Incidental findings can lead to unnecessary testing, expense, and malpractice suits.
Radiologists inevitably worry about missing something, but an equally vexing part of the job is seeing too much. Looking for one thing and finding another—the so-called “incidentaloma”—has long been a familiar conundrum that only gets worse as technology gets better. “The more we can see,” said Leonard Berlin, MD, FACR, “the more we find.”
Incidental findings have likely been a part of the profession since R?ntgen discovered x-rays, but the advent of CT in the early 1970s brought the possibilities to a whole new level. “Then came MRI and more sophisticated CT technology, and we could see 1/2-mm structures,” said Berlin, professor of radiology at Rush University Medical College, Chicago. “People have likened this to looking at a map. With magnified maps, you see all these little islands. It’s similar in medicine, and it’s a major problem. Today we are seeing a lot of things, most of which are normal. But once we see something, what do we do with it?”
The fact is that “better safe than sorry” is not an apt clich? when it comes to incidentalomas. Instead, too safe can lead to a lot of needless expense and pain for patients. “About 98% of incidental findings are of no significance,” Berlin estimated. “If we do a CT of the abdomen for other reasons, and we look at the kidneys, the statistics are that up to 23% of people will have an abnormality in their kidney. Statistically, only two tenths of 1% will turn out to be problematic.”
“If you see a 1-cm lesion in the kidney, and you can’t tell whether it is solid or cystic, the question will be what is the chance that it could turn into a cancer that could metastasize and potentially kill the patient?” asked Lincoln L. Berland, MD, FACR, professor emeritus and vice-chairman for Quality Improvement and Patient Safety, Department of Radiology, University of Alabama at Birmingham. “The answer could be half of 1%, it could be a hundredth of 1% or even less. No one really knows, and that is part of the problem.”
Berlin likens the entire process to a one-way trapdoor. Once you go through, you can’t go back. “I call it the medical maze,” he said. “Once you take the first step in a medical test, there is no backing up. Because if that is equivocal, you are going to the next step. Others refer to it as the cascade of testing. One marginally abnormal test result usually begets another marginally abnormal test result. And that is the problem.”
The Reality of Fear
Leonard Berlin, MD, FACR
Chances may be slim, but failing to report incidental ?ndings can place radiologists in jeopardy for a lawsuit. The specter of malpractice hangs over every decision regarding incidentalomas, as does the prospect of doing a disservice to the patient. No radiologist wants to make a mistake, and no one wants to initiate a cascade of testing that places a mental and physical toll on patients.
In the worst-case courtroom scenario, word choice could come under scrutiny. “If I write, ‘incidentally noticed is a small cyst in the kidney,’ physicians are not going to follow up,” Berlin said. “Now if I phrased it differently and wrote, ‘incidentally noted is a shadow in the kidney which is most likely a cyst but low likelihood of cancer can’t be ruled out,’ then obviously the referring physician is going to be pushed into additional tests.”
A less alarming note such as “small shadow on the kidney, most likely a benign cyst” would also be less likely for follow-up. “Fast forward a year later and let’s say it turns out to be cancer, and now there is a lawsuit,” explained Berlin. “What if I am the radiologist who said there was simply a small shadow on the kidney? The lawyer will ask why I said that, and I’m going to say, ‘Well, these are 99% benign and I can’t mention these all the time.’ They are going to say to me and the jury, ‘This is not about statistics, doctor. This is about one individual who now has cancer. Don’t you think that your job is to at least mention that there is a small likelihood of cancer? Don’t you think the patient ought to be told and the referring physician should be told and let them make the decision whether to do additional tests?'”
The mere prospect of such questioning may send shivers up the spine, but Berlin contends that it’s a real dilemma in our litigious society, and it is hard to defend. “Most radiologists are calling just about everything because they are afraid,” he said. “They don’t want to get sued.”
The standard of care for physicians in all 50 states is to conduct themselves reasonably. The standard is “reasonable conduct,” not “perfect,” and no physician is expected to be right 100% of the time—but that is often little consolation when it comes to incidentalomas.
The definition of reasonable may be a moving target, and resolving the question can often determine who wins a lawsuit. “If I have a reasonable belief that something is significantly abnormal, then I should call it,” said Berlin. “If I see something that is 99.9% or even 99% of no significance, it is certainly reasonable for me not to mention it. We have the theoretical standard of care, which is reasonable conduct, but of course how does the jury establish reasonable? What’s reasonable to one jury is not reasonable to another. It is hard to predict what a jury will do.”
According to Berland, it is difficult right now to find a medical legal suit that has been brought on the basis of an incidental finding. “I think this is currently sort of under the radar of most malpractice attorneys,” said Berland. “But with the attention that it has drawn in recent years, that is going to change. Fortunately, the vast majority of these incidental findings prove to be clinically insignificant, so there would be no harm done by not mentioning them. But that is the concern.”
Papers Get the Ball Rolling
When Berland formed an incidental findings committee in 2006, his colleagues in the American College of Radiology had already been pondering the problem of so-called “incidentalomas” for a long time. Unnecessary tests, worried patients, and stretched resources—particularly at community hospitals—have weighed heavily on the profession.
It took 4 years, but the committee ultimately published a 19-page consensus approach (a white paper) for findings in the kidney, liver, pancreas, and adrenal glands. Authors included flow charts and extensive texts on how to manage these particular findings, and Berland hopes the conclusions have helped lend a measure of consistency in a realm that has seen more than its share of improvisation.
The report, entitled “Managing Incidental Findings on Abdominal CT,” attempts to “systematically describe a variety of the most common potential incidental findings on abdominal CT and provide detailed recommendations to assist practicing radiologists in making informed decisions about reporting such masses and advising their referring clinicians and patients about whether and how these should be managed.”
The white paper is meant to serve as guidance and recommendations based on a consensus of experts, and Berland points out that it is not the official policy or guidelines of the American College of Radiology. “It has no legal standing,” said Berland. “However, if people begin to take a consistent approach, and it is scientifically proven that this approach is reasonable, it could be something that radiologists can use to defend themselves.”
It’s a testament to the enormity of the incidentaloma problem that the widely circulated paper almost immediately sparked hope for still more guidance on the abdomen and pelvis—including ovarian cystic masses, lymph nodes, and vascular abnormalities.
“Obviously, we must get some kind of consensus and there is no consensus right now,” added Berlin. “Our American College of Radiology white paper discussed all this, and from an academic point of view, they are urging everyone to use common sense. If you think there is a reasonable suggestion about a significant abnormality, then by all means mention it. But if you don’t think there is a reasonable likelihood, don’t mention it, because you will be doing a disservice to the patient.”
Tsunami on the Horizon?
More than 2 years ago, Berland penned an article warning of an “impending deluge” of CT colonography-related incidental findings. While colonoscopy remains the gold standard for colorectal cancer screening, the rise of CT colonography represents an ongoing concern that only increases with new technology.
Even before Berland’s article, a former chair of the department of radiology at Atlanta-based Emory University published his own experience with CT colonography to screen for colon polyps. “They found numerous other abnormalities in his abdomen, and it led to a number of other CT scans and procedures, with complications and a long and expensive hospitalization and convalescence,” said Berland. “He actually had surgery that led to a prolonged period of pain and loss of work. Fortunately, everything was benign, but that is something we call a cascade syndrome where one thing leads to another.”
If an exam such as CT colonography becomes extremely popular, Berland estimates that it could add another 3.5 million scans per year in the United States after a decade. “I doubt it will be adopted that widely in the near future,” said Berland, “because it would require public and private insurances to approve it, which they have not done.”
Massive Utilization
In 2010, American patients in hospitals big and small received roughly 70 million CT scans, with many done for a specific purpose. Getting an answer to the question that first prompted the scan is no guarantee, but exposure to incidentalomas is a near certainty.
With 70 million scans, Berlin says it’s not unreasonable to project that 20% will lead to incidentalomas. Jeffrey Alpert, MD, points out that in some of those situations, particularly with the improvement of high-resolution multidetector chest CT, the decision is more clear-cut.
“You want to err on the side of caution,” said Alpert, assistant professor of radiology at Brooklyn, NY-based Kings County Hospital Center, a facility affiliated with SUNY Downstate Medical Center. “The most common incidental finding in the chest is an unsuspected lung nodule. The important question is: Does this represent an early lung cancer? Usually, this question can be answered with follow-up imaging. Without further investigation, consequences could be much more serious than if you fail to follow up other types of incidental findings. Management of lung nodules is something radiologists and clinicians discuss often. Fortunately, there are well-established guidelines regarding follow-up imaging of incidental lung nodules.”
Ultimately, radiologists might be safe by mentioning every incidentaloma that could represent an early cancer. “However, radiologists might be sorry if every such patient undergoes expensive, unnecessary, and sometimes complication-prone testing,” Berlin warned. “Will radiologists in the future be both safe and sorry? That question remains unanswered.”
Greg Thompson is a contributing writer for Axis Imaging News.
