Campaign Cuts Prostate Cancer Imaging (CME/CE)

Published: Jul 23, 2013

Reviewed?by?Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco

Initiatives aimed at discouraging clinicians from performing inappropriate imaging in men with early-stage, low-risk prostate cancers can dramatically lower testing rates, a study in Sweden found.

Imaging rates among the Swedish men with very low-risk prostate cancers plummeted from 45% to 3% (P<0.001) in the decade after the initiation of a campaign which allowed urologists to compare image testing at their institution with nearby centers -- essentially outing those who imaged large numbers of low-risk patients, according to a study by Par Stattin, MD, PhD, of Umea; University in Umea, Sweden, and colleagues, published online in the Journal of the National Cancer Institute.

Seeing their own institution's imaging rate compared with others in public provided an incentive to reduce unwarranted testing, said study co-author Danil V. Makarov, MD, of NYU Langone Medical Center in New York City.

"I think you could consider the tactic a way of gentle shaming of the healthcare providers who did not follow the guidelines," Makarov said.

The routine use of bone scans and axial imaging of the abdomen and pelvis in low-risk patients has been discouraged by many professional groups, including the American Urological Association, because these patients have a very low risk for disease progression. But rates of inappropriate imaging are still high in many parts of the U.S. and in other countries.

Low-risk prostate cancers are generally defined as stage T1 to T2 disease with a Gleason score of 6 or less and a PSA of less than 10 ng/mL to 20 mg/mL.

In a study published last year in the Journal of Urology, Makarov and colleagues found large regional differences in the rate of appropriate and inappropriate prostate cancer imaging across the U.S.

New Jersey was among the states with the highest rates of inappropriate imaging, with 62% of low-risk patients being imaged. Utah was among the states with the lowest rates, with 22% of low-risk patients imaged.

But New Jersey also had one of the highest rates of appropriate imaging of men with more advanced or more aggressive cancers, and Utah was among the states with the lowest rates of appropriate imaging.

"The finding suggests that imaging is really part of the culture of how patients are taken care of in a given region," Makarov told MedPage Today. "The decision to image seems to be less about how aggressive the cancer is than about where a patient lives."

The new retrospective, cohort study, done in collaboration with researchers from Sweden's Umea University, Uppsala University Hospital and Karolinska Institute, involved data from 100,000 Swedish men diagnosed with prostate cancer between 1998 and 2009.

In 2000, a nationwide campaign was begun in Sweden with the aim of convincing urologists to stop imaging low-risk prostate cancer patients. At regional urology meetings, officials presented statistics on appropriate and inappropriate imaging, along with reminders about imaging guidelines.

A total of 36% of the men included in the study underwent imaging within 6 months of their prostate cancer diagnosis.

The study revealed that imaging use decreased over time in all regions of the country and among both low-risk and high-risk patients.

In high-risk patients, rates of appropriate imaging during the study period decreased from 63% to 47% (P<0.001), the researchers found. The finding suggested that efforts to limit inappropriate imaging may have the unintended consequence of negatively impacting appropriate imaging rates, Makarov said.

"We can't just say 'Don't image one group of patients' and leave it at that," he said. "We also have to encourage appropriate imaging where it is warranted."

Makarov added that the Swedish experience proves that initiatives designed to lower rates of unnecessary medical testing and treatment, such as the American Board of Internal Medicine's Choosing Wisely campaign in the U.S., can have an impact.

Choosing Wisely was launched in 1999 with the aim of promoting a dialogue between patients and their physicians about the best use of diagnostic tests and treatments.

Makarov said such initiatives will become increasingly relevant as the focus of health policymakers shifts from expanding access to medical services to bringing down skyrocketing costs.

"The Affordable Care Act doesn't really address costs directly," he said. "It does increase access to care, so we have loaded the boat and we are all in it together. We need to come up with better ways to bring down costs or we are going to be in big trouble."

The research was supported by the Swedish Research Council, the Swedish Cancer Foundation, the U.S. Department of Veterans Affairs, and the Louis Feil Charitable Lead Trust.

Makarov disclosed funding from the Manhattan VA. No other authors reported any conflicts of interest.

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Source: http://www.medpagetoday.com/Urology/ProstateCancer/40652

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