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High-cost imaging use increased among Medicare patients with stage IV cancer
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Medicare patients with stage IV cancer frequently undergo high-cost imaging procedures, and the use of diagnostic imaging increased more rapidly among that patient population compared with those who have early-stage disease, according to study results.
Medicare spending for high-cost diagnostic imaging has increased faster than it has for total cancer care, and although the net costs of cancer care peak in the last year of life, little is known about the use of high-cost imaging in cancer patients during this time, according to background information in the study.
Yue-Yung Hu, MD, MPH, and colleagues used the SEER database to identify Medicare claims for CT, MRI, positron tomography and nuclear medicine scans performed between January 1994 and December 2009 for patients who were diagnosed with stage IV breast, colorectal, lung or prostate cancer.
Hu and colleagues identified 100,594 patients who underwent the scans between January 1995 and December 2006.
The researchers determined the rate of imaging per patient month of survival for each phase of care. They also compared trends in imaging use in early-stage patients with the same tumor types during the same period.
Among stage IV patients diagnosed between January 2002 and December 2006, 95.9% underwent a high-cost diagnostic imaging procedure, according to study results. After diagnosis, 75.3% were scanned again, and 34.3% of patients were scanned in the last month of life.
Between January 1995 and December 2006, the proportion of patients with stage IV cancer who underwent diagnostic imaging increased by 4.6% (95% CI, 3.7%-5.6%), while the relative proportion of patients with early-stage cancer decreased by 2.5% (95% CI, -3.2% to -1.9%).
“Because scans help clinicians determine whether a change in or cessation of treatment is indicated, the expanding use of advanced imaging in stage IV disease is likely a manifestation of the increasing number and types of treatment options available to these patients,” Hu and colleagues wrote. “Imaging, although it often leads to appropriate palliative measures, may also distract patients from focusing on achievable end-of-life goals, require them to spend more of their limited time in medical care settings and/or provoke anxiety.”
Additional studies are needed to “better characterize the appropriate role of advanced imaging in the setting of metastatic disease and thus support physicians in the evidence-based care of these patients,” the researchers wrote.
In an accompanying editorial, K. Robin Yabroff, PhD, MBA, and Joan L. Warren, PhD, of the NCI’s Health Services and Economics Branch, noted that efforts to assess the appropriateness of care for patients with stage IV disease can be complex.
“Physicians tend to overestimate survival for terminally ill cancer patients, which may influence their treatment and related imaging recommendations,” Yabroff and Warren wrote. “Development of practice guidelines for advanced imaging in patients with stage IV disease — with explicit statements about the state of evidence — will be critical, particularly for care outside of the window surrounding patient diagnosis.”
Perspective
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Munir Ghesani, MD
Although it is prudent to be cognizant of imaging costs to society, it would be unwise to do so without carefully reviewing its integral role in clinical management. In this era of personalized medicine, we are constantly striving to match each individual cancer patient with the most appropriate therapeutic combinations based on that individual’s type and extent of cancer, crucial histopathologic information and genetic fingerprints. We all know that cancer cells in any individual can be fairly heterogeneous, and these cells adapt and attempt to become resistant to the therapy being delivered. In this regard, imaging allows oncologists to closely monitor response to the planned therapy and switch it promptly if it becomes ineffective. Consequently, imaging promises to save costs and morbidity of ineffective therapies and improve outcome.
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