To the Editor: I read with interest the article by Ware et al1 and the response from Davies.2 Let me first commend Ware and his colleagues on an excellent piece of investigative journalism.

For the readers’ information, there are about 200 operational positron emission tomography (PET) scanners in the United States, and the United Kingdom has recently committed to 50–60 PET scanners within the next 5–10 years.3 This is based on the vast amount of published evidence with respect to the benefit of PET for the diagnosis, staging and monitoring of a range of malignancies and other disorders.

Despite more than 15 000 publications3 and the fact that some countries reimburse for many indications not covered in Australia (eg, breast cancer restaging, dementia assessment), our authorities request “Australian data” before allowing expansion of the Medicare benefit for PET in Australia. The issuing of only eight Medicare licences (ie, about 1 per 2.5 million population) also impedes access to what may be the most important imaging development of the past 20 years.

What was not mentioned by Ware et al is the grossly inadequate amount paid for PET services under the Medicare Benefits Scheme in Australia. Currently, the reimbursement for a fluorodeoxyglucose PET scan in the US is about US$2000/scan. In Australia, the Medicare Benefits Scheme pays about $900. This makes our reimbursement one of the cheapest in the world. So cheap that it makes no economic sense for private entities to provide PET services in this country (note: isotope cost, about $350/patient; cost of PET set-up, $2.5–5 million). So the Commonwealth has no need to worry — it already has done much to slow the growth of clinical PET in Australia.

Before Davies replies that we need “Australian data”, cost-effectiveness data, etc, before allowing new technology expansion, I ask: are Australian data so much better than those from our colleagues overseas? And what is the level of evidence for much of what we currently do and get paid for in clinical practice? For example, what is the rationale behind the reimbursement, without limit, of regular computed tomography scanning in the follow-up of patients with treated lymphoma? I direct readers to the articles by Guppy et al4 and Dryver et al5 to see what little benefit there is in this practice. Of course, these are British and Canadian studies, so surely they cannot be taken seriously.

To the Editor: In light of our article examining the Australian Government’s review of positron emission tomography (PET),1 it is interesting to note that the accompanying official response is attributed to the Department of Health and Ageing (DOHA).2 When asked to clarify its role in the review of PET, DOHA had previously persuaded the Commonwealth Ombudsman that it had contributed only secretarial support to the process. With no accountability for policy decisions or the review itself, is it any wonder that DOHA’s response does not address the hard evidence that the politicians are “misusing” evidence-based medicine.

The comment that “one of the concerns that has been raised about the PET reviews is that the government did not follow the views of individuals who were involved in the process” does not relate to our text. We are aware that individual opinion is considered very low-level evidence. Our argument is that the supporting committee made a decision that PET was safe, clinically effective and potentially cost-effective on the basis of the evidence it reviewed. The Medical Services Advisory Committee (MSAC) itself did not review any evidence, so, by changing the decision of its supporting committee, MSAC’s own opinion was substituted without any sound scientific basis. Therefore, the decision at a ministerial and government level to restrict Medicare funding for PET is purely a political decision, and must not be misrepresented as “evidence-based”. Indeed, the evidence suggests that the policy decision to restrict Medicare funding for PET prejudiced the objective analysis of the evidence by MSAC.

The suggestion that “the government is funding the collection of data by service providers to improve the evidence base related to the use of PET in a wider range of indications” is misleading. To improve the level of evidence for PET would require, in the words of the permanent medical adviser to MSAC, “very large randomised trials, which are probably not feasible”. The current data collection is not a randomised trial. For many of the indications being examined, the validity of the PET findings and consequent management changes will not be assessed. There is no plan to evaluate cost-effectiveness. Therefore, the process is not going to improve the level of evidence for subsequent decision-making. Perhaps this is the outcome envisaged for 2006!

The problem with the PET review was a fundamental disregard for the promised standards. The ongoing problem is that MSAC is not an appropriately legislated body (unlike the Pharmaceutical Benefits Advisory Committee). MSAC is secretive and its process and decision-making are difficult and costly to penetrate. Unless the structure, process and accountability of MSAC are changed, history is likely to repeat itself. The official response to our article only serves to heighten our concerns.