The rate of inappropriate cancer scans for low-risk prostate cancer patients in Sweden plummeted in the decade following a joint campaign to curtail such tests. The campaign was run by the Swedish County Councils and the National Prostate Cancer Register (NPCR) of Sweden, which is a professional association of Swedish urologists. The results suggest that curtailing unneeded medical tests, an urgent health care policy goal in the United States, is achievable.
According to lead author Danil V. Makarov, MD, of New York University Langone Medical Center, extensive cancer scans checking for metastases are discouraged for patients who have low-grade, slow-growing prostate tumors, which have almost no risk for metastasis. Though quality measures and clinical guidelines by policy organizations and professional societies to limit the use of such scans have been around for almost two decades, for various reasons physicians have been slow to adopt them.
“In the United States we have guidelines about the overuse of imaging tests, but lack a roadmap for their implementation,” said Makarov. “We could learn a lot from what the Swedes have done.”
In the study, done in collaboration with colleagues in Sweden and elsewhere, records were examined from approximately 100,000 Swedish men diagnosed with prostate cancer from 1998 to 2009. In 2000, the NPCR began a campaign to reduce inappropriate diagnostic imaging among men with low-risk prostate cancer.
The campaign involved openly and publicly presenting local statistics on inappropriate imaging at urology meetings, along with reminders about imaging guidelines. Urologists in Sweden could then see imaging rates at their own institution compared with best practices and had an incentive not to be listed as a provider of unnecessary testing. Makarov said, “I think you could consider the tactic a way of ‘gentle shaming’ of the health care providers who did not follow the guidelines.”
During the study period, the percentage of scans deemed inappropriate plummeted from 45% to 3% among patients with low-risk prostate cancer. However, the campaign brought an unwanted side effect, as the rate of appropriate scans in patients with high-risk tumors also fell, from 47% to 63%. The study was published in the Journal of the National Cancer Institute (2013; doi:10.1093/jnci/djt175).
“The caveat here is that when guidelines are implemented to limit the inappropriate use of a health care resource, the appropriate use of that resource should be simultaneously encouraged—otherwise those patients who most need the resource may no longer have access to it,” said Makarov. “But the true lesson from this study is that inappropriate utilization of health care resources can be reduced by giving feedback to practitioners.”
Makarov suggested that instituting a Swedish-style awareness-raising campaign at urological conferences could result in more uniform and appropriate imaging rates in the United States. He also suggested that medical professional societies could explore collaborating with the government to set the policy agenda and implement best practices.