Follow-up Interview with Radiologist Who Cautions Against CT Scans

[Guest guest]

[First noted on nhl-info. CT scans may be done more often because

they generate more revenue for the hospital. Unethical? I'll let

you decide.

Note that a full-body MRI might be the coming thing for the 'worried

well' as well as those with an immediate concern.]

CT Scanning and Cancer: Why You, and Your Family, Are at

Risk, Part 2: An Expert Interview With C. Semelka, MD

Chevrier

Medscape Radiology. 2006;7(1) ©2006 Medscape

Posted 04/28/2006

Editor's Note:

Dr. Semelka's recent article " Imaging X-rays Cause

Cancer: A Call to Action for Caregivers and Patients "

(http://www.medscape.com/viewprogram/5063) has launched an

avalanche of email correspondence to Medscape from imagers

and patients. In this CME/CE article, Dr. Semelka postulated

that it is critical for radiologists and referring

physicians to scrutinize how often a patient is undergoing a

computed tomography (CT) study and whether magnetic resonance

imaging (MRI), in many settings, can replace CT.

In Part 2 of our interview with Dr. Semelka, he expands on

the points made in his CME article and postulates some

solutions for ensuring the appropriate and safe use of imaging

technologies.

Medscape: Dr. Semelka, given your hypotheses that CT

scanning carries a risk of cancer from radiation, where does

whole-body MRI fit in the imaging armamentarium at this point?

Dr. Semelka: Whole-body MRI is swiftly evolving. At this

point, there is a fair amount of interpersonal contact

between the radiologist interpreting the study, and the patient.

So in essence, whole-body MRI is becoming the de facto

physical examination for the new millennium.

Medscape: Radiologists interacting on a regular basis with

patients seems like a revolutionary proposition.

Dr. Semelka: It's absolutely a radical -- and necessary --

paradigm shift in the specialty, where heretofore,

radiologists spent most of their day reading out cases and

dictating reports. In the new radiology paradigm, the radiologist

will act as a primary care physician in working with the

patient directly to determine the best test to solve a given

clinical problem. That way, the financial incentive to

perform certain studies is eliminated, and the patient either

undergoes surgery or does not undergo surgery. The

radiologist is just involved in managing the patient's diagnosis.

Medscape: Please react to this hypothetical: In the next 5

years, the forward-thinking imaging center directors will

view whole-body MRI as a practice revenue enhancer. They

will have their radiologists start to use MRI as the focus of

" consultative radiology, " which will be patient focused and

patient driven. This approach will differentiate their

centers from others in the community, and patients will flock

to this new way of working with radiologists to take charge

of their health and healthcare.

Dr. Semelka: That's absolutely what I believe. And that's

the way it should be. Patients are becoming more and more

empowered; centers that focus on patient education and safety

will gain many new customers. I think that, in fact, we as

radiologists probably do patients a disservice by not

informing them of radiation risk associated with certain imaging

modalities. I truly believe that it's incumbent on the

radiologist to inform patients when they come for a procedure

of the risk inherent in that imaging choice. Patient welfare

is the ultimate starting point. And, if CT scanning,

especially in children, has a higher risk than equivalent or

perhaps even superior diagnostic studies such as MRI, I cannot

see how you can justify doing CT scans in certain settings.

Medscape: Let me play devil's advocate here for a second.

" I'm the CEO of a managed care company, and I believe that

CT is a state-of-the art test that has saved countless lives

through timely and accurate diagnoses. I don't want to pay

to have MRI studies performed. "

Dr. Semelka: I think that, in the short term, patients may

pay out of pocket for a safer procedure such as MRI, rather

than be exposed to the radiation associated with CT

scanning. Now, I am very sad at the potential prospect of what you

brought up that ultimately, all of the studies you know,

the high scientific studies that we've performed showing

superiority of the diagnostic abilities of MRI over CT, may

ultimately at some places not outweigh the fact that CT can be

done faster and make more of a profit for the institution.

Medscape: What about the business aspects of imaging,

especially for the free-standing private-practice radiology

centers; isn't it unrealistic to think these radiology groups

will adopt the more expensive MRI, which is harder to do

than whole-body CT scanning? In addition, CT scanning is a

great test and is a benchmark revenue stream for these sites.

And will the payers reimburse for the level of whole-body

MRI procedures that you are projecting? Can an already

overburdened healthcare system stand more whole-body MRI?

Dr Semelka: The specialty has to change how we order and

use CT scanning, despite the additional costs associated with

MRI. I hate to raise this, but the big stick for payers and

practitioners who persist in overusing CT will be an

avalanche of litigation.

If the pattern of overusing CT scans does not change, there

will be legal suits from patients who can trace their

cancers back to CT that will dwarf the tobacco lawsuits and

settlements. And the reason is, is that the science is all out

there, that radiation causes risk, and if you're not

informing the patients that they're undergoing a study that may

carry with it the risk of developing cancer, then I think

ultimately, my belief is that you're acting unethically. My

belief is also that you're legally responsible for informing

patients about radiation risk.

Chevrier, Editorial Director, Medscape Radiology