Overuse of imaging for staging low risk prostate cancer

Understanding the multilevel determinants of clinicians' imaging decision-making: setting the stage for de-implementation of low-value imaging

BACKGROUND

De-implementation requires understanding and targeting multilevel determinants of low-value care. The objective of this study was to identify multilevel determinants of imaging for prostate cancer (PCa) and asymptomatic microhematuria (AMH), two common urologic conditions that have contributed substantially to the annual spending on unnecessary imaging in the US.

METHODS

We used a convergent mixed-methods approach involving survey and interview data. Using a survey, we asked 33 clinicians (55% response-rate) to indicate their imaging approach to 8 clinical vignettes designed to elicit responses that would demonstrate guideline-concordant/discordant imaging practices for patients with PCa or AMH. A subset of survey respondents (N = 7) participated in semi-structured interviews guided by a combination of two frameworks that offered a comprehensive understanding of multilevel determinants. We analyzed the interviews using a directed content analysis approach and identified subthemes to better understand the differences and similarities in the imaging determinants across two clinical conditions.

RESULTS

Survey results showed that the majority of clinicians chose guideline-concordant imaging behaviors for PCa; guideline-concordant imaging intentions were more varied for AMH. Interview results informed what influenced imaging decisions and provided additional context to the varying intentions for AMH. Five subthemes touching on multiple levels were identified from the interviews: National Guidelines, Supporting Evidence and Information Exchange, Organization of the Imaging Pathways, Patients' Clinical and Other Risk Factors, and Clinicians' Beliefs and Experiences Regarding Imaging. Imaging decisions for both PCa and AMH were often driven by national guidelines from major professional societies. However, when clinicians felt guidelines were inadequate, they reported that their decision-making was influenced by their knowledge of recent scientific evidence, past clinical experiences, and the anticipated benefits of imaging (or not imaging) to both the patient and the clinician. In particular, clinicians referred to patients' anxiety and uncertainty or patients' clinical factors. For AMH patients, clinicians additionally expressed concerns regarding legal liability risk.

CONCLUSION

Our study identified comprehensive multilevel determinants of imaging to inform development of de-implementation interventions to reduce low-value imaging, which we found useful for identifying determinants of de-implementation. De-implementation interventions should be tailored to address the contextual determinants that are specific to each clinical condition.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

The cost, survival, and quality-of-life implications of guideline-discordant imaging for prostate cancer

Background

National Comprehensive Cancer Network (NCCN) guidelines for incident prostate cancer staging imaging have been widely circulated and accepted as best practice since 1996. Despite these clear guidelines, wasteful and potentially harmful inappropriate imaging of men with prostate cancer remains prevalent.

Aim

To understand changing population‐level patterns of imaging among men with incident prostate cancer, we created a state‐transition microsimulation model based on existing literature and incident prostate cancer cases.

Methods

To create a cohort of patients, we identified incident prostate cancer cases from 2004 to 2009 that were diagnosed in men ages 65 and older from SEER. A microsimulation model allowed us to explore how this cohort's survival, quality of life, and Medicare costs would be impacted by making imaging consistent with guidelines. We conducted a probabilistic analysis as well as one‐way sensitivity analysis.

Results

When only imaging high‐risk men compared to the status quo, we found that the population rate of imaging dropped from 53 to 38% and average per‐person spending on imaging dropped from $236 to $157. The discounted and undiscounted incremental cost‐effectiveness ratios indicated that ideal upfront imaging reduced costs and slightly improved health outcomes compared with current practice patterns, that is, guideline‐concordant imaging was less costly and slightly more effective.

Conclusion

This study demonstrates the potential reduction in cost through the correction of inappropriate imaging practices. These findings highlight an opportunity within the healthcare system to reduce unnecessary costs and overtreatment through guideline adherence.

External Validation of and Factors Associated with the Overuse Index: a Nationwide Population-Based Study from Taiwan

BACKGROUND

The Overuse Index (OI), previously called the Johns Hopkins Overuse Index, is developed and validated as a composite measure of systematic overuse/low-value care using United States claims data. However, no information is available concerning whether the external validation of the OI is sustained, especially for international application. Moreover, little is known about which supply and demand factors are associated with the OI.

OBJECTIVE

We used nationwide population-based data from Taiwan to externally validate the OI and to examine the association of regional healthcare resources and socioeconomic factors with the OI.

DESIGN AND PARTICIPANTS

We analyzed 1,994,636 beneficiaries randomly selected from all people enrolled in the Taiwan National Health Insurance in 2013.

MAIN MEASURES

The OI was calculated for 2013 to 2015 for each of 50 medical regions. Spearman correlation analysis was applied to examine the association of the OI with total medical costs per capita and mortality rate. Generalized estimating equation linear regression analysis was conducted to examine the association of regional healthcare resources (number of hospital beds per 1000 population, number of physicians per 1000 population, and proportion of primary care physicians [PCPs]) and socioeconomic factors (proportion of low-income people and proportion of population aged 20 and older without a high school diploma) with the OI.

RESULTS

Higher scores of the OI were associated with higher total medical costs per capita (ρ = 0.48, P < 0.001) and not associated with total mortality (ρ = - 0.01, P = 0.882). Higher proportions of PCPs and higher proportions of low-income people were associated with lower scores of the OI (β = - 0.022, P = 0.016 and β = - 0.224, P < 0.001, respectively).

CONCLUSIONS

Our study supported the external validation of the OI by demonstrating a similar association within a universal healthcare system, and it showed the association of a higher proportion of PCPs and a higher proportion of low-income people with less overuse/low-value care.

Health disparities and inequities in the utilization of diagnostic imaging for prostate cancer

PURPOSE

To review and summarize the reported health disparities and inequities in diagnostic imaging for prostate cancer.

METHODS

We queried the PubMed search engine for original publications studying disparate utilization of diagnostic imaging for prostate cancer. Query terms were as follows: prostate AND cancer AND diagnostic AND imaging AND (magnetic resonance imaging (MRI) OR computed tomography (CT) OR bone scintigraphy OR positron emission tomography (PET)-CT)) AND (inequities OR disparities OR socioeconomic OR race). Studies were included if they involved United States patients, had diagnostic imaging as a part of their care, and addressed health inequities.

RESULTS

A total of 104 studies were captured in the initial query with 17 meeting inclusion criteria, comprising 10 population-based analyses, 5 single institutional analyses, 1 multi-institutional analysis, and 1 review. Socioeconomic status and race were frequently associated with imaging utilization and guideline-concordant care. SEER analyses revealed that African-American men had higher odds of experiencing overuse of pelvic CT/pelvic MRI and bone scans, while older men experienced underuse. Higher income and younger age were more likely to receive imaging that was adherent to NCCN guidelines. African-American and Hispanic men were less likely than white men to receive prostate multiparametric MRI.

CONCLUSION

Race, age, and socioeconomic status play a significant role in the diagnostic management of prostate cancer. Certain demographics are more disparately affected and less likely to receive guideline-concordant care. Continued research and interventions are needed to ensure appropriate and accessible diagnostic imaging for prostate cancer and ultimately the delivery of quality and equitable care.

Induced Demand in Cancer Diagnosis

Context: Supplier-induced demand (SID) is an essential concept in health economics related to the diagnosis of different types of cancer and related expenditures. The current review considered studies on induced demand in cancer diagnosis. Evidence Acquisition: This systematic review investigated the induced diagnosis of cancer in four well-known databases (Scopus, Science Direct, Web of Science, and PubMed) from January 1980 to July 2019 using the keywords “induced demand,” “cancer,” and “diagnosis”. References of the studies found through the original search were also considered for analysis. Results: No studies focused on SID in cancer diagnosis could be found, thus indicating a significant deficiency in the discussion of SID in cancer diagnosis studies. Therefore, the terms most relevant to the concept of SID in cancer diagnosis were examined. Finally, 24 factors were categorized into three groups: economic, socio-cultural, and structural. The majority of evidence for the probability of SID in cancer diagnosis is related to overdiagnosis or early diagnosis caused by unnecessary screening (57.14% of reviewed articles) and the neglect of clinical practice guidelines (42.8% of reviewed articles), mainly by diagnostic imaging. Conclusions: Research focused explicitly on SID in cancer diagnosis is needed. Moreover, economic, social, and structural reforms related to the factors that connect overuse, overdiagnosis, and unnecessary services to cancer diagnosis are required to control costs and harm and provide the best benefits to patients.

Effects of Physician Experience, Specialty Training, and Self-referral on Inappropriate Diagnostic Imaging

BACKGROUND

Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established.

OBJECTIVE

To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral.

DESIGN

A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs.

SETTING

Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain.

MEASUREMENTS

Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting.

RESULTS

Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs.

LIMITATIONS

Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected.

CONCLUSIONS

Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging.

Effects of Physician Experience, Specialty Training, and Self-referral on Inappropriate Diagnostic Imaging

BACKGROUND

Although previous research has demonstrated high rates of inappropriate diagnostic imaging, the potential influence of several physician-level characteristics is not well established.

OBJECTIVE

To examine the influence of three types of physician characteristics on inappropriate imaging: experience, specialty training, and self-referral.

DESIGN

A retrospective analysis of over 70,000 MRI claims submitted for commercially insured individuals. Physician characteristics were identified through a combination of administrative records and primary data collection. Multi-level modeling was used to assess relationships between physician characteristics and inappropriate MRIs.

SETTING

Massachusetts PARTICIPANTS: Commercially insured individuals who received an MRI between 2010 and 2013 for one of three conditions: low back pain, knee pain, and shoulder pain.

MEASUREMENTS

Guidelines from the American College of Radiology were used to classify MRI referrals as appropriate/inappropriate. Experience was measured from the date of medical school graduation. Specialty training comprised three principal groups: general internal medicine, family medicine, and orthopedics. Two forms of self-referral were examined: (a) the same physician who ordered the procedure also performed it, and (b) the physicians who ordered and performed the procedure were members of the same group practice and the procedure was performed outside the hospital setting.

RESULTS

Approximately 23% of claims were classified as inappropriate. Physicians with 10 or less years of experience had significantly higher odds of ordering inappropriate MRIs. Primary care physicians were almost twice as likely to order an inappropriate MRI as orthopedists. Self-referral was not associated with higher rates of inappropriate MRIs.

LIMITATIONS

Classification of MRIs was conducted with claims data. Not all self-referred MRIs could be detected.

CONCLUSIONS

Inappropriate imaging continues to be a driver of wasteful health care spending. Both physician experience and specialty training were highly associated with inappropriate imaging.

Characterising potential bone scan overuse amongst men treated with radical prostatectomy

OBJECTIVES

To characterise bone scan use, and potential overuse, after radical prostatectomy (RP) using data from a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists after RP remains unknown.

PATIENTS AND METHODS

We identified 12 269 patients with prostate cancer treated with RP between 2005 and 2008 using the Veterans Administration Central Cancer Registry. We used administrative and laboratory data to examine rates of bone scan use, including preceding prostate-specific antigen (PSA) levels, and receipt of adjuvant or salvage therapy. We then performed multivariable logistic regression to identify factors associated with post-RP bone scan use.

RESULTS

At a median follow-up of 6.8 years, one in five men (22%) underwent a post-RP bone scan at a median PSA level of 0.2 ng/mL. Half of bone scans (48%) were obtained in men who did not receive further treatment with androgen-deprivation or radiation therapy. After adjustment, post-RP bone scan was associated with a prior bone scan (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.32-1.84), positive surgical margin (aOR 1.68, 95% CI 1.40-2.01), preoperative PSA level (aOR 1.02, 95% CI 1.01-1.03), as well as Hispanic ethnicity, Black race, and increasing D'Amico risk category, but not with age or comorbidity.

CONCLUSION

We found a substantial rate of bone scan utilisation after RP. The majority were performed for PSA levels of <1 ng/mL where the likelihood of a positive test is low. More judicious use of imaging appears warranted in the post-RP setting.

Determinants of the overuse of imaging in low-risk prostate cancer: A systematic review

BACKGROUND

The overuse of radiologic services, where imaging tests are provided in circumstances where the propensity for harm exceeds the propensity for benefit, comprises a risk to patient safety and a burden on health care systems. Advanced imaging in the staging of low-risk prostate cancer is considered an overused procedure by many professional societies, yet the determinants that drive this phenomenon are not fully appreciated.

METHODS

We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that contain original data and describe determinants associated with the overuse of imaging in low-risk prostate cancer. Paired reviewers independently screened abstracts, assessed quality, and extracted data. We synthesized the identified determinants as patient-level, clinician-level, or system-level factors of overuse.

RESULTS

A total of 14 articles were included; the 13 empirical studies defined overuse as being the use of imaging that was discordant with clinical guidelines. Patient- and system-related factors were most commonly described as being associated with overuse; clinician-level determinants were examined infrequently. Older patient age (n = 5), more patient comorbidities (n = 7), and characteristics related to geography (n = 6), higher regional income (n = 6), and less education (n = 5) were the most consistently identified statistically significant determinants of overuse. Meaningful differences were detected between health care settings; large integrated health care systems provided less variable care and had lower rates of overuse. Clinical indicators related to prostate cancer were inconsistently associated with overuse.

CONCLUSION

Many patient- and system-related determinants were identified as contributing to the overuse of advanced imaging to stage low-risk prostate cancer. Overuse may be the consequence of systematized clinician behavior and be relatively invariant of patient characteristics. The identified system-level determinants suggest that payment models that are not tied to volume or that reward, enhanced care co-ordination may curb overuse. We propose further examination of physician-level determinants and implore researchers to rank the relative importance of the identified factors and to test their influence through experimental and quasi-experimental methods.

Overuse of Health Care Services in the Management of Cancer: A Systematic Review

BACKGROUND

Overuse, the provision of health services for which harms outweigh the benefits, results in suboptimal patient care and may contribute to the rising costs of cancer care. We performed a systematic review of the evidence on overuse in oncology.

METHODS

We searched Medline, EMBASE, the Cochrane Library, Web of Science, SCOPUS databases, and 2 grey literature sources, for articles published between December 1, 2011 and March 10, 2017. We included publications from December 2011 to evaluate the literature since the inception of the ABIM Foundation's Choosing Wisely initiative in 2012. We included original research articles quantifying overuse of any medical service in patients with a cancer diagnosis when utilizing an acceptable standard to define care appropriateness, excluding studies of cancer screening. One of 4 investigator reviewed titles and abstracts and 2 of 4 reviewed each full-text article and extracted data. Methodology used PRISMA guidelines.

RESULTS

We identified 59 articles measuring overuse of 154 services related to imaging, procedures, and therapeutics in cancer management. The majority of studies addressed adult or geriatric patients (98%) and focused on US populations (76%); the most studied services were diagnostic imaging in low-risk prostate and breast cancer. Few studies evaluated active cancer therapeutics or interventions aimed at reducing overuse. Rates of overuse varied widely among services and among studies of the same service.

CONCLUSIONS

Despite recent attention to overuse in cancer, evidence identifying areas of overuse remains limited. Broader investigation, including assessment of active cancer treatment, is critical for identifying improvement targets to optimize value in cancer care.

Initiative to reduce bone scans for low-risk prostate cancer patients: A quasi-experimental before-and-after study in a Veterans Affairs hospital

Purpose

Bone scans (BS) are a low-value test for asymptomatic men with low-risk prostate cancer. We performed a quality improvement intervention aimed at reducing BS for these patients.

Methods and materials

The intervention was a presentation that leveraged the behavioral science concepts of social comparison and normative appeals. Participants were multidisciplinary stakeholders from the Radiation Oncology and Urology services at a Veterans Affairs hospital. We determined the baseline rate of BS by retrospectively analyzing cases of asymptomatic men with newly diagnosed low-risk prostate cancer. For social comparison, we presented contemporary peer BS rates in the United States—including Veterans Affairs hospitals. For normative appeals, we reviewed guidelines from various professional groups. To analyze the effect of this intervention, we performed a quasi-experimental, uncontrolled, before-and-after study.

Results

During the 1-year period before the intervention, 32 of 37 patients with low-risk prostate cancer (86.5%) received a BS. The contemporary peer rate was approximately 30%. All reviewed guidelines recommended against BS. During the 1-year period after the intervention, the rate of BS was reduced to 65.5% (19 of 29 patients; P = .043 by one-sided Fisher's exact test).

Conclusions

We observed a modest reduction in guideline-discordant BS after the quality improvement intervention. BS rates might be influenced by initiatives that combine social comparisons with appeals to professional norms.

Diagnosis and treatment for clinically localized prostate cancer. Adherence to the European Association of Urology clinical guidelines in a nationwide population-based study - GESCAP group

OBJECTIVE

To assess the adherence to European Association of Urology (EAU) guidelines in the management of prostate cancer (PCa) in Spain.

PATIENTS AND METHODS

Epidemiological, population-based, study including a national representative sample of 3,918 incident patients with histopathological confirmation during 2010; 95% of the patient's sample was followed up for at least one year. Diagnosis along with treatment related variables (for localized PCa -low, intermediate, high and locally-advanced by D'Amico risk stratification) was recorded. Differences between groups were tested with Chi-squared and Kruskal-Wallis tests.

RESULTS

Mean (SD) age of PCa patients was 68.48 (8.18). Regarding diagnostic by biopsy procedures, 64.56% of all patients had 8-12 cores in first biopsy and 46.5% of the patients over 75 years, with PSA<10ng/mL were biopsied. Staging by Computer Tomography (CT) or Bone Scan (BS) was used for determining tumor extension in 60.09% of high-risk cases and was applied differentially depending on patients' age; 3,293 (84.05%) patients received a treatment for localized PCa. Radical prostatectomy was done in 1,277 patients and 206 out of these patients also had a lymphadenectomy, being 4.64% low-risk, 22.81% intermediate-risk and 36.00% high-risk patients; 86.08% of 1,082 patients who had radiotherapy were treated with 3D or IMRT and 35.77% received a dose ≥75Gy; 419 patients were treated with brachytherapy (BT): 54.81% were low-risk patients, 22.84% intermediate-risk and 12.98% high-risk. Hormonotherapy (HT, n=521) was applied as single therapy in 9.46% of low-risk and 17.92% of intermediate-risk patients. Additionally, HT was combined with RT in 14.34% of lower-risk patients and 58.26% of high-risk patients, and 67.19% low-intermediate risk with RT and/or BT received neoadjuvant/concomitant/adjuvant HT. Finally, 83.75% of high-risk patients undergoing RT and/or BT also received HT.

CONCLUSIONS

Although EAU guidelines for PCa management are easily available in Europe, the adherence to their recommendations is low, finding the highest discrepancies in the need for a prostate biopsy and the diagnostic methods. Improve information and educational programs could allow a higher adherence to the guidelines and reduce the variability in daily practice. (Controlled-trials.com: ISRCTN19893319).

Use of Evidence-Based Prostate Cancer Imaging in a Nongovernmental Integrated Health Care System

PURPOSE

The overuse of imaging, particularly for staging of low-risk prostate cancer, is well documented and widespread. The existing literature, which focuses on the elderly in fee-for-service settings, points to financial incentives as a driver of overuse and may not identify factors relevant to policy solutions within integrated health care systems, where physicians are salaried.

METHODS

Imaging rates were analyzed among men with incident prostate cancer diagnosed between 2004 and 2011 within the Colorado and Northwest regions of Kaiser Permanente. The sample was stratified according to indication for imaging, ie, high risk for whom imaging was necessary versus low risk for whom imaging was discouraged. Logistic regression was used to model the association between imaging receipt and clinical/demographic patient characteristics by risk strata.

RESULTS

Of the men with low-risk prostate cancer, 35% received nonindicated imaging at diagnosis, whereas 42% of men with high-risk prostate cancer did not receive indicated imaging. Compared with men diagnosed in 2004, those diagnosed in subsequent years were less likely to receive imaging across both risk groups. Men with high-risk cancer diagnosed at ≥ 65 years of age and those with clinical stage ≥ T2 were more likely to receive indicated imaging. Men with comorbidities were more likely to receive imaging across both risk groups. Men with low-risk prostate cancer who had higher median household incomes were less likely to receive nonindicated imaging.

CONCLUSION

Nonindicated imaging for diagnostic staging of patients with low-risk prostate cancer was common, but has decreased over the past decade. These findings suggest that factors other than financial incentives may be driving overuse of imaging.

Physician-Driven Variation in Nonrecommended Services Among Older Adults Diagnosed With Cancer

IMPORTANCE

Interventions to address overuse of health care services may help reduce costs and improve care. Understanding physician-level variation and behavior patterns can inform such interventions.

OBJECTIVE

To assess patterns of physician ordering of services that tend to be overused in the treatment of patients with cancer. We hypothesized that physicians exhibit consistent behavior.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of patients 66 years and older diagnosed with cancer between 2004 and 2011, using population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data to assess physician-level variation in 5 nonrecommended services. Services included imaging for staging and surveillance in low-risk disease, intensity-modulated radiation therapy (IMRT) after breast-conserving surgery, and extended fractionation schemes for palliation of bone metastases.

MAIN OUTCOME AND MEASURES

To assess variation in service use between physicians, we used a random effects model and a logistic regression model with a lag variable to assess whether a physician's use of a service for a prior patient predicts subsequent service use.

RESULTS

Cohorts ranged from 3464 to 89 006 patients. The total proportion of patients receiving each service varied from 14% for imaging in staging early breast cancer to 41% in early prostate cancer. From the random effects analysis, we found significant unexplained variation in service use between physicians (P < .001 for each service; ICC, 0.04-0.59). Controlling for case mix, whether a physician ordered a service for the prior patient was highly predictive of service use, with adjusted odds ratios (aORs) ranging from 1.12 (95% CI, 1.07-1.18) for surveillance imaging for patients with breast cancer (28% service use if prior patient had imaging vs 25% if not), to 24.91 (95% CI, 22.86-27.15) for IMRT for whole breast radiotherapy (69% vs 7%, respectively).

CONCLUSIONS AND RELEVANCE

Physicians' utilization of nonrecommended services that tend to be overused exhibit patterns that suggest consistent behavior more than personalized patient care decisions. Reducing overuse may require understanding cognitive drivers of repetitive inappropriate decisions.

Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization

OBJECTIVE

To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system.

DATA SOURCES/STUDY SETTING

Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008).

STUDY DESIGN

We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it.

PRINCIPAL FINDINGS

We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging.

CONCLUSIONS

Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.

Evaluation of Posttreatment Follow-Up of Patients With Prostate Cancer Relative to the American College of Radiology's Appropriateness Criteria

OBJECTIVE

The American College of Radiology (ACR) Appropriateness Criteria panel has recommended that patients with prostate cancer who have received treatment undergo imaging only after suspected cancer recurrence. We examined whether local physicians followed this recommendation and what types of imaging examinations were ordered in a cohort of patients with local prostate cancer.

MATERIALS AND METHODS

The Rochester Epidemiology Project, a research consortium that collects, links, and stores medical record information of Olmsted County, Minnesota, residents, was used to capture the complete medical history of treated patients with prostate cancer from 2000 through 2011. Clinical information and imaging examinations performed were retrieved by chart review. Suspected recurrence was defined as treatment-specific prostate-specific antigen level elevations, bone pain, or abnormal digital rectal examination findings.

RESULTS

Of the 670 treated patients with prostate cancer who were included in the final analysis, 129 (19%) underwent posttreatment imaging. After excluding imaging related to retreatment or another cancer, 13 patients (i.e., 2% of the entire cohort and 10% of imaged patients) underwent imaging in the absence of suspected recurrence. A total of 90 patients (70% of imaged patients) underwent imaging after suspected recurrence. Of these 90 patients, 62 (69%) underwent a bone scan as their first imaging modality either alone or in combination with other imaging modalities. Of the providers who ordered a bone scan first, 27% were urologists, 23% were radiation oncologists, and 24% were primary care physicians.

CONCLUSION

Most patients in this study did not undergo imaging in the absence of suspected recurrence. Various types of imaging examinations were ordered for patients with suspected recurrence.

Staging studies for cutaneous melanoma in the United States: a population-based analysis

BACKGROUND

Routine cross-sectional imaging for staging of early-stage cutaneous melanoma is not recommended. This study sought to investigate the use of imaging for staging of cutaneous melanoma in the United States.

METHODS

Patients with nonmetastatic cutaneous melanoma newly diagnosed between 2000 and 2007 were identified from the Surveillance Epidemiology End Results-Medicare registry. Any imaging study performed within 90 days after diagnosis was considered a staging study.

RESULTS

The study identified 25,643 patients, 3,116 (12.2 %) of whom underwent cross-sectional imaging: positron emission tomography (PET) (7.2 %), computed tomography (CT) (5.9 %), and magnetic resonance imaging (MRI) (0.6 %). From 2000 to 2007, the use of cross-sectional imaging increased from 8.7 to 16.1 % (p < 0.001), driven predominantly by increased usage of PET (4.2-12.1 %). Stratification by T and N classification showed that cross-sectional imaging was used for 8.6 % of T1, 14.3 % of T2, 18.6 % of T3, and 26.7 % of T4 tumors (p < 0.001) and for 33.3 % of node-positive patients versus 11.1 % of node-negative patients (p < 0.001). Factors predictive of cross-sectional imaging included T classification [odds ratio (OR) for T4 vs T1, 2.66; 95 % confidence interval (CI) 2.33-3.03], node positivity (OR 2.70; 95 % CI 2.36-3.10), more recent year of diagnosis (OR 2.05 for 2007 vs 2000; 95 % CI 1.74-2.42), atypical histology, and non-Caucasian race (OR 1.32; 95 % CI 1.02-1.73).

CONCLUSIONS

The use of cross-sectional imaging for staging of early-stage cutaneous melanoma is increasing in the Medicare population. Better dissemination of guidelines and judicious use of imaging should be encouraged.

Guideline-Discordant Use of Imaging During Work-Up of Newly Diagnosed Prostate Cancer

The authors conclude that there is a high prevalence of both overuse and underuse of guideline-recommended imaging in patients with prostate cancer.

Simultaneous vs staged treatment of urolithiasis in patients undergoing radical prostatectomy

AIM: To assess the outcomes of men treated for urolithiasis at the time of radical prostatectomy.

METHODS: From 1991 to 2010, 22 patients were retrospectively identified who were treated simultaneously (n = 10) at radical prostatectomy, or (n = 12) within 120 d prior to prostatectomy, for urolithiasis. Clinical characteristics were reviewed including: type of prostatectomy and stone surgery, location and amount of stone burden, perioperative change in hemoglobin and creatinine, stent frequency, total hospital d, stone-free rates, additional stone procedures and complications. Long-term functional outcomes including stress urinary incontinence and bladder neck contracture were reported. Differences between cohorts (simultaneous vs staged treatment) were assessed.

RESULTS: Among men undergoing radical prostatectomy, primary stone procedures included 12 ureteroscopy, 6 shock wave lithotripsy, 2 open nephrolithotomy and 2 percutaneous nephrolithotomy. In staged shock wave lithotripsy there were 4 complications and 3 additional procedures vs 1 (P = 0.5) and 0 (P = 0.2) in the simultaneous cohort. Meanwhile in staged ureteroscopy there were 5 complications and 1 additional procedure vs 1 (P = 0.2) and 1 (P = 0.9) in the simultaneous cohort. Additional procedures for residual stones was greater among patients with asymptomatic upper tract calculi 3 (60%) relative to patients with symptomatic stones 2 (13%; P = 0.02). Likewise, patients with proximal or multiple calculi had a greater total hospital days 5.5 vs 4.1 (P = 0.04), additional procedures 6 vs 0 (P = 0.04) and lower stone-free rates 39% vs 89% (P = 0.02) relative to men with distal stones. Finally, there was no difference in the incidence of bladder neck contracture (P = 0.4) or stress urinary incontinence (P = 0.7) between cohorts.

CONCLUSION: Ureteroscopic treatment of symptomatic distal urolithiasis at radical prostatectomy appears to be safe and efficacious with a low rate of adverse postoperative outcomes.

Clinical predictors and recommendations for staging computed tomography scan among men with prostate cancer

OBJECTIVE

To identify clinical variables associated with a positive computed tomography (CT) scan and estimate the performance of imaging recommendations in patients from a diverse sample of urology practices.

MATERIALS AND METHODS

This study comprised 2380 men with newly diagnosed prostate cancer seen at 28 practices in the Michigan Urological Surgery Improvement Collaborative from March 2012 through September 2013. Data included age, prostate-specific antigen (PSA) level, Gleason score (GS), clinical T stage, total number of positive biopsy cores, whether or not the patient received a staging abdominal and/or pelvic CT scan, and CT scan result. We fit a multivariate logistic regression model to identify clinical variables associated with metastases detected by CT scan. We estimated the sensitivity and specificity of existing imaging recommendations.

RESULTS

Among 643 men (27.4%) who underwent a staging CT scan, 62 men (9.6%) had a positive study. In the multivariate analysis, PSA, GS, and clinical T stage were independently associated with the occurrence of a positive CT scan (all P values <.05). The American Urological Association's Best Practice Statements' recommendations for imaging when PSA level >20 ng/mL or GS ≥ 8 or locally advanced cancer had a sensitivity of 87.3% and specificity of 82.6%. Compared with current practice, implementing this recommendation in the Michigan Urological Surgery Improvement Collaborative population was estimated to result in approximately 0.5% of positive study results being missed, and 26.1% of fewer study results overall.

CONCLUSION

Successful implementation of CT imaging criterion of PSA level >20, GS ≥ 8, or clinical stage ≥ T3 would ensure that CT scans are performed for almost all men who would have positive study results while reducing the number of negative study results.

Updated trends in imaging use in men diagnosed with prostate cancer

BACKGROUND

Previous studies have found persistent overuse of imaging for clinical staging of men with low-risk prostate cancer. We aimed to determine imaging trends in three cohorts of men.

METHODS

We analyzed imaging trends of men with prostate cancer who were a part of Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) (1998-2006), were insured by Medicare (1998-2006), or privately insured (Ingenix database, 2002-2006). The rates of computed tomography (CT), magnetic resonance imaging (MRI) and bone scan (BS) were determined and time trends were analyzed by linear regression. For men in CaPSURE, demographic and clinical predictors of test use were explored using a multivariable regression model.

RESULTS

Since 1998, there was a significant downward trend in BS (16%) use in the CaPSURE cohort (N=5156). There were slight downward trends (2.4 and 1.7%, respectively) in the use of CT and MRI. Among 54 322 Medicare patients, BS, CT and MRI use increased by 2.1, 10.8 and 2.2% and among 16 161 privately insured patients, use increased by 7.9, 8.9 and 3.7%, respectively. In CaPSURE, the use of any imaging test was greater in men with higher-risk disease. In addition, type of insurance and treatment affected the use of imaging tests in this population.

CONCLUSIONS

There is widespread misuse of imaging tests in men with low-risk prostate cancer, particularly for CT. These findings highlight the need for examination of factors that drive decision making with respect to imaging in this setting.

[The economic burden of prostate cancer. A systematic literature overview of registry-based studies]

INTRODUCTION

Prostate cancer, the most frequent malignant disease in males in Europe, accounts for a great proportion of health expenditures.

AIM

A systematic review of registry-based studies about the cost-of-illness and related factors of prostate cancer, published in the last 10 years.

METHOD

A MEDLINE-based literature review was carried out between January 1, 2003 and October 1, 2013.

RESULTS

Fifteen peer-reviewed articles met the criteria of interest. In developed countries radiotherapy, surgical treatment and hormone therapy account for the greatest per capita costs. In Europe early stage tumours (4-7000 €, 2006), while in the USA metastatic prostate cancer (19 900-25 500 $, 2004) was associated with highest per capita expenses. In Europe the greatest costs incurred within the initial treatment (6400 €/6 months, 2008), while in the USA within the end-of-life care (depending on age: 62 200-93 400 $, 2010).

CONCLUSIONS

Despite public health importance of prostate cancer, the cost-of-illness literature from Europe is relatively small.

Use of bone scan during initial prostate cancer workup, downstream procedures, and associated Medicare costs

PURPOSE

For patients with a high likelihood of having metastatic disease (high-risk prostate cancer), bone scan is the standard, guideline-recommended test to look for bony metastasis. We quantified the use of bone scans and downstream procedures, along with associated costs, in patients with high-risk prostate cancer, and their use in low- and intermediate-risk patients for whom these tests are not recommended.

METHODS AND MATERIALS

Patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with prostate cancer from 2004 to 2007 were included. Prostate specific antigen (PSA), Gleason score, and clinical T stage were used to define D'Amico risk categories. We report use of bone scans from the date of diagnosis to the earlier of treatment or 6 months. In patients who underwent bone scans, we report use of bone-specific x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans, and bone biopsy within 3 months after bone scan. Costs were estimated using 2012 Medicare reimbursement rates.

RESULTS

In all, 31% and 48% of patients with apparent low- and intermediate-risk prostate cancer underwent a bone scan; of these patients, 21% underwent subsequent x-rays, 7% CT, and 3% MRI scans. Bone biopsies were uncommon. Overall, <1% of low- and intermediate-risk patients were found to have metastatic disease. The annual estimated Medicare cost for bone scans and downstream procedures was $11,300,000 for low- and intermediate-risk patients. For patients with apparent high-risk disease, only 62% received a bone scan, of whom 14% were found to have metastasis.

CONCLUSIONS

There is overuse of bone scans in patients with low- and intermediate-risk prostate cancers, which is unlikely to yield clinically actionable information and results in a potential Medicare waste. However, there is underuse of bone scans in high-risk patients for whom metastasis is likely.

Prostate cancer imaging trends after a nationwide effort to discourage inappropriate prostate cancer imaging

BACKGROUND

Reducing inappropriate use of imaging to stage incident prostate cancer is a challenging problem highlighted recently as a Physician Quality Reporting System quality measure and by the American Society of Clinical Oncology and the American Urological Association in the Choosing Wisely campaign. Since 2000, the National Prostate Cancer Register (NPCR) of Sweden has led an effort to decrease national rates of inappropriate prostate cancer imaging by disseminating utilization data along with the latest imaging guidelines to urologists in Sweden. We sought to determine the temporal and regional effects of this effort on prostate cancer imaging rates.

METHODS

We performed a retrospective cohort study among men diagnosed with prostate cancer from the NPCR from 1998 to 2009 (n = 99 879). We analyzed imaging use over time stratified by clinical risk category (low, intermediate, high) and geographic region. Generalized linear models with a logit link were used to test for time trend.

RESULTS

Thirty-six percent of men underwent imaging within 6 months of prostate cancer diagnosis. Overall, imaging use decreased over time, particularly in the low-risk category, among whom the imaging rate decreased from 45% to 3% (P < .001), but also in the high-risk category, among whom the rate decreased from 63% to 47% (P < .001). Despite substantial regional variation, all regions experienced clinically and statistically (P < .001) significant decreases in prostate cancer imaging.

CONCLUSIONS

A Swedish effort to provide data on prostate cancer imaging use and imaging guidelines to clinicians was associated with a reduction in inappropriate imaging over a 10-year period, as well as slightly decreased appropriate imaging in high-risk patients. These results may inform current efforts to promote guideline-concordant imaging in the United States and internationally.

When to perform positron emission tomography/computed tomography or radionuclide bone scan in patients with recently diagnosed prostate cancer

Skeletal metastases are very common in prostate cancer and represent the main metastatic site in about 80% of prostate cancer patients, with a significant impact in patients’ prognosis. Early detection of bone metastases is critical in the management of patients with recently diagnosed high-risk prostate cancer: radical treatment is recommended in case of localized disease; systemic therapy should be preferred in patients with distant secondary disease. Bone scintigraphy using radiolabeled bisphosphonates is of great importance in the management of these patients; however, its main drawback is its low overall accuracy, due to the nonspecific uptake in sites of increased bone turnover. Positron-emitting radiopharmaceuticals, such as fluorine-18-fluorodeoxyglucose, choline-derived drugs (fluorine-18-fluorocholine and carbon-11-choline) and sodium fluorine-18-fluoride, are increasingly used in clinical practice to detect metastatic spread, and particularly bone involvement, in patients with prostate cancer, to reinforce or substitute information provided by bone scan. Each radiopharmaceutical has a specific mechanism of uptake; therefore, diagnostic performances may differ from one radiopharmaceutical to another on the same lesions, as demonstrated in the literature, with variable sensitivity, specificity, and overall accuracy values in the same patients. Whether bone scintigraphy can be substituted by these new methods is a matter of debate. However, greater radiobiological burden, higher costs, and the necessity of an in-site cyclotron limit the use of these positron emission tomography methods as first-line investigations in patients with prostate cancer: bone scintigraphy remains the mainstay for the detection of bone metastases in current clinical practice.

Understanding variation in the quality of the surgical treatment of prostate cancer

More than 80% of men with prostate cancer undergo active treatment, which can be associated with significant morbidity. Outcomes of surgical treatment vary widely depending on who treated the patient and where the patient was treated, implying that there is room for improvement. Factors influencing outcomes include patient characteristics as well as some measure of procedure volume. Although relationships between volume and outcomes for prostatectomy can most likely be explained by differences between surgeons (e.g., experience, technical skill), the hospital environment (e.g., team communication, safety culture) has the potential to either amplify or dampen the effects. Although most patient factors are immutable, these other aspects of surgical care and the delivery environment provide opportunities for quality improvement. Collaborative quality improvement initiatives may prove to be an important vehicle for achieving better prostate cancer care. These grass roots organizations, driven largely by urologists dedicated to providing prostate cancer care, have had initial successes in improving some aspects of quality in prostate cancer care, including reducing unwarranted use of imaging and perioperative morbidity. However, much of the variation in functional outcomes after prostate cancer surgery arises from differences in technical skill. Evaluating and improving intraoperative surgeon performance will inevitably be challenging, as they require acquisition and interpretation of data collected in the operating room. To this end, several methods have been described to objectively assess what happens in the operating room.

Low suspicion lesions on multiparametric magnetic resonance imaging predict for the absence of high-risk prostate cancer

What's known on the subject? and What does the study add? Over-treatment of indolent prostate cancer lesions is a problem which can result in increased human and medical costs. Lesions with a low suspician level at mpMRI of the prostate have low risk of including high risk prostate cancer.

OBJECTIVE

To determine whether multiparametric magnetic resonance imaging (mpMRI) has the potential to identify patients at low risk for cancer, thus obviating the need for biopsy. Prostate cancer is currently diagnosed by random biopsies, resulting in the discovery of multiple low-risk cancers that often lead to overtreatment.

PATIENTS AND METHODS

We reviewed 800 consecutive patients who underwent a 3 Tesla mpMRI of the prostate with an endorectal coil from March 2007 to November 2011. All suspicious lesions were independently reviewed by two radiologists using T2-weighted, diffusion-weighted, spectroscopic and dynamic contrast-enhanced MRI sequences. Patients with only low suspicion lesions (maximum of two positive parameters on mpMRI) who subsequently underwent transrectal ultrasonography (TRUS)/MRI fusion targeted biopsy were selected for analysis.

RESULTS

In total, 125 patients with only low suspicion prostatic lesions on mpMRI were identified. On TRUS/MRI fusion biopsy, 77 (62%) of these patients had no cancer detected, 38 patients had Gleason 6 disease and 10 patients had Gleason 7 (3+4) disease. There were 30 patients with cancer detected on biopsy who qualified for active surveillance using 2011 National Comprehensive Cancer Network guidelines. No cases of high-risk (≥ Gleason 4+3) cancer were identified on biopsy and, of the fifteen patients who underwent radical prostatectomy at our institution, none were pathologically upgraded to high-risk cancer. Thus, for patients with only low suspicion lesions, 107 (88%) patients either had no cancer or clinically insignificant disease.

CONCLUSIONS

The results obtained in the present study show that low suspicion lesions on mpMRI are associated with either negative biopsies or low-grade tumours suitable for active surveillance. Such patients have a low risk of harbouring high-risk prostate cancers.

Appropriate and inappropriate imaging rates for prostate cancer go hand in hand by region, as if set by thermostat

Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.

Is there a role for routine pelvic magnetic resonance imaging in intermediate risk prostate cancer?

Objectives

To determine the role of staging pelvic magnetic resonance imaging (MRI) in men with intermediate risk prostate cancer.

Patients and methods

We identified all patients diagnosed with intermediate risk (NICE definition: PSA 10-20 ng/ml, or Gleason score 7, or clinical stage T2b/T2c) prostate cancer between 1st January 2007 and 31st December 2008. Through retrospective case note review, we determined the number of patients who had undergone a pelvic MRI and whether such an investigation had altered the patient's management by increasing tumour stage.

Results

A total of 222 men (mean age 66 years; range: 48-88) were diagnosed with intermediate risk prostate cancer during our study period. The mean PSA was 11.8 ng/ml (range: 3-20 ng/ml). Of these, 112 (50.5%) underwent an MRI. Overall, in 25/112 (22.3%) patients, pelvic MRI findings impacted significantly upon patient treatment by demonstrating either extra-prostatic extension of cancer, lymph node involvement or bone metastases.

Conclusions

Our retrospective study has demonstrated that a pelvic MRI in men diagnosed with intermediate risk prostate cancer may influence treatment decision in approximately a quarter of patients. Routine pelvic MRI is indicated in men with intermediate risk prostate cancer where radical treatment is contemplated.

Adherence to Guidelines among Italian Urologists on Imaging Preoperative Staging of Low-Risk Prostate Cancer: Results from the MIRROR (Multicenter Italian Report on Radical Prostatectomy Outcomes and Research) Study

Objective. A number of evidence-based guidelines for diagnosis and management of prostate cancer have been published. The aim of this study is to evaluate the adherence of Italian urologists to the guidelines concerning the preoperative imaging staging of prostate cancer. Methods. In October 2007 a multicentric observational perspective study called Multicentric Italian Report on Radical prostatectomy Outcome and Research (MIRROR) was started in 135 Italian urology centers. Recruitment was closed in December 2008 and 2,408 cases were collected. In this paper we have taken into consideration all examinations carried out for preoperative imaging staging, evaluating compliance with the recommendations in the American Urological Association (AUA) and European Association of Urology (EAU) guidelines. Results. Five hundred sixty-seven (53.34%) patients were not managed according to the EAU guidelines concerning T-staging, 545 (51.27%) concerning N-staging and 757 (71.21%) concerning M-staging. According to AUA guidelines, we also analyzed patients with a Gleason grade of biopsy specimens of 7: 238 (57.35%) of these patients had undergone testing for T staging, 244 (57.35%) for N-staging and 322 (77.60%) for M-staging. Conclusions. The compliance of Italian urologists with the guidelines is low, leading to an inappropriate increase in cost of care and unnecessary anxiety for the patients.

Hepatic splenosis diagnosed after inappropriate metastatic evaluation in patient with low-risk prostate cancer

A man interested in active surveillance of low-risk prostate cancer sought a second opinion after having undergone an inappropriate metastatic evaluation that demonstrated multiple enhancing liver masses. Because of his history of splenectomy for trauma, hepatic splenosis was suspected. Despite reassurance, the patient desired biopsy of the masses to confirm splenosis. The imaging features and pathophysiology of hepatic splenosis are presented. Owing to the low rates of metastatic disease, the current guidelines do not recommend diagnostic imaging for low-risk prostate cancer. The present case illustrates the dangers of the current widespread practice of inappropriate diagnostic imaging of patients with low-risk prostate cancer.

The population level prevalence and correlates of appropriate and inappropriate imaging to stage incident prostate cancer in the medicare population

PURPOSE

According to guidelines most men with incident prostate cancer do not require staging imaging. We determined the population level prevalence and correlates of appropriate and inappropriate imaging in this cohort.

MATERIALS AND METHODS

We performed a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. Low risk (no prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or clinical stage greater than T2) and high risk (1 or more of those features) groups were formed. Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate. Logistic regression modeled imaging in each group.

RESULTS

Of 18,491 men at low risk 45% received inappropriate imaging while only 66% of 10,562 at high risk received appropriate imaging. For patients at low risk inappropriate imaging was associated with increasing clinical stage (T2 vs T1 OR 1.35, 95% CI 1.27-1.44), higher Gleason score (7 vs less than 7 OR 1.80, 95% CI 1.69-1.92), increasing age and comorbidity as well as decreasing education. Appropriate imaging for men at high risk was associated with lower stage (T4, T3 and T2 vs T1 OR 0.63, 95% CI 0.48-0.82, OR 0.67, 95% CI 0.60-0.80 and OR 0.87, 95% CI 0.80-0.86) and with higher Gleason score (greater than 8 and 7 vs less than 7 OR 2.18, 95% CI 1.92-2.48 and 1.51, 95% CI 1.35-1.70, respectively) as well as with younger age, white race, higher income, lower stage and more comorbidity.

CONCLUSIONS

We found poor adherence to imaging guidelines for men with incident prostate cancer. Understanding the patterns by which clinicians use imaging for prostate cancer should guide educational efforts as well as research to suggest evidence-based guideline improvements.

Performance characteristics of computed tomography in detecting lymph node metastases in contemporary patients with prostate cancer treated with extended pelvic lymph node dissection

BACKGROUND

Computed tomography (CT) is a commonly used noninvasive procedure for prostate cancer (PCa) staging. All previous studies addressing the ability of CT scan to predict lymph node invasion (LNI) were based on historical patients treated with limited pelvic lymph node dissection (PLND).

OBJECTIVE

Assess the value of CT in predicting LNI in contemporary PCa patients treated with extended PLND (ePLND).

DESIGN, SETTING, AND PARTICIPANTS

We evaluated 1541 patients undergoing radical prostatectomy and ePLND between 2003 and 2010 at a single center. All patients were preoperatively staged using abdominopelvic CT scan. All lymph nodes with a short axis diameter ≥ 10 mm were considered suspicious for metastatic involvement.

INTERVENTION

All patients underwent preoperative CT scan, radical retropubic prostatectomy, and ePLND, regardless of PCa features at diagnosis.

MEASUREMENTS

The performance characteristics of CT scan were tested in the overall patient population, as well as according to the National Comprehensive Cancer Network (NCCN) classification and according to the risk of LNI derived from a nomogram developed on an ePLND series. Logistic regression models tested the relationship between CT scan findings and LNI. Discrimination accuracy was quantified with the area under the curve.

RESULTS AND LIMITATIONS

Overall, a CT scan that suggested LNI was found in 73 patients (4.7%). Of them, only 24 patients (32.8%) had histologically proven LNI at ePLND. Overall, sensitivity, specificity, and accuracy of CT scan were 13%, 96.0%, and 54.6%, respectively. In patients with low-, intermediate-, or high-risk PCa according to NCCN classification, sensitivity was 8.3%, 96.3%, and 52.3%, respectively; specificity was 3.6%, 97.3%, and 50.5%, respectively; and accuracy was 17.9%, 94.3%, and 56.1%, respectively. Similarly, in patients with a nomogram-derived LNI risk ≥ 50%, sensitivity, specificity, and accuracy were only 23.9%, 94.7%, and 59.3%, respectively. At multivariable analyses, inclusion of CT scan findings did not improve the accuracy of LNI prediction (81.4% compared with 81.3%; p=0.8). Lack of a central scan review represents the main limitation of our study.

CONCLUSIONS

In contemporary patients with PCa, the accuracy of CT scan as a preoperative nodal-staging procedure is poor, even in patients with high LNI risk. Therefore, the need for and the extent of PLND should not be based on the results obtained by CT scan.

Concordance of preoperative prostate endorectal MRI with subsequent prostatectomy specimen in high-risk prostate cancer patients

OBJECTIVE

Endorectal MRI (ER-MRI) may identify areas suspicious for prostate cancer. We evaluated the accuracy of ER-MRI compared with subsequent pathology specimen from prostatectomy.

MATERIALS AND METHODS

We reviewed 309 open radical retropubic prostatectomy cases (RRP) from 2003 to 2008 to identify 94 men with a preoperative ER-MRI, which was obtained in patients with high-risk factors suspicious for local extension (Gleason grade ≥ 4+3, PSA ≥ 10 ng/ml, abnormal rectal exam, or extensive biopsy core involvement). Findings of extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymphadenopathy (LAD) on ER-MRI were compared with subsequent findings on pathology specimens.

RESULTS

Ninety-four men underwent preoperative ER-MRI. No tumor was seen on ER-MRI in 9 men (10%). Of 94 ER-MRIs, 4% showed SVI, and 12% had ECE. At prostatectomy, lymph nodes were pathologically positive in 10 men, none of which were enlarged on ER-MRI. RRP was aborted in 3 of these 10 patients due to positive nodes confirmed on frozen section. Comparing ER-MRI results to subsequent prostatectomy specimen the results for accuracy, positive predictive value, negative predictive value, sensitivity, specificity were 70%, 27%, 76%, 14%, 88% for ECE and 93%, 75%, 94%, 38%, 99% for SVI. The accuracy of ECE prediction was 86% in abnormal rectal exam vs. 66% in normal exam (P < 0.05).

CONCLUSIONS

Endorectal MRI in the evaluation of high-risk prostate cancer was moderately accurate for SV involvement but inaccurate for ECE and insensitive for metastatic lymph node involvement. The predictive accuracy of ER-MRI improved in patients with an abnormal rectal exam.