According to the American Cancer Society (ACS), approximately 8.2 million Americans alive today have a history of cancer. Some of these individuals can be considered cured, while others still have evidence of cancer and may be undergoing treatment. The ACS estimates that 1,221,800 new cancer cases are expected to be diagnosed in 1999; 563,100 Americans are expected to die of cancer this year. The costs of detection, diagnosis, and treatment are, according to the National Institutes of Health, $107 billion: $37 billion for direct medical care, $11 billion for indirect morbidity costs (cost of lost productivity due to cancer), and $59 billion for indirect mortality costs (cost of lost productivity due to premature death). Treatment of breast, lung, and prostate cancer accounts for more than 50% of direct medical costs. Despite a decline in overall cancer rates in the United States, the toll on Americans is expected to increase as our population ages. For radiology and radiologists, the challenges in providing the level of care to meet these demands are considerable.
Until the advent of cross-sectional imaging techniques, the radiologist relied on rudimentary tools to assist in the diagnosis and subsequent management of patients evaluated for the suspected diagnosis of various neoplasms. These early efforts were hampered by a dearth of medical imaging tools and the absence of meaningful ways to screen for a suspected diagnosis of, among other entities, breast cancer. A generation ago, staging laparotomy, pneumoencephalography, and diagnostic angiography were among the more advanced procedures available. Lymphangiography was considered the most sensitive and specific procedure to assess the presence of lymph nodes in the pelvis and retroperitoneum. The concept of percutaneous biopsy of abnormalities throughout the body was an idea whose time had not yet come.
As we approach the 21st century, these procedures have assumed the status of relics, replaced by magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET). New and promising technological advances have led to a resurgence in the role of ultrasound and nuclear medicine. The challenges we face now in the assessment of disease and the monitoring of response to therapeutic intervention are a welcome contrast to the uncertainty and conjecture of earlier times.
Oncologic imaging represents a unique challenge for diagnostic imaging. Providing imaging services to the oncologic patient requires a different mind-set and a broader approach to diagnostic assessment and subsequent management. Unlike other specialties in medical imaging, assessing the patient with cancer necessitates the coordination of care that is physician intensive and, unless properly orchestrated, can result in less than optimal care and multiple layers of frustration for patients and consulting physicians alike.
THE CASE FOR COLLABORATION
Breast cancer is a common disease affecting one in eight women. According to the ACS, an estimated 175,000 new invasive cases of breast cancer are expected to occur in women during 1999 and 43,700 women will succumb to their disease. Approximately 1,300 new cases of male breast cancer are expected to be diagnosed in 1999. Effective treatment requires a comprehensive approach to assessment of, among other parameters:
- Cell type
- Tumor size
- Status of regional nodes
- Staging for distant disease
- Surgical options for treatment of the primary tumor and assessment of axillary lymph nodes
- Role of radiation therapy
- Consideration of multimodality therapy including chemotherapy in combination with radiation treatment
- Access to and eligibility for clinical trials
- Role of tamoxifen and other chemoprevention tools
- Surveillance with imaging, including follow-up mammography.
Under ideal circumstances, this assessment requires a forum for the discussion of these and other aspects of care, preferably after all the consulting physicians have had the opportunity to review relevant pathology, diagnostic imaging studies, and medical records, and appropriate examination of the patient has been conducted by the medical oncologist, surgeon, and radiation therapist.
In most instances women are not the beneficiaries of this type of assessment. Too often those afflicted with breast cancer are not aware of their treatment options. Many women are not apprised of their options, including breast conservation therapy, radiation therapy, and other alternatives to a more traditional approach to their disease. The reasons commonly cited for this are many, including coordinating the schedule of the physicians and support staff necessary to support this model, convenient location for hosting a multidisciplinary conference, adequate reimbursement for physicians to participate, and critical mass of patients who warrant this institutional investment of time and financial resources. A willing group of physicians interested in the described collaborative relationship must be present to sustain this effort over time.
The absence of a knowledgeable physician in a consultative role can dramatically alter the treatment of women with breast cancer. This pertains not only to the radiologist involved in the assessment, but also to the skill and expertise of the pathologist in arriving at a true assessment of the type and extent of disease. The availability of qualified physicians interested in discussing the various treatment options and the perpetual turf battles that ensue are likely culprits contributing to this dilemma.
PLAYING A PROACTIVE ROLE
Radiologists can participate in the management of the oncologic patient throughout the course of care, but it takes an understanding of multiple imaging modalities and a willingness to assume the role of consultant rather than the traditional and often passive role of film reader. This role extends beyond diagnosis to the treatment of the primary tumor (chemoembolization), the complications of surgical procedures, and, in many instances, palliation when obstruction of, for example, the biliary system manifests as jaundice. The placement of catheters to relieve renal obstruction and the management of abscesses and fistulas are becoming commonplace as are methods for providing intermediate and long-term venous access when other options are not available.
Most physicians involved in management of cancer patients lament the absence of access to physicians adept at all imaging modalities. Contemporary radiology focuses on cross-sectional imaging; thus, the radiologist involved in an oncologic practice must be proficient at, among other modalities, CT, MRI, ultrasound, and nuclear medicine. Access to expertise in breast imaging and interventional radiology, additionally, is a prerequisite for a department with the goal of providing a service in the oncologic milieu. Radiology departments fall short of the needs of their clinical colleagues when these basic services are not available.
Departments also must be configured in some manner to deal with the review of studies performed at other institutions. In this era of restricted access to imaging, many patients with diagnoses of cancer present to their physicians seeking an opinion based on, among other factors, work performed at other facilities. The reluctance on the part of the imaging community to step forward and participate in care is to the detriment of the patients and the physicians who seek the guidance of consulting radiologists.
UNIQUE SERVICE REQUIREMENTS
Recent changes in patient management due to new treatment options and the incorporation of new imaging technologies hold enormous promise for the future and in many instances are already in place. PET, conformal therapy, and fusion of images from several sources are among the procedures discussed with great enthusiasm. Favorable reimbursement, lower cost of equipment procurement and operations, and new computer-assisted methods for data management represent an area of growth for the radiology practice seeking new opportunities and sources of revenue.
In an ideal world, a department of radiology needs to invest in equipment, professional expertise, and a proactive administration committed to servicing cancer patients and their referring physicians. This necessitates an in-depth assessment of these specific needs, ranging from flexibility in scheduling patients to rapid turnaround of reports. Above all, it demands a mind-set of accommodation and sensitivity to this subset of patients who demand a level of care not seen in most other areas of medical imaging. There was a time not long ago when the diagnostic tools and treatment options relegated oncologic imaging to a back seat. In the absence of a serious effort to develop postgraduate training programs in this area, most practices will need to develop imaging specialists who can roll up their sleeves and work with their clinical colleagues in a necessary, yet frequently overlooked aspect of diagnostic imaging. The mere presence of sufficient bodies to cover the various modalities is a poor alternative to a select group of radiologists committed to providing the best care and service possible. The risk of providing highly specialized individuals in a conventional setting where opinions are rendered in the absence of knowledgeable individuals has the potential for lowering the quality of care by fragmenting the delivery of consultative services. Oncologic imaging at the level of an individual patient must be tailored to the diagnosis and treatment options available. Passing patients from one imaging specialist to another denies the patients and referring physicians a global view of the problem and the ability to offer recommendations based on a review of all the imaging studies.
THE DIAGNOSTIC-THERAPY AXIS
Invariably, our ability to provide high- quality care rests on several factors. Operating in a collaborative manner can either be proactive or reactive. Establishing collaborative relationships with referring physicians benefits both parties. Meaningful dialogue provides the opportunity to plan the appropriate evaluation of the oncologic patient. Knowledge of the diagnostic and treatment options available to referring physicians enhances care through the appropriate utilization of imaging — the best test first — and eliminates the ambiguities of a shotgun approach to managing these patients.
Forging strong ties with medical oncologists, surgeons, radiation therapists, and others involved in patient management produces high-quality service, the benefits of which accrue to everyone. As physicians, our ability to serve in a consultative role is perhaps the most powerful tool we have to offer. Abdicating this responsibility creates the perception that we are nothing more than film readers, as well as an entree into the realm of radiology for other specialists.
The 21st century offers enormous promise and hope for patients confronting a diagnosis of cancer. Early detection, safer and more efficacious treatment options, and improved survival rates represent real benefits that we can expect in the coming years. Radiology can expect to play a central role in this expanding field.
Howard B. Kessler, MD, is chairman of radiology at Graduate and Warminster hospitals, former chairman of radiology at the Fox Chase Cancer Center, and president of the American Cancer Society southeast region, Philadelphia.
- Cancer Facts and Figures — 1999. American Cancer Society; 1999, Atlanta.