Optimizing strategy

Medical imaging is supposed to supply information that guides physicians in an effort to improve a patient’s health. But what about situations where the use of imaging leads to questionable outcomes? How can we ensure that the clinical benefit of an imaging exam outweighs the risks from overdiagnosis or excessive downstream testing and the associated costs?

These are questions that have loomed large for radiology in general, but featured especially prominently in this week’s top stories in Health Imaging.

Two such studies dealt with breast imaging. The first, published online in Breast Cancer Research and Treatment, found that increasing use of preoperative breast MRI was associated with significant increases in bilateral cancer diagnoses and subsequent aggressive surgeries for treatment. While breast conserving surgery is preferred for women with early stage cancer, there was an increased likelihood of mastectomy compared with breast conserving surgery, with an adjusted odds ratio of 1.21. For women undergoing mastectomy, the odds that both breasts would be removed also increased with use of MRI.

This could have big implications for breast cancer imaging, as the rate of preoperative breast MRI use jumped from 0.8 percent in 2000-2001 to 25.2 percent in 2008-2009.

A second breast cancer-related study called into question the current follow-up strategy for women with ultrasound-detected lesions assessed as Breast Imaging-Reporting and Data System (BI-RADS) category 3. This classification is for lesions that are “probably benign,” but current guidelines recommend imaging follow-up at six months. The multicenter study, published in Radiology, found the malignancy rate of BI-RADS 3 lesions to be 0.8 percent with few suspicious changes at six months, leading the authors to suggest that the follow-up imaging interval could be extended to one year to reduce the number of biopsies and imaging exams performed.

Shifting from breast cancer to kidney cancer, a study published in the American Journal of Managed Care found that one in six patients who had their kidneys removed due to renal cell carcinoma were later found to have a benign renal mass. As more extensive imaging for abdominal complaints increases early detection of renal cell carcinomas, better strategies must be developed to manage care. Authors Aviva G. Asnis-Alibozek, PA-C, of IBA Molecular, Dulles, Va., and colleagues wrote that the results of the study “reveal that a substantial number of patients might have been spared the inherent morbidity and cost of surgery and postoperative care had better preoperative characterization of their tumor been available.”

Fortunately, the radiology community can adapt in the presence of new information, and often the professional associations lead the way. Case in point, a joint statement recently issued by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInternational Surgery proposed a simple, pragmatic approach to determining an imaging strategy for stroke patients.

As more data are collected in the fight against cancer, those management strategies will continue to be optimized as well.

-Evan Godt
Sr. Staff Writer – Health Imaging