After a steady decline in sales for the past few years, manufacturers are heartened to see CT is finally making a comeback. “Over the last four quarters in a row we’re seeing sales growth,” says Eric Stahre, vice president and general manager, global CT/ PET, at GE Healthcare.

And the good news isn’t just confined to sales. “We’ve seen not only equipment growth but procedure growth,” says Dominic Smith, vice president and general manager, global computed tomography, at Philips Healthcare.

A report by WinterGreen Research shows that the global CT market is due to reach $6 billion by 2019 with two to three percent annual growth, driven by gains in imaging clarity and increased demand for higher-quality screening tools.

One of the biggest factors in the current market rebound, experts agree, is pent-up demand for new equipment. The sour economy coupled with the uncertainty around the impact of health reform has made hospitals nervous about pulling the trigger on big ticket items. Spending on capital equipment has thus remained largely stagnant, taking a backseat to other more pressing operational costs.

But the rosier sales figures in 2012 seem to indicate a shift in attitude. After all, try as hospitals might to put off purchases, aging machines do eventually need to be replaced. Still, according to Stahre, the average age for CT scanners in the United States is approaching nine years—the highest it’s ever been. “Maybe we’ve hit that point where this isn’t the standard state of affairs anymore,” he says.

Measure up
Though CT suffered a sales hit in recent years, its trajectory over the long run is considered a huge success. Since the modality was introduced in the ‘70s, its use has ballooned, and experts estimate about 68 million CT scans are performed annually in the U.S. alone.

The reason for its popularity is simple: CT is the best imaging tool out there for countless procedures.

“Used wisely and optimally, CT is one of the most valuable imaging modalities we have and it has changed our world. It can improve medical care and diagnose some illnesses that no other tests can. It can help determine the best treatment plan and avoid other tests or surgery,” says Dr. Marilyn Siegel, professor of radiology at Washington University School of Medicine in St. Louis and highly regarded expert in pediatric dose.

But every modality has its drawback. The biggest downside of CT, radiologists agree, is the relatively high level of radiation dose it uses. A CT chest scan uses 70 times the amount of radiation of a traditional X-ray.

The benefits of CT scanning far outweigh its risks, but dose reduction continues to be a relevant and much-discussed topic partly because stories around the risks of CT radiation exposure continue to pop up in the media, causing consternation among the public.

Dose concerns have popped up again this year with a recent study that showed CT scans resulted in an increased cancer risk among pediatric patients. Children, who undergo two or three CT scans before they turn 15, face a three times greater risk for brain cancer, for example.

The study suggested alternative methods of screening whenever possible along with widespread adoption of dose reduction techniques such as diagnostic reference standards, which set guidelines around how much radiation to use for certain patients. Such practices are already standard in Europe where physicians must stay within the limits of these standards or justify the extra dose they’re using.

Dose by any other name
Though there’s a concerted push within the United States to standardize, regulate and reduce dose, some daunting obstacles stand in the way of widespread dose reduction.

The first one is pretty basic: not everyone agrees on what dose is or how to measure it. “It’s like alphabet soup,” explains Siegel. “There are multiple terms thrown around.”

For example, one metric, the CT dose index, is a measurement of scanner output. But there’s also another metric called the dose length product. And recently, the American Association of Physicists in Medicine came out with yet another metric called size-specific dose estimates (SSDE) based on patient size.

These different metrics create confusion among practicing physicians, who typically don’t have time to fiddle with measurements or figure out the best metric to use. Different terminologies among different vendors further exacerbate the problem.

There’s also a big challenge on the training front. Though radiologists typically receive scattershot training in CT dose and physics, dose reduction is far from standard in all training programs. “There’s no push for them to look at dose, there’s no teeth behind it,” says Siegel.

Lack of education and training isn’t just limited to technologists or radiologists, either. A new study published in the August issue of Pediatrics indicated that most parents did not know that CT scans could increase their child’s risk of developing cancer. Siegel observes this in her own practice: “I rarely get questions from parents. They should understand that we’re also exposed to naturally occurring background radiation every day. They should clearly understand that if CT is the best test to evaluate their child’s illness, the radiation dose will be kept as low as possible. They should be empowered to ask if their imaging facility is using low dose techniques.”

Texas is leading the charge on radiation dose legislation that experts expect will be the increasing norm in the future. The law, a revision of earlier legislation from 2010, specifies that CT systems must be accredited through an approved modality-specific or facility-wide accreditation process.

The new law also sets specific dose reference protocols very similar to those practiced in Europe. If the administered dose levels exceed the threshold, facilities must report to various agencies within five, 10 or 15 business days, depending on the error.

But apart from state-mandated legislation, dose reduction will be impossible without widespread hospital buy-in and standardization. For the effort to truly succeed, major associations such as the American Academy of Family Physicians and the American Academy of Pediatrics will also need to put their full weight behind the message.

“Hospitals should have brochures on dose for people to read in their waiting rooms or handed out like a HIPPA form — just to increase their awareness of what they’re getting. Handouts can increase understanding about CT radiation exposure without causing parents to refuse studies’” says Siegel.

Taking the thinking out of dose
The most crucial aspect of dose reduction has more to do with what technologists aren’t required to learn — in other words, automated features on the machine that reduce dose without the need for extra education or training. “Honestly, it starts and ends with the technology,” says Stahre.

Training and education are important aspects of dose reduction, but what if manufacturers could create a CT scanner that doesn’t need high dose, eliminating problems on the technician side? Vendors are hard at work trying to make this possibility a reality.

For example, iterative reconstruction uses algorithms to reduce image noise, significantly reducing dose while improving image quality. GE offers its model based image reconstruction technology, Veo, while Siemens offers its own iterative reconstruction feature called SAFIRE.

And Siemens also offers CarekV, a feature introduced in 2012, that helps select the optimal kV level for the image acquisition. “The technologist wants to do the right thing, but is the scanner helping them to do it?” asks Jakub Mochon, product manager at Siemens Healthcare.

Studies in Radiology and Investigative Radiology indicate that this new feature has led to a decrease in dose by 28 percent, and its efficacy is further confirmed by Siegel, who says that the technology in combination with iterative reconstruction has helped reduce her median dose from 5.7 to 2.7 in her own practice. “It takes the guesswork out based on size,” says Siegel.

Eliminating or at least greatly mitigating the concerns around dose will go a long way towards making CT an even more appealing modality for wider indications, experts say. “If CT can get much closer to mammography dose, then CT has the ability to bring all the clinical value at an acceptable level of dose — a huge leap forward,” says Smith.

End of slice wars
In years past, manufacturers fought for CT market share by upping the number of slices on their machines. Slice wars propelled the industry at one point, spurring surges in sales with each new release. But this one-upmanship has largely become a thing of the past as the appetite for new scanners diminished. Since the height of the $1.7 billion market for new CT units in 2006, sales have plunged by more than half.



There’s a bell curve in today’s CT market – high-end systems comprise one end and low six to16 slice systems comprise the other end. When customers are looking to buy new equipment, they usually decide on something that falls in the middle, according to experts. “You can still probably find many single slice scanners out there in small hospitals, but when it comes to scanners that are being sold today, majority of them fall under the 64 slice category,” says Mochon.

Though customers have in the past have erred on the side of more gadgets and slices, , times have changed. “Customers are more educated about what they need and more cautious now,” says Mochon. In keeping with this budget-conscious trend, Siemens offers their customers the option of upgrading to a higher slice machine down the road if they initially buy a low-slice scanner. “In this reality where budgets are not getting higher, customers appreciate this approach,” he says.

When it comes to head, chest and abdomen scans, which drive the bulk of CT imaging procedure volumes, a low-slice scanner can handily do the job. “Really, any of the scanners can handle this basic bread and butter imaging,” explains Mochon.

In short, the CT market and its manufacturers have long since evolved past thinking in terms of slice count, focusing instead on technology and image enhancements that maximize each slice. “We haven’t been focused on the number of slices, it’s been more around better slices and better information from those slices,” says Stahre.

Lung power
In late July this year, the industry was abuzz with excitement as the United States Preventative Services Task Force recommended annual CT scans for high-risk smokers and former smokers. If CMS follows up with Medicare reimbursement approval for the screening as experts predict, this will have an enormous impact on the CT market, since providers would be able to tap into the Medicare reimbursements offered for the 9 million Americans who qualify.

A much-discussed study released by the National Cancer Institute called the National Lung Screening Trial (NLST) demonstrated that using low-dose CT instead of traditional X-ray resulted in a 20 percent decrease in mortality. “A study like this doesn’t happen too often these days,” says Mochon.

What’s more, the figure also doesn’t necessarily get at the true value of the screening, since the NLST advisory board recommended ending the study—the most expensive screening study ever proposed—after it reached a “statistically significant” 20 percent decrease in mortality.

This is a potential point of controversy among physicians who feel that the study was stopped too early. “It could have been extended for another five years to look at the overall effect on disease-specific mortality. If this had been done, 20 percent might actually be a significant underestimation,” says Dr. David Naidich, professor of radiology (specializing in chest radiology) at NYU Langone Medical Center.

The modality shows particular promise for detecting early stage lung cancer before patients even develop symptoms. Most lung cancers are found when the tumor is relatively large and the disease has already progressed too far for treatment. By catching the disease early with CT scans, patients could avoid prolonged chemotherapy, surgeries and other treatment, potentially reducing the overall cost of care.

Recently, a first-of-its-kind actuarial study in Health Affairs that examined the economics of CT lung cancer screening seemed to confirm that these screenings had a clear cost benefit. CT lung cancer scans would cost less per life-year-saved than cervical and breast cancer screening, according to the study.

Too much of a good thing?
On the other hand, CT screening for lung cancer is not without its critics. For one, some people may question the fairness of putting public dollars toward treating a disease whose cause is widely known. “Many people think smokers brought it on themselves and don’t want to invest in preventative screening programs,” says Bruce Pyenson, co-author of the actuarial study in Health Affairs and principal and consulting actuary at Milliman.

Furthermore, some experts still say that the benefits of the screening may not outweigh its potential drawbacks. This isn’t a criticism confined to just lung cancer — in recent years, breast and ovarian cancer screenings have received flak from critics who allege that the false positives, overdiagnosis and overtreatment caused by screening actually result in greater harm than good, on balance.

Moreover, the dramatic mortality rate cutbacks in the NLST haven’t been recreated in major European studies, though this may be due to factors such as small cohort size and lower-risk patient selection. Nevertheless, some doctors point to such results as reasons to exercise some caution.

Such questions come as increasingly sensitive screening technologies are able to pick up on lesions that are actually harmless and best left alone.

“Part of the problem is that CT is too sensitive,” says Naidich. But he also adds that the clear benefits shown in the NLST have put such worries to rest. “We now have a handle on minimizing the number of unnecessary procedures. The NLST shows it’s highly manageable and that it’s not going to be the issue people thought it would be,” says Naidich.

For more on the practical challenges of implementing mass screenings for lung cancer, go online: HERE

To view the CT New Equipment Guide, click HERE

DOTmed Registered September 2013 CT Companies

Names in boldface are Premium Listings.
Domestic
Ankita Kapoor, A & R Investments International, CA
Elie Semaan, Rayon-x Engineering, LLC, CA
DOTmed Certified
Michaelle Serrano, Oxford Instruments Service, LLC, FL
DOTmed 100
Todd King, KING Equipment Services, Inc, IL
DOTmed Certified
Davyn McGuire, Med Exchange International, Inc., MA
DOTmed Certified
DOTmed 100
Bruce Hull, Network Imaging Systems, NC
DOTmed Certified
Eric Smith, SOS Medical Imaging, NC
DOTmed Certified
DOTmed 100

DOTmed Registered September 2013 CT Companies

Names in boldface are Premium Listings.
Domestic
Ankita Kapoor, A & R Investments International, CA
elie semaan, Rayon-x Engineering, LLC, CA
DOTmed Certified
Michaelle Serrano, Oxford Instruments Service, LLC, FL
DOTmed 100
Todd King, KING Equipment Services, Inc, IL
DOTmed Certified
Davyn McGuire, Med Exchange International, Inc., MA
DOTmed Certified
DOTmed 100
Bruce Hull, Network Imaging Systems, NC
DOTmed Certified
Eric Smith, SOS Medical Imaging, NC
DOTmed Certified
DOTmed 100
Alison Fortin, Global Inventory Management, NH
DOTmed Certified
DOTmed 100
Lynn Williams, Advanced Imaging Management, TX
Paul Zahn, Shared Medical Services, Inc., WI
DOTmed Certified
DOTmed 100
David Stopak, A. Imaging Solutions, AL
DOTmed Certified
DOTmed 100
Rick Stockton, Atlas Medical Technologies, CA
DOTmed Certified
DOTmed 100
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DOTmed 100
John Pereira, United Medical Technologies, FL
DOTmed Certified
DOTmed 100
Ronen Bechor, ElsMed Ltd. & Relaxation, Inc., FL
DOTmed Certified
DOTmed 100
David Pac, American Radiology Resource, MD
DOTmed Certified
DOTmed 100
Anthony Orlando, Complete Medical Services, MI
DOTmed Certified
DOTmed 100
Rob Manetta, Nationwide Medical Equipment Service, Inc., NK
DOTmed Certified
DOTmed 100
Ian Alpert, Tandem Medical Equipment, NY
DOTmed Certified
DOTmed 100
John Kolleger, Bayshore Medical Equipment, Inc., NY
DOTmed Certified
DOTmed 100
Mark Silverman, Hitachi Medical Systems America, Inc., OH
DOTmed Certified
DOTmed 100
Doug Baker, SafeScan Imaging Service, WI
Ryan Gilday, Clinical Imaging Systems, Inc., NJ
DOTmed 100
Ed Sloan, Ed Sloan & Associates, TN
George Tyler, Altair Imaging LLC, CA
Chris Ash, Scanworks, CO
Olga de la Paz, Puma Export, FL
Paul Crawford, Block Imaging International, Inc., MI
David Palmer, Blue Vista Medical Supply, LLC, MT
Mark Koers, Modular Devices, Inc., IN
Mike Ghazal, Zetta Medical Technologies, IL
Carlos Lopez, XRay Connection, CA
DOTmed Certified
Jeff Rogers, Medical Imaging Resources, Inc., MI
DOTmed 100
Robert Serros, Amber Diagnostics, FL
Charles Gauthier, Imaging Services, IL
DOTmed Certified
Steve Basterash, Technological Horizon Enterprises, GA
DOTmed Certified
Jim Gallagher, LG Medical Technologies, Inc., IL
DOTmed Certified

International
Florian Dickopp, Medicopex GmbH, Germany
DOTmed Certified
Gustavo Volpi, DICOM IT, Argentina
Eduardo Arr, Primco, Peru
Jose Morillo, J Morillo Sistemas Biomedicos, Venezuela
Mads Vittrup, Medicopex GmbH, Denmark
DOTmed 100