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New scanner triggers hopes, fears

St. Joseph's Hospital is hurtling into the future on a wing and a prayer. The wing is a two-story, 4,000-square-foot area of the Medical Arts Building devoted to the latest in medical technology _ a PET scanner.

The prayer is that Medicare will help pay for it.

The PET scanner can read your mind and tell whether you have a broken heart. It reveals the body's secrets as no machine ever has, but its complexity and expense have placed it beyond the reach of Florida hospitals. Until now.

St. Joseph's apparently is about to become the first hospital in the country to make and sell radioactive chemicals to other hospitals for PET scanning. It's a $5-million-plus project.

To pull it off, St. Joseph's had to persuade two private companies to front millions of dollars for a cyclotron and "nuclear pharmacy." And it had to form a partnership with a group of cardiologists to afford the $2.4-million scanner.

Some question whether PET is ready for use in a community hospital. Others wonder whether it's appropriate for the doctors who own the scanner to be sending patients to it. And Medicare, nervous over the cost of the test, has stalled a decision on reimbursement for PET scans.

Still, at St. Joseph's there is only excitement as the PET team gets ready to accept patients in the next two to three weeks. The hospital's goal is to become the heart of a satellite system of scanners around Tampa Bay and beyond.

"We're real high on the technology and what it can do," said Judith E. Belt, new ventures coordinator. "It will really enhance patient care."

PET, short for positron emission tomography, is the great-grandchild of the X-ray. The intervening generations were filled with the CAT (computerized axial tomography) scan and MRI (magnetic resonance imaging).

All the scans provide a peek inside the body without the messy, risky business of opening patients up or sticking tubes inside them. But while CAT and MRI display what an organ looks like, the PET scan shows how well the organ is doing its job.

PET scanners watch the way cells consume sugar by lighting up the sugar with a tiny, harmless dose of a radioactive chemical. The scanner translates what it sees into a color-coded image on a computer screen.

Two hospitals in Florida have PET scanners without cyclotrons that are limited to heart studies. The one at St. Joseph's is far more versatile.

Studies suggest that full-service PET scanners can diagnose Alzheimer's disease, detect recurrent brain tumors, pinpoint the origin of seizures and reveal beyond doubt whether heart bypass surgery will help.

Because PET shows how the brain works, it may someday usher in a cure for mental illness. The psychiatry department at the University of South Florida (USF) hopes to work out an agreement with St. Joseph's that would permit access to the machine for research.

"It opens up incredible things that have not been possible before," said Dr. Anthony Reading, psychiatry chairman.

University researchers are finding that they can get different parts of the brain to light up on a PET scan just by getting the patient to wiggle his toe, recite a poem or look at a blinking light.

The possibilities in brain research are mind-boggling. What would you see if you scanned the brains of rapists? Autistic children? Left-handed artists?

PET expert Frank J. Menolascino, chairman of psychiatry at Creighton University in Nebraska, has written that the machine will revolutionize the field of psychiatry because it provides "a functional biopsy of the living brain."

However, exploring such questions doesn't make money, it costs money. Profits lie in hearts. That's also where the controversy lies.

Benefits vs. cost

Last year, a PET manufacturer made Dr. Walter E. Drane a heck of an offer. The chairman of nuclear medicine at Shands Hospital at the University of Florida (UF) could have the use of a heart PET scanner for a year, for free. Drane only would have to buy the chemicals and pay the technicians.

Drane and his colleagues thought it over. Finally, they said no.

"I want to practice cutting-edge, state-of-the-art medicine," Drane said. "But we didn't see a clinical use."

The UF professor said what he could glean from a PET scan of the heart would only duplicate what he already learns from cheaper tests, a combination of thallium stress tests and SPECT. Both those tests use radioactive chemicals and imaging processes, but they provide a narrower range of information than PET.

"Just because it can be done with a PET scanner doesn't mean that is the way to do it," Drane said.

Dr. David Hess disagrees. By preventing mistakes, he said, PET saves money.

Hess, a cardiologist at Memorial Medical Center in Jacksonville, said the PET machine there earns its keep by flagging normal hearts before they're subjected to cardiac catheterization. That procedure, in which a thin tube is threaded through a blood vessel to the heart, shows what is wrong and whether bypass surgery will help.

About 30 percent of catheterizations done each year are unnecessary because the patients have nothing wrong with their hearts, Hess said. They are subjected to the catheterization because thallium and other tests are too imprecise and indicate there are problems when there aren't, he said.

"There are 300,000 unnecessary catheterizations each year, at a cost of $1.5-billion. PET will end most of those," he said.

In 1987, before the PET scanner arrived, Hess' rate of unnecessary catheterization was 24 percent, he said. With PET, that rate has fallen to 3 percent.

That means PET could save lives, he said, because a catheterization itself carries a 1-in-1,000 risk of causing a stroke or heart attack.

Another benefit of the PET scanner, according to Hess, is that patients who are admitted to the hospital on suspicion of having suffered a heart attack can be checked and released much more quickly if nothing is wrong. The average length of stay for such patients has been cut from 3.7 days to 2 days, he said.

"I don't know why this particular piece of equipment is creating so much controversy," Hess said, "because it's really a wonderful thing.

"When the (Tampa) PET is up and running, doctors in your area will wonder, "How could we have practiced effective medicine without it?' "

Proceeding cautiously

Although it sounds like a machine from Tomorrowland, the PET scanner has been around for more than a decade on a few university campuses. Gradually a few commercial models evolved.

One, a stripped-down PET system that only analyzes blood flow in the heart, costs $2.5-million. Most of the 47 PETs in use or under construction across the country, including the ones in Jacksonville and Miami, are of this type. They use a chemical that can be purchased, so they need only a generator to operate.

But doctors at St. Joseph's wanted a more powerful machine, one that would provide better information on heart function and would study brains as well. They would have to make their own chemicals, so they'd need a cyclotron on site. That's what ran the cost to more than $5-million.

They worked out the deal with the cyclotron company to build it for free and with the cardiologists to buy the scanner.

Some in the medical field are concerned about the appearance of a conflict of interest in the ownership of the Tampa scanner.

"Whenever a PET center is owned by physicians, there is a major potential for self-referral and abuse," said Drane of UF.

Dr. Stephen P. Glasser, medical director of a heart research program at USF, agreed. "If you have a PET scan in your office," he said, "you're likely to use it."

The cardiologists who put up most of the cash for the scanner call themselves PSC Partners. Only Dr. Peter Alagona, who serves as spokesman for the group, has been identified.

He said the doctors who invested are taking a considerable risk. They don't look at the project as a moneymaker, he said, but as the only way of providing a service that their patients need.

Isaac Mallah, St. Joseph's chief operating officer, said the hospital had to have the doctors' help because it couldn't swing the deal alone. The cardiologists' willingness to commit their own money helped convince the hospital of the project's importance, he said.

Even if they were tempted to abuse the machine, Alagona said, they would be prevented from doing so by Dr. Edward A. Eikman, medical director for the PET Center. Eikman said he intends to document the need for each case so the hospital will be sure of reimbursement from insurers.

The partners in the cooperative venture are all betting that other hospitals will buy PET scanners that require chemicals made in the cyclotron at St. Joseph's. So far, though, other hospitals are holding back, unconvinced that they can afford a PET scanner and unsure whether they even need one.

Insurers, too, are being cautious. While the majority are paying for some PET scans, Medicare is not. Federal officials have said they will study the issue another 18 months before deciding.

The American College of Cardiology has not fully embraced PET scanning, either. In a statement issued March 17, it endorsed PET's use in studying damaged heart tissue to determine whether bypass surgery would succeed or flop. But the cardiologists didn't endorse the use of PET for diagnosing heart disease, because they said there is no proof yet that it is better than the standard tests, which are cheaper.

Unwilling to wait for officials to give PET scanning their unqualified blessing and payment, some hospitals with scanners are bypassing the medical community and advertising directly to the public. For its new scanner, South Miami Hospital plans to place ads in business sections of newspapers in hopes that executives will pay the $1,500 to $2,000 to find out if they have clogged arteries.

The result may be that people who aren't sick but are well-to-do will be using the machine, while people who are sick and need to use it won't be able to because they don't have the money.

To avoid this situation at St. Joseph's, said Eikman, patients must be referred by a physician. Those who need a scan won't be turned away for lack of money, he said.

"We can't sit here and wait" until the insurance companies and Medicare come around, Eikman said. "The principle here is to deliver the care."