Dr. Daniel Dow, Medical Director for Diagnostic Imaging Services for HealthHelp notes the findings from a study published January 11, 2023 in the American Journal of Roentgenology.
“Approximately 15–30% of all diagnostic imaging and 20–40% of CT examinations contain at least one incidental finding.”
The intent in pursuing imaging, clinical, interventional, or surgical follow-up of incidental findings is to prevent harm through early diagnosis, but in many instances, this has been shown to cause the opposite effect—increased harm without patient benefit. This is paradoxically true for many patients who are diagnosed with incidental, early-stage cancer (e.g., grade group 1 prostate cancer, cystic kidney cancer, micropapillary thyroid cancer) [8–15]. In addition to physical harm from iatrogenic complication, pursuit of incidental findings causes emotional harm and financial toxicity from what has been termed ‘cascades of care,’ in which the index test begets a series of expensive additional tests and interventions that themselves trigger ever more tests and interventions.
Numerous studies have shown that intervention on incidental findings, including those that are cancer, can result in low-value care and cause harm (e.g., detecting a cancer that—had it not been identified—would otherwise not have affected a patient’s life or detecting a cancer for which intervention does not change disease trajectory).
In addition to questionable efficacy, there also are harms, including false-positive results, need for confirmatory testing or follow-up, cost, complications of diagnosis and therapy, and acute and chronic anxiety. The challenge in incidental finding management is determining which incidental findings require management and which do not. Additionally, if management is required, it must be done in a way that maximizes patient value. This is nonintuitive, requires detailed study, and necessitates incorporation of many factors beyond imaging features: patient risk, disease risk, patient preference, available therapies, harms of confirmatory diagnosis, and harms of therapy. It is complicated. Odds favor incidental finding management causing harm.”
One example demonstrating the increased detection and diagnosis of thyroid cancer without affecting mortality identifies the costs and harms of presumed overdiagnosis.
“In the United States, from 1975 to 2009, the incidence of thyroid cancer approximately tripled (4.9–14.3 per 100,000 patients; relative rate: 2.9 [95% CI, 2.7–3.1]) and was associated with an estimated cost of billions of dollars [10, 42]. The increase was nearly entirely explained by increased diagnosis of asymptomatic, indolent papillary thyroid cancer (papillary cancer incidence increased from 3.4 to 12.5 per 100,000). The absolute increase was approximately fourfold higher in women despite a lower prevalence of thyroid cancer in autopsy studies. Meanwhile, during the same period, mortality from thyroid cancer remained unchanged (0.5 per 100,000). Marked rise in incidence with unchanged mortality strongly implicates overdiagnosis.”
Another example is the increased incidental detection of kidney cancer from 1975 to 2019 with associated increased costs and complications without changing mortality rates.
“SEER data from 1975 to 2019 show marked increase in incidence of kidney cancer due to increased incidental detection (6.82 per 100,000 in 1975 vs 15.85 per 100,000 in 2019) but unfortunately unchanged mortality (3.61 per 100,000 in 1975 vs 3.44 per 100,000 in 2020). The increased incidence is largely explained by detection of incidental masses less than or equal to 4 cm. Increased detection without decrease in mortality strongly implicates overdiagnosis. The effort to diagnose and treat early-stage renal masses has been associated with substantial cost and harm. From 2000 to 2009, there was an estimated 82% increase (from 3098 to 5624) in the number of surgically resected benign kidney masses in the United States. In a study of 15 million Medicare beneficiaries 65–85 years old from 2010 to 2014, 43% underwent CT of the chest or abdomen. In that population, imaging 1000 additional beneficiaries was associated with four additional nephrectomies (95% CI, three to five nephrectomies; corresponding to roughly 25,000 additional nephrectomies overall). The nephrectomy-associated mortality rate was 2.1% at 30 days and 4.3% at 90 days. These data imply that more imaging leads to more detection, more surgery, and more complications. Meanwhile, the mortality from renal cancer remains flat. Recognition of overdiagnosis and overtreatment of small kidney masses has led to the emergence of active surveillance as an accepted management strategy.”
Collaborating with Physicians, ordering providers, and payers to effectively manage Diagnostic Imaging including the management of incidental findings is important to avoid the “cascading harm” to patients that may result from pursuing imaging, interventional procedures, and/or surgical follow-up of these findings. Complex healthcare issues like this motivate and inspire the physicians, leadership, and employees at HealthHelp to develop innovative Utilization Management programs like the Virtual Nodule Board, designed to assist Physicians and ordering providers with the follow-up of incidental findings.
About the Virtual Nodule Board
The Virtual Nodule Board (VNB) product was developed to educate physicians on the proper diagnostic steps to take when an incidental nodule (mass) is found during routine examination. By working in collaboration with HealthHelp’s team of leading oncologists, a patient’s physician will develop a schedule to ensure these nodules are monitored appropriately. The patients will benefit not only from receiving the proper early interventional steps but by also avoiding unnecessary biopsies and other surgical procedures.
The VNB’s focus on early intervention and diagnosis compliments HealthHelp’s existing Virtual Tumor Board (VTB) Program that harnesses the expertise of academically affiliated oncology specialists to actively engage and collaborate with care providers to develop appropriate treatment plans for patients.
Both the VNB and VTB are key components of HealthHelp’s integrated Oncology program that delivers a population health approach to cancer care. The goal of the program is to maximize the outcomes for a patient throughout their cancer care journey, while eliminating costly and unnecessary procedures and treatments.