2. Scourge of Incidental Findings More CTs (26M in 1998, 61M in 2006) If CTC reimbursed: 3.5M/yr at 10 years CTC brings problems of whole-body screening, with benefits of polyp detection Extracolonic Findings (ECFs) helping to keep CTC from reimbursement

3. Cascade Effect William Casarella, MD, Former Chair, Emory Radiology: William Casarella, MD, Former Chair, Emory Radiology: Negative CT colonography Negative CT colonography Renal, hepatic and lung masses detected Renal, hepatic and lung masses detected Additional CT scans Additional CT scans PET scan PET scan Liver biopsy Liver biopsy Video-aided thoracoscopy with wedge resection Video-aided thoracoscopy with wedge resection Excruciating post-operative pain, 5 weeks of recuperation, over $50,000 in charges Excruciating post-operative pain, 5 weeks of recuperation, over $50,000 in charges All findings benign All findings benign

4. Frequency, Cost of Incidentalomas

5. Extracolonic Findings on CTC ArticlePatients Patients with Missed Findings Patients Getting Surgery, Bx Patients Malignant, Serious Dx Cost of Workup/ Population Xiong, 2005 32802.7%0.8%3.7%-- Yee, 2005 5001.6%1%2.6%$28.12 Xiong, 2006 225 -- 0.4%--$297 Kim, 2007 3120 -- 0.3%-- Tolan et al, AJR 2007 400 -- 12.3%$66.59

6. Incidental Findings on CTC Hassan, et al: 100,000 patients - Monte Carlo simulation Cost: $162/patient 2292 life years gained, mostly from AAA Only 13% of life years saved from cancer $7,063/life-year saved

7. Incidental Findings at CT for Hematuria 1295 patients at UAB: CT for hematuria Incidental findings: 17% “Significant”: 3.3% Downstream costs: 106 additional imaging studies ($14,761) 50 specialist visits ($6,143) 29 interventions 12 percutaneous 7 endoscopic 10 major surgery………

8. Incidental Findings at CT for Hematuria AAA repair > $225,000 Adnexal cyst (x-lap, appy, BSO) >$165,000 Pancreatic head mass >$69,000 8 other cases >$10,000: Pancreatic resection Adenopathy AAA repair - 2 Gynecologic - 4

9. Incidental Findings at CT for Hematuria Total cost: $716,945 Average cost per patient: $554 (!!!)

11. Incidental Findings at Research Studies Study in Sept, 2010 Archives of Internal Medicine 1,426 examinations 567 incidental findings 6 unambiguously beneficial findings 3 unnecessary surgeries Numerous unnecessary examinations, cost

12. Summary - ECFs on CTC Important incidental findings ~10% if average risk ~30% if high risk or symptomatic Patients getting additional tests ~5-15% Patients getting additional tests with benign result ~2.5% Patients getting surgery or biopsy ~0.5-1%

13. Copyright ©Radiological Society of North America, 2005 Furtado, C. D. et al. Whole-Body CT Screening: Spectrum of Findings and Recommendations in 1192 Patients. Radiology 2005;237:385-394 Frequency of Recommendations - Incidentalomas

14. Pilot - Total Body Screening 50 patients - 25 screened Followed 2 years Chest, cardiac and abdominal radiologists Clinically important (actionable) findings in abdomen/pelvis in 28% (7 pts) 3 cystic renal lesions 1 cystic hepatic lesion 1 hyperdense liver 2 cystic ovarian lesions

15. Pilot - Total Body Screening Chest, abdomen and pelvis findings: Non-contrast, low dose (high noise), lower specificity 36% different recommendations Kappa 0.52 - moderate agreement 2 cases Both radiologists reported, 1 called actionable 10 cases 1 reported actionable, 9 didn’t report at all

16. Proposed categorization system for extracolonic findings Zalis M E et al. Radiology 2005;236:3-9 ©2005 by Radiological Society of North America

17. Classifying Incidentalomas No incidental finding E1: Normal variant E2: Unimportant E3: Likely unimportant E4: Significant, needs WU JCAT 32: 497-503, August, 2008 376 patients

18. ACR, SCBT-MR, SGR, SUR approach the problem

19. ACR Involvement in Incidentaloma Problem Incidental Findings Committee, under Body Imaging Commission Also working with SCBT-MR and SGR-SUR Commission: Reed Dunnick, then James Brink Chair: Lincoln Berland Four subcommittees established Renal – Stuart Silverman Liver – Richard Gore Adrenal – William Mayo-Smith Pancreas – Alec Megibow Decided to defer other (vascular, ovarian, etc.) Paper published in JACR, October, 2010

27. Summary Early incidental detection may not lead to longer survival. Early incidental detection may not lead to longer survival. Detecting and following incidentalomas provides no benefit for many conditions. Detecting and following incidentalomas provides no benefit for many conditions. Incidental findings, false positives and overdiagnosis lead to healthy people getting extra tests. Incidental findings, false positives and overdiagnosis lead to healthy people getting extra tests. Aggressively pursuing findings probably does more harm than good. Aggressively pursuing findings probably does more harm than good. A consistent approach may minimize the economic implications and optimize the health effects of incidentalomas A consistent approach may minimize the economic implications and optimize the health effects of incidentalomas

28. Incidentalomas – What Should We Do? Appreciate the insignificance of the overwhelming majority of incidentalomas Appreciate the insignificance of the overwhelming majority of incidentalomas Limit reporting of incidentalomas to those that could herald diseases in which the course of disease may be altered Limit reporting of incidentalomas to those that could herald diseases in which the course of disease may be altered Strive to definitively characterize incidentalomas, but balance with risk and cost of additional studies Strive to definitively characterize incidentalomas, but balance with risk and cost of additional studies If reporting an incidentaloma, quantify the probability of its importance If reporting an incidentaloma, quantify the probability of its importance Help direct referring clinicians to the most cost-effective approach to managing the few incidentalomas that must be pursued Help direct referring clinicians to the most cost-effective approach to managing the few incidentalomas that must be pursued