Swedes Stop Inappropriate Prostate Cancer Imaging

Fran Lowry

July 25, 2013

A campaign in Sweden against the inappropriate imaging of men with low-risk prostate cancer has produced a very significant decrease in unnecessary imaging.

A retrospective cohort study of 99,879 men diagnosed with prostate cancer in Sweden from 1998 to 2009 demonstrated that the rate of inappropriate cancer scans for low-risk prostate cancer patients in Sweden plummeted from 45% to 3% (P < .001) over 10 years.

The results were published online July 13 in the Journal of the National Cancer Institute.

Dr. Danil Makarov

"The joint campaign by local county governments and the National Prostate Cancer Register [NPCR] of Sweden, which is an association of Swedish urologists, was incredibly effective at stamping out inappropriate imaging," lead author Danil V. Makarov, MD, from the NYU Langone Medical Center in New York City, told Medscape Medical News.

However, the campaign also decreased appropriate imaging in men with high-risk prostate cancer. The rate of appropriate screening in high-risk cancer patients fell from 63% to 43% over the same 10 years.

"We would have loved to have seen the appropriate imaging rate go from the baseline of 63% to 100%, but in fact it went down," he said.

"Nevertheless, the results tell us is that it is indeed possible to stop unneeded medical tests. They did it in Sweden, and I think we can do it here in the United States," Dr. Makarov said.

Campaign of "Gentle Shaming"

They did it in Sweden, and I think we can do it here in the United States.

The NPCR used what Dr. Makarov refers to as "gentle shaming" to curtail inappropriate imaging.

Their campaign, which began in 2000, publicly presented local statistics on inappropriate imaging at urology meetings. At the same time, it posted reminders about imaging guidelines.

The urologists in Sweden could compare the imaging rates at their own institution with those at best practices.

"Urologists would get together at regional meetings and everyone would see the numbers. No one wants to be the outlier, so this gave them an incentive not to be listed as a provider of unnecessary testing. But the campaign did not necessarily encourage specifically appropriate imaging in high-risk patients. Perhaps because they did not do this, they saw a decline in appropriate imaging," Dr. Makarov explained.

A Cancer Practice That Must Stop

Last year, as reported by Medscape Medical News, the American Society of Clinical Oncology (ASCO) recommended 5 cancer procedures or tests that should no longer be used (J Clin Oncol. 2012;30:1715-1724).

Imaging for low-risk prostate cancer is on that list.

In addition, ASCO recommends that oncologists limit the use of advanced and costly imaging techniques for breast cancer and for detecting breast cancer recurrences, stop the unnecessary use of chemotherapy in patients with advanced cancers who are unlikely to benefit, and curb their use of colony-stimulating factor drugs in patients undergoing chemotherapy.

"By tackling the overuse of treatments and tests for some of the most common cancers, we hope to achieve substantial improvements in the quality of cancer care in the United States," Lowell Schnipper, MD, from the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, and lead author of the recommendations, said in a statement.

The move to curb unnecessary tests is part of the Choose Wisely campaign, organized by the American Board of Internal Medicine.

"The eradication of bone scans to look for metastatic prostate cancer would save money and improve quality of care. This is a top agenda item in the United States," Dr. Makarov said.

Lessons for the United States

Healthcare stakeholders in the United States could learn from the Swedish experience, he noted.

"Obviously, the Swedish and American healthcare systems are very different, but the Swedes have an explicit partnership between their professional societies and the regional governments that are putting policies in place. In Sweden, the professional society is helping to set the agenda. I think that's a very effective model, and perhaps something we could try in this country," Dr. Makarov said.

"If Health and Human Services came to the American Urological Association and asked what we think is important and how we can save money, that would be a very fruitful partnership. Now that we have the Affordable Care Act, which improves access to care in the United States, we have to work on cutting costs. Now that everybody has access to care, I hope that there will be opportunities for physicians to engage in that process," he said.

Although the campaign to cut inappropriate imaging worked in Sweden, Dr. Makarov explained that it needs some "tweaking" for it to work in the United States. "We should use it as a road map, but we should also be open to the experiences of other countries. This will be very valuable to us as we move forward."

Dr. Makarov reports being a consultant for Castlight Health. Dr. Schnipper reports serving as a consultant for ITA partners.

J Natl Cancer Inst. Published online July 13, 2013. Abstract


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