BERKELEY, CA (UroToday.com) - When there is a suspicion of metastasis, radionuclide bone scan imaging remains the gold standard for detecting hematogenous spread of cancer to skeletal structures such as the vertebral column, pelvis, and long bones of extremities.
With a positive bone scan indicating skeletal metastasis, androgen deprivation therapy is the recommended primary treatment modality, since men with metastatic disease do not benefit from aggressive local treatment of their cancer. Based on the high likelihood of negative bone scan imaging in men with low-risk prostate cancer and non-trivial cost, the American Urological Association (AUA) established clinical guidelines for appropriate use of this staging tool. The most recent updates published in 2007 and 2009 state that bone scan imaging should be reserved for men presenting with: PSA ≥20 ng/mL, clinical Stage ≥T3a , Gleason score of ≥8, or bony pain on examination.
In an effort to determine the rate of bone scan use and positivity, we retrospectively reviewed the medical records of 1598 men newly-diagnosed with prostate cancer at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers between 1998-2004. Among the 519 men with low-risk prostate cancer (defined by PSA <10, clinical stage ≤cT2a, and Gleason Score ≤6), 132 (25%) underwent bone scan imaging, none of which were positive. Fortunately, we discovered a significant reduction in bone scan overutilization after 2000 – from 36% (prior) to 20% (after). While this may be reassuring, there is still ample room for improvement, as 1 out of every 5 men with low-risk prostate cancer underwent unnecessary bone scan imaging. Moreover, among the 609 men with intermediate-risk prostate cancer (defined as PSA 10–19.9, clinical Stage cT2b, or Gleason score 7), 342 (56%) underwent bone scan imaging, of which 6 (<2%) were positive. This finding further validates the AUA guidelines recommendation and emphasizes the importance of restricting bone scan use for men with high-risk disease or bony pain.
As the issue of resource utilization becomes more relevant given the nation’s current health care crisis, measures of quality will be increasingly used to score physician practice patterns. In fact, adherence to this quality metric is emphasized in the 2011 Physician Quality Reporting System (PQRS). PQRS offers financial incentive for physicians to participate in a voluntary quality-reporting program. In order to submit a claim for clinical performance evaluation, measure #102 of this reporting system mandates abstinence from bone scan imaging for patients with low-risk prostate cancer. If a bone scan is still warranted, it must be justified by medical or systemic reasons such as documented pain, salvage therapy, or another medical condition requiring a radionuclide bone scan. Furthermore, the American Medical Association has developed electronic specifications through Electronic Health Records to assess compliance. It measures the percentage of patients with a diagnosis of prostate cancer that did not have a bone scan performed at any time since diagnosis.
Although bone scan imaging remains the gold standard for detecting skeletal metastasis, its utility as a staging tool should be reserved for those men presenting with high-risk disease. In an era of pervasive annual PSA screening that has resulted in the early detection of prostate cancer, this quality-of-care measure is timely and has potential for high impact in reducing wasteful healthcare spending. By being linked with physician reimbursement, this quality metric will serve to limit overutilization of scarce health care resources without compromising oncologic outcomes.
Written by:
Roland Palvolgyi* as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
*3rd Year Medical Student, David Geffen School of Medicine, University of California, Los Angeles
Bone scan overuse in staging of prostate cancer: An analysis of a Veterans Affairs cohort - Abstract
UroToday.com Prostate Cancer Section