Incidentalomas

Peggy Zuckerman peggyzuckerman at GMAIL.COM
Wed Dec 10 20:09:07 UTC 2014


My perspective is quite different than the discussion above, as I am a
kidney cancer patient, where fully 40% of RCC tumors are found
"incidentally" to something else.  The reality is that  with a generally
non-symptomatic cancer, the value of response to such a finding is rather
mixed.  Many patients are told that the mass--not always the primary kidney
mass--is nothing, not a worry, everyone has this, etc.

My goal is to have these incidental findings be diagnosed properly, and
that the subsequent imaging be appropriate to the initial diagnosis.  For
example, if there is a kidney mass, then a CT with contrast is more helpful
than a PET scan.  Too often a person who has a large, confirmed kidney mass
is at risk for lung mets, but those will not show up while they are still
small with an x ray--similar to lung cancer lesions.  Failing to provide a
chest scan may delay the diagnosis of metastatic disease, much more
treatable at the earlier stage.

How is this situation balanced against the risk of possibly getting an
increase in risk of cancer in twenty years?  Of course I ask this as a
patient who has received 20+ CTs, and who will always wonder if an earlier
ultrasound would have been in my best interest.

Peggy Z

On Wed, Dec 10, 2014 at 10:57 AM, Bruno, Michael <mbruno at hmc.psu.edu> wrote:

>  *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
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *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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-- 
Peggy Zuckerman
www.peggyRCC.com






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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