The substantial medical costs associated with cancer care in the United States are expected to increase by about 27% between 2010 and 2020, due only to projected increases in cancer prevalence ( 1 ). Changes in cancer treatment patterns, including increasing use of expensive targeted therapies ( 2 , 3) , supportive agents, and advanced imaging ( 4 ), will contribute to an even more rapid escalation of the costs of cancer care. Notably, recent increases in the costs associated with advanced imaging, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and nuclear medicine (NM), have outpaced increases in the overall costs of care in Medicare beneficiaries with cancer ( 4 ). Use of less expensive imaging tests, such as ultrasound and radiograph, either increased or declined only slightly, suggesting that advanced imaging tests are being used in addition to, rather than as a substitute for, the older tests. Increases in use of high-cost advanced imaging have occurred despite limited evidence that advanced imaging improves patient outcomes ( 5 ), compared with older less expensive technologies.

In this issue of the Journal, Hu et al. ( 6 ) used the linked S urveillance , Epidemiology, and End Results (SEER)-Medicare data to study trends in use of high-cost advanced imaging among elderly patients with stage IV breast, colorectal, lung, and prostate cancer. Their adaptation of a phase of care approach in cohorts of patients with advanced disease allowed evaluation of imaging performed during the diagnostic period, the last month of life, and the continuing care phase, the interval between the diagnosis period and the last month of life. They found that the proportion of patients undergoing any high-cost imaging increased between 1995 and 2006 for all four cancer types. The majority of patients with stage IV cancer received advanced imaging in the diagnostic (90.4%) and continuing care (75.3%) phases. Fewer patients received advanced imaging in the last month of life (34.3%).

The authors also reported that for patients with stage IV cancer who were diagnosed in 2002–2006, the mean and median numbers of high-cost imaging procedures per patient were 9.6 and 7, respectively. The use of high-cost imaging found in this study may seem excessive, and intensive care at the end of life is expensive to the Medicare program ( 8 ), the health care system overall ( 1 , 9) , and for patients and their families ( 9 , 10) . Yet, assessing the appropriateness of care for patients with advanced disease is complex. Even patients with advanced (ie, stage IV) cancer will have different survival trajectories—median survival for elderly patients with stage IV lung cancer is substantially less than 1 year, whereas for elderly patients with stage IV prostate cancer, it is approximately 3 years ( 11 ). Furthermore, identifying patients clearly at the “end of life” is difficult. Physicians tend to overestimate survival for terminally ill cancer patients ( 12 ), which may influence their treatment and related imaging recommendations. However, because prognosis is obviously poor at the time of diagnosis with stage IV disease, physicians’ consideration of high-cost imaging use will be important for patient management.

The phase of care approach used by Hu et al. ( 6 ) can improve understanding of the multiple roles of advanced imaging in stage IV patients. In the diagnostic phase, imaging tests are most likely used to determine the extent of disease and identify the best approach to treatment and/or supportive care. In the final month of life, advanced imaging may help to determine treatment cessation or hospice referral. However, the purposes of advanced imaging tests in the continuing phase of care are more diverse—imaging results may inform decisions about continuing or changing treatment, symptom management, or hospice referral. The incremental benefits of advanced imaging compared with older less expensive technologies for informing clinical decisions may vary for each of these different purposes. In situations where high-cost imaging is used to evaluate response to third- or fourth-line therapies, evaluation of appropriateness extends to the decision to continue treatment of patients with poor prognoses. Identifying the appropriateness of advanced imaging for these clinical decisions requires better understanding of the underlying purpose and use of imaging findings to inform decisions about care.

Many calls for improving the quality of cancer care and reducing costs promote adherence to evidence-based guidelines ( 13–15 ), and explicit measures have been developed to allow the assessment of the quality of cancer care delivery ( 16 ). Although practice guidelines make recommendations about when to use (and when not to use) advanced imaging for surveillance in patients with early-stage (stages I and II) cancers, currently, guidelines in the United States are largely silent about the use of advanced imaging tests for ongoing evaluation of patients with stage IV breast, colorectal, lung, and prostate cancer in the absence of symptoms ( 17–20 ). Development of practice guidelines for advanced imaging in patients with stage IV disease, with explicit statements about the state of the evidence, will be critical, particularly for care outside of the window surrounding patient diagnosis.

In turn, guidelines must be informed by better evidence about the incremental benefit of advanced imaging over other technologies in guiding a multitude of clinical decisions, not only comparisons of the technical quality of images. The Centers for Medicare & Medicaid has a policy for reimbursement with evidence development related to the use of PET with F-18 fluorodeoxyglucose in cancer patients ( 21 ). The National Oncologic PET Registry collects data about changes in pretest assessments and management strategies for initial staging, treatment monitoring, and suspicion of recurrence. For patients receiving treatment, data on treatment goals (ie, curative, palliative) and types of treatment are also collected. Although studies using these data have reported that use of PET has changed decisions ( 22 ), these data are mainly collected retrospectively, after test results have been reviewed. Ideally, pretest assessments would also be available, limiting any biases in recall. Beyond registries, improvements in the information contained in electronic medical records at the point of ordering high-cost imaging tests will inform the guideline development process. Finally, the integration of decision support within electronic medical records has been reported to improve care ( 23 ). Explicit reference to the absence of practice guidelines or lack of evidence supporting use of advanced imaging compared with other technologies within the electronic medical record may aid decision-making while guidelines are under development.

In the United Kingdom, the National Institute for Clinical Excellence, the organization that evaluates both medical and economic evidence for the National Health Service, has issued “do not do” recommendations for some high-cost imaging in patients with advanced cancer ( 24 ). In the United States, the rapid increase in use of advanced imaging in the Medicare fee-for-service setting has been a policy focus of the Medicare Payment Advisory Commission ( 25 , 26) . Policy development in the United States must also consider that increases in advanced imaging were also observed in managed care ( 27 ), where physicians do not have financial incentives to increase use, suggesting that widespread availability of imaging machines, malpractice concerns, patient demand, and critically, the technological imperative, influence these trends ( 5 , 28) . More recently, between 2009 and 2010, after the years evaluated by Hu et al. ( 6 ), use of CT, PET, MRI, and NM by Medicare beneficiaries has declined slightly ( 25 ). Evaluating this trend with more recent data in patients with stage IV cancer using a phase of care approach, with more detailed evaluation of the continuing phase, will be important. In the meantime, determining how best to promote optimal use of advanced imaging in an environment of constrained resources remains a challenge. Better data coupled with evidence-based practice guidelines may help physicians and patients and their families choose wisely about the intensity of cancer care, including advanced imaging, in the face of serious illness.

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Funding

The authors are employees of the National Cancer Institute, and no funding was provided for this work.

Notes

The authors declare no conflict of interest.