Adnexal Cyst Follow-up When to Image Based on Choosing Wisely® and Society of Radiologists in Ultrasound (SRU) Consensus Conference Statement Standard template

What Is R-SCAN? Collaborative activity for referring clinicians and radiologists to improve patient care through clinical improvement R-SCAN Collaboration Goals: Ensure patients receive the most appropriate imaging exam at the most appropriate time based on evidence ACR Appropriateness Criteria, other appropriate use criteria, and consensus statements Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics Lower the cost of care Standard template Intro to what the program is about and its benefits. Website is www.rscan.org Time commitment: staff time dedicated to an R-SCAN project ranges from 15 to 30 hours over a three- to six-month period. You can also gain experience using a clinical decision support (CDS) tool; gaining experience with CDS now will help referring clinicians be prepared for the implementation of federal reimbursement requirements for CDS consultation prior to ordering advanced imaging. This alternative to pre-authorization reduces time and expense for practices and patients when imaging is the next step in the diagnostic process.

Why Participate? R-SCAN Offers: Data-driven system for moving toward value- based imaging and patient care Opportunity to focus on highly relevant imaging exams to improve utilization Collaborators can fulfill their Improvement Activity requirements under the MIPS Easy way to practice with clinical decision support (CDS) technology In preparation for PAMA Free and immediate access to Web-based tools and CME activities Standard template Participants earn improvement activity credits. More here: https://rscan.org/images/PDFs/RSCAN_Improvement-Flyer_v4.Web_09-11-17pdf.pdf Information about Protecting Access to Medicare Act here: https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-April-21-2017-Issue/ACR-Answers-Frequent-Questions-About-CDS-Mandate

Problem: Unnecessary Imaging Follow-up for Asymptomatic Simple Adnexal Cysts High utilization of pelvic ultrasound results in the incidental detection of a large number of ovarian cysts. Among simple cysts in premenopausal women, fewer than 1% of simple cysts represent malignancy [1]. In postmenopausal women, the risk for ovarian malignancy is extremely low, with most demonstrating stability or resolution on follow-up. These findings are almost always of no clinical importance in asymptomatic women and can be safely ignored [2]. Despite the low risk for malignancy in some cysts, however, it is common practice for radiologists to recommend surveillance and follow-up imaging. This can sometimes lead to unnecessary surgeries to remove a cyst that is unlikely to become cancerous or may have healed on its own. The problem statement More information on the issue here: https://www.jacr.org/article/S1546-1440(17)30465-9/fulltext https://pubs.rsna.org/doi/full/10.1148/radiol.10100213 http://www.choosingwisely.org/patient-resources/imaging-tests-for-ovarian-cysts/ References: Ekerhovd E, Wienerroith H, Staudach A, Granberg S. Preoperative assessment of unilocular adnexal cysts by transvaginal ultrasonography: a comparison between ultrasonographic morphologic imaging and histopathologic diagnosis. Am J Obstet Gynecol. 2001;184(2):48–54. Levine D, Brown DL, Andreotti RF, et al. Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement. Radiology. 2010;256(3):943-954.

Using Evidence to Guide Imaging Ordering Choosing Wisely campaign Collaborative effort between ABIM Foundation and over 70 medical specialty societies Helps patients and medical professionals avoid wasteful or unnecessary medical tests, treatments, and procedures The American College of Radiology recommends through the Choose Wisely campaign that follow- up imaging is not necessary for clinically inconsequential adnexal cysts Standard template Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty society provided recommendations. Learn more: www.choosingwisely.org

SRU Consensus Conference Statement The Society of Radiologists in Ultrasound (SRU) convened a panel of specialists to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged at ultrasonography (US) in asymptomatic women. The conference made recommendations on: Which masses require no follow-up Which masses need imaging follow-up When this evaluation should occur Which masses warrant surgical evaluation Full text is located here: https://pubs.rsna.org/doi/full/10.1148/radiol.10100213 Customized topic slide Management of Asymptomatic Ovarian and Other Adnexal Cysts Imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement: https://pubs.rsna.org/doi/full/10.1148/radiol.10100213 6

Categorizing Adnexal Cysts Simple Thin wall (<3 mm) No calcification or septate Completely anechoic (may not be when there is internal hemorrhage) Through transmission No solid components Complex Note the complexity, eg, septations, wall thickening, nodules If it is not simple, it is complex Customized topic slide 7

When Follow Up Imaging in Indicated in Asymptomatic Patients Pre-menopausal Post-menopausal No follow up Simple Cysts ≤ 3 cm: No need to mention in report Simple Cysts > 3 and ≤ 5 cm: Describe in the report stating they are almost certainly benign Cysts ≤ 1 cm: At the radiologist’s discretion to describe in the report US follow-up in 12 months Cysts >5 and ≤7 cm: Describe in the report stating they are almost certainly benign Cysts >1 and ≤7 cm: Describe in the report stating they are almost certainly benign* MRI or Surgical Evaluation should be considered Cysts >7 cm Customized topic slide *Some practices may opt to increase the lower size threshold for follow-up from 1 cm to as high as 3 cm. One may opt to continue follow-up annually or to decrease the frequency of follow-up once stability or decrease in size has been confirmed. Cysts in the larger end of this range should still generally be followed on a regular basis. 8

Indeterminate Cysts A cyst that is otherwise simple but has a single thin septation (<3 mm) or a small calcification in the wall is almost always benign. Such cysts should be followed in a similar fashion as a simple cyst, as indicated by patient age and cyst size. Other indeterminate features are multiple thin septations or a solid nodule without detectable flow at Doppler US. These findings are suggestive of neoplasms, most often benign. Irregularity or tiny areas of focal thickening of the cyst wall may be difficult to distinguish from a small solid component and thus are indeterminate for malignancy. Cysts with either of these indeterminate features merit more attention. In a woman of reproductive age, this entails a short-interval follow-up (6–12 weeks) with US or occasionally MRI. Customized topic slide 9

Key Points: Talking With Patients Here are talking points to explain to patients why imaging follow-up is not necessary for benign, simple cysts: Most ovarian cysts are low-risk for cancer, do not cause symptoms, and can be ignored. Simple ovarian cysts often appear during the menstrual cycle and heal on their own. Research has shown that if the cyst does not show signs of cancer, cancer is not likely to grow later. For cysts already classified as benign, repeated ultrasounds are highly unlikely to identify anything of value. Customized topic slide Patient handout: http://www.choosingwisely.org/patient-resources/imaging-tests-for-ovarian-cysts/

Getting Started With R-SCAN rscan.org Standard template To access ACR Select, visit the R-SCAN site and click on “Start your project.” 11

Standard template Log in with an ACR username/password. If you don’t have an ACR username and password, the R-SCAN team can provide one. 12

Standard template Click on “Practice with ACR Select.”

Standard template Check out the instructions for how to enter data and then click on the “Enter case data” button to explore the AC guidelines and exam ratings.

Standard template Here’s an example: Enter a patient’s age and gender. Select the body area of interest. Search on a clinical indication. Select the indication that’s the best match. Review the appropriateness score and note the associated cost and radiation exposure. Select the exam.

R-SCAN Adnexal Cyst Follow-up Educational Resources Visit: rscan.org Click: Resources Click: Topic-specific Resources Podcast Imaging Order Simulation activity Articles Materials to share with patients Standard template A library of educational materials is available for each R-SCAN Choosing Wisely topic. 16

Next Steps Define the group’s goal Define participants and roles Tasks Ensure consistency in follow up Provide definitive follow up guidance Promote adherence to guidelines Define participants and roles Tasks Identify cases Review cases for baseline Plan and implement the educational intervention Review cases for post education improvements Customized topic slide

Self-Assessment Question Which are characteristic of a simple cyst (select more than 1)? Solid elements Thick septations (≥3 mm) Thin wall (<3 mm) Completely anechoic Answer: C and D

Self-Assessment Question At what size should a simple cyst be considered for immediate further imaging or surgical evaluation? <10 cm >3 cm >7 cm ≥5 cm Answer: C

Blank slide for radiologist to add custom info Suggested topics for additions

Blank slide for radiologist to add custom info Suggested topics for additions

Summary Adnexal cysts are a common clinical finding on US. Most simple cysts under 10 cm are benign, with a risk of malignancy under 1%, and a majority of them resolve on their own. Clinically inconsequential cysts, as outlined in this presentation, should not be recommended for follow-up imaging. Additional imaging is unlikely to uncover any useful, actionable information, and is more likely to identify conflicting, misleading information that may result in unnecessary surgical intervention. Explain to patients concerned about ovarian cancer why their risk is negligible, and for those being seen for pelvic pain what their next options are. Standard template, but content will be customized

Questions?