1. ADVANCED IMAGING IS OVERUSED PRIOR TO REFERRAL TO A MUSCULOSKELETAL ONCOLOGIST: A PROSPECTIVE, MULTI-CENTER INVESTIGATION Benjamin J. Miller, MD, MS on behalf of the Musculoskeletal Oncology Research Initiative

2. Conflicts of Interest  Nothing to disclose

3. Background  Bone and soft tissue tumors initially seen by general orthopaedist or PCP  No clear guidelines for use of advanced imaging (MRI, CT, bone scan, U/S, PET)  Medical imaging identified as contributor to overspending  Reducing superfluous imaging studies prior to referral is important

4. Prior studies  Aboulafia et al, CORR, 2002  Prospective, single center, 100 patients  34% unnecessary MRI scans  Martin et al, CORR, 2012  Retrospective, single-center, 920 patients  3% unnecessary MRI

5. Questions  Is there regional variation in the use of advanced imaging?  Are there common characteristics predictive of excessive studies?

6. Materials and Methods  8 centers  Prospective  50 patients or 6 months of referrals  Bone and soft tissue tumors  All anatomic locations

7. Data elements  Patient details  Age, sex, race, insurance  Tumor type  Bone or soft tissue  Specialty of referring MD  Distance travelled  Studies performed prior to referral

8. Subjective material  Determined only by the single treating orthopaedic oncologist  What happens in actual practice?  Presumptive diagnosis  Likely benign (Benign tumor or non-neoplastic)  Likely malignant (Malignant tumor or unknown)  Necessary or excessive study

9. “Necessary study” criteria  Needed for routine work-up of condition  Helpful in determining diagnosis  Borderline studies considered “necessary”  Benefit of the doubt given to referring physician

10. “Necessary study” criteria  MRI specifically  Soft tissue Biopsy proven sarcoma >5 cm Deep to fascia Painful Growing  Bone Concern for sarcoma on x-ray

11. Statistical analysis  Chi-square and t test  Univariate and multivariate logistic regression  Post hoc power analysis  90% power to detect 20% difference between centers

12. Results  371 patients  301 (81%) with at least 1 study  263 (71%) with MRI  54 (15%) with CT  40 (11%) with bone scan  21 (6%) with ultrasound  14 (4%) with PET scan  81 (22%) with multiple studies

13. Results  Regions differed by age, race, insurance status, and distance travelled  Demographics variable  No differences in use of prereferral imaging by region (p=0.164)  Range 66% to 88%

14. Results  113 (30%) with unnecessary studies  46 (17%) MRI  40 (74%) CT  25 (62%) bone scan  16 (76%) ultrasound  7 (50%) PET scan  No difference between orthopaedic or PCP referrals (p=0.940)

15. Univariate analysis  Benign bone tumors more likely to have excessive imaging (OR 2.18, 95% CI 1.39-3.43)  Differences by practice location  Findings held in multivariate analysis

16. Effect of Region  No obvious differences in number or types of studies  Generalizable results  Differences in labeling “unnecessary”  Substantial variation between fellowship-trained tumor surgeons  Consistent with prior studies Minimum 3% (Martin 3%) and maximum 31% (Aboulafia 34%)  Need for clearer guidelines based on objective, reproducible criteria

17. Summary  Helpful – MRI  Most utilized study (71%)  83% deemed necessary  Use contrast, visualize entire compartment 6% repeated  Not helpful – everything else  High rate of “unnecessary”  Should be left to treating team

18. Recommendations  Appropriate advanced imaging is beneficial  Goal is not to totally eliminate  No imaging other than MRI  No MRI in radiographically benign bone tumors  Would change 30% excessive studies to 4%

19. MORI participants  Raffi Avedian  Judd Cummings  Tessa Balach  Kevin MacDonald  Lee Leddy  Jeremy White  Raj Rajani  Ben Miller