1. Advanced Imaging for Early Prostate Cancer Staging
When to Image Based on Choosing Wisely® and ACR Appropriateness Criteria®
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2. 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-based appropriate use criteria
Reduce unnecessary imaging tests focused on imaging Choosing Wisely® topics
Lower the cost of care
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Intro to what the program is about and its benefits.
Website is
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.

3. 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
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Participants earn improvement activity credits.
More here:
Information about Protecting Access to Medicare Act here:

4. Problem: Unnecessary Use of CT, bone, PET scans in Staging of Low Risk Prostate Cancer
Multiple studies have shown CT and radionuclide bone scans do not improve detection of metastatic disease in men with low risk prostate cancer.
A 2004 study looked at the efficacy of bone and CT scans in prostate cancer from 23 studies of bone scans and 25 studies of CT.
Bone scans detected metastases in 2.3% of men with PSA < 10 ng/mL and 5.6% of men with Gleason scores ≤ 7.
CT detected metastases in 0.7% of men with clinically localized disease and 1.2% of men with Gleason scores ≤ 7, with nodal metastases detected in no patients with PSA < 20 ng/mL [1].
FDG PET scans involve technical challenges, making FDG unpopular for prostate cancer detection and staging generally.
CT and bone scans in the low risk population may produce incidental findings causing patient anxiety, using clinician time to explain them, and resulting in further unnecessary testing and cost.
The problem statement
More information on the issue here:
References:
Abuzallouf S, Dayes I, Lukka H. Baseline staging of newly diagnosed prostate cancer: a summary of the literature. J Urol. 2004;171:2122–2127.
Flanigan RC, McKay TC, Olson M, Shankey TV, Pyle J, Waters WB. Limited efficacy of preoperative computed tomographic scanning for the evaluation of lymph node metastasis in patients before radical prostatectomy. Urology. 1996;48:428–432.

5. 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
Many medical associations agree that CT scans are not necessary in the staging of early prostate cancer at low risk for metastasis, including:
American Society of Clinical Oncology
American Urological Association
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Choosing Wisely includes 150 patient-friendly resources and more than 500 specialty society provided recommendations.
Learn more:

6. Using Evidence to Guide Imaging Ordering
ACR Appropriateness Criteria®
Assist referring physicians and other providers in making the most appropriate imaging or treatment decisions for specific clinical conditions
Employs input of physicians from other medical specialties and societies to provide important clinical perspectives
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See next slide for more info on the Appropriateness Criteria (AC). 6

7. ACR Appropriateness Criteria: The Facts
178 clinical imaging topics and over 875 clinical variants 
Basic access is free
Learn more at acr.org/ac
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New AC topics are added annually. 7

8. ACR Appropriateness Criteria for Prostate Cancer–Pretreatment Detection, Surveillance, and Staging
Variant 1: Clinically suspected prostate cancer, no prior biopsy (biopsy naïve). Detection. Variant 2: Clinically suspected prostate cancer, prior negative TRUS- guided biopsy. Detection. Variant 3: Clinically established low-risk prostate cancer. Active surveillance. Variant 4: Clinically established intermediate-risk prostate cancer. Staging and/or surveillance. Variant 5: Clinically established high-risk prostate cancer. Staging.
The AC variants for the specific R-SCAN topic will be in all templates.
The major clinical indications – or “variants” – are considered for each AC topic. Explain how AC works and what the variants are. Note variant 4 relates to the Choosing Wisely topic. 8

9. Appropriateness Criteria Rating by Value
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Exams associated with imaging for the individual clinical indications are rated according to their value as determined by the members of the AC panels. The panels use the following approach for determining the exam’s rating, or value:
The guideline authors conduct a systematic search of scientific literature, identify most relevant articles, and develop initial ratings.
A larger panel reviews and carries out rating rounds.
Topics updated every 3 years or more frequently where needed. 9

10. Alignment of Appropriateness Criteria and Choosing Wisely
An AC example for the specific R-SCAN topic will be in all templates.
All 5 variants are located here:
All imaging variants and clinical scenarios: 10

11. Alignment of Appropriateness Criteria and Choosing Wisely
An AC example for the specific R-SCAN topic will be in all templates.
All 5 variants are located here:
All imaging variants and clinical scenarios: 11

12. Assessing Need for Advanced Imaging
Standard clinical tools, such as digital rectal examination, serum prostate-specific antigen (PSA) assay, and systematic biopsy results such as fraction of cores positive for cancer and Gleason score are used to determine prostate risk stratification.
The D’Amico risk stratification system classifies low risk prostate cancer in patients who have all of the following:
PSA <10 ng/mL
Gleason sum ≤6
Clinical stage T1-T2a
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13. Assessing Need for Advanced Imaging
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14. Assessing Need for Advanced Imaging
The primary role of CT in prostate cancer is the detection of nodal metastases. The poor performance of CT for detection of nodal metastases has been confirmed in recent studies.
Bone scintigraphy remains the standard test used for detection of bone metastases.
Patients with low risk prostate cancer are unlikely to have metastatic disease documented by bone scan or CT. Therefore, these scans are generally not recommended unless higher risk disease has been established.
Evidence has emerged that MRI or MRI-targeted biopsy may be appropriate for detection and active surveillance in low risk men, and can provide better evaluation when compared with traditional systematic biopsy.
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15. R-SCAN and Clinical Decision Support
CareSelect is a web-based version of the ACR Appropriateness Criteria, comprising over 3,000 clinical scenarios and 15,000 imaging indications
CareSelect provides evidence-based decision support for the appropriate utilization of medical imaging procedures
R-SCAN participants gain free access to a customized, web-based version of CareSelect, a helpful first step for aligning ordering patterns with appropriate use criteria
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One of R-SCAN’s many free tools is the CareSelect CDS product, a digital version of the ACR AC. Specifically, the team uses CDS to rate the value of exams ordered for one of R-SCAN’s Choosing Wisely topics before and after an educational program is carried out.
All R-SCAN participants have free access to the web-based tool to explore the AC guidelines for other imaging topics. Consulting CDS will be a requirement for the ordering of advanced imaging for Medicare patients starting in 2019, so R-SCAN provides a good way to check out this technology. 15

16. Getting Started With R-SCAN rscan.org Standard template
To access ACR Select, visit the R-SCAN site and click on “Start your project.” 16

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Log in with an ACR username/password. If you don’t have an ACR username and password, the R-SCAN team can provide one. 17

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Click on “Practice with ACR Select.” 18

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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. 19

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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. 20

21. R-SCAN Early Prostate Cancer Staging Educational Resources
Visit: rscan.org
Click: Resources
Click: Topic-specific Resources
Podcast
Imaging Order Simulation activity
Articles
Materials to share with patients
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A library of educational materials is available for each R-SCAN Choosing Wisely topic. 21

22. R-SCAN Resources With CME
Podcast
A radiologist and referring physician discuss appropriate image ordering for early prostate cancer staging; approved for .5 CME
Learn more
Imaging Order Simulation Activity
Test your knowledge in selecting the best imaging exam for various indications
Free with CME
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23. Key Points: Talking With Patients
Here are talking points to explain to patients why imaging is not necessary for low risk prostate cancer:
If the Gleason test shows that you have low risk prostate cancer, you usually do not need more testing. Evidence has shown the cancer is not likely to have spread to other organs, and that CT and bone scans do not produce useful results in low risk patients.
Additional imaging may produce incidental findings, requiring further tests and time just to confirm they are benign.
CT scans expose you to a strong dose of radiation, which can increase your risk for cancer. In some cases, it’s the same as having about 200 chest x-rays.
Certain costs associated with imaging are not covered by insurance, such as payments to meet deductible thresholds and co-pays. 
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When they’re needed, CT scans are very helpful. And the risk from a single scan is very small. But CT scans expose you to a strong dose of radiation. In some cases, it’s the same as having about 200 chest X-rays. Your body can often repair the damage CT scans cause to your tissue—but not always. And when it doesn’t, the damage could lead to cancer. The more times you’re exposed, the greater your risk of cancer.
Patient handout:

24. Self-Assessment Question
Which of the following characterize low risk prostate cancer?
PSA <10 ng/mL
Gleason sum ≤6
Clinical stage T1-T2a
All of the above
Answer: D

25. Case 1
A 60-year-old man presents with a recent diagnosis of prostate cancer (Gleason score = 2; low risk).
Questions:
What imaging would be most appropriate for this patient?
What other questions would you ask?
What is the focus of your physical exam?
Each template will include a few case examples.
Answer: The most appropriate course of action for a low-risk scenario is no imaging.

26. Case 2
A 71-year-old man with prostate cancer is diagnosed with transrectal ultrasound-guided biopsy (with a Gleason score of 7) and is clinically staged as T2b.
Questions:
What imaging would be most appropriate for this patient?
What other questions would you ask?
What is the focus of your physical exam?
Each template will include a few case examples.
Answer: MR imaging of the pelvis without and with IV contrast. The patient has a relatively low Gleason score and is staged as if the disease has localized to the prostate/pelvis. MR imaging without and with contrast would be the best to evaluate localized regional disease, extraprostatic extension, and regional lymphadenopathy.

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

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Suggested topics for additions

29. Summary
Evidence has shown that men who are risk stratified into the low risk prostate cancer group do not benefit from CT or bone scans, since their early stage cancer is unlikely to have metastasized to other organs.
FDG PET scans are considered a modality not generally selected for this scenario.
Use the D’Amico risk stratification system to identify patients as low risk.
Radiation, cost, and time (of both patients and clinicians) are not worth the low yield of metastatic findings from CT and bone scans in this population.
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30. Questions?