Sadly, prostate cancer (PCa) patients with low-risk disease are still being sent for needless diagnostic bone and CT scans. This was the finding of an impressive multi-disciplinary research team from several institutions (U.S. Veterans Administration and various medical and public policy departments within New York University and Yale University). The investigators found that nearly 45% of men diagnosed with low-risk prostate cancer from 2004-7 had received unnecessary bone scans and CT scans in some U.S. regions.[i] “Unnecessary” suggests overuse – even abuse – of diagnostic scans resulting in higher medical costs.
In fact, the routine use of bone and CT scans for low-risk prostate cancer patients has not been recommended for years, so how can this practice be stopped?
In 2010, the American Board of Internal Medicine (ABIM) Foundation along with Consumer Reports created the Choosing Wisely campaign, a response to research data suggesting that healthcare dollars could be saved by eliminating unnecessary tests for many disease conditions, not just PCa. From an ethics viewpoint, it’s an abuse of patients’ and taxpayers’ dollars if more money is spent on diagnostic and staging tests than what is essential for making good treatment decisions. Additional testing can also raise patient anxiety, as well as expose them to risks like radiation from X-rays, CT and PET scans.
Traditionally, PCa patients were staged (extent/location of cancer) using the following routine tests:
- Digital rectal exam (DRE)
- Gleason grade
- Bone scan (to rule out spread or metastasis to the bones)
- CT scan (to rule out metastasis to other organs such as liver or lung)
Even patients considered to be “low risk” (clinical stage < T2a, PSA level < 10 mg/ml, and Gleason score ? 6) were sent for the additional tests as a way to rule out metastatic disease before radical treatment (prostatectomy or radiation). This would seem to be a sensible caution: why put a patient through an expensive treatment with risks of side effects if “the horse is already out of the barn”? Yet as far back as the late 1990s, experts were questioning the added costs of bone and CT imaging if there was a very high probability that low risk patients had localized disease.
Avoiding Scan Abuse
The intent of Choosing Wisely is to avoid scan abuse by encouraging enlightened decisions, made between doctor and patient, about which tests are essential and which are not in choosing a treatment. ABIM asked professional societies in all major healthcare specialties to submit their “Top Five” lists of things they would change in the interest of equitable healthcare economics. With the collaboration of ASCO (American Society of Clinical Oncology, Consumer Reports Health and ABIM developed a 2-page document called “Imaging Tests for Early Prostate Cancer: When You Need Them—and When You Don’t.”[ii] It educates patients on how PCa is staged, and coaches them on speaking with their doctor about testing in their own case. Near the end, the document clarifies risk factors that warrant additional scans:
When should you have an imaging test [bone scan or CT scan]? If your Gleason score is 7 or above and your PSA level is above 10 nanograms/mL, your cancer may have spread. In these cases, your doctor should order a CT, PET, or bone scan to find out whether the cancer has spread outside the prostate gland. If your doctor does not recommend one, ask why.
It’s important for patients to understand the purpose behind scans used to detect PCa, and whether such scans are relevant in their case. We are at a crossroads in prostate cancer history. We know that the PSA blood test is inadequate as a cancer-specific biomarker, and the search is ongoing for a blood or urine test that will be not only specific but perhaps even definitive. We know that conventional TRUS biopsy is flawed in two opposing directions, over-detection of clinically insignificant cells, and under-detection (false negative) of clinically significant disease.
We also know that Choosing Wisely is taking aim at bone and CT scans, not the 3T multiparametric MRI (mpMRI) we offer. Our imaging has no radiation exposure and gives key pictorial information about the size, shape, location and aggression level to prostate tumors. It is today’s most accurate imaging for localized PCa and for very early spread into the seminal vesicles, neurovascular bundles, and prostate bed. It is the most efficient imaging cost because with appropriate treatment matching, it allows the most cost-conscious way to delay treatment (active surveillance), minimize treatment (focal therapies), and minimize the long term price of treating side effects from radical therapies that constitute a “sledgehammer” approach to treating insignificant cancer. It further reduces the dollars spent on repeat biopsies after an initial false negative biopsy.
In my opinion, scan abuse occurs in three ways. The first is the prescription of bone and CT scans for patients who don’t need them. The second is the underuse of more effective scans for possible metastasis, such as Choline C11 PET scans (see https://sperlingprostatecenter.com/choline-c-11-pet-scans-prostate-cancer/ ). The third is when patients are challenged by their urologists when they request a prescription for a 3T mpMRI, and told they don’t need that.
Our Center supports the recommendations of Choosing Wisely against the overuse of bone and CT scans. We encourage patients to question what imaging is being prescribed as well as what is not, and to pursue explanations from their doctors. We look forward to the day when 3T mpMRI is routinely prescribed before a biopsy as the best way to save both short- and long-term prostate cancer detection, diagnostic and treatment dollars. When that day arrives, I hope it will mean the end of scan abuse.
[i] Makarov D, Soulos P, Gold H et al. Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for Choosing Wisely campaign. JAMA Oncol. Published online March 12, 2015. doi:10.1001/jamaoncol.2015.37