Bone scan controversy

Bone scans are routinely over-prescribed. Not only do unnecessary bone scans raise the cost of health insurance for all of us - a cost I am acutely aware of with my health insurance plan raising my premiums by over $100/mo - but they can be dangerous to one's health.

Based on the AUA guidelines, a bone scan is recommended with localized disease when the serum PSA level is >20 ng/mL or GS≥7, or if there is clinical evidence of bone metastasis. This guideline is estimated to miss <1% of positives, and would reduce negatives by about 40%. In spite of such a clear, evidence-based guideline, bone scans are routinely ordered for low and intermediate risk disease. In a recent analysis of the SEER-Medicare database, 45% of low risk men received inappropriate imaging, and a third of high risk men did not receive appropriate imaging.

A bone scan detects areas of active bone turnover - not necessarily tumors. It also shows areas of inflammation, trauma, fractures, infections, arthritis, etc. Because it is not specific to cancer, there is a very high rate of false positives. Even when the AUA guidelines are followed, the false positive rate is about 20%. In fact, it is impossible to know just from a bone scan whether a lesion is cancerous or not. It has to be confirmed by biopsy, or further imaging studies. CTs and MRIs are usually used to investigate whether anything further can be seen (often they are inconclusive as well). PET scans can identify whether they are metabolically active (often a hallmark of cancer). Many of the follow-up PET scans are not covered by insurance. Follow-up bone scans can sometimes demonstrate growth of the suspicious lesions, sometimes not. A very good diagnostic test is to see whether ADT reduces the lesion, but that may force a man with low risk PC to unnecessarily undergo all the side effects of hormone therapy.

So why do I call inappropriate bone scan dangerous? Firstly, they may unnecessarily increase the anxiety of the already anxious patient, which is never good for one's health and wellbeing. The high possibility of false negatives may lead to harmful and inappropriate treatments for a disease that is not really there. I know that Lupron Jim has a lot to say on this subject. It may also cause delay in receiving appropriate treatments, and force one to have very expensive and anxiety-producing follow-up testing. I know super max will have a lot to say on this subject.

- Allen

This is a great topic you bring up, TA. The first bone-scan of my father was inconclusive. The MRI "confirmed" the reading of the bone scan, but still even with an MRI result, a radiation oncologist we consulted expressed some doubt.

And this anxiety-producing testing is not limited to bone-scans. Some years ago I had an MRI scan that showed unusual spots that turned out to be an MRI artifact. A few months ago, an acquaintance underwent lung-nodule removal based on the worsening scans. The lung nodule turned out to be harmless. People need to be aware of the downsides or even as you mention, dangers of these scanning techniques.

Who is super max?

Also, one thing is confusing me. You say:
"Based on the AUA guidelines, a bone scan is recommended with localized disease when the serum PSA level is >20 ng/mL or GS≥7, or if there is clinical evidence of bone metastasis." Then later you say: " In spite of such a clear, evidence-based guideline, bone scans are routinely ordered for low and intermediate risk disease. "

Well, according to the guidelines you posted, a GS = 7 is sufficient to warrant a scan. But this is intermediate risk disease. What am I missing?

Mel

I asked about a bone scan early on. My URO said, it was unlikely to show anything useful but if I really wanted a base line, they'd order the test. Since I am on Kaiser, there no discussion of the cost but clearly the HMO wasn't interested in spending more money on me than needed. My RO outright dismissed the notion of doing a bone scan since he had to a CT of abdomen anyway to set up the IGRT program. He felt that was more than enough imaging in an intermediate risk case like mine.

There is a tendency in our medical system to over test and over treat.

Mel said...
Well, according to the guidelines you posted, a GS = 7 is sufficient to warrant a scan. But this is intermediate risk disease. What am I missing?

The NCCN risk stratification system classifies intermediate risk as GS7 or PSA 10-20 or T2b or T2c. So, for example, if your PSA is 15 and you are GS6 and T1c, you are classified as intermediate risk, but would not be recommended for a bone scan under the AUA guidelines.

- Allen

Actually, all this talk about rampant bone scanning makes me feel rather left out, never having had one. Just something I'll have to live with, somehow.

Nice skew, but I believe the point is that a gl7 is intermediate disease, I think, and there are many gl7, probably diagnosed with a psa in single digits. Me for an example, and yes I had a useless bone scan by protocol. I agree with your point on over use and as I posted on another thread the trend is moving away. I believe my lack of evidence to that point is as solid as your sketchy "evidence" to yours In proving a point that I totally agree with but for different reasons,which I won't go into as I am more of a caveat emptor type, than agenda based. Not that there's anything wrong with that. We have had discussions early on, on your "evidence" based posts. You consider studies as evidence... I do not and will not go there again. It would be nice if you answered compilers post to the point I made in the beginning of this post. But icy mach nix to me, If compiler is happy with it, we can leave it at that. I personally think you use the term "evidence based" loosely, but hey this a forum, of patients, not doctors and we all should recognize that and be very careful in pushing the envelope in our self imposed and/or peer imposed certification of knowledge. Being a great researcher/advocate is a different animal, than the pushed envelope indicates. But hey thats my opinion among many opinions on this forum. Again caveat blah blah

Mel - yes, the guidelines would call for a G7 to get a scan.

personally I am not sure that scanning with lower PSAs at G7 is worth it, but then I've never looked at any hard data.

Andrew

Compiler, nor was I. Its a forum, its cool to agree to disagree. If there was anything that could be considered untoward to Allen, I see only " self-imposed and/or peer imposed ", as a possibility to some, but the term "and/or" negates that. And even if it wasn't there, there is no evidence to suggest the phrase was pejorative , unless some one views it that way. Something I have no control over, nor do I want. The folks here are adults and make there own decision. If there was 100% agreement that it was pejorative, it would change nothing. It would just mean that they disagree with me. I suppose I could have salved any possible misunderstanding, but thats what clubs do. Frank discussions are the norm in all arena's of society. No boundary was crossed. It is my opinion that a certificate of knowledge that pushes the envelope dangerously has been issued. No evidence that Allen did. Only he would know that. The same is not true of a peer issuance. My opinion is that the issuance is not warranted. Nothing more nothing less. My posts are meant to address not just the a single poster but all, especially new folks. I believe Allen is a great asset to the forum, truly.

Mel, in the other thread, Tall Allen referenced me to his support group as the poster child for the danger of bone scans.

The danger was not any excess radiation but rather a mis-diagnosis by a rural Florida imaging firm not accustomed to anything but slips and falls scans. They wrongly deemed me to have had bony mets, but not lymph node involvement.

It was not until I had the less subjective F18 sodium scan by Dr. Fabio Almeida at AZ Moilecular Imagining in Phoenix that the bony mets were negated and there was a suspicion of lymph nodes. I had the C-11 Acetate scan that confirmed I had 3 micro lymph nodes all contained in pelvic area.

The PSA threshold is normally >=2.0 for a C-11 Choline at Mayo that is covered by Insurance or for a C-11 Acetate that is $2500 out of pocket (would have been $3,000 if not done the same week as F-18).

It's highly likely the Lupron I have been taking since 3-28-13 is masking some more mets be that bony or LN, but it would take months to wean off the half-life of Lupron even after the 4-months expired. Though this would eventually cause the PSA to rise, it might also cause to mets to increase in size or quantity, a risk I was not willing to take.

My ratioale was that the SBRTwould zap the mets even if the scans could not see them.

So I was downgraded from state IV treatabel to not cureable to stage 3 potentially cureable with radiation. So that is how I came to follow Tall Allen's sage advice on SBRT and Provenge to leverage the abscopal effect

prostate-cancer.org/abscopal-effect/

LupronJim

I related to Allen yesterday the problems I'm having with a bone scan. So here's the short story for anyone interested.

I'm heading towards a treatment decision soon, and my oncologist referred me for a bone scan at a local lab. I blindly went along and had the scan performed this week. The initial report was pretty scary to me, indicating multiple skull and rib mets. A 2nd reading from the same facility reported "low-suspicion for metastases", and my oncologist sent the scan out for a reading by yet another radiologist.

Yesterday I had a consultation at UCLA and the doctor said I had "opened Pandora's box" by getting what he felt was an unwarranted bone scan. Now that there is even a suspicion of mets the scan can't be ignored and has to be clarified. This means the possibility of another bone scan, this time at UCLA, or even a skull x-ray. And any treatment decision is delayed while this gets resolved.

I was expecting a bone scan to be a pass/fail type of test, but like everything PC related it's very much open to interpretation. So even with a somewhat low and stable PSA, I'm now caught up in this new mess.

Allen,

We have to stop meeting like that!

My bone scan was "7.4 mCi NAF", so I assume that is the sodium fluoride PET we were discussing.
Scan is being sent to UCLA for another reading. Dr Marks wants the scan repeated at UCLA if still ambiguous.

My Gleason is now GS(3+4).

Thanks again for your help with this.

super max-

That's not a bone scan, it's a PET scan.(It may have been a PET/CT scan - UCLA offers NaF PET/CT scans) The term "bone scan" refers to a gamma ray picture taken after an injection of Technetium 99m, a gamma ray emitter. By contrast, most PET scans pick up positron emissions from any of several molecules that cancer uses in metabolism. A bone scan has a positive predictive value (PPV) of around 64% in high risk men (there is no data for low/intermediate risk men because it's almost always negative). This means that over a third of men who are told the bone scan was positive will actually turn out to be negative for bone mets. NaF PETs are a little better- their PPV goes up to about 74% - a quarter of men will get an erroneous reading.

The NaF PET is much better at detecting rib mets than mets elsewhere. In one study, its PPV was only 29% for skull mets --almost three-quarters of men told they have skull mets will turn out to not have them. Hopefully, that's the case for you, but now you have to go through a lot of trouble and anguish before you can breathe easy - the Pandora's Box.

I hope your experience will help others avoid such harms. It is very reasonable to ask doctors questions like:
• Why are you ordering this test?
• What are the risks/benefits associated with it?
• How might the test outcomes affect my treatment plan?
• What is the cost of this test?

Answers like "it's just to gather more info" is not a good enough answer in my opinion, and a full discussion of potential harms and benefits ought to be part of a shared decision-making process.

I hope this turns out to be nothing and you can get on with your treatment.

- Allen