The average Medicare patient with lung cancer receives a battery of imaging studies: 11 radiographs, six CTs, a PET scan, another non-PET molecular imaging scan, an MRI, two echocardiograms, and an ultrasound—all within two years of diagnosis.
According to new research, there was a steady increase in the use and cost of imaging Medicare cancer patients from 1999 to 2006, at a rate double that of any other cost related to caring for such patients. The trend is likely continuing, said researchers from the Duke Center for Clinical and Genetic Economics in Durham, N.C., who cite emerging technologies, changing diagnostic treatment patterns, and changes in Medicare reimbursement as likely contributors to an increasing use of advanced imaging in cancer patients.
"Are all these [imaging studies] essential? Are they all of value? Is the information really meaningful?" said co-author Kevin A. Schulman, MD, director of the center. "We have to go back and ask the question: 'What is changing as a result of all this imaging?'"
Conjecture over why the use of high technology was accelerating at such a rate included the possible roles played by economic incentives to perform imaging studies and the novelty of new technologies. Also considered was whether patient outcomes were really improved through their use. The answers take on greater significance in light of the possibility that the Medicare data may only hint at the true scope of imaging use for all cancer patients in this country.
"Our data are on patients who average 76 years old," Dr. Schulman said. "If this is what they are getting, obviously younger patients might be getting more."
What Duke study determined
The Duke study looked at imaging performed over the course of nearly 101,000 cases of breast cancer, colorectal cancer, leukemia, lung cancer, non-Hodgkin's lymphoma, and prostate cancer among Medicare beneficiaries. Extensive use of imaging emerged not only in lung cancer but in lymphoma, where patients by 2006 averaged eight conventional radiographs, six CTs, a PET scan, a nuclear medicine test, an MRI, three echocardiograms, and three ultrasounds within two years of diagnosis (JAMA 303:1625-1631, 2010).
"New technology seems to be additive to the old technology. New technologies are not being substituted for the old," Dr. Schulman said.
That’s a good thing, said Larry Habelson-Wilf, MD, director of oncologic imaging for ICON (Integrated Community Oncology Network) in Jacksonville, Fla. He argued that substituting new for old technologies would mean all patients suspected of cancer would immediately go for CT or PET/CT, rather than beginning the work-up with the least invasive, least costly and least informative methods.
'Less reason for concern'
This affects the bottom line of Medicare costs, however, less severely than might be expected. In 2006, medical imaging expenses accounted for less than 6% of the overall cost of caring for Medicare cancer patients, according to the authors. If all imaging studies were eliminated at once, the total savings would be minimal, while physicians would be blindly making decisions about patient management. The situation would not be much better if imaging were restricted to just diagnosis and staging.
LARRY HABELSON-WILF, MD
Dr. Habelson-Wilf interpreted the Duke team's conclusions in the broader context of cancer care for Medicare patients. He said he saw less reason for concern than Dr. Schulman's team does. Dr. Habelson-Wilf scoffed at the idea that the number of imaging exams ordered for cancer patients should be restricted. "The correct number is however many are needed to make the correct decision for the appropriate care of the patient," he said.
CARL JAFFE, MD
"The patient is not a fixed object," agreed C. Carl Jaffe, MD, a professor of radiology at the Boston Medical Center. "We can't just cluster all of our imaging at the front of the process and then blindly give [patients] therapy. It would be like going to Europe and photographing yourself as you board the plane in the U.S. It wouldn't tell you anything about your trip."