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Good News, Bad News On Prostate Imaging

August 14, 2013
Written by: , Filed in: Abdominal Imaging, Nuclear Medicine, Practice Management
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The good news: a campaign by local governments and a urology association reduced prostate imaging in Sweden. The bad news: a campaign by local governments and a urology association reduced prostate imaging in Sweden.

The “good” reduction involved imaging among men with prostate cancers at low risk of spreading or growing rapidly, as defined by a modified version of National Comprehensive Cancer Network (NCCN) guidelines. In 1998, a new study found, 45 percent of low-risk men received prostate imaging, which NCCN guidelines say is not indicated in low-risk cases. In 2009, only 3 percent received imaging.

Unfortunately, imaging for the high-risk group—which according to the guidelines should have been 100 percent—fell from 63 percent in 1998 to 47 percent in 2009.

Danil Makarov, MD, lead author of the study, told Medscape Medical News:

The joint campaign by local county governments and the National Prostate Cancer Registry of Sweden, which is an association of Swedish urologists, was incredibly effective at stamping out inappropriate imaging.

Dr. Makarov is an assistant professor and director of urological health services at NYU Langone Medical Center in New York. The Journal of the National Cancer Institute published the study’s findings online in an open-access article last month.

Bone scans accounted for the vast majority of the imaging. A few patients received MRI or CT. The campaign against inappropriate imaging, which Dr. Makarov described as “gentle shaming,” involved presenting statistics about inappropriate imaging at urology meetings and posting reminders about imaging guidelines, among other things.

Dr. Makarov said the Swedish model would need “tweaking” to work in the United States. However, he said, “We should also be open to the experiences of other countries.”

Regarding the imaging of high-risk patients, he said, “We would have loved to have seen the appropriate imaging rate go from the baseline of 63 percent to 100 percent, but in fact it went down.”

And that’s the issue. Campaigns to reduce “inappropriate” imaging have to balance the negatives—radiation exposure, false positives, expense, etc.—associated with scans that seldom produce medically useful information against the possibility of missing something scary, even fatal, because of a decision not to scan.

Guidelines are not mandates. Ultimately, the physician’s judgment needs to be the deciding factor. Dr. Makarov told DOTmed News that the residual 3 percent of “inappropriate” scans actually probably were appropriate. He said a few low-risk patients with certain symptoms often do benefit from scanning.

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