- Email: [email protected]
R-SCAN: Appropriate Imaging for Low-Risk Prostate Cancer
IMAGING STEWARDSHIP IN THE AGE OF VALUE MAX WINTERMARK, MD
R-SCAN: Appropriate Imaging for Low-Risk Prostate Cancer Steven C. Eberhardt, MD, Satyan K. Shah, MD INTRODUCTION The US health system is characterized by high cost and outcome inefficiency, driven by policies and incentives of reimbursement, patterned medical practices, technology costs, and health consumer choices [1]. Waste contributes to cost, and the use of unnecessary and inappropriate imaging has been identified as a target for improving cost-effective care [2]. Specifically, physicians are being guided to reduce the use of imaging tests for which there is a strong evidence base against positive yield or outcome benefit for a particular clinical circumstance. Costs for these types of studies exceed immediate utility, as unrelated incidental findings are frequently discovered and pursued, with additional expense and unproven benefits [3]. Specifically, CT scans, nuclear medicine bone scans, and 18 F-fluorodeoxyglucose (FDG) PET examinations in the setting of low-risk prostate cancer have been singled out as being wasteful. Prostate cancer is the most common noncutaneous malignancy in US men, with approximately 220,800 new cases and 27,540 deaths in 2015 [4]. The majority of men diagnosed with prostate cancer have serum prostate-specific antigen (PSA) elevation, leading to ultrasound-guided prostate biopsy. There are concerns that this practice results in overdiagnosis and overtreatment of low-risk and clinically insignificant
cancers. The US Preventive Services Task Force issued a statement in 2012 opposing the use of PSA as a screening test [5]. Men diagnosed with prostate cancer are risk-stratified for recurrent or metastatic disease after treatment on the basis of histology (Gleason sum) and clinical (digital rectal) examination. PSA may be incorporated as an additional risk parameter. Some men undergo prostate MRI to complement local staging at the time of diagnosis or increasingly commonly as a tool for cancer detection and biopsy guidance [6]. A significant fraction of men diagnosed with prostate cancer fall into the low-risk category [7]. Definitions vary, but as an example, the D’Amico criteria classify low-risk prostate cancer as PSA less than or equal to 10 ng/mL, a Gleason sum less than or equal to 6, and clinical stage T1-2a [8]. Many authors note the propensity of patients with low-risk prostate cancer to undergo imaging for systemic staging for metastasis detection [7,9-12]. Imaging for metastatic disease in these low-risk individuals has been shown to have such low yields that utility has been called into question [9-11]. In this paper we explore (1) the evidence for imaging utility with traditional staging examinations (CT, bone scans, and FDG PET) in patients with low-risk prostate cancer, (2) the opinion that these examinations are not routinely justified, (3) the slow change in imaging use despite
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.01.041
evidence and guidelines, and (4) how interventions such as the Radiology Support, Communication, and Alignment Network (R-SCAN) initiative can generate improvements in appropriate imaging utilization.
EFFICACY EVIDENCE There is ample evidence that men with low-risk prostate cancer rarely if ever benefit from whole-body imaging examinations for staging. For example, in 2004 Abuzallouf et al [13] studied the efficacy of bone scans and CT scans in prostate cancer from 23 studies of bone scans and 25 studies of CT. The results showed that bone scans detected metastases in 2.3% of men with PSA < 10 ng/mL and 5.6% of men with Gleason scores 7. CT detected metastases in 0.7% of men with clinically localized disease and 1.2% of men with Gleason scores 7, with nodal metastases detected in no patients with PSA < 20 ng/mL. The investigators concluded that these examinations should not be standard practice in men with low-risk disease. An earlier, larger study looked at CT scans in preoperative staging of prostate cancer in 173 patients. CT understaged 9 of 12 patients with proven metastases and detected nodal metastases in only 3 of 9 patients with PSA > 25 ng/mL. The investigators concluded that the use of CT in men with prostate cancer and PSA < 25 ng/mL should be considered unjustified [14].
1
The evidence for FDG PET scan efficacy in the initial staging of low-risk prostate cancer is limited and less studied than bone scans and CT. There are technical challenges involved, including urine FDG activity obscuring disease in the prostate, making FDG unpopular for prostate cancer detection and staging generally. In a 1999 study of 11 patients, FDG PET was considered unreliable, as 3 of 11 men studied who had nodal metastases at surgery had negative results on FDG PET examinations [15]. Also, in a 2001 study by Liu et al [16] in which furosemide was used to reduce bladder FDG activity, FDG PET showed no significant findings in 23 of 24 men with clinically organ-confined (low-risk) prostate cancer and faint positivity in the prostate gland in 1 individual, with no metastases detected.
RECOMMENDATIONS IN GUIDELINES FROM PROFESSIONAL GROUPS As results such as these have accumulated, so have clinical guidelines from various professional groups advising against imaging in patients with low-risk prostate cancer. The “best practices” guidelines of the American Urological Association cover imaging in patients with low-risk prostate cancer along with serum PSA testing. Last updated in 2013, this recommendation advises that the routine use of bone scans is not required for asymptomatic men with clinically localized prostate cancer and serum PSA < 20 ng/mL [17]. The same document advises that CT or MR (for pelvic staging) be reserved for men with PSA > 20 ng/mL or when locally advanced disease is suspected, or with Gleason scores 8 [17]. The ACR has published evidence-based guidelines as the ACR Appropriateness Criteria since the 1990s, including coverage for imaging use in staging for prostate cancer. These guidelines, updated in 2016, judge bone scans and 2
CT scans in patients with clinically established low-risk prostate cancer in the lowest category, “usually not appropriate” [18]. FDG PET scans were not included in specific coverage for the guideline, being considered a modality not generally selected for this scenario. The National Comprehensive Cancer Network guidelines for prostate cancer in 2015 stated that imaging (including CT) should be used for nomogram probability of lymph node involvement > 10%, generally excluding low-risk patients. The same document recommended limiting bone scans to men with Gleason scores 8, T3 or T4 disease clinically, bone symptoms, or T1 disease with PSA > 20 ng/mL [19]. Multiple societies, including the American Society of Clinical Oncology, collaborated on the Choosing Wisely campaign, introduced by the American Board of Internal Medicine in 2012 to reduce wasteful health care spending. The ongoing campaign includes lowrisk prostate cancer, with the American Society of Clinical Oncology recommendation that PET, CT, and bone scans not be performed in the staging of men at low risk for metastases (stages T1c-T2a, PSA < 10 ng/mL, and Gleason score < 6) [20]. Additional similar guidelines and initiatives parallel these in the United States and internationally.
CHANGE HAS OCCURRED, BUT IMPROVEMENTS ARE STILL POSSIBLE AND NEEDED Despite such guidelines since the 1990s, resistance or neglect in the adoption of reduced imaging in men with low-risk prostate cancer has persisted. Prasad et al [10] studied the Surveillance, Epidemiology, and End Results Medicare database of prostate cancer in 2004 and 2005, finding that 34% of low-risk patients underwent inappropriate imaging and judged this
as “widespread over utilization.” Imaging use varied among practice types, and costs to Medicare for these inappropriate examinations for low- and intermediate-risk patients exceeded $2 million annually. Multiple databases were studied by Porten et al [7] in 2014, showing declining imaging use in lowrisk patients with prostate cancer since the 1980s, but the investigators nevertheless concluded that the level of misuse was still too high, particularly for CT, and that additional efforts were needed to curb this. They noted particular overuse of imaging for patients electing to undergo radiation therapy for treatment and postulated a link to practice patterns varying by specialty. They also noted an increased likelihood for imaging among more affluent individuals, as well as inappropriate imaging at less than average levels in the Veterans Affairs population (in which the financial incentive for test utilization is absent), suggesting that legal, social, or financial factors may drive inappropriate imaging utilization.
EXAMPLES THAT SHOW EVIDENCE OF SUCCESSFUL INTERVENTIONS More targeted interventions driven by guidelines have shown better imaging reductions in prostate cancer. In Sweden, for example, a national effort to educate clinicians on appropriate imaging over a 10-year period led to significantly reduced use, particularly in patients with low-risk prostate cancer (from 45% to 3%) [21]. Similarly, a large group of urologists participating voluntarily in a quality improvement collaborative of diverse practices in Michigan pledged to follow guidelines that included appropriate imaging use in low-risk patients [12]. Baseline assessments were made in 2012 and 2013, with reassessment in 2015, after the interventions. There was a reduction in inappropriate use of bone scans
Journal of the American College of Radiology Volume - n Number - n - 2017
from 11.0% to 6.5% and a drop in inappropriate use of CT from 14.7% to 7.7%. The investigators also noted decreased variability in imaging use among practices and stable appropriate imaging use. These efforts point to the effectiveness of interventions that are modeled appropriately and could be successfully duplicated in state-based or insurance coverage–based systems, voluntary or otherwise.
CONCLUSIONS Evidence-based guidelines for appropriate imaging use in patients with lowrisk prostate cancer have been well publicized since the 1990s. Nevertheless, studies have shown only gradual reductions in inappropriate imaging use. Targeted interventions and initiatives such as the R-SCAN program have demonstrated effectiveness in reducing rates of inappropriate imaging. Those interested in joining such an initiative can begin by learning more and taking the recruitment pledge and survey at https://rscan.org.
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REFERENCES 1. Kumar S, Ghildayal NS, Shah RN. Examining quality and efficiency of the US healthcare system. Int J Health Care Qual Assur 2011;24:366-88. 2. American Board of Internal Medicine Foundation. Choosing Wisely. Available at: http://www.choosingwisely.org. Accessed February 24, 2017. 3. Lam DL, Pandharipande PV, Lee JM, Lehman CD, Lee CI. Imaging-based
12.
screening: understanding the controversies. AJR Am J Roentgenol 2014;203:952-6. Siegel RL, Miller KD, Jemal A. Cancer statistics 2015. CA Cancer J Clin 2015;65:5-29. US Preventive Services Task Forces. Final recommendation statement: prostate cancer: screening. Available at: https://www.usprevent iveservicestaskforce.org/Page/Document/Reco mmendationStatementFinal/prostate-cancerscreening. Accessed December 15, 2016. Rosenkrantz AB, Verma S, Choyke P, et al. Prostate magnetic resonance imaging and magnetic resonance imaging targeted biopsy in patients with a prior negative biopsy: a consensus statement by AUA and SAR. J Urol 2016;196:1613-8. Porten SP, Smith A, Odisho AY, et al. Updated trends in imaging use in men diagnosed with prostate cancer. Prostate Cancer Prostatic Dis 2014;17: 246-51. Hernandez DJ, Nielsen ME, Han M, Partin AW. Contemporary evaluation of the D’amico risk classification of prostate cancer. Urology 2007;70:931-5. Makarov DV, Soulos PR, Gold HT, et al. Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the Choosing Wisely campaign. JAMA Oncol 2015;1:185-94. Prasad SM, Gu X, Lipsitz SR, Nguyen PL, Hu JC. Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States. Cancer 2012;118:1260-7. Carroll P, Albertsen PC, Greene K, et al. PSA testing for the pretreatment staging and posttreatment management of prostate cancer: 2013 revision of 2009 best practice statement. Available at: https:// www.auanet.org/common/pdf/education/ clinical-guidance/Prostate-Specific-Antigen. pdf. Accessed February 24, 2017. Hurley P, Dhir A, Gao Y, et al. A statewide intervention improves appropriate imaging in localized prostate cancer. J Urol. In press.
13. Abuzallouf S, Dayes I, Lukka H. Baseline staging of newly diagnosed prostate cancer: a summary of the literature. J Urol 2004;171:2122-7. 14. Flanigan RC, McKay TC, Olson M, Shankey TV, Pyle J, Waters WB. Limited efficacy of preoperative computed tomographic scanning for the evaluation of lymph node metastasis in patients before radical prostatectomy. Urology 1996;48:428-32. 15. Sanz G, Robles JE, Gimenez M, et al. Positron emission tomography with 18fluorine-labelled deoxyglucose: utility in localized and advanced prostate cancer. BJU Int 1999;84:1028-31. 16. Liu IJ, Zafar MB, Lai Y-H, Segall GM, Terris MK. Fluorodeoxyglucose positron emission tomography studies in diagnosis and staging of clinically organ-confined prostate cancer. Urology 2001;57:108-11. 17. American Urological Association. PSA testing for the pretreatment staging and posttreatment management of prostate cancer: 2013 revision of 2009 best practice statement. Available at: https://www.auanet. org/education/guidelines/prostate-specificantigen.cfm. Accessed February 24, 2017. 18. American College of Radiology. ACR Appropriateness Criteria prostate cancer—pretreatment detection, surveillance, and staging. Available at: https://acsearch. acr.org/docs/69371/Narrative. Accessed December 28, 2016. 19. National Comprehensive Cancer Network. Prostate cancer (version 1 2015). Available at: http://www.nccn.org/professionals/physician_ gls/pdf/prostate.pdf. Accessed December 2016. 20. American Society of Clinical Oncology. Ten things physicians and patients should question. Available at: http://www. choosingwisely.org/societies/american-societyof-clinical-oncology/. Accessed December 28, 2016. 21. Makarov DV, Loeb S, Ulmert D, Drevin L, Lambe M, Stattin P. Prostate cancer imaging trends after a nationwide effort to discourage inappropriate prostate cancer imaging. J Natl Cancer Inst 2013;105:1306-13.
Steven C. Eberhardt, MD, is from the Department of Radiology, University of New Mexico, Albuquerque, New Mexico. Satyan K. Shah, MD, is from the Department of Surgery, Division of Urology, University of New Mexico, Albuquerque, New Mexico. The Radiology Support, Communication, and Alignment Network (R-SCAN; http://www.rscan.org) is a CMS-sponsored effort leveraging the collaboration between radiologists and referring physicians to improve the appropriate utilization of imaging in patient care. R-SCAN is aligned with the American Board of Internal Medicine Foundation’s Choosing Wisely campaign and targets a number of emergency and outpatient imaging topics, including CT angiographic imaging for pulmonary embolism. The authors have no conflicts of interest related to the material discussed in this article. Steven C. Eberhardt, MD: Department of Radiology, University of New Mexico, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131-0001; e-mail: [email protected].
Journal of the American College of Radiology Eberhardt, Shah n Imaging Stewardship in the Age of Value
3
R-SCAN: Appropriate Imaging for Low-Risk Prostate Cancer Steven C. Eberhardt, MD, Satyan K. Shah, MD INTRODUCTION The US health system is characterized by high cost and outcome inefficiency, driven by policies and incentives of reimbursement, patterned medical practices, technology costs, and health consumer choices [1]. Waste contributes to cost, and the use of unnecessary and inappropriate imaging has been identified as a target for improving cost-effective care [2]. Specifically, physicians are being guided to reduce the use of imaging tests for which there is a strong evidence base against positive yield or outcome benefit for a particular clinical circumstance. Costs for these types of studies exceed immediate utility, as unrelated incidental findings are frequently discovered and pursued, with additional expense and unproven benefits [3]. Specifically, CT scans, nuclear medicine bone scans, and 18 F-fluorodeoxyglucose (FDG) PET examinations in the setting of low-risk prostate cancer have been singled out as being wasteful. Prostate cancer is the most common noncutaneous malignancy in US men, with approximately 220,800 new cases and 27,540 deaths in 2015 [4]. The majority of men diagnosed with prostate cancer have serum prostate-specific antigen (PSA) elevation, leading to ultrasound-guided prostate biopsy. There are concerns that this practice results in overdiagnosis and overtreatment of low-risk and clinically insignificant
cancers. The US Preventive Services Task Force issued a statement in 2012 opposing the use of PSA as a screening test [5]. Men diagnosed with prostate cancer are risk-stratified for recurrent or metastatic disease after treatment on the basis of histology (Gleason sum) and clinical (digital rectal) examination. PSA may be incorporated as an additional risk parameter. Some men undergo prostate MRI to complement local staging at the time of diagnosis or increasingly commonly as a tool for cancer detection and biopsy guidance [6]. A significant fraction of men diagnosed with prostate cancer fall into the low-risk category [7]. Definitions vary, but as an example, the D’Amico criteria classify low-risk prostate cancer as PSA less than or equal to 10 ng/mL, a Gleason sum less than or equal to 6, and clinical stage T1-2a [8]. Many authors note the propensity of patients with low-risk prostate cancer to undergo imaging for systemic staging for metastasis detection [7,9-12]. Imaging for metastatic disease in these low-risk individuals has been shown to have such low yields that utility has been called into question [9-11]. In this paper we explore (1) the evidence for imaging utility with traditional staging examinations (CT, bone scans, and FDG PET) in patients with low-risk prostate cancer, (2) the opinion that these examinations are not routinely justified, (3) the slow change in imaging use despite
ª 2017 American College of Radiology 1546-1440/17/$36.00 n http://dx.doi.org/10.1016/j.jacr.2017.01.041
evidence and guidelines, and (4) how interventions such as the Radiology Support, Communication, and Alignment Network (R-SCAN) initiative can generate improvements in appropriate imaging utilization.
EFFICACY EVIDENCE There is ample evidence that men with low-risk prostate cancer rarely if ever benefit from whole-body imaging examinations for staging. For example, in 2004 Abuzallouf et al [13] studied the efficacy of bone scans and CT scans in prostate cancer from 23 studies of bone scans and 25 studies of CT. The results showed that bone scans detected metastases in 2.3% of men with PSA < 10 ng/mL and 5.6% of men with Gleason scores 7. CT detected metastases in 0.7% of men with clinically localized disease and 1.2% of men with Gleason scores 7, with nodal metastases detected in no patients with PSA < 20 ng/mL. The investigators concluded that these examinations should not be standard practice in men with low-risk disease. An earlier, larger study looked at CT scans in preoperative staging of prostate cancer in 173 patients. CT understaged 9 of 12 patients with proven metastases and detected nodal metastases in only 3 of 9 patients with PSA > 25 ng/mL. The investigators concluded that the use of CT in men with prostate cancer and PSA < 25 ng/mL should be considered unjustified [14].
1
The evidence for FDG PET scan efficacy in the initial staging of low-risk prostate cancer is limited and less studied than bone scans and CT. There are technical challenges involved, including urine FDG activity obscuring disease in the prostate, making FDG unpopular for prostate cancer detection and staging generally. In a 1999 study of 11 patients, FDG PET was considered unreliable, as 3 of 11 men studied who had nodal metastases at surgery had negative results on FDG PET examinations [15]. Also, in a 2001 study by Liu et al [16] in which furosemide was used to reduce bladder FDG activity, FDG PET showed no significant findings in 23 of 24 men with clinically organ-confined (low-risk) prostate cancer and faint positivity in the prostate gland in 1 individual, with no metastases detected.
RECOMMENDATIONS IN GUIDELINES FROM PROFESSIONAL GROUPS As results such as these have accumulated, so have clinical guidelines from various professional groups advising against imaging in patients with low-risk prostate cancer. The “best practices” guidelines of the American Urological Association cover imaging in patients with low-risk prostate cancer along with serum PSA testing. Last updated in 2013, this recommendation advises that the routine use of bone scans is not required for asymptomatic men with clinically localized prostate cancer and serum PSA < 20 ng/mL [17]. The same document advises that CT or MR (for pelvic staging) be reserved for men with PSA > 20 ng/mL or when locally advanced disease is suspected, or with Gleason scores 8 [17]. The ACR has published evidence-based guidelines as the ACR Appropriateness Criteria since the 1990s, including coverage for imaging use in staging for prostate cancer. These guidelines, updated in 2016, judge bone scans and 2
CT scans in patients with clinically established low-risk prostate cancer in the lowest category, “usually not appropriate” [18]. FDG PET scans were not included in specific coverage for the guideline, being considered a modality not generally selected for this scenario. The National Comprehensive Cancer Network guidelines for prostate cancer in 2015 stated that imaging (including CT) should be used for nomogram probability of lymph node involvement > 10%, generally excluding low-risk patients. The same document recommended limiting bone scans to men with Gleason scores 8, T3 or T4 disease clinically, bone symptoms, or T1 disease with PSA > 20 ng/mL [19]. Multiple societies, including the American Society of Clinical Oncology, collaborated on the Choosing Wisely campaign, introduced by the American Board of Internal Medicine in 2012 to reduce wasteful health care spending. The ongoing campaign includes lowrisk prostate cancer, with the American Society of Clinical Oncology recommendation that PET, CT, and bone scans not be performed in the staging of men at low risk for metastases (stages T1c-T2a, PSA < 10 ng/mL, and Gleason score < 6) [20]. Additional similar guidelines and initiatives parallel these in the United States and internationally.
CHANGE HAS OCCURRED, BUT IMPROVEMENTS ARE STILL POSSIBLE AND NEEDED Despite such guidelines since the 1990s, resistance or neglect in the adoption of reduced imaging in men with low-risk prostate cancer has persisted. Prasad et al [10] studied the Surveillance, Epidemiology, and End Results Medicare database of prostate cancer in 2004 and 2005, finding that 34% of low-risk patients underwent inappropriate imaging and judged this
as “widespread over utilization.” Imaging use varied among practice types, and costs to Medicare for these inappropriate examinations for low- and intermediate-risk patients exceeded $2 million annually. Multiple databases were studied by Porten et al [7] in 2014, showing declining imaging use in lowrisk patients with prostate cancer since the 1980s, but the investigators nevertheless concluded that the level of misuse was still too high, particularly for CT, and that additional efforts were needed to curb this. They noted particular overuse of imaging for patients electing to undergo radiation therapy for treatment and postulated a link to practice patterns varying by specialty. They also noted an increased likelihood for imaging among more affluent individuals, as well as inappropriate imaging at less than average levels in the Veterans Affairs population (in which the financial incentive for test utilization is absent), suggesting that legal, social, or financial factors may drive inappropriate imaging utilization.
EXAMPLES THAT SHOW EVIDENCE OF SUCCESSFUL INTERVENTIONS More targeted interventions driven by guidelines have shown better imaging reductions in prostate cancer. In Sweden, for example, a national effort to educate clinicians on appropriate imaging over a 10-year period led to significantly reduced use, particularly in patients with low-risk prostate cancer (from 45% to 3%) [21]. Similarly, a large group of urologists participating voluntarily in a quality improvement collaborative of diverse practices in Michigan pledged to follow guidelines that included appropriate imaging use in low-risk patients [12]. Baseline assessments were made in 2012 and 2013, with reassessment in 2015, after the interventions. There was a reduction in inappropriate use of bone scans
Journal of the American College of Radiology Volume - n Number - n - 2017
from 11.0% to 6.5% and a drop in inappropriate use of CT from 14.7% to 7.7%. The investigators also noted decreased variability in imaging use among practices and stable appropriate imaging use. These efforts point to the effectiveness of interventions that are modeled appropriately and could be successfully duplicated in state-based or insurance coverage–based systems, voluntary or otherwise.
CONCLUSIONS Evidence-based guidelines for appropriate imaging use in patients with lowrisk prostate cancer have been well publicized since the 1990s. Nevertheless, studies have shown only gradual reductions in inappropriate imaging use. Targeted interventions and initiatives such as the R-SCAN program have demonstrated effectiveness in reducing rates of inappropriate imaging. Those interested in joining such an initiative can begin by learning more and taking the recruitment pledge and survey at https://rscan.org.
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REFERENCES 1. Kumar S, Ghildayal NS, Shah RN. Examining quality and efficiency of the US healthcare system. Int J Health Care Qual Assur 2011;24:366-88. 2. American Board of Internal Medicine Foundation. Choosing Wisely. Available at: http://www.choosingwisely.org. Accessed February 24, 2017. 3. Lam DL, Pandharipande PV, Lee JM, Lehman CD, Lee CI. Imaging-based
12.
screening: understanding the controversies. AJR Am J Roentgenol 2014;203:952-6. Siegel RL, Miller KD, Jemal A. Cancer statistics 2015. CA Cancer J Clin 2015;65:5-29. US Preventive Services Task Forces. Final recommendation statement: prostate cancer: screening. Available at: https://www.usprevent iveservicestaskforce.org/Page/Document/Reco mmendationStatementFinal/prostate-cancerscreening. Accessed December 15, 2016. Rosenkrantz AB, Verma S, Choyke P, et al. Prostate magnetic resonance imaging and magnetic resonance imaging targeted biopsy in patients with a prior negative biopsy: a consensus statement by AUA and SAR. J Urol 2016;196:1613-8. Porten SP, Smith A, Odisho AY, et al. Updated trends in imaging use in men diagnosed with prostate cancer. Prostate Cancer Prostatic Dis 2014;17: 246-51. Hernandez DJ, Nielsen ME, Han M, Partin AW. Contemporary evaluation of the D’amico risk classification of prostate cancer. Urology 2007;70:931-5. Makarov DV, Soulos PR, Gold HT, et al. Regional-level correlations in inappropriate imaging rates for prostate and breast cancers: potential implications for the Choosing Wisely campaign. JAMA Oncol 2015;1:185-94. Prasad SM, Gu X, Lipsitz SR, Nguyen PL, Hu JC. Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States. Cancer 2012;118:1260-7. Carroll P, Albertsen PC, Greene K, et al. PSA testing for the pretreatment staging and posttreatment management of prostate cancer: 2013 revision of 2009 best practice statement. Available at: https:// www.auanet.org/common/pdf/education/ clinical-guidance/Prostate-Specific-Antigen. pdf. Accessed February 24, 2017. Hurley P, Dhir A, Gao Y, et al. A statewide intervention improves appropriate imaging in localized prostate cancer. J Urol. In press.
13. Abuzallouf S, Dayes I, Lukka H. Baseline staging of newly diagnosed prostate cancer: a summary of the literature. J Urol 2004;171:2122-7. 14. Flanigan RC, McKay TC, Olson M, Shankey TV, Pyle J, Waters WB. Limited efficacy of preoperative computed tomographic scanning for the evaluation of lymph node metastasis in patients before radical prostatectomy. Urology 1996;48:428-32. 15. Sanz G, Robles JE, Gimenez M, et al. Positron emission tomography with 18fluorine-labelled deoxyglucose: utility in localized and advanced prostate cancer. BJU Int 1999;84:1028-31. 16. Liu IJ, Zafar MB, Lai Y-H, Segall GM, Terris MK. Fluorodeoxyglucose positron emission tomography studies in diagnosis and staging of clinically organ-confined prostate cancer. Urology 2001;57:108-11. 17. American Urological Association. PSA testing for the pretreatment staging and posttreatment management of prostate cancer: 2013 revision of 2009 best practice statement. Available at: https://www.auanet. org/education/guidelines/prostate-specificantigen.cfm. Accessed February 24, 2017. 18. American College of Radiology. ACR Appropriateness Criteria prostate cancer—pretreatment detection, surveillance, and staging. Available at: https://acsearch. acr.org/docs/69371/Narrative. Accessed December 28, 2016. 19. National Comprehensive Cancer Network. Prostate cancer (version 1 2015). Available at: http://www.nccn.org/professionals/physician_ gls/pdf/prostate.pdf. Accessed December 2016. 20. American Society of Clinical Oncology. Ten things physicians and patients should question. Available at: http://www. choosingwisely.org/societies/american-societyof-clinical-oncology/. Accessed December 28, 2016. 21. Makarov DV, Loeb S, Ulmert D, Drevin L, Lambe M, Stattin P. Prostate cancer imaging trends after a nationwide effort to discourage inappropriate prostate cancer imaging. J Natl Cancer Inst 2013;105:1306-13.
Steven C. Eberhardt, MD, is from the Department of Radiology, University of New Mexico, Albuquerque, New Mexico. Satyan K. Shah, MD, is from the Department of Surgery, Division of Urology, University of New Mexico, Albuquerque, New Mexico. The Radiology Support, Communication, and Alignment Network (R-SCAN; http://www.rscan.org) is a CMS-sponsored effort leveraging the collaboration between radiologists and referring physicians to improve the appropriate utilization of imaging in patient care. R-SCAN is aligned with the American Board of Internal Medicine Foundation’s Choosing Wisely campaign and targets a number of emergency and outpatient imaging topics, including CT angiographic imaging for pulmonary embolism. The authors have no conflicts of interest related to the material discussed in this article. Steven C. Eberhardt, MD: Department of Radiology, University of New Mexico, MSC10 5530, 1 University of New Mexico, Albuquerque, NM 87131-0001; e-mail: [email protected].
Journal of the American College of Radiology Eberhardt, Shah n Imaging Stewardship in the Age of Value
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