Nearly all elderly patients with stage IV cancer underwent at least one CT, MRI, PET or nuclear medicine scan between diagnosis and death or the end of follow-up, according to research published July 30 in the Journal of the National Cancer Institute.

Yue-Yung Hu, MD, MPH, from the Center for Outcomes and Policy Research at Dana-Farber Cancer Institute in Boston, and colleagues explained that more than 25 percent of Medicare spending is incurred at the end of life. The most rapidly growing component of Medicare-reimbursed service is diagnostic imaging, they added, and explained imaging costs associated with cancer have risen at a rate higher than total costs of care.

Hu and colleagues sought to describe existing patterns of high-cost imaging (CT, MRI, PET and nuclear medicine) among elderly patients ages 65 and older with stage IV cancer.

The researchers examined Surveillance, Epidemiology, and End results (SEER)-Medicare data for 100,594 patients diagnosed with stage IV breast, colorectal, lung or prostate cancer between January 1995 and December 2006. The study included a recent care cohort diagnosed between January 2002 and December 2006. They defined three phases of care: the diagnostic phase, continuing care phase and the last month of life.

Among the recent care cohort, 95.9 percent underwent at least one high-cost imaging procedure. “On average, patients underwent almost 10 scans or more than one scan per month during the course of their illness,” wrote Hu et al. Most of the scans did not occur in the diagnostic phase, and 34.3 percent of patients underwent at least one high-cost exam in the last month of life.

When Hu and colleagues reviewed data over time, they found the proportion of patients imaged at least once during the course of their disease increased statistically significantly between January 1995 and December 2006. They noted that the proportion of stage I and II patients undergoing at least one high-cost exam decreased during this time period.

The researchers acknowledged the difficulties of examining SEER data, as they could not determine intent behind the ordering patterns. “If one assumes that the rationale behind the majority of imaging during the diagnostic period is staging, the higher absolute rate of scanning in the stage IV population may reflect the ability of advanced imaging to upstage cancer diagnosis.” Imaging also may help inform decisions about changing or ceasing treatment. However, they noted research suggests patients with cancer unresponsive to chemotherapy continue to undergo treatment.

Hu and colleagues called for additional research to determine the appropriate use of advanced imaging in this setting and inform the development of evidence-based guidelines. Discretionary decision-making when recommendations are equivocal or nonexistent drives higher spending, they noted.

“Imaging, although it often leads to (appropriate) palliative measures, may also distract patients from focusing on achievable end-of-life goals, require them to spend their limited time in medical care settings, and/or provoke anxiety,” Hu et al added.

In an accompanying editorial, K. Robin Yabroff, PhD, MBA, and Joan L. Warren, PhD, of the National Cancer Institute in Bethesda, Md., referred to the escalating costs of cancer care in the U.S., which are expected to increase 20 percent between 2010 and 2020, due to prevalence of the disease. Changes in treatment and imaging will spur additional increases.

They referred to the challenges of assessing appropriate imaging for these patients. However, they wrote, “Development of practice guidelines for advanced imaging in patients with stage IV disease, with explicit statements about the state of evidence will be critical, particularly for care outside of the window surrounding diagnosis.”

Such evidence must extend beyond an examination of the technical quality of images and include evidence about the benefits of advanced imaging over other technologies to inform clinical decisionmaking, they explained.