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Serving Up Incidental Findings: Just the Way You Like ’Em
ACR CHAIR’S MEMO JAMES A. BRINK, MD
Serving Up Incidental Findings: Just the Way You Like ’Em Because of the inherent delay in the publication world, I am writing this column over Labor Day weekend and reflecting back on a summer punctuated by boundless sunshine and long warm days. Some summers are marked by a so-called song of the summer. As I recall, the summer of 2012 was memorialized with a clear-cut song of the summer: “Call Me Maybe” by Carly Rae Jepsen. Although this summer a clear-cut song of the summer did not materialize as strongly as in 2012, a clear-cut theme for radiology emerged and seemed to build upon itself with each passing day. Incidental findings have captured the attention of the radiology community, the lay press, and even the Massachusetts Board of Registration in Medicine. First, two provocative reports were published in JACR this summer: “Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings” [1] and “Exome and Genome Sequencing and Parallels in Radiology: Searching for PatientCentered Management of Incidental and Secondary Findings” [2]. In the first, Pandharipande et al proposed four potential criteria for not reporting clinically unimportant findings and recommended that these criteria be debated in other contexts using a Bosniak category 1 renal cyst as an example. The authors proposed that such findings not be reported when n the cyst is not the reason for examination, n the cyst has no meaningful anatomic or physiologic consequence (eg, mass effect),
n
the cyst has no excess malignant potential given known or suspected patient risk (eg, von Hippel-Lindau syndrome), and n the cyst is not likely to indicate a nonmalignant disease (eg, polycystic kidney disease). In the second article, Kang et al suggested that patients’ attitudes and preferences should play a large part in how low-risk incidental findings are reported and managed. The authors suggested using patient preferences to inform more uniform recommendations for low-risk findings, recognizing that patients may endorse a strong preference to not discover low-risk incidental findings. Radiologists can use information from patients to tailor their reporting to specific circumstances. The lay press identified the controversy associated with this issue when the Wall Street Journal published “When a Medical Test Leads to Another, and Another” on August 29, 2016 [3]. The article builds primarily on the JACR article by Kang et al [2] but also references points made by Pandharipande et al [1]. The article highlights the high rate of incidental findings in CT scans of the abdomen (up to 70%). One possible explanation was offered by H. Gilbert Welch, MD, MPH, author of the book Less Medicine, More Health, who pointed out that radiologists “feel trapped legally” by the fear of malpractice suits. “They are only punished for under diagnosing, not over diagnosing, so they throw it back to the clinician,” wrote Welch. Dr Pandharipande, chair of the ACR Committee on Incidental
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.09.019
Findings, says that doctors need “to get better at identifying who will benefit from an incidental finding and who will not.” Both she and Dr Kang push for recommendations that are safe, responsible, and evidence based. Continuing with the theme of incidental findings, I received an e-mail at 10:40 PM on August 31, 2016, from the Commonwealth of Massachusetts Board of Registration in Medicine’s Quality and Patient Safety Division announcing its “incidental findings advisory” [4]. The division stated that it has received a number of safety and quality review reports of patient events associated with what are commonly referred to as incidental findings on imaging studies. The advisory highlights the risks of incidental findings that prove to be clinically significant but are lost to follow-up and lead to significant morbidity and mortality down the road. Two cases are cited in which downstream morbidity and mortality could have been avoided had incidental clinical findings been evaluated and treated when they were first discovered. The advisory goes on to identify several topics for health care facility systems review, including challenges along the continuum of care, barriers inherent to electronic health care records, unwieldy radiology and health IT systems, and the risks of incidental findings before testing. The advisory highlights the importance of the ACR’s incidental findings white papers as well as the appropriateness criteria for guiding practitioners to appropriate follow-up testing for such findings.
1285
Finally, the month of August also saw the release of the ACR’s Engage platform for enabling online community discussions around topics of interest among its members. The discussion group focused on incidental findings has proved to be one of the most vigorous and hotly debated forums to date. Topics seemed to have touched a nerve, as the words insulting, paternalistic, demeaning, irrational, and illogical quickly entered the discussion. I have read through the most recent posts, and most radiologists who participated believe that all findings should be reported, as the clinical significance and relevance for any particular patient are unknown to the radiologist. However, a few took the position articulated in the aforementioned JACR articles, stating that some thought needs to be given to the downstream consequences of needless cost and morbidity from inappropriate workup of clinically insignificant findings. I would like to take a slightly broader view of this issue with the following notion. In the future, machine-learning algorithms will become more commonplace for recognition and documentation of specific imaging findings. At that point, the notion of incidental findings will become irrelevant. I envision a point in the future when a multidimensional imaging examination yields a multidimensional database of image findings that are autopopulated by machinelearning algorithms. The radiologist’s job will be to filter the database of autoextracted findings that are germane to the clinical question at hand and ensure the accuracy of those findings while integrating them with necessary clinical information to result in a meaningful set of diagnoses and recommendations for consideration by the
ordering practitioner. In this regard, the database of imaging findings may be viewed as akin to a “review of systems” in a history and physical report. The patient’s referring physician may focus on elements in the database of findings that are germane to the chief symptom and present illness. Meanwhile, another specialist may view the database of findings differently, focusing primarily on those data elements germane to symptoms in his or her area of expertise. For example, the report of a CT scan of the abdomen and pelvis performed for diverticulitis may focus primarily on findings related to the clinical question, with a cursory summary of potentially important ancillary findings. However, the same scan may result in a different report prepared for an orthopedic surgeon who is seeing the patient for chronic low back pain. Here, the report may expound upon findings germane to the lower lumbar spine, as culled from the database of imaging findings. Moreover, how many of us as radiologists have gone back to review CT scans performed on ourselves to see how our internal organs are faring as we age? Because we have the ability to look at all of our images and understand the consequence of incidental findings we might discover, we are eager to see how much vascular calcification is present or how much degenerative disc disease we might have. In addition to filtering the database of imaging findings by clinical relevance, I can also imagine a filter called “personal health.” Here, patients may review their imaging findings with the same intent as radiologists who seek to review imaging findings solely for the purpose of evaluating their own personal health. Certainly, the radiology consultation clinic piloted at Massachusetts General Hospital has proved to
be highly popular among patients who are curious about the effects of their lifestyle choices on their overall health. In almost all circumstances, the patients come away feeling that the experience was highly worth their while, as a picture is worth a thousand words. Although the controversy of incidental findings has become our song of the summer in 2016, I’m confident that the controversy that accompanies this issue will continue to morph as technology enables greater recognition and documentation of such findings with a high degree of accuracy and thoroughness. Our job will be to apply the appropriate filters to a database of imaging findings that may be populated in part by machine-learning algorithms. From there, we must apply our clinical acumen to ensure the accuracy of those findings and distill the information into meaningful diagnoses and recommendations. I’m confident that the future of radiology will be enhanced by the efficient and personalized approach to reporting that clinical data science may bring to our specialty.
REFERENCES 1. Pandharipande PV, Herts BR, Gore RM, et al. Rethinking normal: benefits and risks of not reporting harmless incidental findings. J Am Coll Radiol 2016;13:764-7. 2. Kang SK, Spector-Bagdady K, Caplan AL, Braithwaite RS. Exome and genome sequencing and parallels in radiology: searching for patient-centered management of incidental and secondary findings. J Am Coll Radiol 2016. Available at: http://dx.doi.org/ 10.1016/j.jacr.2016.06.050. 3. Lagnado L. When a medical test leads to another and another. The Wall Street Journal August 29, 2016. 4. Commonwealth of Massachusetts, Board of Registration in Medicine, Quality and Patient Safety Division. Incidental findings advisory. August 2016. Available at: http://www.mass. gov/eohhs/docs/borim/incidental-findingsadvisory.pdf. Accessed September 26, 2016.
The author has no conflicts of interest related to the material discussed in this article. James A. Brink, MD: Massachusetts General Hospital, 55 Fruit Street, FND-216, Boston, MA 02114-2698; e-mail: jabrink@ partners.org.
1286
Journal of the American College of Radiology Volume 13 n Number 11 n November 2016
Serving Up Incidental Findings: Just the Way You Like ’Em Because of the inherent delay in the publication world, I am writing this column over Labor Day weekend and reflecting back on a summer punctuated by boundless sunshine and long warm days. Some summers are marked by a so-called song of the summer. As I recall, the summer of 2012 was memorialized with a clear-cut song of the summer: “Call Me Maybe” by Carly Rae Jepsen. Although this summer a clear-cut song of the summer did not materialize as strongly as in 2012, a clear-cut theme for radiology emerged and seemed to build upon itself with each passing day. Incidental findings have captured the attention of the radiology community, the lay press, and even the Massachusetts Board of Registration in Medicine. First, two provocative reports were published in JACR this summer: “Rethinking Normal: Benefits and Risks of Not Reporting Harmless Incidental Findings” [1] and “Exome and Genome Sequencing and Parallels in Radiology: Searching for PatientCentered Management of Incidental and Secondary Findings” [2]. In the first, Pandharipande et al proposed four potential criteria for not reporting clinically unimportant findings and recommended that these criteria be debated in other contexts using a Bosniak category 1 renal cyst as an example. The authors proposed that such findings not be reported when n the cyst is not the reason for examination, n the cyst has no meaningful anatomic or physiologic consequence (eg, mass effect),
n
the cyst has no excess malignant potential given known or suspected patient risk (eg, von Hippel-Lindau syndrome), and n the cyst is not likely to indicate a nonmalignant disease (eg, polycystic kidney disease). In the second article, Kang et al suggested that patients’ attitudes and preferences should play a large part in how low-risk incidental findings are reported and managed. The authors suggested using patient preferences to inform more uniform recommendations for low-risk findings, recognizing that patients may endorse a strong preference to not discover low-risk incidental findings. Radiologists can use information from patients to tailor their reporting to specific circumstances. The lay press identified the controversy associated with this issue when the Wall Street Journal published “When a Medical Test Leads to Another, and Another” on August 29, 2016 [3]. The article builds primarily on the JACR article by Kang et al [2] but also references points made by Pandharipande et al [1]. The article highlights the high rate of incidental findings in CT scans of the abdomen (up to 70%). One possible explanation was offered by H. Gilbert Welch, MD, MPH, author of the book Less Medicine, More Health, who pointed out that radiologists “feel trapped legally” by the fear of malpractice suits. “They are only punished for under diagnosing, not over diagnosing, so they throw it back to the clinician,” wrote Welch. Dr Pandharipande, chair of the ACR Committee on Incidental
ª 2016 American College of Radiology 1546-1440/16/$36.00 n http://dx.doi.org/10.1016/j.jacr.2016.09.019
Findings, says that doctors need “to get better at identifying who will benefit from an incidental finding and who will not.” Both she and Dr Kang push for recommendations that are safe, responsible, and evidence based. Continuing with the theme of incidental findings, I received an e-mail at 10:40 PM on August 31, 2016, from the Commonwealth of Massachusetts Board of Registration in Medicine’s Quality and Patient Safety Division announcing its “incidental findings advisory” [4]. The division stated that it has received a number of safety and quality review reports of patient events associated with what are commonly referred to as incidental findings on imaging studies. The advisory highlights the risks of incidental findings that prove to be clinically significant but are lost to follow-up and lead to significant morbidity and mortality down the road. Two cases are cited in which downstream morbidity and mortality could have been avoided had incidental clinical findings been evaluated and treated when they were first discovered. The advisory goes on to identify several topics for health care facility systems review, including challenges along the continuum of care, barriers inherent to electronic health care records, unwieldy radiology and health IT systems, and the risks of incidental findings before testing. The advisory highlights the importance of the ACR’s incidental findings white papers as well as the appropriateness criteria for guiding practitioners to appropriate follow-up testing for such findings.
1285
Finally, the month of August also saw the release of the ACR’s Engage platform for enabling online community discussions around topics of interest among its members. The discussion group focused on incidental findings has proved to be one of the most vigorous and hotly debated forums to date. Topics seemed to have touched a nerve, as the words insulting, paternalistic, demeaning, irrational, and illogical quickly entered the discussion. I have read through the most recent posts, and most radiologists who participated believe that all findings should be reported, as the clinical significance and relevance for any particular patient are unknown to the radiologist. However, a few took the position articulated in the aforementioned JACR articles, stating that some thought needs to be given to the downstream consequences of needless cost and morbidity from inappropriate workup of clinically insignificant findings. I would like to take a slightly broader view of this issue with the following notion. In the future, machine-learning algorithms will become more commonplace for recognition and documentation of specific imaging findings. At that point, the notion of incidental findings will become irrelevant. I envision a point in the future when a multidimensional imaging examination yields a multidimensional database of image findings that are autopopulated by machinelearning algorithms. The radiologist’s job will be to filter the database of autoextracted findings that are germane to the clinical question at hand and ensure the accuracy of those findings while integrating them with necessary clinical information to result in a meaningful set of diagnoses and recommendations for consideration by the
ordering practitioner. In this regard, the database of imaging findings may be viewed as akin to a “review of systems” in a history and physical report. The patient’s referring physician may focus on elements in the database of findings that are germane to the chief symptom and present illness. Meanwhile, another specialist may view the database of findings differently, focusing primarily on those data elements germane to symptoms in his or her area of expertise. For example, the report of a CT scan of the abdomen and pelvis performed for diverticulitis may focus primarily on findings related to the clinical question, with a cursory summary of potentially important ancillary findings. However, the same scan may result in a different report prepared for an orthopedic surgeon who is seeing the patient for chronic low back pain. Here, the report may expound upon findings germane to the lower lumbar spine, as culled from the database of imaging findings. Moreover, how many of us as radiologists have gone back to review CT scans performed on ourselves to see how our internal organs are faring as we age? Because we have the ability to look at all of our images and understand the consequence of incidental findings we might discover, we are eager to see how much vascular calcification is present or how much degenerative disc disease we might have. In addition to filtering the database of imaging findings by clinical relevance, I can also imagine a filter called “personal health.” Here, patients may review their imaging findings with the same intent as radiologists who seek to review imaging findings solely for the purpose of evaluating their own personal health. Certainly, the radiology consultation clinic piloted at Massachusetts General Hospital has proved to
be highly popular among patients who are curious about the effects of their lifestyle choices on their overall health. In almost all circumstances, the patients come away feeling that the experience was highly worth their while, as a picture is worth a thousand words. Although the controversy of incidental findings has become our song of the summer in 2016, I’m confident that the controversy that accompanies this issue will continue to morph as technology enables greater recognition and documentation of such findings with a high degree of accuracy and thoroughness. Our job will be to apply the appropriate filters to a database of imaging findings that may be populated in part by machine-learning algorithms. From there, we must apply our clinical acumen to ensure the accuracy of those findings and distill the information into meaningful diagnoses and recommendations. I’m confident that the future of radiology will be enhanced by the efficient and personalized approach to reporting that clinical data science may bring to our specialty.
REFERENCES 1. Pandharipande PV, Herts BR, Gore RM, et al. Rethinking normal: benefits and risks of not reporting harmless incidental findings. J Am Coll Radiol 2016;13:764-7. 2. Kang SK, Spector-Bagdady K, Caplan AL, Braithwaite RS. Exome and genome sequencing and parallels in radiology: searching for patient-centered management of incidental and secondary findings. J Am Coll Radiol 2016. Available at: http://dx.doi.org/ 10.1016/j.jacr.2016.06.050. 3. Lagnado L. When a medical test leads to another and another. The Wall Street Journal August 29, 2016. 4. Commonwealth of Massachusetts, Board of Registration in Medicine, Quality and Patient Safety Division. Incidental findings advisory. August 2016. Available at: http://www.mass. gov/eohhs/docs/borim/incidental-findingsadvisory.pdf. Accessed September 26, 2016.
The author has no conflicts of interest related to the material discussed in this article. James A. Brink, MD: Massachusetts General Hospital, 55 Fruit Street, FND-216, Boston, MA 02114-2698; e-mail: jabrink@ partners.org.
1286
Journal of the American College of Radiology Volume 13 n Number 11 n November 2016