Scourge of Incidental Findings More CTs (26M in 1998, 61M in 2006) If CTC reimbursed: 3.5M/yr at 10 years CTC brings problems of whole-body

screening, with benefits of polyp detection Extracolonic Findings (ECFs) helping to keep

CTC from reimbursement

Cascade Effect William Casarella, MD, Former Chair, Emory Radiology:William Casarella, MD, Former Chair, Emory Radiology:

Negative CT colonographyNegative CT colonography Renal, hepatic and lung masses detected Renal, hepatic and lung masses detected

Additional CT scansAdditional CT scansPET scanPET scanLiver biopsy Liver biopsy Video-aided thoracoscopy with wedge resectionVideo-aided thoracoscopy with wedge resection

Excruciating post-operative pain, 5 weeks of recuperation, over Excruciating post-operative pain, 5 weeks of recuperation, over $50,000 in charges$50,000 in charges

All findings benignAll findings benign

Frequency, Cost of Incidentalomas

Extracolonic Findings on CTC

Article PatientsPatients with

Missed FindingsPatients Getting

Surgery, BxPatients Malignant,

Serious DxCost of Workup/

Population

Xiong, 2005 3280 2.7% 0.8% 3.7% --

Yee, 2005 500 1.6% 1% 2.6% $28.12

Xiong, 2006 225 -- 0.4% -- $297

Kim, 2007 3120 -- -- 0.3% --

Tolan et al, AJR 2007 400 -- -- 12.3% $66.59

Incidental Findings on CTC

Hassan, et al: 100,000 patients - Monte Carlo simulation Cost: $162/patient 2292 life years gained, mostly from AAA

Only 13% of life years saved from cancer$7,063/life-year saved

Incidental Findings at CT for Hematuria

1295 patients at UAB: CT for hematuria Incidental findings: 17% “Significant”: 3.3% Downstream costs:

106 additional imaging studies ($14,761) 50 specialist visits ($6,143) 29 interventions

12 percutaneous 7 endoscopic 10 major surgery………

Incidental Findings at CT for Hematuria

AAA repair > $225,000 Adnexal cyst (x-lap, appy, BSO) >$165,000 Pancreatic head mass >$69,000 8 other cases >$10,000:

Pancreatic resection Adenopathy AAA repair - 2 Gynecologic - 4

Incidental Findings at CT for Hematuria

Total cost: $716,945

Average cost per patient: $554 (!!!)

Incidental Findings at Research Studies Study in Sept, 2010 Archives of Internal Medicine

1,426 examinations 567 incidental findings 6 unambiguously beneficial findings 3 unnecessary surgeries Numerous unnecessary examinations, cost

Summary - ECFs on CTC Important incidental findings

~10% if average risk ~30% if high risk or symptomatic

Patients getting additional tests ~5-15% Patients getting additional tests with benign result

~2.5% Patients getting surgery or biopsy ~0.5-1%

Copyright ©Radiological Society of North America, 2005

Furtado, C. D. et al. Furtado, C. D. et al. Whole-Body CT Screening: Spectrum of Findings Whole-Body CT Screening: Spectrum of Findings and Recommendations in 1192 Patients.and Recommendations in 1192 Patients. Radiology 2005;237:385-394 Radiology 2005;237:385-394

Frequency of Recommendations - Incidentalomas

Pilot - Total Body Screening 50 patients - 25 screened Followed 2 years Chest, cardiac and abdominal radiologists Clinically important (actionable) findings in

abdomen/pelvis in 28% (7 pts) 3 cystic renal lesions 1 cystic hepatic lesion 1 hyperdense liver 2 cystic ovarian lesions

Pilot - Total Body Screening Chest, abdomen and pelvis findings:

Non-contrast, low dose (high noise), lower specificity 36% different recommendations Kappa 0.52 - moderate agreement 2 cases

Both radiologists reported, 1 called actionable 10 cases

1 reported actionable, 9 didn’t report at all

Proposed categorization system for extracolonic findings

Zalis M E et al. Radiology 2005;236:3-9

©2005 by Radiological Society of North America

Classifying IncidentalomasNo incidental finding

E1: Normal variant

E2: Unimportant

E3: Likely unimportant

E4: Significant, needs WU

JCAT 32: 497-503, August, 2008376 patients

ACR, SCBT-MR, SGR, SUR approach

the problem

ACR Involvement in Incidentaloma Problem Incidental Findings Committee, under Body Imaging Commission Also working with SCBT-MR and SGR-SUR Commission: Reed Dunnick, then James Brink

Chair: Lincoln Berland Four subcommittees established

Renal – Stuart Silverman Liver – Richard Gore Adrenal – William Mayo-Smith Pancreas – Alec Megibow

Decided to defer other (vascular, ovarian, etc.) Paper published in JACR, October, 2010

Summary Early incidental detection may not lead to longer survival.Early incidental detection may not lead to longer survival. Detecting and following incidentalomas provides no benefit Detecting and following incidentalomas provides no benefit

for many conditions.for many conditions. Incidental findings, false positives and overdiagnosis lead to Incidental findings, false positives and overdiagnosis lead to

healthy people getting extra tests.healthy people getting extra tests. Aggressively pursuing findings probably does more harm Aggressively pursuing findings probably does more harm

than good.than good. A consistent approach may minimize the economic A consistent approach may minimize the economic

implications and optimize the health effects of incidentalomasimplications and optimize the health effects of incidentalomas

Incidentalomas – What Should We Do?

Appreciate the insignificance of the overwhelming majority of Appreciate the insignificance of the overwhelming majority of incidentalomasincidentalomas

Limit reporting of incidentalomas to those that could herald diseases Limit reporting of incidentalomas to those that could herald diseases in which the course of disease may be alteredin which the course of disease may be altered

Strive to definitively characterize incidentalomas, but balance with Strive to definitively characterize incidentalomas, but balance with risk and cost of additional studiesrisk and cost of additional studies

If reporting an incidentaloma, quantify the probability of its If reporting an incidentaloma, quantify the probability of its importanceimportance

Help direct referring clinicians to the most cost-effective approach to Help direct referring clinicians to the most cost-effective approach to managing the few incidentalomas that must be pursuedmanaging the few incidentalomas that must be pursued