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BOUTIS SPEAKING-IMAGING IN ADVANCED CANCER

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The use of high-cost diagnostic imaging "steadily increased" in Medicare patients with advanced cancers from 1995 to 2006, which raises concerns about overuse in this setting, according to a new study.
In the second half of the study period (2002 to 2006), the use of scanning was especially zealous, with 95.9% of patients undergoing a high-cost diagnostic imaging procedure and an average of 9.79 scans per patient, despite their limited survival times, report the study authors, led by Yue-Yung Hu, MD, MPH, from Brigham and Women's Hospital in Boston, Massachusetts.
The analysis, which was restricted to patients with stage IV breast, colorectal, lung, or prostate cancer, waspublished online July 31 in the Journal of the National Cancer Institute.
The types of scans analyzed were computed tomography, magnetic resonance imaging, positron emission tomography, and nuclear medicine.
The increasing use of big-ticket scans is not simply the result of vulnerable patients being overscanned, suggest a pair of experts in an accompanying editorial"The use of high-cost imaging found in this study may seem excessive," write K. Robin Yabroff, PhD, and Joan L. Warren, PhD, from the National Cancer Institute in Bethesda, Maryland. "Yet, assessing the appropriateness of care for patients with advanced disease is complex."
Part of the problem, say the editorialists, is that guidelines in the United States are "largely silent about the use of advanced imaging tests for ongoing evaluation" of patients with these advanced cancers "in the absence of symptoms."
This is in stark contrast to guidelines for early-stage disease, which make recommendations about "when to use (and when not to use)" advanced imaging for surveillance, they write.
Not surprisingly, the study authors found that from 1995 to 2006, the proportion of stage IV cancer patients imaged increased by 4.6% and the proportion of early-stage (stages I and II) cancer patients imaged decreased by 2.5%.
Evidence-based guidelines for these newer imaging technologies are needed, the editorialists assert. This is especially true because there is "limited evidence that advanced imaging improves patient outcomes, compared with older less expensive technologies," they note, referring to ultrasound and radiograph.
Nevertheless, guidelines can be developed.
In the United Kingdom, the National Institute for Clinical Excellence has issued "do not do" recommendations for some high-cost imaging in patients with advanced cancer, the editorialists report.
In their study, Dr. Hu and colleagues shed some light on the current situation in the United States.
It does not appear that physicians with financial incentives to scan are running up medical bills. In a previous study (Health Aff. 2008;27:1491-1502), increases in advanced imaging were observed in managed care, where there is no profit motive, according to the editorialists. Thus, the trend toward increased use is probably a combination of the "widespread availability of imaging machines, malpractice concerns, patient demand, and critically, the technological imperative," they write.
Costs for Imaging Rising Faster Than for Total Cancer Care
The study authors were inspired to review patterns of use in the United States because previous research found that "Medicare expenditures for high-cost diagnostic imaging have risen faster than those for total cancer care."
Dr. Hu and colleagues reviewed claims data from the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for the 4 types of big-ticket scans. They found more than 100,000 patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer during the study period.
They looked at imaging performed during 3 periods of time during the course of the disease: the diagnostic period, the last month of life, and the continuing-care phase (the interval between the diagnosis period and the last month of life).
The majority of patients with stage IV cancer received advanced imaging in the diagnostic (90.4%) and continuing-care (75.3%) phases. About a third of patients received advanced imaging in the last month of life (34.3%).
The purposes of scanning in the continuing-care phase of advanced care are "more diverse" than in the other 2 phases, according to the editorialists.
Imaging results can inform decisions about the continuation or modification of treatment, symptom management, and hospice referral, they write. "The incremental benefits of advanced imaging compared with older less expensive technologies for informing clinical decisions may vary for each of these different purposes," they add.
"In situations where high-cost imaging is used to evaluate response to third- or fourth-line therapies, evaluation of appropriateness extends to the decision to continue treatment of patients with poor prognoses," the editorialists explain.
Thus, identifying the appropriateness of advanced imaging for these clinical decisions requires a better understanding of how imaging can improve care, the editorialists explain. In other words, there is much work to be done in this field.
Despite many areas of concern, there is some good news, say the editorialists. In 2009 and 2010, the period after that evaluated by Dr. Hu and colleagues, the use of high-cost imaging for Medicare beneficiaries has declined slightly, according to recent report on Medicare payment policy.

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