In the tiny seaside town of Yacahts, Oregon, Buck Henderson is ready to die.
Diagnosed with terminal prostate cancer, the 55-year-old spends his days practicing on his electronic drum set, fussing with his cat, Tiger Balm, and smoking pot to keep his appetite up. He says that when he told his employer, an aerospace fabrication company, that he had cancer, they fired him. That was nine years ago.
Though his cancer was found by way of biopsy, he says that since his diagnosis, he can’t even count the number of CT scans he’s had. He’s sick from radiation, navigating hot flashes, the lack of appetite, and a full-time catheter.
“I don’t know why they do much of [the treatment anymore]. I’ve accepted I’m going to die,” says Henderson. “More than that, it’s a struggle just to get it done.”
The bearded and longhaired “country boy,” as he refers to himself, even tried raising money for his treatment with a failed crowdfunding campaign. He raised only a few hundred dollars of $30,000 he was searching for.
Henderson is not alone in his confusion about why diagnostic medical imaging, like CT scans, continues to be performed even though he has been diagnosed as terminal. A recent article in the Journal of American Medical Association noted that “a sizeable proportion of patients with advanced cancer continue to undergo cancer screening tests that do not have a meaningful likelihood of providing benefit.” Another published in the September 28, 2010 issue of Health Imaging noted that “as many as 30 percent of diagnostic imaging procedures are inappropriate or contribute no useful information.” Elsewhere, statistics cited by the American College of Radiology (ACR) estimate that “60 million CT scans and 20 million nuclear medicine scans annually in the US might cause up to 40,000 fatal cancers.”
“We know that at very high doses ionizing radiation does cause cancer,” Michael Bettmann, a practicing radiologist and the emeritus chairman of the ACR Appropriateness Criteria Task Force, told The Daily Beast. “Diagnostic radiation does increase the risk or incidence of cancer. So we need to think about the risk-benefit ratio of every scan we do. We can’t really quantify the risk precisely. But if there’s some potential benefit, then by all means we should do it.”
It’s deciding just what procedures are actually beneficial that strikes many medical professionals as troublesome. In January of this year, The New York Times published an op-ed titled “We Are Giving Ourselves Cancer.” The authors asserted that CT scans, 100 to 1,000 times more powerful than X-rays, were partially to blame for rising cancer rates in the United States. While the experts weigh in that it’s impossible to determine whether or not a CT scan could actually be responsible for a cancer, receiving high doses of radiation certainly isn’t good for anyone. The frequency of radiological and nuclear scans in the United States has increased 600 percent since 1980—there’s nothing deniable about the amount of radiation Americans are blasting into their own bodies, for the sake of health.
Imaging accounts for about 5 percent of medical expenditure and is still a growing segment of the health care industry, yet it is hard to determine how much, if any, improvement in overall health outcomes can be attributed to more imaging.
“Outpatient imaging actually subsidizes other medical departments,” Chris Sistrom, MD, MPH, Ph.D., told The Daily Beast. “Health care providers like imaging and they like to do it. Nobody likes uncertainty. Imaging offers the hope, oftentimes not fulfilled, about resolving the uncertainty that comes along with illness,” he said.
Determining just what treatment is necessary, and when, is one of the greatest dilemmas of modern medicine. These decisions and criteria are referred to as “appropriateness.” As the public demands health care based on the incredible access to information afforded by the Internet, it can be a slippery slope. An educated public can lead to many procedures that just aren’t needed. And an overzealous medical professional, hoping to safeguard against malpractice, can also be a cause of unneeded procedure.
When it comes to imaging and radiology scans, it doesn’t always seem like a liability to run that extra X-ray. But it definitely is a liability to pass over something. Patients often expect doctors to act in some capacity, despite initial diagnoses. Further, the technology behind imaging moves so rapidly it is not always clear to physicians when or what is necessary imaging procedure.
The ACR does have appropriateness guidelines. A numerical data set helps physicians and other doctors know when to order scans of any kind. On a scale of 1 to 9, the ACR criteria evaluates about 700 tests through anywhere between 2,000 and 3,000 scenarios. 1-3 is inappropriate to scan a patient, 4-6 is questionable, and 7-9 is appropriate. Obviously, it would be nearly impossible for any medical professional to keep track of all of these guidelines, which get more specific and nuanced as time and technology advance.
Enter the ACR Select system, a new innovation that helps medical professionals know when to make the kind of decisions that can be iffy, because of cost or benefit (such has Henderson’s follow-up screenings).
“We took the criteria for the ACR and we digitized them,” said Michael Mardini, the CEO of National Decision Support Company (NDSC) and the brains behind ACR Select. “These criteria on the one-to-nine scale were narratives, commentary on what should and shouldn’t be done. We took those recommendations and turned them into ones and zeroes. We then made it available at the point of order, whether those scans are appropriate or inappropriate,” he explained.
In short, the ACR Select system, which was derived from the ACR appropriateness criteria, is a computer program connected to a central database with all the criteria and information needed to make crucial medical decisions—specifically in regard to ordering imaging. It is making its way to market by way of a predetermined agreement with at least 3,000 hospitals adopting it, and Medicaid has agreed to finance the tech as well—reducing unnecessary imaging is good for the nation’s pocketbook.
“We’re trying to save money and improve care,” Mardini said. “At the end of the day, this world, and this country specifically, is trying to figure out how to control the cost of health care. What we haven’t done is define what care is. What do you do, what’s appropriate, specifically for imaging? Doctors don’t know everything, especially in imaging. So we’re presenting an agreed-upon set of guidelines that can be presented to a doctor at point of care. All of this information now becomes available immediately, before any tests are done.”
“NDSC is trying to decrease and change the appropriateness of imaging,” Bettmann said. “It’s a worldwide problem. It’s worth addressing for a number of reasons. You don’t want to spend money needlessly. And you don’t want to not provide care when you should. We’re looking at the entire prospect not in terms of saving money, but in improving the quality of care. If we can save money at the same time, why wouldn’t we want to do that?”
"What we’re doing here truly, truly is the future of medicine," Mardini said.