ORLANDO–Over one-third of patients with low-risk prostate cancer patients are getting radiographic imaging scans that are not recommended by treatment guidelines, while nearly 40% of high-risk patients who should be receiving the tests aren't getting them, according to a study of 30,183 patients reported here at the Genitourinary Cancers Symposium.
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Since 2000, the American Urological Association has recommended pretreatment staging of prostate cancer only in the setting of high-stage disease, noted Sandip M. Prasad, MD, a Fellow in Urologic Oncology at the University of Chicago Medical Center. In addition, the National Comprehensive Cancer Network recommends radiographic imaging only in the setting of high-risk pathology, he said at his poster presentation.
The current study, which aimed to characterize utilization patterns for radiographic diagnostic imaging relative to these guidelines, “turned up disturbing patterns,” Dr. Prasad said.
The results showed that 36% of men with low-risk prostate cancer and 49% of men with intermediate-risk prostate cancer underwent magnetic resonance imaging, computed tomography, or bone scan imaging studies.
“In low-risk and intermediate-risk patients, the chance of finding disease outside the prostate on one of these scans is less than one percent. These men should not be getting these tests,” he said.
Even more concerning, he added, was the finding that 39% of men with high-risk prostate cancer did not receive the tests.
“All high-risk patients should be getting the scans. Despite existing guidelines of the American Urological Association and the National Comprehensive Cancer Network, costly and unnecessary imaging studies continue to be performed in men with low-risk and intermediate-risk prostate cancer, while a significant number of men with high-risk disease do not receive adequate staging prior to treatment,” Dr. Prasad said.
“The annual Medicare expenditure for unnecessary studies exceeded $35 million—more than 10% of the annual budget of the National Cancer Institute for prostate cancer research. When you consider that private insurers for younger men may reimburse at higher rates, the unnecessary expense may be even higher.”
For the study, Dr. Prasad and colleagues identified 30,183 men with newly diagnosed prostate cancer in 2004 and 2005 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Using NCCN guidelines, the researchers categorized 9,640 men as having low-risk prostate cancer, 12,966 men as intermediate-risk, and 7,577 as having high-risk prostate cancer.
A multivariate analysis showed that overuse was more common in men who were over age 75, who were black, who made at least $60,000 a year, and who resided in rural areas. Higher education predicted greater adherence to the guidelines.
There was no association between use of imaging and either marital status or Charlson comorbidity score, Dr. Prasad said.
Patients, Physicians Driving Misuse
Dr. Prasad said he suspects that both patients and doctors contribute to the high rates of unnecessary tests among low-risk and intermediate-risk patients.
“Men may read about [the tests] and ask for them. With physicians, there may an aspect of defensive medicine as well as a need for reassurance that they haven't missed anything when prescribing definitive treatment.
“The most frequently ordered tests were bone scans, usually aimed at determining if there were distance metastases,” he said.
Dean F. Bajorin, MD, Attending Physician in the Genitourinary Oncology Service in the Division of Solid Tumor Oncology at Memorial Sloan Kettering Cancer Center and Professor of Medicine at Weill Medical College of Cornell University, said that the study addresses the important question of how often physicians follow guidelines.
“In prostate cancer and other genitourinary cancers, there are multiple studies suggesting that Level 1 evidence supporting certain tests and treatments is not always followed,” he said, adding, though, that his belief is that it is patient request, not defensive medicine, that is driving overuse of radiographic imaging scans.
“We need to sit down with low-risk men and explain that the tests are not useful, as well as the drawbacks of too much radiation exposure. Men come in and want no stone left unturned. If they understand that the tests they are asking for are not only unnecessary, but also possibly harmful, they will be more comfortable not having them.”
Misuse Can Lead to Incorrect Treatment
Mack Roach III, MD, Professor and Chair of Radiation Oncology and Professor of Urology at the University of California, San Francisco, called the results “a perfect example of how we are wasting money on inappropriate tests and then denying other people appropriate care.”
Misuse of tests can lead to inappropriate treatment: “If the scans show that cancer has spread in high-risk patients, there is no sense in the patient having his prostate taken out. He'll need chemotherapy and hormone therapy.
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“In a low- or intermediate-risk patient, on the other hand, any sign of metastasis is likely a false-positive test. But the patient may be denied local treatment because of the results.”
Sandip M. Prasad, MD, received an ASCO Cancer Foundation Merit Award for the study. The awards are designed to promote clinical cancer research by young scientists and provide them with the opportunity to present their research for peer review at the symposium. The 25 researchers who received awards at this year's meeting were selected based on the scientific merit of their abstracts and received funding to help with travel expenses.
The Genitourinary Cancers Symposium is cosponsored by American Society of Clinical Oncology, the American Society for Radiation Oncology, and the Society of Urologic Oncology.
© 2011 Lippincott Williams & Wilkins, Inc.