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Findings from a multicentre, openlabel, randomised, controlled trial in Canada have shown that routine screening with a CT scan of the abdomen and pelvis does not improve detection of occult cancer in patients with unprovoked venous thromboembolism. Because venous thromboembolism might be the earliest sign of cancer, Marc Carrier (University of Ottawa, Ottawa, Canada) and colleagues aimed to assess the efficacy of a screening strategy for occult cancer that included CT scan of abdomen and pelvis in these patients. 854 patients were randomised into two groups: 431 underwent limited occult cancer screening (basic blood tests, chest radiography, and breast, cervical, and prostate cancer screening) and 423 underwent limited screening plus a CT scan of abdomen and pelvis. After the
initial screening, the absolute occult cancer incidence was 0·93% (95% CI 0·36–2·36) among the patients who underwent the limited screening strategy and 1·18% (95% CI 0·51–2·74) among the patients who underwent the limited screening plus CT scan strategy (absolute difference 0·25 percentage points, 95% CI 1·12–1·63). During a year of follow-up, 33 patients (3·9%, 95% CI 2·8–5·4) were newly diagnosed with occult cancer, of which 14 (3·2%, 95% CI 1·9–5·4) were found in the limited screening group and 19 (4·5%, 95% CI 2·9–6·9) in the limited screening plus CT scan group (p=0·28). Carrier said, “Less screening investigations for patients with occult cancer with unprovoked venous thrombosis avoids radiation exposure and potential complications from the procedures. It will
also allow [reallocation] scarce health care resources.” Steven Coutre (Stanford University School of Medicine, Stanford, CA, USA) said, “This is a well-designed study that provides much needed clarity for physicians evaluating patients with an unprovoked [deepvein thrombosis]. A thorough history, physical exam, and basic laboratory testing is sufficient without the need for extensive and expensive tests such as CT scans.” Sunandana Chandra (Northwestern University Feinberg School of Medicine, Chicago, IL, USA) adds, “Given the financial costs of imaging and the toxic effects of cumulative radiation, there is a benefit to a more conservative approach to managing these patients”.
Amelie-Benoist/BSIP/Science Photo Library
Routine screening with CT not justified for occult cancer
Published Online June 26, 2015 http://dx.doi.org/10.1016/ S1470-2045(15)00116-3 For the study by Carrier and colleagues see New Engl J Med 2015; published online June 22. DOI:10.1056/NEJMoa1506623
Sanjeet Bagcchi
Excessive imaging for breast cancer in Ontario Women with early stage breast cancer in the Canadian province of Ontario are routinely referred for unnecessary imaging, according to a new study by Demetrios Simos and colleagues. The investigators examined records, drawn from the Ontario Cancer Registry, of 26 547 women diagnosed with stage I and II breast cancer from 2007 to 2012. They found that 85·9% of these women had undergone imaging of the skeleton, thorax, and abdomen or pelvis within three months of diagnosis. 92·7% of patients with stage II and 79·6% of those with stage I breast cancer were imaged, yet the chances of discovering radiologically evident metastases in such patients are 1·2% and 0·2%, respectively. “Our current study confirms that non-adherence with evidence-based guidelines is common across Ontario”, concluded the authors. The Cancer Care Ontario www.thelancet.com/oncology Vol 16 August 2015
guidelines recommend no imaging for stage I and a bone scan for stage II. “The guidelines are very clear” says co-author Angel Arnaout (Ottawa Hospital Research Institute, Ottawa, Canada). “All over the world, they say physicians should not be requesting this kind of additional imaging to look for distant disease, but it is still happening”. Such imaging requests likely come down to a combination of physician and patient factors— after a cancer diagnosis, patients often need reassurance that the disease has not spread. “The sense of relief that patients experience from a negative diagnostic test is palpable”, notes Steven Narod (University of Toronto, Toronto, Canada). “It is rational that women want the additional testing, even if it is not rational from the healthcare provider standpoint”. He added that under the Canadian system,
physicians have no real disincentive to order unnecessary imaging. Indeed many physicians might not fully appreciate the harm that could result from disregarding testing guidelines. “All of these imaging tests are delaying treatment”, explains Arnaout. Moreover, around one third of the cohort in this study had been called back for additional imaging. “They are having double or triple the imaging that was unnecessary in the first place”, she adds. Arnaout suggests that physicians might be worried about possible legal ramifications if subsequent problems were to emerge in a patient who had not been fully imaged. Such concerns should be easy to dispel. Narod notes, “if you are a doctor and you follow the guidelines exactly, the chances of being successfully litigated against in Canada are close to zero”.
Published Online July 3, 2015 http://dx.doi.org/10.1016/ S1470-2045(15)00130-8 For more on the study by Simos and colleagues see CMAJ 2015; published online June 22. DOI:10.1503/cmaj.15003
Talha Khan Burki e381
Findings from a multicentre, openlabel, randomised, controlled trial in Canada have shown that routine screening with a CT scan of the abdomen and pelvis does not improve detection of occult cancer in patients with unprovoked venous thromboembolism. Because venous thromboembolism might be the earliest sign of cancer, Marc Carrier (University of Ottawa, Ottawa, Canada) and colleagues aimed to assess the efficacy of a screening strategy for occult cancer that included CT scan of abdomen and pelvis in these patients. 854 patients were randomised into two groups: 431 underwent limited occult cancer screening (basic blood tests, chest radiography, and breast, cervical, and prostate cancer screening) and 423 underwent limited screening plus a CT scan of abdomen and pelvis. After the
initial screening, the absolute occult cancer incidence was 0·93% (95% CI 0·36–2·36) among the patients who underwent the limited screening strategy and 1·18% (95% CI 0·51–2·74) among the patients who underwent the limited screening plus CT scan strategy (absolute difference 0·25 percentage points, 95% CI 1·12–1·63). During a year of follow-up, 33 patients (3·9%, 95% CI 2·8–5·4) were newly diagnosed with occult cancer, of which 14 (3·2%, 95% CI 1·9–5·4) were found in the limited screening group and 19 (4·5%, 95% CI 2·9–6·9) in the limited screening plus CT scan group (p=0·28). Carrier said, “Less screening investigations for patients with occult cancer with unprovoked venous thrombosis avoids radiation exposure and potential complications from the procedures. It will
also allow [reallocation] scarce health care resources.” Steven Coutre (Stanford University School of Medicine, Stanford, CA, USA) said, “This is a well-designed study that provides much needed clarity for physicians evaluating patients with an unprovoked [deepvein thrombosis]. A thorough history, physical exam, and basic laboratory testing is sufficient without the need for extensive and expensive tests such as CT scans.” Sunandana Chandra (Northwestern University Feinberg School of Medicine, Chicago, IL, USA) adds, “Given the financial costs of imaging and the toxic effects of cumulative radiation, there is a benefit to a more conservative approach to managing these patients”.
Amelie-Benoist/BSIP/Science Photo Library
Routine screening with CT not justified for occult cancer
Published Online June 26, 2015 http://dx.doi.org/10.1016/ S1470-2045(15)00116-3 For the study by Carrier and colleagues see New Engl J Med 2015; published online June 22. DOI:10.1056/NEJMoa1506623
Sanjeet Bagcchi
Excessive imaging for breast cancer in Ontario Women with early stage breast cancer in the Canadian province of Ontario are routinely referred for unnecessary imaging, according to a new study by Demetrios Simos and colleagues. The investigators examined records, drawn from the Ontario Cancer Registry, of 26 547 women diagnosed with stage I and II breast cancer from 2007 to 2012. They found that 85·9% of these women had undergone imaging of the skeleton, thorax, and abdomen or pelvis within three months of diagnosis. 92·7% of patients with stage II and 79·6% of those with stage I breast cancer were imaged, yet the chances of discovering radiologically evident metastases in such patients are 1·2% and 0·2%, respectively. “Our current study confirms that non-adherence with evidence-based guidelines is common across Ontario”, concluded the authors. The Cancer Care Ontario www.thelancet.com/oncology Vol 16 August 2015
guidelines recommend no imaging for stage I and a bone scan for stage II. “The guidelines are very clear” says co-author Angel Arnaout (Ottawa Hospital Research Institute, Ottawa, Canada). “All over the world, they say physicians should not be requesting this kind of additional imaging to look for distant disease, but it is still happening”. Such imaging requests likely come down to a combination of physician and patient factors— after a cancer diagnosis, patients often need reassurance that the disease has not spread. “The sense of relief that patients experience from a negative diagnostic test is palpable”, notes Steven Narod (University of Toronto, Toronto, Canada). “It is rational that women want the additional testing, even if it is not rational from the healthcare provider standpoint”. He added that under the Canadian system,
physicians have no real disincentive to order unnecessary imaging. Indeed many physicians might not fully appreciate the harm that could result from disregarding testing guidelines. “All of these imaging tests are delaying treatment”, explains Arnaout. Moreover, around one third of the cohort in this study had been called back for additional imaging. “They are having double or triple the imaging that was unnecessary in the first place”, she adds. Arnaout suggests that physicians might be worried about possible legal ramifications if subsequent problems were to emerge in a patient who had not been fully imaged. Such concerns should be easy to dispel. Narod notes, “if you are a doctor and you follow the guidelines exactly, the chances of being successfully litigated against in Canada are close to zero”.
Published Online July 3, 2015 http://dx.doi.org/10.1016/ S1470-2045(15)00130-8 For more on the study by Simos and colleagues see CMAJ 2015; published online June 22. DOI:10.1503/cmaj.15003
Talha Khan Burki e381
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