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Understanding over-imaging

Conquest - Spring 2014

By  Laura Sussman



There ’s no denying the medical marvel of imaging. The technology has dramatically altered all aspects of cancer care — from diagnosis and treatment to surveillance and prevention.

It began with the revolutionary introduction of the computerized tomography (CT) scan in the 1970s. For the first time, physicians were provided with a 3-D view of the body’s organs, bones and other tissues, as well as tumors. Since then, CT technology has evolved in such a transformative way that in the not-too-distant future, novel therapies may be guided in real time based on what the most sophisticated of imaging equipment identifies.

“Thirty years ago, the most common surgery done was an exploratory laparotomy — a high-risk procedure that’s associated with morbidities and, in some cases, death,” explains Marshall Hicks, M.D.,head of Diagnostic Imaging. “Now it’s hardly ever performed because of the ability to diagnose and determine therapy using cross-sectional imaging.”

Imaging’s impact reaches far beyond cancer, stretching across the entire health care spectrum. Yet, as technology has advanced and its potential has skyrocketed, so have concerns about overuse and appropriate use of imaging, as well as the cost to the nation’s health care system. According to the National Council of Radiation Protection and Measurements, it’s estimated that annual medical
radiation exposure has increased six-fold since the 1980s.

The reasons for that eye-popping statistic are as obvious as they are complex. Clinical, legal and economic factors are involved, as well as the empowered patient’s demand.

“Clearly, imaging has revolutionized medicine. Yet there’s an obvious paradox,” notes Hicks. “When applied and used appropriately, imaging is undeniably valuable. But as it has become more accessible and more prevalent, an overuse issue has developed — both across the country and beyond cancer — that we’re now trying to address as a society.”

As the nation continues to try and tackle growing health care costs, the field of medical imaging is on notice, with policy makers and insurers taking a stand against excessive use and cost. Many professional medical societies have launched campaigns promoting “appropriateness criteria” and/or clinical guidelines for imaging and procedures.

In fact, the imaging community has been barraged with recommendations over the past few years, says Wei Yang, M.D., professor in Diagnostic Radiology and section chief of Breast Imaging.

“But it’s a very difficult issue to perfectly navigate. From the policy point of view, we want something for everyone that offers maximum benefit at minimal cost,” she explains. “That doesn’t always work on a personal level, especially for the patients who may want all the imaging possible and feel that empowerment will help them navigate their cancer journey.” 

“As we evolve as physicians who practice clinical diagnostic
imaging, I’ve found that the more time we spend helping our
patients understand the quality of care, the less heavily they 
rely on imaging,” says Wei Yang, M.D.
Photographer: Wyatt McSpadden

Over-imaging and breast cancer

One professional society’s surprising recommendations motivated MD Anderson researchers to investigate the issue of over-imaging in diagnosing early-stage breast cancer.

In 2011, the American Board of Internal Medicine launched “Choosing Wisely,” an initiative that encourages conversations between physicians and patients that, ultimately, may discourage the overuse
of the country’s health resources. In 2012, as part of its participation in the national campaign, the American Society of Clinical Oncology (ASCO) recommended against the use of CT, positron emission
tomography (PET), tumor markers and nuclear bone scans in early-stage breast cancers.

Carlos Barcenas, M.D., points out that the recommendations of the National Comprehensive Cancer Network — the gold standard for treatment guidelines — clearly state that for women with early disease, the proper procedures for diagnosis only include mammograms, ultrasounds, clinical exams and blood work.

“ASCO’s broad recommendations against procedures that are not recommended by the national guidelines gave us the idea to investigate and understand just how pervasive over-testing and imaging really are,” says Barcenas, an assistant professor in Breast Medical Oncology. “We’ve known that the overuse of staging procedures is a problem and may also affect the cost-effectiveness in diagnosing women with early breast cancer — just not to what extent.”

For the retrospective study, Barcenas and his MD Anderson colleagues analyzed claims from a national database of 42,651 women with an initial diagnosis of breast cancer between 2005 and 2010.
All were younger than 65 and had undergone breast cancer surgery. Claims for imaging and tumor markers were analyzed between the specific period of three months before surgery and one month after.

Of the patients, 37% had at least one claim for an unnecessary staging test, with minimal change in rate over the five-year period. Most alarming to the researchers was that 18% had tumor markers performed — a staging procedure with no role in the nonmetastatic breast cancer diagnosis setting. 

Undergoing chemotherapy had the highest association with overuse of staging procedures, with hormone and radiation therapy also being overused. Finally, the youngest of breast cancer patients — women under 35 years old — were most likely to undergo inappropriate testing. However, this statistic may reflect the perception that the younger population is perceived to be at higher risk of metastatic and/or aggressive disease, Barcenas explains.

The researchers found regional differences in overuse trends, as well as a higher rate of unnecessary procedures in women with preferred provider organization (PPO) coverage compared to those with health maintenance organization (HMO) coverage.

Sharon Giordano, M.D., says that the research should offer some validation to physicians, granting them permission to not order unnecessary tests.

“Often doctors think they’re not being good to their patients if they don’t do all they can by way of testing,” explains Giordano, chair of Health Services Research, who co-authored the study with Barcenas. “But there’s a shift in focus to doing what matters for the patient and what’s proven to improve outcomes, rather than testing for the sake of testing. Ultimately, our goal is to bring the best care and value to our patients.”

Partnering with the patient

To ensure success in reducing the demand for imaging, MD Anderson experts agree that strong communication between physician and patient is paramount.

“As we evolve as physicians who practice clinical diagnostic imaging, I’ve found that the more time we spend helping our patients understand the quality of care, the less heavily they rely on imaging,” says Yang.

Overwhelmingly and understandably, says MD Anderson’s George Chang, M.D., a colorectal surgeon, a major concern for cancer patients is recurrence. And as cancer patients — fortunately — live longer, their desire for surveillance continues.

“Specifically for colorectal cancer surveillance, there’s very little data to help us monitor patients and guide the care we provide — the guidelines we use actually are based more on expert opinion,” says Chang, professor in Surgical Oncology. “Therefore, we really don’t have a way to appropriately communicate with patients.”

Chang and colleagues across the country have embarked on a study, with the help of their patients, to specifically address the data issue, as well as understand their personal needs. Conducted by the Alliance Cooperative Group and sponsored by a nonprofit research institute funded by the Affordable Care Act, the researchers hope to better understand what patients look for in surveillance. Ultimately, they want to identify ways surveillance can be tailored according to risk of recurrence, ability to be treated and, just as important, a patient’s personal preference.

“Our study partners physicians and patients in hopes of developing a decision-making tool for both,” says Chang, the study’s principal investigator. “Surveillance is inherently patient-centered, yet that communication is critical throughout their cancer experience. Ultimately, the patient is the most important component of all aspects of care.”

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MD Anderson ’s checks and balances

With patients’ best care in mind, a unique system of imaging checks and balances is the standard at MD Anderson, which is unique, even for academic cancer centers, says Joseph Steele, M.D., deputy division head of Clinical Operations in Diagnostic Imaging. When a clinician orders a CT, PET or MRI, that order — along with the patient’s medical history — is thoroughly reviewed by an MD Anderson radiologist before imaging.

“Our radiologists look at all relevant clinical information such as previous imaging studies, prior surgeries, pathology reports and treatment regimens. We want to ensure that the imaging study ordered is the most appropriate and, if it is, determine how best to proceed with the testing,” says Steele, a professor in Diagnostic Radiology. “Our goal is to ensure that the imaging protocol ordered answers the specific question of the clinician, so we tailor the examination to meet each patient’s unique needs.”

This practice is very different from the majority of imaging conducted in the United States, he explains. Often, the first time a radiologist learns of the patient’s care is when their image comes up on a screen to be reviewed. 

With additional imaging exams, there often comes additional radiation exposure, reminds Steele. It’s critical that both clinicians and radiologists explain to the patient that, while often minimal, additional radiation exposure does come with risk. Anecdotally, Steele has noted a stark contrast in patients’ understanding and comfort level with additional radiation exposure: some are overly fearful and may even refuse necessary testing, while others want as much testing as possible, regardless of the risk-benefit ratio.

To address the issue, Steele and his colleagues have opened an MD Anderson survey-based study in lung cancer patients, measuring their personal knowledge about risk from radiation exposure.

“Our concern is that some patients don’t understand their own risk and may make poorly informed decisions — either for or against imaging — that may not be in their best interest,” he says. “We hope our findings will identify populations in need of greater understanding, and then we can focus our education efforts on those people.”

© 2014 The University of Texas MD Anderson Cancer Center