In a retrospective analysis reported in JCO Oncology Practice, Durani et al found that use of surveillance imaging in patients with diffuse large B-cell lymphoma (DLBCL) decreased following publication of the American Society of Hematology (ASH) Choosing Wisely recommendations to limit such imaging in aggressive lymphoma.
Study Details
The study involved data from a national insurance claims database (OptumLabs Data Warehouse) on 1,472 patients with private insurance from three periods:
- Period 1 (2008–2010; n = 298)
- Period 2 (2011–2013; n = 397)
- Period 3 (2014–2016, post–Choosing Wisely campaign; n = 777).
Any nonbrain positron-emission tomography (PET), PET/computed tomography (CT), CT-chest, or CT-abdomen/pelvis was considered surveillance imaging. The cohort included only patients treated with curative intent.
Stage data were not available. Selection of only lower-risk patients for the cohort was attempted by exclusion of patients with recurrence indicated by subsequent chemotherapy or radiation during follow-up.
Key Findings
During the first and second years of surveillance, the frequency of any imaging did not change significantly between period 1 (91% and 83%) and period 2 (88% and 77%; P = .38) but decreased significantly during the post–Choosing Wisely period 3 (78% and 61%; P < .01).
During the first and second years of surveillance, the frequency of PET/PET-CT surveillance imaging was 62% and 40% during period 1, 48% and 31% during period 2, and 43% and 25% during period 3 (P < .001 for trend).
The median number of scans per person in the first year of surveillance decreased from two in period 1 (interquartile range [IQR] = 1–3) and two in period 2 (IQR = 1–2) to one in period 3 (IQR = 1–2; P < .01).
Overuse of imaging, defined as more than two surveillance scans per year (based on National Comprehensive Cancer Network® guidelines recommending at most one scan every 6 months for up to 2 years after treatment in advanced disease) during the first year of surveillance decreased over time, from 32% in 2008 to 10% in 2016. On multivariate analysis adjusting for age, sex, race, and geographic region, significant reductions in overuse compared with 2008 were observed for 2013 (odds ratio [OR] = 0.49, P = .02), 2014 (OR = 0.34, P < .01), 2015 (OR = 0.24, P < .01), and 2016 (OR = 0.11, P < .01).
“Although our study found that imaging during surveillance for DLBCL has decreased over time, imaging still occurs frequently. More work is needed to understand provider decision-making and the most effective ways to disseminate guideline changes and encourage adoption of cost-beneficial practices in the oncology community.”— Durani et al
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The investigators concluded: “Our study demonstrated the rate of surveillance scans—both computed tomography and positron-emission tomography imaging—in DLBCL decreased after the ASH Choosing Wisely campaign. Multiple factors, such as changes in recommendations, reimbursement, and provider knowledge base, may have all contributed and should be studied further.”
They also noted, however, that “Although our study found that imaging during surveillance for DLBCL has decreased over time, imaging still occurs frequently. More work is needed to understand provider decision-making and the most effective ways to disseminate guideline changes and encourage adoption of cost-beneficial practices in the oncology community.”
Ronald S. Go, MD, of the Division of Hematology, Mayo Clinic, Rochester, is the corresponding author for the JCO Oncology Practice article.
Disclosure: The study was supported a Transform the Practice grant from the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery. For full disclosures of the study authors, visit ascopubs.org.
