Surveillance imaging of post-treatment cancer patients may cause more problems than it solves

After completing primary radiation therapy, patients in remission from cancers of the head and neck are better served by expectant management than routine imaging.

This is so for two main reasons. One, false positives have proven common in such follow-up imaging. And two, new research shows imaging fails to boost rates of positive outcomes yet may spur unnecessary downstream testing.

The research was conducted at the University of California, Irvine, and published this month in JAMA Network Open.[1]

For the study, Allen Chen, MD, MBA, and colleagues reviewed records of 501 consecutive patients who had radiation therapy at their institution between 2014 and 2022.

Focusing on 340 patients in the cohort who had definitive negative results up to three years after treatment, the team found no difference in overall survival between those who had been imaged versus those managed expectantly.

Nor was there significant difference in progression-free survival or distant metastasis.

The authors define expectant management as follow-up history-taking and physical examination, including endoscopy.

In their discussion, the authors remark that, while the use of imaging in the context of clinical suspicion has been shown to be valuable, the routine acquisition of surveillance imaging in asymptomatic patients should be discouraged.

This assertion is “consistent with published guidelines recommending follow-up imaging after the initial posttreatment baseline only if the patient displays worrisome or equivocal signs or symptoms,” they write. “While a discussion regarding the implications with respect to cost-effectiveness lies beyond the scope of this work and has been reported by others, most patients in this study underwent routine surveillance for no apparent benefit.”

Taking up the question of why surveillance imaging remains a go-to strategy, Armstrong and co-authors posit the practice may owe to such “external factors” as professional pressure, family demands, malpractice fears or perceived convenience.

The inclination to image rather than argue should be resisted, they suggest, not least because abnormal or incidental findings “may produce a cascade effect, potentially leading to unnecessary invasive procedures (including ironically, in some cases, additional imaging surveillance), increased costs and undue patient anxiety for a finding that is ultimately benign.”

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“Indeed, in the present study, the use of biopsy because of surveillance imaging with pathology subsequently showing fibrosis or necrotic tissue was the most common source of false-positive findings.”

The authors call for further research that would span multiple centers and take into account recurrence probabilities, metastatic distributions and availability of effective therapies for recurrent disease.

The study is available in full for free.