Legitimate expanded use

Ultrasound provides another example of expanded use. “Urology has been using ultrasound for the diagnosis and management of prostate cancer since the mid-1980s, but as urologists have become more and more expert in using ultrasound in the office, we’re evaluating kidneys and bladders and doing other testing,” Dr. Fulgham said.

With an expertise in ultrasound, Dr. Fulgham was instrumental in developing and now teaching the course used to verify skill in ultrasound technical use and interpretation of imaging. The course satisfies those insurers once leery of allowing urologists to perform their own ultrasound studies. Furthermore, becoming adept in sonography is not as challenging for the physicians to master as one might think.

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“Urologists have been doing transrectal ultrasound of the prostate for many years,” Dr. Fulgham pointed out. “They just need to take the same principles they already know and apply them to organs that they’re not used to imaging.”

One of his main teaching goals has been to encourage urologists to be the sonographer. “I want them to actually perform and interpret the study,” Dr. Fulgham said. “That way, the studies are done by someone who knows precisely what clinical question needs to be answered. The urologists will do the study quickly and efficiently and reply immediately back to the patient. This is surely more convenient for the patient as well.”

Teaching imaging techniques also helps Dr. Fulgham—who represented the AUA on the ACR Appropriateness Criteria panels—achieve what he calls his “stealth goal” of ultimately reinforced appropriate usage. “As I’m talking about technique and how to use the machine appropriately, I can talk about indications as well—if you’re teaching people a new technique, it’s the perfect opportunity to try to inculcate in them the right reasons for using it.”

A number of urologic treatments have become image-guided therapies, such as brachytherapy for prostate cancer and percutaneous cryoablation of kidney tumors. Add all that up, Dr. Fulgam said, “and pretty soon the utilization of imaging becomes integral to the management of urologic disease.”

As more and more imaging applications in urologic disease are discovered and the population ages, utilization of these techniques has grown. This does not necessarily translate to an overall hike in usage, however. “We’ve got some very good data to show that while there an increase in utilization by urologists, there is a concomitant decrease in the number of these [tests] being performed by radiologists,” said Dr. Fulgham, citing Medicare data demonstrating this shift in utilization from radiologists to urologists and other specialists.

Risks associated with diagnostic radiation

As his upcoming AUA presentation will demonstrate, Dr. Fulgham is well aware of the risks associated with complex imaging studies, particularly with regard to CT scanning and nuclear medicine. “Those have very high radiation exposures per test, and everybody has recently become more alert to the fact that diagnostic radiation has potential risk of inducing secondary malignancy,” he cautioned.

The latency period is long—usually about 20 years—but the effect of the dosage is cumulative over a patient’s lifetime. “So, someone who has been imaged a dozen times in their lifetime has a significantly increased risk for developing a secondary cancer as a result of diagnostic imaging,” Dr. Fulgham said.

To reduce risk, urologists have begun to develop protocols that limit the voltage used on CT scans and other studies. “That dramatically reduces the effective dose on the patient,” Dr. Fulgham said. “We have begun to substitute non-ionizing radiation studies like ultrasound and magnetic resonance imaging for CT scan when it’s appropriate. And we developed protocols for CT scanning that actually reduced the number of individual exposures that need to be made to answer whatever clinical question is being asked.”

Dr. Fulgham said he believes that urologists are acutely aware of the secondary risk of diagnostic radiation. However, “I think in many cases, they may not fully appreciate their own risk associated with exposure to fluoroscopy and how potentially dangerous that is to them as well as to the patient.”

The second part of this feature, appearing next month, will look at specific ways to address the overutilization of diagnostic imaging.