Advanced Imaging for Early Prostate Cancer Staging - PowerPoint Presentation

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Advanced Imaging for Early Prostate Cancer Staging

When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria®

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What Is R-SCAN?

2Collaborative activity

for referring clinicians and radiologists to improve patient

care through

clinical improvement

R-SCAN Collaboration Goals:

Ensure

patients receive the most appropriate imaging exam at the most appropriate time based on evidence-based appropriate use

criteria

Reduce

unnecessary imaging tests focused on imaging

Choosing Wisely

®

topics

Lower

the cost of care

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Why Participate?

R-SCAN Offers:Data-driven system for moving toward value-based imaging and patient

care

Opportunity to focus

on highly relevant imaging exams to improve

utilization

Collaborators can fulfill their Improvement Activity requirements under the MIPS

Easy way to practice with clinical decision support (CDS) technology In preparation for PAMAFree and immediate access to Web-based tools and CME activities

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Problem

: Unnecessary Use of CT, bone, PET scans in Staging of Low Risk Prostate CancerMultiple studies have shown CT and radionuclide bone scans do not improve detection of metastatic disease in men

with low risk prostate

cancer.

A 2004 study looked at the

efficacy of bone

and

CT scans in prostate cancer from 23 studies of bone scans and 25 studies of CT. 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 [1].FDG PET

scans involve technical challenges, making

FDG unpopular for prostate cancer detection and staging generally

.CT and bone scans in the low risk population may produce incidental findings causing patient anxiety, using clinician time to explain them, and resulting in further unnecessary testing and cost.

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Using Evidence to Guide Imaging Ordering

Choosing Wisely campaignCollaborative effort between ABIM

Foundation and over 70 medical specialty societies

Helps patients and medical professionals avoid

wasteful or unnecessary medical tests,

treatments,

and

proceduresMany medical associations agree that CT scans are not necessary in the staging of early prostate cancer at low risk for

metastasis,

including:

American Society of Clinical

Oncology

American Urological

Association

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Using Evidence to Guide Imaging Ordering

ACR Appropriateness Criteria®Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditionsEmploys input of physicians from other medical specialties and societies to provide important clinical perspectives

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ACR Appropriateness Criteria: The Facts

178 clinical imaging topics and over 875 clinical

variants

 

Basic access is

free

Learn more at

acr.org/ac

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Variant 1:

Clinically suspected prostate cancer, no prior biopsy (biopsy naïve). Detection. Variant 2: Clinically suspected prostate cancer, prior negative TRUS-guided biopsy. Detection.

Variant

3:

Clinically established low-risk prostate cancer. Active surveillance.

Variant

4:

Clinically established intermediate-risk prostate cancer. Staging and/or surveillance. Variant 5: Clinically established high-risk prostate cancer. Staging.ACR Appropriateness Criteria for

Prostate Cancer–Pretreatment Detection, Surveillance, and Staging

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Appropriateness

Criteria Rating by Value

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Alignment of Appropriateness Criteria and

Choosing WiselyAll imaging variants and clinical scenarios: https://acsearch.acr.org/docs/69371/Narrative/

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Alignment of Appropriateness Criteria and

Choosing WiselyAll imaging variants and clinical scenarios: https://acsearch.acr.org/docs/69371/Narrative/

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Assessing Need for Advanced Imaging

S

tandard

clinical

tools, such

as digital rectal examination, serum prostate-specific antigen (PSA) assay, and systematic biopsy results such as fraction of cores positive for cancer and Gleason

score are used to determine prostate risk stratification.

The

D’Amico risk stratification

system

classifies low risk prostate cancer

in patients who have all of the following:

PSA <10 ng/mL

Gleason

sum ≤

6

Clinical

stage

T1-T2a

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Assessing Need for Advanced Imaging

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The

primary role of CT in prostate cancer is the detection of nodal

metastases. The

poor performance of CT for detection of nodal metastases has

been confirmed

in

recent studies.

Bone scintigraphy remains the standard test used for detection of bone metastases.

Patients

with low risk prostate cancer are unlikely to have metastatic disease documented by bone scan or CT. Therefore,

these scans

are generally not recommended unless

higher risk disease has been established.

Evidence has emerged that MRI or MRI-targeted biopsy may be appropriate for detection and active surveillance in low risk men, and can provide better evaluation

when compared with traditional

systematic

biopsy.

Assessing Need for Advanced Imaging

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R-SCAN and Clinical Decision Support

CareSelect is a web-based version of the ACR Appropriateness Criteria, comprising

over 3,000 clinical scenarios and 15,000

imaging indications

CareSelect

provides evidence-based

decision support for the appropriate utilization

of medical imaging proceduresR-SCAN participants gain free access to a customized, web-based version of CareSelect, a helpful first step for aligning ordering patterns with appropriate use criteria

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rscan.org

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Getting Started

With

R-SCAN

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R-SCAN Early Prostate Cancer Staging Educational Resources

Visit: rscan.orgClick: Resources

Click:

Topic-specific

Resources

Podcast

Imaging Order Simulation

activityArticlesMaterials to share with patients

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R-SCAN Resources With CME

Podcast A radiologist and referring physician discuss appropriate image ordering for early prostate cancer staging; approved for .5 CME

Learn more

Imaging Order

Simulation Activity

Test your knowledge in selecting the

best imaging exam

for various indicationsFree with CME22

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Key Points: Talking With Patients

Here are talking points to explain to patients why imaging is not necessary for low risk prostate cancer:If the Gleason test shows that you have low risk prostate cancer, you usually do not need more testing. E

vidence has shown the

cancer is not likely to have

spread to other organs, and that CT and bone scans do not produce useful results in low risk patients.

Additional imaging may produce incidental findings, requiring further tests and time just to confirm they are benign.

CT

scans expose you to a strong dose of radiation, which can increase your risk for cancer. In some cases, it’s the same as having about 200 chest x-rays.Certain costs associated with imaging are not covered by insurance, such as payments to meet deductible thresholds and co-pays. 23

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Self-Assessment Question

Which of the following characterize low risk prostate cancer?PSA <10 ng/mL

Gleason sum ≤6

Clinical stage T1-T2a

All of the above

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Case 1

A 60-year-old man presents with a recent diagnosis of prostate cancer (Gleason score = 2; low risk).25

Questions:

What imaging would be most appropriate for this patient?

What other questions would you ask?

What

is the focus of your

physical exam?

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Case 2

A 71-year-old man with prostate cancer is diagnosed with transrectal ultrasound-guided biopsy (with a Gleason score of 7) and is clinically staged as T2b.

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Questions:

What imaging would be most appropriate for this patient?

What other questions would you ask?

What

is the focus of your

physical exam?

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Summary

Evidence has shown that men who are risk stratified into the low risk prostate cancer group do not benefit from CT or bone scans, since their early stage cancer is unlikely to have metastasized to other organs.FDG PET scans are considered a modality not generally selected for this scenario.Use the D’Amico risk stratification system to identify patients as low risk.

Radiation, cost, and time (of both patients and clinicians) are not worth the low yield of metastatic findings from CT and bone scans in this population.

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Questions?

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