CORRESPONDENCE: LETTER TO THE EDITOR
Reply
John A. Rumberger, PhD, MD, FACC*
* Emerald Professional Building, 5747 Perimeter Drive, Suite 105, Dublin, Ohio 43017 (Email: jrumberger{at}healthwisecenter.com).
Dr. Fleet raises important questions, and there is legitimate concern that computed tomography (CT) scan "incidentalomas" can result in unnecessary or inappropriate testing at the expense of the insurance system and/or risk to the patient (1,2).
The main issue regarding cardiac CT is, of course, coincident imaging of the adjacent lungs. Although lung cancer is the number one cause of cancer-related deaths in all men and women in America, the finding of variable size "lung nodules" is much more common than true malignant disease. Dr. Fleet asks: "When found, are the newly discovered malignancies curable or amenable to treatment that prolongs life or improves quality of life?" We may never have a complete answer to this inquiry. However, the overall survival rates for lung cancer are dismal, and the most recent report from the ELCAP (Early Lung Cancer Action Program) study (3) may provide a partial response. Henschke and colleagues (3) did screening lung scans in adults over 40 years old with either a history of cigarette smoking, an occupational exposure risk, or significant exposure to second-hand smoke, and they found that stage I lung cancers discovered (and treated) resulted in a projected 80% 10-year survival. These subjects are, coincidentally, at greatest risk for atherosclerotic heart disease. Importantly, however, lung cancer was found in only 484 (1.5%) of 31,567 screened individuals.
Dr. Fleet asks, "What is the morbidity and mortality attendant to the biopsies and surgery for lesions that ultimately turn out to be benign?" This is a rhetorical question as we do not have this information; however, in most instances biopsies are unnecessary, and follow-up low-dose CT scanning may be the only suggested consequence. In medicine we tend to "pass the buck" when it comes to test results that are unanticipated, and the best way to reduce unnecessary follow-up testing or procedures is physician education. There are guidelines published by the ELCAP investigators (4), which prescribe follow-up on the basis of lung nodule dimensions. More recently the Fleischner Society (5) described the workup of small pulmonary nodules incorporating smoking history as part of the clinical algorithm.
I agree that we are at a crossroad to define the clinical impact of diagnostic CT angiography and "extravascular" pathology, regardless of whether it involves the heart/chest, neck, abdomen, or periphery. The issue clearly extends beyond traditional single-specialty medicine. Recently, a published commentary (6) addressed training in advanced cardiovascular imaging, stating that "specific interpretation of the extra-cardiac fields should be performed.... Regarding the cardiovascular medicine specialist performing a cardiac CT, the American College of Cardiology recognizes and endorses education and training of such individuals in the recognition of incidental scan findings in support of quality imaging care of patients with cardiovascular disease.... To this end, it is felt that Level 2 and Level 3 training should include review of all cardiac CT for noncardiac findings."
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1. Onuma Y, Tanabe K, Nakazawa G, et al. Noncardiac findings in cardiac imaging with multidetector computed tomography J Am Coll Cardiol 2006;48:402-406.[Abstract/Free Full Text]2. Rumberger JA. Noncardiac abnormalities in diagnostic cardiac computed tomography. Within normal limits or we never looked!. J Am Coll Cardiol 2006;48:407-408.[Free Full Text] 3. Henschke CI, Yankelevitz DF, Libby DM, et al. Survival of patients with stage I lung cancer detected on CT screening: the International Early Lung Cancer Action Program investigators N Engl J Med 2006;355:1763-1771.[Abstract/Free Full Text] 4. Libby DM, Smith JP, Nasser KA, et al. Managing the small pulmonary nodule discovered by CT Chest 2004;125:1522-1529.[CrossRef][Web of Science][Medline] 5. MacMahon H, Bao B, Austin JHM, et al. Guidelines for the management of small pulmonary nodules detected on CT scans: a statement from the Fleischner Society Radiology 2005;237:395-400.[Abstract/Free Full Text] 6. Budoff MJ, Achenbach S, Fayed Z, et al. Task force 12: training in advanced CV imaging (CT) J Am Coll Cardiol 2006;47:915-920.[Free Full Text]
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