Tag Archives: RSNA

New Questions on Lung Cancer Screening

Would you allow patients to self-refer for a CT lung cancer screening? Would you screen a never-smoker? What size nodule would trigger a follow-up exam? What is your lower age limit and lower pack-year limit for screening?

These are just a few of the questions tackled during an interactive lung cancer screening session at the recent Radiological Society of North America meeting, and that highlight the uncharted waters physicians face in the wake of the pivotal National Lung Screening Trial.

The NLST demonstrated a 20% reduction in lung cancer mortality when low-dose CT screening was used, compared to chest X-ray, among 53,000 asymptomatic current or former heavy smokers. However, CT produced more than three times the number of positive results and a higher false-positive rate than radiography.

Without a clear plan to manage abnormal findings or a firm handle on cost, policymakers and payors are hesitant to back reimbursement for widespread lung cancer screening. Results of the ongoing NLST cost-effectiveness analysis are expected early next year. Based on already published data, however, a crude back-of-the-envelope estimate puts the incremental cost-effectiveness ratio at $38,000 per life-year gained, NLST investigator Dr. William Black told attendees.

“That actually is a pretty good deal compared to a lot of things we do in medicine, and in fact most people would put the threshold for acceptability somewhere between $50,000 to $100,000 per life-year gained,” he said. “So it certainly is feasible”

Dr. Black pointed out that low-dose CT saved one lung cancer death per 346 persons screened in NLST, which again is very favorable compared to the rate of 1 per 2,000 patients for mammography.

Although the session provided just a small snapshot in time, audience responses suggest there is much work ahead. A full 77% of attendees were not using low-dose CT to screen for lung cancer and 72% reported not being familiar with the recently published National Comprehensive Cancer Network guidelines for lung cancer screening.

One-quarter of the audience had no lower age limit for screening, and 34% said they did not provide either decision support or obtain informed consent.

Dr. Caroline Chiles. Image by Patrice Wendling/Elsevier Global Medical News

Radiologist and NLST collaborator Dr. Caroline Chiles said informed consent in NLST helped prepare patients for the potential risks of a screen, the likelihood of a positive result and that a positive result didn’t mean they had lung cancer.

“It made a huge difference once they got that letter saying they had a positive screen, because at that point you don’t want everyone rushing out to a surgeon to get that nodule resected,” she added.

What attendees and panelists could agree on is the need for smoking cessation to be included in any future lung cancer CT screening program, with 60% of attendees saying they already do so.

Dr. Chiles pointed out that 16.6% of participants in the NELSON lung screening trial quit smoking compared with 3%-7% in the general public, but that participants were less likely to stay non-smokers. She also cited a recent MMWR that found 70% of adult smokers want to quit smoking, but only about half had been advised by a health professional to quit.

“We really have to think of lung cancer screening as being a teachable moment,” she said.

She suggested physicians visit www.smokefree.gov for help in guiding their patients. Dr. Black also noted that the NLST team is working on a lung cancer screening fact sheet for physicians and patients that will be ready in a few weeks and made available on the Internet.

—Patrice Wendling

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Filed under Cardiovascular Medicine, Family Medicine, Health Policy, IMNG, Internal Medicine, Oncology, Physician Reimbursement, Practice Trends, Pulmonary Diseases and Sleep Medicine, Radiology, Surgery, Thoracic Surgery

Hypnosis Takes the Bite Out of MRI Anxiety

I’d rather have an MRI.

OK, it doesn’t have the same ring as the traditional punch line, but for many patients the fear of being slipped in a scanner surrounded by the clicking and banging sounds of an MRI ranks right up there with a root canal.

Rather than sedating these patients, a radiology group in France has been offering hypnosis on a daily basis since 2004.

Over a 15-month period, 45 patients were identified as being claustrophobic and refused the scheduled MRI, including four patients who experienced a panic attack.

All 41 patients who agreed to undergo a brief 3- to 5-minute single session of hypnosis just before the MRI completed the exam, including those with panic attacks.

Conversely, none of the four patients who refused hypnosis were able to withstand the procedure, radiologist and co-author Dr. Bruno Suarez reported at the Radiological Society of North America  meeting.

Dr. Bruno Suarez

“The more a patient is claustrophobic, the more hypnosis is efficient,” Dr. Suarez, with L’Hôpital Privé de Thiais in the outskirts of Paris, said in an interview. “For us it’s a surprise. It’s a very interesting technique.”

The technique is based on the late American psychiatrist Dr. Milton Erickson’s approach to hypnosis, but modified to integrate the repetitive noise of the MRI. Patients are given a tour of the MRI room, assured that the scanner and its magnets are safe and prompted to mentally recall a pleasant memory involving a repetitive noise while the MRI exam is performed.

During hypnosis, the brain is more susceptible to suggestions, Dr. Suarez said, noting that a Belgian study showed that hypnosis reduces the perception of pain by 50%.

Hypnosis requires a good memory and language skills, so it’s not used on those under five years of age or those with dementia or Alzheimer’s, he added.

So far, a radiologist, two MRI technicians and even the two office receptionists have been trained in the technique.

Marc Andre Fontaine (left) and Dr. Suarez

“I like the contact with the patient, and I want the best results for the patient,” MR technician and co-author Marc Andre Fontaine said in an interview.

The 45 patients in the series represent just 1.4% of the roughly 3,300 patients seen by the group over the 15 months, but the appeal of the drug-free method has attracted referrals from other centers. It’s also a big financial boon due to shorter exam times, fewer appointment cancellations and no procedural side effects, Dr. Suarez said.

A recent study by interventional radiologist and hypno-analgesia pioneer Dr. Elvira Lang reported that self-hypnotic relaxation added an extra 58 minutes to the room time for an outpatient radiologic procedure, but still saved $338 per case compared with standard IV conscious sedation.

That’s a big savings for just getting patients to relax with a few words, especially when you consider that  nine out of ten patients are probably already muttering something under their breath during their MRI.

—Patrice Wendling

Images by Patrice Wendling/Elsevier Global Medical News

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Filed under Alternative and Complementary Medicine, Anesthesia and Analgesia, IMNG, Radiology

Renaissance RSNA

This year’s meeting of the Radiologic Society of North America felt as foreign to the current American landscape as Harry Potter’s Hogwarts School of Witchcraft and Wizardry.

While politicians in Washington played hide-and-go-seek with desperately needed government funding and unemployment benefits,  rows and rows of glistening CT and MRI machines spanned the floor of Chicago’s McCormick Place. Physicians clutching cups of made-to-order espresso were wooed into private imaging suites created with elaborate screens and partitions. One was even shaped to resemble a pagoda, with an exquisite black and floral kimono inside.

“I believe one of the exhibitors said in a meeting that we had down here that they considered this the Renaissance RSNA, everything’s back solid and strong,” says RSNA assistant executive director Steve Drew.

When asked the dollar value of the equipment on display, Drew says they’ve never stopped to calculate it, but that $100 million would probably be a “very conservative guess.”

Exhibits have remained solid in terms of the amount of space being bought and the size of the booths, with about 700 exhibitors on hand this year, down slightly from an all-time high in the mid-700s.

“We feel good about it,” he says. “Based on information gathered through partnership meetings we have with our major exhibitors and market indicators, we had actually budgeted down 7% and we’re about even with where we were last year. So, depending on how you look at it, it’s almost a 7% increase.”

RSNA isn’t the only one feeling good about this year’s meeting.

The city of Chicago, which struggled this past year to retain its competitive edge in the convention trade, anticipates that the 6-day show will bring in $120 million, says Meghan Risch, director of public relations for the Chicago Convention and Tourism Bureau.

The economic impact of RSNA, arguably one of the biggest medical meetings in the world, has remained relatively constant, she contends, despite the economic downturn.

Attendance this year was about 57,500, according to unaudited attendance figures. Of these, 36,000 were professional registrants, defined as everyone but exhibitors and guests.

“We’re running about 4% ahead on professional attendance and the really good numbers there are the non-North American registrants, which came in at 36% of the professional registrants,” Mr. Drew says.

The average hotel stay for RSNA is five days – roughly double that for most medical meetings. Its international makeup is also probably the highest of Chicago conventions, according to Ms. Risch.

“International attendance is growing and RSNA is a great example,” she says.

–Patrice Wendling (on Twitter @pwendl)

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Filed under IMNG, Internal Medicine, Nuclear Medicine, Radiology, Uncategorized

Stones, flowers and a rope

Just back from the International Society for Traumatic Stress Studies annual meeting in Chicago and I’m struck by the diversity of research being conducted on behalf of the many survivors of severe stress and trauma around the world. There were data on everything from prolonged exposure therapy, cognitive processing therapy, and EMDR (eye-movement desensitization and reprocessing) to imagery rehearsal for nightmares and acupuncture – the latter approach being studied by physicians at Walter Reed Army Medical Center in Washington, D.C.

 

Researchers in Israel are using repeated, brief interventions in the ED to help structure memory and aid in meaning acquisition in patients with acute stress disorder who are still receiving emergency treatment for their physical wounds.

 

German researchers are treating child survivors of the Rwandan genocide and former child soldiers with narrative exposure therapy in which the person’s life is fully documented from birth through the present day in hopes of inhibiting the fear structure. Few of these children are able to read, so the tools are simple – a clinician’s notebook and a rope to represent the child’s lifeline. Stones are placed on the rope to indicate the traumas they’ve endured, while flowers are used to mark and reinforce the good events. Knowing that conducting therapy among refugees can be a moving target, the researchers also trained laypeople to conduct the therapy.

 

The simplicity of this effort and the dedication of its practitioners were stunning. It also stands in stark contrast to many of the other meetings I attend in which high-tech or pharmaceutical treatments rule the day. ISTSS attendees inside the poster/exhibition hall were busy snapping up books for sale rather than hearing the latest sales pitch. A nearby sign acknowledged Eli Lilly as the only pharmaceutical company to help sponsor the 3-day event.

 

In roughly two weeks, I’ll cover what is often billed as the largest medical meeting in the world – the annual meeting of the Radiological Society of North America (www.rsna.org). The value of the equipment on the exhibition floor of Chicago’s massive McCormick Place will run into the millions. The detailed images of the human body captured by these machines will be stunning as well. Yet I can’t help but think that ISTSS (www.istss.org) and its 2,464 members have tapped into an equally powerful tool – man’s resourcefulness in caring for those in pain.

 

—Patrice Wendling

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Filed under Family Medicine, Practice Trends, Psychiatry