Table 4.

Challenges for therapy risk-adapted by early positron emission tomography (PET).

PET scan acquisition and interpretation 
  • Consensus versus standard reading

  • Use of other clinical information

  • Adjudication of conflicts

  • Minimal residual uptake

  • Visual versus SUV versus rate of change

  • Technical: equipment, recording

  • Inexperienced readers

  • Factoring likelihood of false positives and negatives

 
Escalation of therapy 
  • Not known to be effective

  • Early PET-positive may also predict failure of intensive therapy

  • Not an option for elderly

 
De-escalation of therapy 
  • Does not eliminate all risks (acute toxicity, sterility)

  • Not known to be effective

 
Study design and conduct 
  • Assumptions made on clinical risk

  • Assumptions made on efficacy of cross-over design

  • Necessity for blinding

  • Equipoise for patients and physicians based on published and presented results

 
PET scan acquisition and interpretation 
  • Consensus versus standard reading

  • Use of other clinical information

  • Adjudication of conflicts

  • Minimal residual uptake

  • Visual versus SUV versus rate of change

  • Technical: equipment, recording

  • Inexperienced readers

  • Factoring likelihood of false positives and negatives

 
Escalation of therapy 
  • Not known to be effective

  • Early PET-positive may also predict failure of intensive therapy

  • Not an option for elderly

 
De-escalation of therapy 
  • Does not eliminate all risks (acute toxicity, sterility)

  • Not known to be effective

 
Study design and conduct 
  • Assumptions made on clinical risk

  • Assumptions made on efficacy of cross-over design

  • Necessity for blinding

  • Equipoise for patients and physicians based on published and presented results

 
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