Urologic oncologist Matthew R. Cooperberg, MD, MPH, of the University of California-San Francisco (UCSF) School of Medicine and UCSF’s Helen Diller Family Comprehensive Cancer Center, has a few ideas on how to decrease the number of unnecessary or inappropriate imaging studies.

“There need to be incentives against overutilization,” he said. “The PQRI [CMS’s Physician Quality Reporting Initiative; www3.cms.gov/PQRI/] approach, I think, is a the first small step in that direction, but ultimately, I think there should be criteria by which these tests will not be covered in routine situations. And that’s very much a slippery slope, and tends to be very political.”

Dr. Cooperberg and co-investigators have written a number of papers exploring health services research and care in prostate cancer, based in large part on the CaPSURE [Cancer of the Prostate Strategic Urologic Research Endeavor;

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http://urology.ucsf.edu/fellowship/Foncology_CaP.html] database of more than 13,800 men with the disease. In a relatively early analysis of CaPSURE data, Dr. Cooperberg and his team found that in the absence of established clinical practice guidelines, many men with clinically localized prostate cancer posing low or intermediate risk continued to undergo unnecessary testing. The overall time trend, however, was toward less use of imaging, particularly for those with lower-risk disease, (J Urol. 2002;168:491-495).

“An important aspect of care of the patient with low-risk prostate cancer, or any prostate cancer, is looking at utilization of imaging tests,” Dr. Cooperberg said. “This is because the tests carry significant costs and some carry radiation exposure. We can see false positives and the creation of anxiety in patients.”

High-quality care

Dr. Cooperberg said he believes there is growing awareness that appropriately utilizing these tests is a mark of high-quality prostate cancer care. “But certainly I think there is still an issue with overutilization. Despite guidelines, we still commonly see that a patient who comes in [to Dr. Cooperberg’s tertiary referral center] after being diagnosed in the community often has had one or more imaging tests for a cancer that is extremely unlikely to have metastasized.”

A number of reasons could explain why this occurs, he said. For example, the patient might push for tests to ease his mind, the physician may order the test to guard against a malpractice suit, or perhaps some physician owners of scanners have a financial incentive to order the tests.

In urology, imaging overutilization is not unique to prostate cancer, Dr. Cooperberg observed. Most renal masses are detected in patients who present with completely unrelated conditions, such as stomach pain, he said. “It seems like many patients these days get a CT scan on their way to the triage desk when they visit the emergency room,” he said.

But low-risk prostate cancer serves as a good example of imaging overuse because clear criteria exist to show when tests are and are not indicated. In his 2002 article, Dr. Cooperberg and collaborators noted that utilization overall had fallen over the preceding few years, but they observed a greater association between tumor risk and likelihood of utilization, which he said is a positive trend.

Why do we test?

National data reveal practice patterns suggesting “that a lot of bone scans get done that should not get done, and a lot of CT scans get done that should not get done,” Dr. Cooperberg said. “One problem from the physician’s perspective is, if a man with prostate cancer that is unlikely to metastasize wants a bone scan and I tell him that it’s not appropriate, and then if he is the one in 1,000 that go on to develop metastatic disease, am I going to get sued? This type of defensive medicine remains a concern, and is clearly a driver of ongoing utilization of tests.”

Curtailing overutilization of imaging tests will be a challenge, “but ultimately, I think there needs to be changes in the way these tests are approved and ordered,” he said.

One idea, he said, might be for payers to track how often a physician performs a bone scan on a prostate cancer patient with low-risk disease, with bonuses for good performance along the lines of the PQRI initiative.

Although there is no formalized curriculum in appropriateness at UCSF, according to Dr. Cooperberg (“Maybe we should be heading in that direction,” he suggested), he and other instructors do try to teach appropriateness as part of clinical education.

“It’s essential that we address appropriateness issues throughout training since they are pervasive in clinical practice, and I think our residence and medical students get a pretty good sense of what the risks and costs of overutilization of imaging are.”