Health technology assessment and cancer imaging: who should be setting the agenda?

Health technology assessment (HTA) has become an integral part of health policy generation and is actively supported by many government agencies throughout the world. When performed within the framework of evidence-based medicine (EBM), such evaluations have the potential to guide clinicians and patients regarding the appropriate use of new technologies and as to their safety. EBM is oriented towards optimising health outcomes for individual patients by facilitating better-informed clinical decisions. The improved outcomes that ought to result from effective application of EBM may however come at the cost of increased health care expenditure [1]. Analysis of the relationship between the cost of a procedure and its benefits can be evaluated in several ways but is broadly termed ‘cost-effectiveness analysis’. While clinical efficacy is the prime consideration for the consumer of health services, it is also an essential component of cost-effectiveness that is primarily relevant to the purchaser of health care. The level at which cost-effectiveness is considered to be achieved depends on arbitrary decisions related to the fiscal resources and perspective of the purchaser. When an individual is responsible for their own medical expenses, the cost of a procedure compared to expected outcomes can be fairly balanced. However, when health care is subsidised in part or completely by a third party, societal perspectives come into play and clinical efficacy may be judged to be less important than cost minimisation. This is more likely if fiscal resources are limited. Groups performing HTA reviews of new diagnostic and therapeutic procedures seek to address issues of safety, clinical and cost-effectiveness by employing EBM methodology, as well as providing guidance for resource allocation decisions. The potential conflict between the objectives of quality health care delivery regardless of cost and the rationing of health services based on notional relative values of cost-effectiveness requires that the process of HTA be rigorous, transparent and well understood by those who use this information. Furthermore, it is vital that benchmarks used to judge cost-effectiveness be prospectively defined and consistently applied in health policy. This has become particularly important since the major funding source for HTA agencies has become third-party funding bodies that have a vested interest in limiting health expenditure. Despite a growing and clinically compelling body of evidence demonstrating the accuracy and impact of PET in oncology [2], recent HTA reviews sponsored by government agencies in Australia (http://www.health. gov.au:80/msac/reports.htm), Canada (http:// www.ices.on.ca/) and Scotland (http://www.htbs. org/uk) to evaluate the justification for expansion of public funding of PET have been critical of the quality of evidence currently available. Since these reviews purport to be comprehensive assessments of the PET literature using principles of EBM and, as such, to provide doctors, their patients and those funding PET studies with the best possible advice on the role of PET,