ASCO says most “hi tech” scans are inappropriate in low-risk prostate cancer

In an article just published in the Journal of Clinical Oncology, the American Society of Clinical Oncology (ASCO) has strongly recommended against the use of advanced imaging technologies  for determining the spread of prostate cancer in men with early stage, low-risk disease.

Although there will always be rare exceptions that do demonstrate the value of “hi tech” imaging in carefully selected men with early stage, and apparently low-risk disease, the widespread use of techniques like positron emission spectroscopy (PET) scans, CT scans, MRI scans, and bone scans is large unjustified in newly diagnosed patients with low-risk, clinically localized prostate cancer, i.e., a Gleason score of 6 or less and a PSA level < 10 ng/ml. Most such use of “hi tech” imaging in these patients is carried out to protect the physician from risk of malpractice law suits or simply as a way to make additional money for hospital systems and practice groups.

The problem with this recommendation is not that it is wrong or that it may stop some men getting an appropriate diagnosis. The problem is that it doesn’t matter what ASCO says on this subject because most men with early stage, low-risk prostate cancer aren’t seeing a medical oncologist; they are seeing a urologist or a urologic oncologist, and it is the American Urology Association (AUA) that needs to be issuing this guidance very clearly to its members too.

To be fair to the AUA, it has long stated that bone scans are inappropriate in this group of patients unless there are other clear signs and symptoms that might suggest higher risk disease. However, The “New” Prostate Cancer InfoLink continues to see low-risk patients being referred for bone scans, CT scans, and MRIs on a regular basis, with no specific justification for such referrals. The AUA might argue that they already support this recommendation from ASCO that is part of the wider Choosing Wisely® initiative. However, it would have been more gratifying to see the AUA participate in the Choosing Wisely program and include the same recommendation as one of their “Top Five” things that urologists should not generally be doing because there are no data to support value.

The “New” Prostate Cancer InfoLink does, however, want to draw a clear distinction between the widespread use of MRI in the work-up of men with low-risk prostate cancer and the elective use of MRI in men who are considering enrollment in (or are actually on) active surveillance protocols. We do not yet have definitive proof of the value of repeat MRIs instead of repeat biopsies in management of men on active surveillance. However, there is significant evidence to support this methodology — particularly in careful clinical trials of the value of active surveillance.

For more information on the Choosing Wisely initiative, please see this article in the New York Times. The recommendation from ASCO regarding “hi tech” imaging and low-risk patients is the only recommendation from the Choosing Wisely initiative that is specific to prostate cancer.

One Response

  1. I confess to being a staunch liberal who reacts to the phrase “tort reform”. Still, any physician practicing within his or her society’s guidelines should have as a minimum a presumption of innocence from malpractice under federal law: a necessary piece of the solution.

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