> 40 percent of low-risk prostate cancer patients were getting inappropriate imaging tests

A new paper in JAMA Oncology has shown that between 2004 and 2007 nearly 45 percent of men initially diagnosed with low-risk prostate cancer were receiving unnecessary bone scans and CT scans in some regions of the USA.

Unless there are exceptional risk indicators (e.g., the presence of significant lower-back pain) the need for a bone scan and a CT scan in the work-up of a man diagnosed with low-risk prostate cancer (clinical stage < T2a, PSA level < 10 mg/ml, and Gleason score ≤ 6) has not been recommended in clinical guidelines for years. Nevertheless, at many centers around the USA, such patients were commonly given such scans — for two possible reasons:

  • Giving the scan created revenue for the institution
  • Giving the scan provided legal protection for the institution and its clinicians

The new paper by Makarov et al. looks in detail at the association between clinical diagnosis and the use of such scans in > 9,000 patients diagnosed with prostate cancer at 84 different hospital referral regions (HRRs) in the USA between 2004 and 2007, based on data from the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database. A key study finding is that the overuse of these tests appears to have been driven by regional practice patterns as opposed to individual physician decision-making.

From the point of view of The “New” Prostate Cancer InfoLink, the important issue here is that Markarov et al. have been able to validate the decision by the American Urology Association (AUA) and the American Society of Clinical Oncology (ASCO) — as part of the Choosing Wisely campaign — to clearly advise the urology and the medical oncology communities, respectively, that the use of these scans among men with low-risk disease is inappropriate and strongly discouraged.

Certainly there is always going to be a small number of men diagnosed with low-risk prostate cancer who demonstrate signs and symptoms highly suggestive of risk for metastatic disease (which can occur occasionally even in men with PSA levels of < 10 ng/ml). However, such men are rare. The vast majority of men with metastatic disease are going to have at least one other very clear risk factor that would indicate the appropriateness of and necessity for such scans (e.g., a Gleason score of 4 + 3 = 7 or higher or a PSA level of ≥ 20 ng/ml).

Whether there has been a dramatic decline in the numbers of patients with low-risk prostate cancer receiving unnecessary bone and CT scans since 2007 is not yet known. There does appear to have been a considerable shift, since we come across far fewer men with low-risk disease since 2010 who received a bone or a CT scan as part of their work-up … but it does still occur. Newly diagnosed men with low-risk disease who are advised that they need a bone or a CT scan would be correct to question their doctors as to the necessity for such scans in their individual cases.

3 Responses

  1. Karmonos Cancer Center has linked the same genetic anomalies that exist in breast cancer as prostate cancer. Tamoxifen has shown good results in breast cancer. Why isn’t the same testing being done for these genetic anomalies to predict outcomes of treatments?

  2. Dear Thomas:

    The fact that there is a genetic association between risk for breast cancer and risk for prostate cancer does not mean that the disorders are expressed clinically in the same way at all. For example, with a single exception, there are no data that I am aware of to suggest that any drug commonly used in the hormonal management of prostate cancer is effective in the hormonal management of breast cancer. Nor are there any data to suggest that drugs like tamoxifen, used in the hormonal management (and prevention) of breast cancer have any clinical value in the hormonal management of prostate cancer.

    The single exception above-mentioned is that enzalutamide (Xtandi), which is approved for the treatment of metastatic, castration-resistant prostate cancer (mCRPC), has recently been demonstrated to have potential clinical value in the treatment of one subtype of breast cancer.

  3. Thank you for drawing attention to one of my pet peeves — the inappropriate use of imaging studies. I hope they will also look at the inappropriate use of MRIs and CDUs, and the hazard of basing decisions on the opinions of insufficiently trained radiologists.

    Inappropriate use of imaging studies not only raises healthcare/medical insurance costs for all of us, but may actually be hazardous. Recently, a low-risk patient in my support group went to a medical oncologist (choosing the wrong type of doctor is another pet peeve!) who ordered a bone scan for him. Because a bone scan detects areas of bone overgrowth, and not necessarily bone metastases, it found several suspicious areas. Investigation of those required even more expensive tests and intrusive procedures. Of course, all the tests were negative. But those extra tests cost him money, time, increased his anxiety level, and delayed his treatment. The intrusive follow-up procedures carry the risk of infection and pain.

    I don’t only blame doctors, patients are often complicit with their doctors in demanding unnecessary tests. I believe that we patients should rightly question the need for medical tests — their risks, benefits, and costs. We should also be clear as to what may be done differently based on one outcome or another.

    I’ll dismount from my high horse now.

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