Imaging Rates Scrutinized; Conclusions Mixed

Older Medicare beneficiaries with a diagnosis of stage IV cancer receive expensive advanced imaging tests at steadily increasing rates, despite limited proof of benefit.

That's according to a study in the Journal of the American Cancer Society July 30 by researchers at Dana-Farber Cancer Institute, Brigham and Women's Hospital, and the University of Wisconsin Surgical Outcomes Research Program.

During the study, these tests, which included CT, MRI, PET (positron emission tomography), and nuclear medicine scans, continued to increase even after the patients were scanned to determine that they had reached stage IV.

"Although many of these procedures occurred during the diagnostic phase...the majority did not," wrote lead author Caprice C. Greenberg, MD, director of the Wisconsin program, and colleagues. "Three-quarters of patients were scanned during the continuing care phase; on average, including patients who had no tests, patients were scanned every 6 weeks."

The study used data for nearly 200,000 patients with stage IV breast, colorectal, lung, or prostate cancer collected by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, which includes 28% of the U.S. population.

Between January, 2002 and December, 2006, 95.9% of these patients underwent an advanced imaging test with a mean of 9.79 scans per patient, or 1.38 scans each per month of survival. After the diagnostic phase of their disease, 75.3% were scanned again, and 34.3% were scanned in the last month of life, the researchers found.

Between January, 1995 and December 2006, the proportion of stage IV cancer patients who received an advanced imaging test increased 4.6%.

Additionally, between 1995 and 2006, the mean number of times per month that a stage IV patient received an advanced imaging test went from 1 to 1.57.

However, for patients with much earlier cancers of stage I and II, "frequency and intensity of imaging outside of the diagnostic period declined over time."

The researchers postulated that clinicians are performing these studies in the absence of evidence that they prolong survival, even though there are an increasing number of treatments.

They also suggest that the increase is due to the lack of evidence-based guidance on when the studies help prolong life or make determinations further treatment or hospice.  To date, routine use of imaging is recommended only in stage IV patients with colorectal cancer that has spread to the liver or lung to determine suitability for resection.

"Such discretionary decision-making, ie, the 'gray' area where recommendations are equivocal or nonexistent, is known to drive higher healthcare spending," the researchers wrote.

Additionally, the researchers discovered tremendous variability throughout the country, with patients in the top 10% receiving at least one scan per month during continuing care, and at least three in their last month of life.

"Imaging, although it often leads to (appropriate) palliative measures, may also distract patients from focusing on achievable end-of-life goals, require them to spend more of their limited time in medical care settings, and/or provoke anxiety."

In an accompanying JNCI editorial, Robin Wabroff and Joan Warren of the NCI's Health Services and Economics Branch, wrote that "the use of high-cost imaging found in the Greenberg study may seem excessive, and intensive care at the end of life is expensive to the Medicare program, the healthcare system overall and for patients and their families."

However, they continued, the survival trajectory for stage IV patients is variable, and conducting such tests may "inform decisions about continuing or changing treatment, symptom management or hospice referral."

The JNCI researchers' conclusions, however, are attenuated by a more recent report in the journal Health Affairs, which found that growth in the use of advanced imaging tests in the Medicare population has slowed in recent years. In part, the reasons are that there are fewer radiologists, and payments from federal and other payers have been reduced.

These reports are further confounded by a report in the June 13 Journal of the American Medical Associationby researchers at the University of California San Francisco, that found that between 1996 and 2010, use of advanced imaging by providers in integrated healthcare systems, who are bound in large part by bundled payments, has increased significantly.

"Given the high costs of imaging—estimated at $100 billion annually—and other harms, these benefits should be quantified and evidence-based guidelines for using imaging should be developed that clearly balance benefits against financial costs and health risk," they wrote.

Meanwhile, Medicare has targeted expensive imaging for further cost cuts, and is seeking to inform consumers and others about potentially unnecessary MRI, CT, and mammography imaging and the wide variation in their use.