Bruno, Michael mbruno at HMC.PSU.EDU
Wed Dec 10 18:57:31 UTC 2014

Robert is 100% right, and I think this is a very important point deserving of a great deal more attention than it has received.

While occasionally the discovery of an incidental finding can be of great significance, most are not-but their discovery typically provokes a cascade of what amounts to varying degrees of over-reaction on the part of physicians.  On the whole, I think this presents patients with more risk than benefit.

While we all are understandably focused on keeping ionizing radiation exposure at a minimum, I think that the increased radiation exposure related to a patient undergoing an unnecessary follow-up radiological exam may well turn out to be the very least of the many risks to patients from us chasing these sorts of "red herrings."  Beyond adding such inappropriate or "extra" radiation exposure-which may pose an increased cancer risk above baseline with a 20+ year latency-there are many immediate risks from chasing incidentalomas, such as patients undergoing unnecessary biopsy and other procedures (with all of their attendant risks and complications) an increased opportunity for mis-diagnosis leading to unnecessary or redundant treatments, with all of the risks and side-effects of those un-needed treatments, as well as needlessly increased costs, patient anxiety and physical pain... all with little or no possibility of accruing any actual benefit to affected patients.  Not to mention that merely taking the time to pursue a diagnostic diagnostic dead-end can potentially (and often does) distract physicians and patients from recognizing and addressing the patient's actual, urgent problem(s) in a timely way, i.e., the opportunity cost of incidentalomas is actually very high.

So, in my view, there are many urgent and immediate reasons why the discovery, or more importantly the mis-handling of these "incidentalomas" can lead to more harm than good.  I think that was one of Dr. Brawley's points at the meeting in Atlanta.  The issue is timely as advancements imaging technology have made many more such incidentalomas detectable, and thus our technological progress has created / amplified what was previously a much smaller problem.  I think the issue has grown into something that urgently needs to be addressed in a comprehensive, rational and coherent way.  And I am concerned that, by limiting the discussion of the risk-side of this equation to the relatively small issue of radiation safety, the true magnitude of the problem is being widely underestimated.

Michael A. Bruno, M.D.

From: robert bell [mailto:rmsbell at ESEDONA.NET]
Sent: Tuesday, December 09, 2014 8:44 PM
Subject: [IMPROVEDX] Incidentalomas

There is an interesting article about Incidentalomas and their Management in the American Family Physician, Dec 1. 2014. Page 784

These are incidental findings found on imaging and possibly leading to unexpected diagnoses.

Although many of these are benign they often lead to a cascade of testing which can be harmful exposing patients to more radiation.

So an unexpected finding or diagnosis that with work-up can lead to patient harm.

Robert Bell



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