CT, the workhorse of radiology, took center stage at last week's 89th Annual Scientific Assembly and Annual Meeting of the Radiological Society of North America as two separate studies presented compelling cases for using the X-ray-based technology for screening millions of people for lung and colon cancers.
The implications for the hospital industry are vast. Both studies will boost efforts to persuade payers to reimburse for the tests, which subsequently could bring millions of new patients to hospital doorsteps. That would spur the production of CT scanners and further escalate the "slice wars" between CT vendors who are pushing the envelope in developing CT scanners with capabilities to image thinner and thinner anatomical slices that offer higher resolution and better speed.
The studies also potentially open a new can of worms for those who grapple with the cost benefits of mass screenings. And in the case of virtual colonoscopy, the study released at the RSNA meeting in Chicago and published in last week's New England Journal of Medicine sets the stage for yet another turf war for radiologists.
"I think there will be a big shift in how we study screening," said Claudia Henschke, principal investigator of the 10-year Early Lung Cancer Action Project and director of chest imaging at 2,163-bed New York-Presbyterian Hospital-Weill Cornell Medical Center. "We have to find better ways to evaluate patients in a more timely, less costly and more accurate fashion."
Henschke's study, more or less an update from the groundbreaking project, reported that annual CT scans of smokers effectively detect early-stage lung cancer, the most curable form of the deadly disease. More then 80% of lung cancers found in initial and annual repeat screenings were Stage I, bettering the chances of reducing deaths.
The project so far has analyzed data from 9,000 patients at 12 institutions, but a total of 18,000 patients at 34 institutions have been enrolled. Henschke said she hopes to eventually enroll 50,000 people, which will produce enough data to answer all the questions that remain, such as whether mass screening will result in over-diagnosis of suspicious nodules.
Another study unveiled at RSNA determined that for people at average risk for colon cancer, three-dimensional virtual colonoscopy is as good as conventional colonoscopy, which seems to be universally dreaded by everyone over the age of 50. Consumers were informed that they could conceivably forgo sedation and a 4-foot-long scope for a probe no bigger than the size of a pinky finger.
The study "establishes virtual colonoscopy as a front-line screening tool," said Perry Pickhardt, associate professor of radiology at the University of Wisconsin Medical School in Madison and the study's lead author. The government-sponsored trial was conducted at naval medical centers in Bethesda, Md., and San Diego, as well as at Walter Reed Army Medical Center in Washington. "Hopefully these results are the first step to reimbursement," he said.
Pickhardt said the less invasive test, which costs as little as $250 compared with $1,500 for the conventional screening, could open the floodgates, considering only about 15% of people over the age of 50 are undergoing conventional colonoscopy once every 10 years as advised. Rather than replace the conventional test, during which troublesome polyps can be removed, virtual colonoscopy could bring more patients in the door. The more people who are screened, the more problems will be found. Although everyone participating in the study underwent both tests, virtual colonoscopy gave clean bills of health to more than 90% of the 1,233 participants, Pickhardt said, and thus would have spared them from the more invasive test.
The emergence of virtual colonoscopy as a screening tool sets up a battle between gastroenterologists, who now perform the conventional tests, and radiologists, who have been losing ground to other specialties in recent years, particularly cardiology (Dec. 1, p. 28). Indeed, separate research also presented at last week's meeting reported that in 2001, radiologists received only a little more than half of the pie from Medicare for noninvasive diagnostic imaging services. Cardiologists, on the other hand, scooped up 25% of the Medicare Part B fees for noninvasive imaging tests that same year. And their portion of the pie is growing twice as fast as radiologists', said Vijay Rao, professor and chairman of the radiology department at 805-bed Thomas Jefferson University Hospital in Philadelphia and the study's lead author.
Extrapolating the findings to colonoscopy, Rao said, "I think if you want to control healthcare costs for imaging and create checks and balances, imaging should be done by radiologists. If you allow nonradiologists to self-refer their patients, because of economic incentives, there's a potential for overutilization."
Pickhardt said he thinks there is more than enough business to go around.
"We're not trying to take (colonoscopy) over," he said. "A small number of people are getting it and there are not enough gastroenterologists to possibly put even a small dent in what remains. I think the best fit is to evaluate the healthiest and low-risk segment and that way you reserve (gastroenterologists) for the more invasive tests." In the end, the percentage of conventional colonoscopies as therapeutic procedures would increase and the number of invasive tests performed simply for diagnostic purposes would decrease, he said.