Are we over imaging?

Advancements in imaging have dramatically altered all aspects of cancer care — from diagnosis and treatment to surveillance and prevention. Its impact reaches far beyond cancer, stretching across the entire health care spectrum. Yet, as technology has advanced and its potential 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 concerning 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," says Marshall Hicks, M.D., head of Diagnostic Imaging at MD Anderson Cancer Center. "When applied and used appropriately, imaging is undeniably valuable. Yet, 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 United States 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.

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. As part of its participation in the national campaign, in 2012, the American Society of Clinical Oncology (ASCO) generated a "top five list" that 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., an assistant professor in Breast Medical Oncology, 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 is," says Barcenas. "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 between 2005 and 2010 with an initial diagnosis of breast cancer. 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 non-metastatic 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, and 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., chair of Health Services Research, says that the research should offer some validation to physicians, in effect, 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

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 of 2010, 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, their own 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."