Researchers: Ora Paltiel¹, Rachel Bar-Shalom², Neta Goldschmidt¹, Eldad Dann³

Background: In 2013, under the framework of "Choosing Wisely" American professional organizations called for limiting surveillance imaging among asymptomatic cancer patients in remission. FDG-PET-CT has been widely used in Israel for routine follow-up of lymphoma patients despite low PPV and related risks of false positive (FP) results, radiation exposure, and considerable cost

Objectives: To assess:
• the extent of FDG-PET-CT surveillance imaging of asymptomatic lymphoma patients in remission in Israel
• rates, reasons and implications of FP results
• attitudes of professionals and patients to surveillance imaging after curative treatment for lymphoma.

Method: Mixed-methods (quantitative and qualitative) studies. We analyzed findings of FDG-PET-CT studies of 215 patients in routine follow-up and 203 clinical trial participants who underwent surveillance scans in remission to determine FP rates, resultant interventions and costs. We surveyed attitudes among Hematologists and Nuclear Medicine Physicians and held focus-groups among patients and in-depth interviews among professionals.

Findings: FP results were seen in >25% of studies and 42% of patients, resulting in a cost of ~$50,000/per-relapse-detected. Patients were convinced of the accuracy of PET-CT, were aware of radiation risks, but were not concerned about FP results or their costs. Communication with the treating physician appeared crucial in reassuring patients of the limited value of routine imaging. Professionals generally believed (with important exceptions) that routine imaging did not affect prognosis, whether or not they were aware of the "Choosing Wisely" recommendation, and rejected regulatory limitations on testing.

Conclusions: Physicians limit surveillance imaging when convinced that it has little added value. Patients seek reassurance via imaging, are aware of radiation risks but not of implications of FP results. When trust and communication levels with their physician are high they can be reassured by clinical follow-up without imaging

Recommendations: Israeli hematologists are receptive to "Choosing Wisely" principles, which together with guidelines and patient education, may directly or indirectly influence the appropriate use of imaging.

Research end date: 12/2016