studies to these trials however due to the lack of Amyloid tracers in Scotland, the patients enrolled may need to travel to Newcastle for the PET scans. Action: Dr Gardiner informed the group he would ascertain if there was a possibility of securing Flutametamol and or Florbetapir from within Scotland. 6.2 Aberdeen 5
Dr McKiddie reported that NHS Grampian was part of a multi centre trial that was on-going for lymphomas and lung cancer. NHS Grampian had also recently started a local trial investigating PET in differentiating between ARVC and cardiac sarcoidosis. Dr McKiddie advised that Aberdeen was scoping the benefit of procuring a 68Ga generator to produce DOTATATE for the diagnosis of neuroendocrine tumours and PSMA for the diagnosis of prostate cancer. NHS Grampian had received an application for funding from a local cancer charity but this could not be supported by NHS Grampian as no scan costs were included. 6.3 Edinburgh Dr Fletcher reported that no multi centre trial work was being carried out at present. Dr Patel informed the group that NHS Lothian was producing a cost benefit analysis on why PSMA might supersede Choline. It was considered that there could be significant savings in nuclear medicine, and Dr Patel agreed to share the analysis. Action: Dr Patel 7. Finance Capital The group noted that that there was 7 year capital replacement programme for PET-CT scanners but this did not include cyclotron provision. Planning was in hand for replacement of the new machine in NHS Lothian. 8. Business Case to increase PET-CT staffing in NHS Grampian Dr McKiddie presented the business case for modest investment ( 22k) in the PET-CT service in Aberdeen. The indications for PET-CT had widened from diagnosis and staging, to include assessment of treatment response, restaging, and informing choice of chemotherapeutic regimens. Demand had continued to rise as both the evidence base for the clinical value of PET-CT strengthened and the research applications expanded. One of the current PET only technologists retired in March 2015 and without investment, within 6 months the service would have to limit access to PET to control the radiation exposure to staff. The retirement provided the opportunity to increase the technologist provision and to design a post that would attract quality candidates. Mrs Evans advised that the PET-CT group had a remit to consider and make recommendations to Scottish Government on the provision of PET-CT in Scotland and therefore invited the group to provide peer review of the business case. After thorough scrutiny of the proposal, and the comparative staffing levels of Aberdeen in relation to the other centres, the working group concluded that the proposal from NHS Grampian was justified. It would sustain capacity in Aberdeen in the light of growing demand, and would avoid over exposure to radiation in individual staff. Taking into account the modest additional funding sought, the PET-CT group unanimously supported the Business Case. Mrs Evans agreed to make the recommendation on behalf of the Group to SGHSCD and encouraged NHS Grampian to include the additional funding required ( 21,344 in a full year) in its annual return to SGHSCD for recompense of the costs of providing PET-CT scanning. NHS Grampian should include the prorata costs incurred from the time an appointment is made in its end year statement to SGHSCD. Mrs Evans advised that she would contact the Scottish Government to gain confirmation that SGHSCD approves this recommendation from the PET-CT Working Group. 6
Action: Mrs Evans 9. SINAPSE Professor Zanda reported that the SINAPSE /Edinburgh 2016 bid for the UK PET Chemistry meeting had been successful. He would provide the group with more information in due course. Professor Zanda encouraged members of the group to join SINAPSE; one particular item that the members of the PET-CT group may find particularly interesting was the list of PET facilities that have been made available to members only. He informed the group that if they were interested in participating in this group to either contact Sally Pimlott (Sally.Pimlott@glasgow.ac.uk) or look at the SINAPSE website for more details. Professor Zanda thought it pertinent to mention the SINAPSE/SANON (Scottish Adult Neuro-oncology Network) meeting that discussed PET imaging research in brain tumour patients. A teleconference was to be set up to discuss a potential FET PET imaging grant application to set up the production of 18-FET in one of the PET cyclotron units. Subsequent email discussion had identified 18F-FACBC as a potential candidate tracer. Mr Anderson agreed to share the minutes with Ms Brand, Senior Programme Manager in NSD who commissioned the SANON network. He also agreed to include the SINAPSE minutes on the SCIN website under the PET-CT section. Action: Mr Anderson 10. AOCB The group did not have any AOB to discuss. 11. Dates of Future Meetings It was agreed to cancel the meeting that had been arranged for Friday 22 January 2016. It was agreed that the next meeting date will be for a joint meeting of the PET-CT and PET-CT Review of Indications group and will be held on 4 April 2016. 7