Health Care Delivery
Commentary
Increasing Use of Advanced Imaging: Evidence That We Need to Do More to Help Our Patients Tolerate the Uncertainty of Living With Cancer By Jennifer L. Malin, MD, PhD
Overuse of imaging in patients with cancer is a growing concern. Four of the 10 areas that ASCO has highlighted as interventions whose “common use and clinical value are not supported by available evidence” as part of the American Board of Internal Medicine Foundation Choosing Wisely initiative involve diagnostic imaging. The initial ASCO top five list, published in 2012, identified the use of imaging in the staging evaluation of patients with breast and prostate cancer at low risk of metastases and the use of surveillance positron emission tomography with computed tomography (PET/CT) for asymptomatic breast cancer survivors as common practices that are not supported by the evidence.1 In their 2013 update, ASCO expanded this to include surveillance of any cancer treated with curative intent.2 In addition to the tremendous costs of unnecessary imaging, the potential safety issues of repeated exposure to low doses of ionizing radiation, the time required of patients and caregivers to submit to testing, and the worry experienced while awaiting results are additional burdens whose impact should not be underestimated. With the advent of new imaging technologies, use of diagnostic imaging has increased tremendously over the last decade. In this issue of Journal of Oncology Practice, Loggers et al3 present results of a study showing that imaging studies were common in patients with cancer and were being performed with increasing frequency, from an average of 7.4 images per patient in 2003 to 12.9 in 2006. These findings corroborate prior research that has similarly found increased use of medical imaging among Medicare patients with cancer.4 The rapid increase in use of new imaging technology has raised concerns about inappropriate use and factors such as “self-referral,” or referral of a patient to a test facility in which the ordering physician has a financial interest, being important drivers of increased imaging.5 What is striking about the results reported by Loggers et al3 is that the increased use in diagnostic imaging was similar to that observed in previous studies despite the fact that this study was conducted in a population of patients treated in health maintenance organizations (HMO), in which physicians ordering the studies did not receive any financial benefit from performing imaging. These results suggest that the increase in Copyright © 2014 by American Society of Clinical Oncology
J U L Y 2014
imaging among patients with cancer may not be related to solely to self-referral, because even in HMOs, use of imaging increased by more than 30% in just 3 years. If the increased use of diagnostic imaging is occurring in environments where it is not being driven by financial incentives, then what is contributing to the increase? Because the studies to date in oncology have primarily assessed use and have not considered the clinical context in which imaging studies are ordered, it is not possible to discern how much of the diagnostic imaging being performed is consistent with guideline recommendations and what is truly inappropriate according to current clinical standards. Repeated testing is another issue that has been identified as contributing to increase use of imaging. Hillner et al found that nearly half of the patients with cancer who had a PET/CT had received another CT scan in the 30 days prior, and 23% had a CT scan in the 30 days after.6 Although there may be clinical circumstances in which an additional imaging study is needed to clarify a finding that was not definitive on the first study, it seems unlikely that this would be the case in almost three quarters of patients undergoing a PET/CT. However, what is not known is whether repetitive testing is related to incentives to perform unnecessary tests or is the result of poor coordination of care, in which repeat testing is performed by different specialists who are unaware that a test has already been performed at another facility. And, despite the concerns regarding overuse, as in many things in health care, it is possible that underuse of appropriate imaging coexists with overuse. In order to have a better understanding of the factors contributing to the greater use of imaging in patients with cancer, we need to move beyond just looking at use and instead focus on evaluating imaging in the context of quality of care. Uncertainty is a fundamental element of the experience of illness in general, and cancer in particular, and lower tolerance for uncertainty is associated with patient distress.7-10 Perhaps the exquisite resolution of advanced diagnostic imaging, which provides a visual representation of illness, contributes to its increased use by creating an illusion of certainty. As oncologists, we not infrequently face patients who request a scan to reassure themselves that they are cancer free. And, often in an effort to assuage patient anxiety, ordering the scan seems to be the most humane response. However, generally any reassurance or certainty provided by a negative study is fleeting, and all too often, unexpected findings on imaging studies raise new uncertainty that patients are unprepared to manage, which only heightens their distress.11 Future efforts should seek to not only understand how to improve education of our patients about the risks •
jop.ascopubs.org
239
Information downloaded from jop.ascopubs.org and provided by at University of Washington on March 6, 2015 from 205.175.97.18 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Medicine is a science of uncertainty and an art of probability. — William Osler Uncertainty! fell demon of our fears! The human soul that can support despair, supports not thee. — David Mallet
Jennifer L. Malin
and benefits of imaging, but also to develop better approaches to helping them tolerate the uncertainty inherent in living with cancer.
Corresponding author: Jennifer L. Malin, MD, PhD, 21555 Oxnard St, Woodland Hills, CA 91367-4943; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001421; published online ahead of print at jop.ascopubs.org on May 20, 2014.
References 1. Schnipper LE, Smith TJ, Raghavan D, et al: American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: The top five list for oncology. J Clin Oncol 30:1715-1724, 2012
6. Hillner BE, Tosteson AN, Song Y, et al: Growth in the use of PET for six cancer types after coverage by Medicare: Additive or replacement? J Am Coll Radiol 9:33-41, 2012
2. Schnipper LE, Lyman GH, Blayney DW, et al: American Society of Clinical Oncology 2013 top five list in oncology. J Clin Oncol 31:4362-4370, 2013
7. Mishel MH: The measurement of uncertainty in illness. Nurs Res 30:258-263, 1981
3. Loggers ET, Fishman PA, Peterson D, et al: Advanced imaging among health maintenance organization enrollees with cancer. J Oncol Pract 10:231238, 2014
8. Babrow AS, Kasch CR, Ford LA: The many meanings of uncertainty in illness: Toward a systematic accounting. Health Comm 10:1-23, 1998
4. Dinan MA, Curtis LH, Hammill BG, et al: Changes in the use and costs of diagnostic imaging among Medicare beneficiaries with cancer, 1999-2006. JAMA 303:1625-1631, 2010 5. Bhargavan M, Sunshine JH, Hughes DR: Clarifying the relationship between nonradiologists financial interest in imaging and their utilization of imaging. AJR 197:w891-w899, 2011
240
JOURNAL
OF
ONCOLOGY PRACTICE
•
9. Yu Ko WF, Degner LF: Uncertainty after treatment for prostate cancer: Definition, assessment, and management. Clin J Oncol Nurs 12:749-755, 2008 10. Kurita K, Garon EB, Stanton AL, et al: Uncertainty and psychological adjustment in patients with lung cancer. Psycho-Oncology 22:1396-1401, 2013 11. Wiener RS, Gould MK, Woloshin S, et al: What do you mean, a spot? A qualitative analysis of patients’ reactions to discussions with their physicians about pulmonary nodules. Chest 143:672-677, 2013
V O L . 10, I S S U E 4
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at University of Washington on March 6, 2015 from 205.175.97.18 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Author’s Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Employment or Leadership Position: Jennifer L. Malin, WellPoint (C) Consultant or Advisory Role: None Stock Ownership: Jennifer L. Malin, WellPoint Honoraria: None Research Funding: None Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: None
Commentary
Increasing Use of Advanced Imaging: Evidence That We Need to Do More to Help Our Patients Tolerate the Uncertainty of Living With Cancer By Jennifer L. Malin, MD, PhD
Overuse of imaging in patients with cancer is a growing concern. Four of the 10 areas that ASCO has highlighted as interventions whose “common use and clinical value are not supported by available evidence” as part of the American Board of Internal Medicine Foundation Choosing Wisely initiative involve diagnostic imaging. The initial ASCO top five list, published in 2012, identified the use of imaging in the staging evaluation of patients with breast and prostate cancer at low risk of metastases and the use of surveillance positron emission tomography with computed tomography (PET/CT) for asymptomatic breast cancer survivors as common practices that are not supported by the evidence.1 In their 2013 update, ASCO expanded this to include surveillance of any cancer treated with curative intent.2 In addition to the tremendous costs of unnecessary imaging, the potential safety issues of repeated exposure to low doses of ionizing radiation, the time required of patients and caregivers to submit to testing, and the worry experienced while awaiting results are additional burdens whose impact should not be underestimated. With the advent of new imaging technologies, use of diagnostic imaging has increased tremendously over the last decade. In this issue of Journal of Oncology Practice, Loggers et al3 present results of a study showing that imaging studies were common in patients with cancer and were being performed with increasing frequency, from an average of 7.4 images per patient in 2003 to 12.9 in 2006. These findings corroborate prior research that has similarly found increased use of medical imaging among Medicare patients with cancer.4 The rapid increase in use of new imaging technology has raised concerns about inappropriate use and factors such as “self-referral,” or referral of a patient to a test facility in which the ordering physician has a financial interest, being important drivers of increased imaging.5 What is striking about the results reported by Loggers et al3 is that the increased use in diagnostic imaging was similar to that observed in previous studies despite the fact that this study was conducted in a population of patients treated in health maintenance organizations (HMO), in which physicians ordering the studies did not receive any financial benefit from performing imaging. These results suggest that the increase in Copyright © 2014 by American Society of Clinical Oncology
J U L Y 2014
imaging among patients with cancer may not be related to solely to self-referral, because even in HMOs, use of imaging increased by more than 30% in just 3 years. If the increased use of diagnostic imaging is occurring in environments where it is not being driven by financial incentives, then what is contributing to the increase? Because the studies to date in oncology have primarily assessed use and have not considered the clinical context in which imaging studies are ordered, it is not possible to discern how much of the diagnostic imaging being performed is consistent with guideline recommendations and what is truly inappropriate according to current clinical standards. Repeated testing is another issue that has been identified as contributing to increase use of imaging. Hillner et al found that nearly half of the patients with cancer who had a PET/CT had received another CT scan in the 30 days prior, and 23% had a CT scan in the 30 days after.6 Although there may be clinical circumstances in which an additional imaging study is needed to clarify a finding that was not definitive on the first study, it seems unlikely that this would be the case in almost three quarters of patients undergoing a PET/CT. However, what is not known is whether repetitive testing is related to incentives to perform unnecessary tests or is the result of poor coordination of care, in which repeat testing is performed by different specialists who are unaware that a test has already been performed at another facility. And, despite the concerns regarding overuse, as in many things in health care, it is possible that underuse of appropriate imaging coexists with overuse. In order to have a better understanding of the factors contributing to the greater use of imaging in patients with cancer, we need to move beyond just looking at use and instead focus on evaluating imaging in the context of quality of care. Uncertainty is a fundamental element of the experience of illness in general, and cancer in particular, and lower tolerance for uncertainty is associated with patient distress.7-10 Perhaps the exquisite resolution of advanced diagnostic imaging, which provides a visual representation of illness, contributes to its increased use by creating an illusion of certainty. As oncologists, we not infrequently face patients who request a scan to reassure themselves that they are cancer free. And, often in an effort to assuage patient anxiety, ordering the scan seems to be the most humane response. However, generally any reassurance or certainty provided by a negative study is fleeting, and all too often, unexpected findings on imaging studies raise new uncertainty that patients are unprepared to manage, which only heightens their distress.11 Future efforts should seek to not only understand how to improve education of our patients about the risks •
jop.ascopubs.org
239
Information downloaded from jop.ascopubs.org and provided by at University of Washington on March 6, 2015 from 205.175.97.18 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Medicine is a science of uncertainty and an art of probability. — William Osler Uncertainty! fell demon of our fears! The human soul that can support despair, supports not thee. — David Mallet
Jennifer L. Malin
and benefits of imaging, but also to develop better approaches to helping them tolerate the uncertainty inherent in living with cancer.
Corresponding author: Jennifer L. Malin, MD, PhD, 21555 Oxnard St, Woodland Hills, CA 91367-4943; e-mail: [email protected].
DOI: 10.1200/JOP.2014.001421; published online ahead of print at jop.ascopubs.org on May 20, 2014.
References 1. Schnipper LE, Smith TJ, Raghavan D, et al: American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: The top five list for oncology. J Clin Oncol 30:1715-1724, 2012
6. Hillner BE, Tosteson AN, Song Y, et al: Growth in the use of PET for six cancer types after coverage by Medicare: Additive or replacement? J Am Coll Radiol 9:33-41, 2012
2. Schnipper LE, Lyman GH, Blayney DW, et al: American Society of Clinical Oncology 2013 top five list in oncology. J Clin Oncol 31:4362-4370, 2013
7. Mishel MH: The measurement of uncertainty in illness. Nurs Res 30:258-263, 1981
3. Loggers ET, Fishman PA, Peterson D, et al: Advanced imaging among health maintenance organization enrollees with cancer. J Oncol Pract 10:231238, 2014
8. Babrow AS, Kasch CR, Ford LA: The many meanings of uncertainty in illness: Toward a systematic accounting. Health Comm 10:1-23, 1998
4. Dinan MA, Curtis LH, Hammill BG, et al: Changes in the use and costs of diagnostic imaging among Medicare beneficiaries with cancer, 1999-2006. JAMA 303:1625-1631, 2010 5. Bhargavan M, Sunshine JH, Hughes DR: Clarifying the relationship between nonradiologists financial interest in imaging and their utilization of imaging. AJR 197:w891-w899, 2011
240
JOURNAL
OF
ONCOLOGY PRACTICE
•
9. Yu Ko WF, Degner LF: Uncertainty after treatment for prostate cancer: Definition, assessment, and management. Clin J Oncol Nurs 12:749-755, 2008 10. Kurita K, Garon EB, Stanton AL, et al: Uncertainty and psychological adjustment in patients with lung cancer. Psycho-Oncology 22:1396-1401, 2013 11. Wiener RS, Gould MK, Woloshin S, et al: What do you mean, a spot? A qualitative analysis of patients’ reactions to discussions with their physicians about pulmonary nodules. Chest 143:672-677, 2013
V O L . 10, I S S U E 4
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at University of Washington on March 6, 2015 from 205.175.97.18 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Author’s Disclosures of Potential Conflicts of Interest Although all authors completed the disclosure declaration, the following author(s) and/or an author’s immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO’s conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Employment or Leadership Position: Jennifer L. Malin, WellPoint (C) Consultant or Advisory Role: None Stock Ownership: Jennifer L. Malin, WellPoint Honoraria: None Research Funding: None Expert Testimony: None Patents, Royalties, and Licenses: None Other Remuneration: None
