Incidental Findings, Without Incident
We’re encountering more incidental findings than ever, thanks to exciting advances in imaging technology. How are radiologists managing these unexpected discoveries?
A referring physician suspects that a patient with flank pain has a kidney stone and orders a CT study. But while interpreting the imaging exam, the radiologist detects something abnormal in the patient’s pancreas. Unexpected and unrelated to the patient’s clinical condition, the finding is classified as incidental. With few formal guidelines about how to manage incidental findings, the radiologist and referring physician must work with the patient to decide what to do next. Should they schedule more imaging? Arrange a biopsy? Monitor the patient? Or ignore the finding altogether?
As imaging technology has advanced over the past 25 years, such incidental findings — and the many questions they raise — have become increasingly common. Modern modalities and improved imaging techniques allow radiologists to identify findings that would have been undetectable with early X-rays. While these technological advances have no doubt improved patient care, radiologists and referring physicians don’t always know how to handle incidental findings. “It’s a hot topic in organized medicine because there are no clear-cut guidelines for addressing every incidental finding,” says Jonathan W. Berlin, MD, MBA, FACR, radiologist at North Shore University Health System and clinical professor of radiology at the University of Chicago Pritzker School of Medicine.
Without comprehensive guidelines, radiologists often act on incidental findings by recommending further imaging or interventional procedures. Lincoln L. Berland, MD, FACR, professor emeritus in the department of radiology at the University of Alabama at Birmingham and chair of the ACR Commission on Body Imaging, says radiologists do this for two reasons: first, they want to be as certain as possible about every finding’s risk to patients, and second, they don’t want to be legally liable if they minimize the importance of a finding that causes a negative outcome down the line. But Berland says that acting on every incidental finding can actually do patients more harm than good. “Instead, we must differentiate between the findings where action is going to benefit the patient versus the ones in which action may lead to unnecessary biopsies or surgeries,” he says.
To help radiologists determine whether incidental findings warrant action, the ACR, the Society of Radiologists in Ultrasound, the Fleischner Society, and other specialty groups have drafted incidental findings recommendations. The ACR began developing its recommendations in 2006, when Berland formed the College’s Committee on Incidental Findings, an expert panel responsible for forming a consensus about how to handle the most common incidental findings in the abdomen and pelvis on CT exams. In 2010, the JACR® published the committee’s first white paper, with recommendations for incidental findings in the liver, kidneys, adrenal glands, and pancreas. To date, the paper remains one of the journal’s most popular articles. “The interest in the paper really highlighted, somewhat to my surprise, how hot this topic was and how much radiologists yearned for guidance about how to handle incidental findings,” Berland says.
“It’s a hot topic in organized medicine because there are no clear-cut guidelines for addressing every incidental finding.”
— Jonathan W. Berlin, MD, MBA, FACR
Since then, the JACR has published five additional incidental findings papers from the committee. The papers cover 10 topics, including vascular and ovarian incidental findings, and each offers recommendations for different incidental finding types. “Most of the papers have flow charts, so the recommendations are often based on the size and characteristics of the lesion and, when appropriate, the patient’s age,” Berland says. Radiologists can use the recommendations to determine whether additional action is necessary to manage particular incidental findings effectively. Radiologists who can make these determinations will bring greater value to the health care team, as outlined in Imaging 3.0™. “The white papers help radiologists provide greater value because they offer credible, supported, and consistent recommendations for managing similar incidental findings in different patients,” Berland says.
While the papers attempt to offer a consistent approach to managing incidental findings across patients, they do not address every finding and case imaginable. “It’s impossible to standardize everything because every patient and every case is different,” Berlin notes. The committee hopes to make the recommendations more robust by incorporating the insights of experts outside of radiology and formalizing the recommendations as guidelines. Achieving this will require a more in-depth validation process, with consensus from a much larger panel of experts and revisions to some of the existing recommendations. “These recommendations have been put out there, but most of them haven’t been tested with subsequent research to demonstrate that they’re appropriate to use,” Berland says.
Another challenge the committee faces is making the recommendations accessible to radiologists. Currently radiologists who want to consult the recommendations during their interpretations must memorize them, access them through the JACR online, save them to their desktops, or post them in hard-copy form near their workstations. “Right now, compliance with the recommendations is relatively low because there are obstacles to accessing them at the time of interpretation,” Berland explains. “This makes it difficult to apply the recommendations.”
The ACR is addressing the issue by developing ACR Assist™, a tool designed to support computer-aided reporting systems, which will automatically display the recommendations at the point of image interpretation. ACR Assist will enable such reporting systems to recognize when the radiologist describes an incidental pancreas nodule, for example. Once the radiologist enters the size of the nodule, the reporting system will automatically couple that information with the patient’s age, medical history, and risk factors. It will then display the recommendations for managing that specific incidental finding. “As time goes on and the recommendations are more refined, they will be integrated into our dictation systems and will automatically pop up based on the radiologist’s description of the finding,” Berlin explains.
“We must differentiate between the findings where action is going to benefit the patient versus the ones in which action may lead to unnecessary biopsies or surgeries.”
— Lincoln L. Berland, MD, FACR
Pari V. Pandharipande, MD, MPH, director of the Massachusetts General Hospital Institute for Technology Assessment and chair of the ACR Committee on Incidental Findings, says that once the recommendations are integrated into dictation systems and more radiologists use them, it may be possible to track how these findings impact patients in the long term. “These data have the potential to substantially benefit the way we practice by allowing us to shape our recommendations in response to patient outcomes,” she notes. They may also increase the possibility of standardizing the management of incidental findings across the country so that a patient with an incidental finding detected in one center, in one part of the country, would receive the same care in a completely different practice setting, Pandharipande says.
In addition to improving the existing recommendations and increasing their accessibility, the Committee on Incidental Findings is developing recommendations for the chest and other body regions that are not addressed in the existing papers. All of the recommendations will likely evolve over time as physicians research the recommendations’ impact on patient care and gain a better understanding of incidental findings overall. “Every recommendation in medicine is subject to change with increasing medical knowledge,” Berlin says. “These recommendations are here to stay, but they will continue to evolve along with the rest of medicine.”
Learn More at ACR 2015
Radiologists attending the annual meeting can explore the challenges, controversies, and recommendations associated with incidental findings. Don’t miss the session entitled “Recommendations for Incidental Findings on CT and MRI: How Useful, How Dangerous, and How to Make Them Work.” The panel discussion will be led by Lincoln L. Berland, MD, FACR, professor emeritus in the department of radiology at the University of Alabama at Birmingham and chair of the ACR Commission on Body Imaging; Jonathan W. Berlin, MD, MBA, FACR, radiologist at North Shore University Health System and clinical professor of radiology at the University of Chicago Pritzker School of Medicine; and Mark A. Baker, MD, FACR, diagnostic radiologist at the Cleveland Clinic.
And Read This Too
The JACR rounded up their most popular articles on incidental findings.
By Jenny Jones, freelance writer for the ACR Bulletin