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Study Questions Imaging In Stage IV Cancer

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A new study in the Journal of the National Cancer Institute wonders why so much high-cost advanced diagnostic imaging is used for elderly patients with stage IV cancer.

Well, let’s think about it for a second. “OK, Mr. Smith, we’re not quite sure about those new symptoms that you’ve mentioned. They could be related to your cancer, or they could be something else. We could run a CT scan to find out, but you’re probably going to be dead in a few months anyway, so why bother?”

Is that really how we want our health-care system to operate?

As an accompanying editorial puts it, “Assessing the appropriateness of care for patients with advanced disease is complex. Even patients with advanced (i.e., stage IV) cancer will have different survival trajectories—median survival for elderly patients with stage IV lung cancer is substantially less than 1 year, whereas for elderly patients with stage IV prostate cancer, it is approximately 3 years.”

Going even more directly to the heart of the matter, the editorial adds:

Furthermore, identifying patients clearly at the ‘end of life’ is difficult.

The editorial was written by K. Robin Yabroff, PhD, and Joan L. Warren, PhD, who both work for the National Cancer Institute’s Division of Cancer Control and Population Studies.

Both the editorial and the study itself were published online Tuesday. The study examined the SEER-Medicare Database (Surveillance, Epidemiology, and End Results) for CT, MRI, PET, and nuclear medicine scans from January 1994 through December 2009 performed on patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer.

Among elderly (65 or older) stage IV patients diagnosed from January 2002 through December 2006, 95.9 percent underwent an expensive diagnostic imaging procedure, with a mean number of 9.79 scans per patient and 1.38 scans per month of survival. During the entire period of the study, advanced imaging increased among stage IV patients while actually decreasing among early-stage cancer patients.

“Because scans help clinicians determine whether a change in (or cessation of) treatment is indicated, the expanding use of advanced imaging in stage IV disease is likely a manifestation of the increasing number and types of treatment options available to these patients,” the study says. It continues:

Imaging, though it often leads to (appropriate) palliative measures, may also distract patients from focusing on achievable end-of-life goals, require them to spend more of their limited time in medical settings and/or provoke anxiety.

To patients, that sounds like: “You’re toast, so we don’t want to spend any more money on you.” The study notes a lack of guidelines about the use of imaging in older patients with stage IV cancer. Developing such protocols would certainly be appropriate. But they need to focus on the “life” part, not the “end of” part.

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