APPROPRIATE USE OF BONE SCINTIGRAPHY

Appropriate use criteria (AUC) for bone scintigraphy to aid in the diagnosis of bone metastases in cancer patients have been issued by the Society of Nuclear Medicine and Molecular Imaging (SNMMI) in an effort to help physicians fulfil the requirements of the 2014 Protecting Access to Medicare Act (PAMA), which comes into effect at the beginning of next year.

The new recommendations, which are limited to prostate and breast cancer, were published online April 6 in the Journal of Nuclear Medicine.

"Beginning January 1, 2018, PAMA will require referring physicians to consult AUC developed by a provider-led entity to ensure cost-effective and appropriate utilization of advanced diagnostic imaging services," the SNMMI explained in a statement.

"As new regulations take effect requiring referring physicians to consult clinical decision support tools before ordering bone scintigraphy, access to this important technology may become severely limited unless AUC are written for inclusion of this test as an option in clinical decision support tools," the AUC authors comment.

The document was developed by experts from the SNMMI, the European Association of Nuclear Medicine, and the American Society of Clinical Oncology.

Their expert opinion was complemented by a review of published evidence carried out by the Oregon Health Science University's Evidence-based Practice Center.

Bone Scintigraphy in Prostate Cancer Patients

Applying expertise and evidence first to the management of prostate cancer, the authors tailored their recommendations to a variety of clinical scenarios for which AUC indicated whether imaging was appropriate or not.

Bone scintigraphy was judged to be rarely appropriate for use as initial staging for asymptomatic patients in the following scenarios:

• Patients with normal alkaline phosphatase levels, a prostate specific antigen (PSA) level <10 a="" and="" gleason="" i="" score=""> "This scenario represents a very low risk for metastasis of prostate cancer to bone prostate cancer," the AUC authors note, "and therefore patients fitting this clinical picture are unlikely to have true-positive bone scintigraphy results."
• Patients with a PSA <10 and="" cancer:="" gleason="" i="" nbsp="" prostate="" score="" t2="">This scenario again applies to a very-low-risk group of patients who are unlikely to ever have findings that are positive for bone metastases on a bone scan.

Several scenarios warranted a may be appropriate approach for initial staging in asymptomatic patients. These included the following:

• Patients with elevated alkaline phosphatise level, PSA <10 a="" and="" gleason="" i="" nbsp="" score="">An elevated alkaline phosphatase can be caused by bone metastases, but a low PSA level and Gleason score suggest these patients are still at low risk.
• Patients with PSA = 10 - 20 or a Gleason score =7. "Bone imaging may be appropriate in those with a predominantly Gleason 4 pattern," the experts concur.
• Patients with PSA < 10, Gleason score =7, and T2 prostate cancer: Especially if the tumor exhibits a dominant Gleason 4 pattern, the experts felt there is enough of a chance that patients have bone metastases to warrant a bone scan despite other low-risk features.

Use of bone scintigraphy as initial staging was judged to be appropriate in many other clinical scenarios, many of which involved symptomatic patients.

Bone Scintigraphy in Breast Cancer Patients

"Like prostate cancer, breast cancer does not require bone scintigraphy in all patients at the time of diagnosis," the AUC experts note.

"Unless there are signs or symptoms suggesting metastasis in early-stage disease, bone imaging is not necessary," they add.

Bone scintigraphy was judged to be rarely appropriate or may be appropriate for patients with prior F-FDG PET/CT studies in the following scenarios:

Bone scintigraphy used primarily for initial staging but also for restaging is considered appropriate in the following scenarios:

"It is hoped that this evidence-based expert guidance will help make the use of bone scintigraphy more consistent and improve healthcare outcomes for the intended patient population while minimizing unnecessary imaging costs," the AUC authors write.

"Integration of an AUC into clinical decision support tools can assist healthcare providers and offer a way to track comparisons between the AUC model and the payer's reimbursement policy," they add.

The work group members have disclosed no relevant financial relationships.

J Nucl Med. Published online April 6, 2017. Full text