Today’s Science Is Tomorrow’s Clinical Practice
Exploring radiology's central role in the age of precision medicine.
In March, I had the pleasure of attending the Massachusetts Radiological Society (MRS) meeting. Phillip M. Devlin, MD, FACR, MRS president, was a wonderful host, and the meeting was outstanding.
It was the second time I have attended the MRS meeting, and each time I have been impressed with the chapter’s commitment to education, awareness of practice management issues, prioritization of political involvement, and commitment to advocacy. (Read more about the chapter at http://massrad.org.)
Most importantly, the relationship between the chapter and residents is exemplary. The chapter sponsors numerous educational activities for the residents during the year, including an evening where fellows and more senior chapter members show first-year residents cases they wish they had seen before taking call. Other events provide business and practice management training for residents that they do not get as part of their residency training.
The highlight of the evening was a lecture by the former chair of the radiology department at Massachusetts General Hospital, James H. Thrall, MD, FACR, who is also former ACR president and former ACR board chair. During his presentation, “Looking Forward: Radiology in the Age of Precision Medicine,” Jim discussed how, even before we become fully transitioned from experience-based practice to evidence-based practice, science is on a path to take us to a level where medical care will become more precise and personalized based on the phenotype or genotype of our patients and their diseases. In essence, we will be able to use biomarkers to classify our patients into subpopulations that differ in their susceptibility to a particular disease or response to a specific treatment. Imaging will play a central role because it will likely be imaging that detects the earliest stages of a disease process in high-risk patients. During treatment, imaging findings will become biomarkers for responsiveness to therapy. The ability to identify the subsets of patients who are most likely to benefit, or not benefit, from often expensive or toxic therapies will continue to make imaging invaluable to the health care system and to society.
So as I am sitting in Boston, listening to Jim’s fabulous rundown of the current research and scientific thinking about precision medicine, I begin to wonder not only about what this means for me in my clinical practice in Birmingham, Ala., but also, wearing my ACR board chair’s hat, about what it means for all of us in our new era of health care reform. I’ll begin with the latter. The American Recovery and Disabilities Act (H.R. 1 of 2009), a.k.a. the Stimulus Package, passed by Congress a year before the Affordable Care Act, set the tone for policy-makers’ thinking about medical research. The act provides $1.1 billion in funding for medical research through the Patient Centered Outcomes Institute. Health reform has brought with it a value proposition for medical providers: treatment decisions should be based on the likelihood of benefit, and the likelihood of benefit should be informed by the evidence. The marching orders from those who will fund our research are not just about “Can we do it?” but are more about “Should we do it?” This has been termed by many as comparative effectiveness research, but for most of us it means cost effectiveness research. Screening for lung cancer with low-dose computed tomography is an example of this. Were we as a society to undertake screening all patients at risk for lung cancer, the cost per life year saved would be millions of dollars. However, when we use a crude biomarker to define a population subset at high risk for disease (such as a 30 pack-year smoking history), screening for lung cancer makes much more economic sense. As a result, based on the ACR Imaging Network– sponsored National Lung Screening Trial, the U.S. Preventive Services Task Force has recommended coverage for lung cancer screening. Eventually, the identification of genetic or molecular biomarkers will direct even more targeted imaging, further expanding the indications for the appropriate use of medical imaging.
These are exciting times. Every New Years’ Eve we proclaim, “Out with the old and in with the new!” as a way of showing our enthusiasm for the year ahead. As I think about what precision medicine means for our clinical practices, I am equally excited. Precision medicine will expand the indications for the appropriate and scientifically based use of medical imaging. And that means we will be doing more of the work that matters most to our patients.
To prepare for the onslaught and the inevitable pressure on reimbursement that will be associated with increased utilization (even when beneficial to patients), we need to embrace the use of appropriateness criteria and clinical decision support in our practices. This is integral to help ensure that the care we provide is the care that matters.
Incorporating precision medicine into our practices will demand other adjustments as well. The 2013 ACR Forum, themed “The Future of Imaging Biomarkers in Clinical Practice,” detailed the direction we need to take. (Find out more about forum at http://bit.ly/JACR2013Forum.) Whether we like it or not, standardization in our examination processes and in our reporting will be necessary. The Quantitative Imaging Biomarker Alliance, a multidisciplinary group convened by the RSNA, is defining the optimal use of quantitative imaging and bioinformatics in research and in routine clinical care. Ultimately, radiologists will need to move away from the radiology-centric vernacular we use in our reporting and toward standardized language. This is particularly important when the language radiologists use differs from that used in the rest of medicine. There will be opportunities for organized radiology to participate collaboratively in supporting research, reporting standards, education, and economic and political advocacy to facilitate the translation of the science to clinical practice.
Integration of imaging biomarkers and precision medicine into clinical practice will be a cornerstone of the value radiologists bring to the health care system and can be leveraged as we advocate for our specialty’s value-based initiatives in the future. So thanks, Jim, for this look into the future. I, for one, am excited.
By Bibb Allen Jr., MD, FACR, Chair