3.1. Factors to Refer PC Patients for Imaging
Question number 48 was, “Which factors are likely to influence your willingness to refer a patient for an imaging procedure, assuming that availability is not limited?”, and panelists were asked to choose all that apply. Results are reported in
Table 1.
Before moving to further consideration, it is necessary to clarify some possible implications deriving from this question (number 48), as well as from the next (number 49). Some of the answers, and in particular “personal relationship” and “personal experience”, may raise an ethical issue. If a “personal relationship” between a medical professional and the imaging professional has the ability to influence the outcome of the patient care, then we could have a major ethical violation. However, this was not the meaning of the answers and rather referred to professional trust that is developed when you personally know the imaging specialist and you are used to personally contacting him in case of any doubtful findings. Wording may seem somewhat vague, and therefore it is important to emphasize that all questions were reviewed and approved by all panelists, before being submitted, and no ethical concern was raised. The main reason to offer those possible answers was related to awareness that doctors may prescribe imaging exams not recommended by guidelines, for nonscientific reasons [
26], and we were aimed at evaluating such possibility.
The panelists considered all the possible factors as potential influencers, but some of them were chosen by a small minority. In particular, the personal relationship with imaging professionals was regarded as a possible influencer by less than 20% of the panel. This indicates strong independence from a factor that may have either positive or negative implications.
Indeed, the personal relationship does not have much scientific value. It may be speculated that long-lasting collaboration may result in a fruitful professional relationship. Nonetheless, this factor seems less reliable than others. Surprisingly, the out of pocket cost of the examination for the patient gained the same low percentage of votes, while being a more relevant factor for appropriateness. It could be speculated that the experts regarded as minor the expense of an imaging procedure as compared with the overall costs of treatment. Further considerations regarding patient preference are detailed in question number 51 (see below).
A relatively low number of votes was also scored by the influence of the prescriber’s personal experience, confirming that all the factors relating to nonscientific data were regarded as less relevant. Indeed, the first three answers are clearly related to objective scientific facts and gained a clear preference among the experts, while the two answers relating to individual personal perception did not obtain many votes. Factors relating to patient perspective scored somewhere in between. These results are in line with a scientifically oriented approach of the panelists, who clearly preferred rational, evidence-based factors to less measurable issues.
Question number 49 was as question 48, but in this case, panelists were asked to choose one answer only: results are reported in
Table 2.
When it comes to identifying the most relevant factor among the many proposed, there was a clear winner in data from scientific literature. Please note the sum of percentages is greater than 100% because several panelists, despite the question explicitly asking them not to, chose more than one answer. A formal consensus was reached regarding the most relevant factor (data from scientific literature), with almost 82% of the panelists voting for it. This consensus is in line with the principles of EBM (Evidence-based medicine) which consider scientific articles published in peer-reviewed journals as the most valuable source of evidence to decide whether to use a certain imaging procedure or not.
The panelists also considered incorporation into guidelines as a relevant factor, but to a minor extent. It should be mentioned that data from the literature is the prerequisite for proper incorporation into guidelines. Therefore, this factor implies the existence of the previous and most selected factor. The impression is that experts tend to prefer their own evaluation of original articles over guidelines, given that guidelines are only updated several months later.
There is much debate about the problems of timing required to have a new imaging method incorporated into PC guidelines. Previously, before the development of an EBM culture, conventional imaging methods such as CT and BS were incorporated without any formal evaluation of the positive effects on patient outcome. In the 1970’s, these methods were simply introduced and rapidly considered mandatory without a specifically designed clinical trial being undertaken. Thirty years later, rapid developments in the field of imaging still pose issues for guideline development. Indeed, new methods such as MRI and PET are available and have been adopted in clinical practice before evidence-generating clinical trials have been performed, resulting in a significant increase in their use. With the growth of medical imaging, the concern that not all examinations are necessary has increased, and it is argued that up to 40% of diagnostic imaging studies may be inappropriate
17-18. Furthermore, as mentioned, there are intrinsic problems in building EBM literature for diagnostic imaging
11 and this fact has led to significant disagreement in the field of PC imaging. At the Advanced Prostate Cancer Consensus Conference held in St. Gallen there was no consensus on most questions relating to advanced PC imaging [
27]. The problem of reliability in the sources of recommendations was further investigated in the next question.
3.2. Source of Recommendations
Question number 50 was, “Which recommendations are more relevant for you when prescribing an imaging procedure?”: results are reported in
Table 3.
There could be several reasons why a minority of the panelists chose the option of EBM/Health Technology Assessment-promoted guidelines. Firstly, in the area of prostate cancer, there is a complete lack of such guidelines, and the panel was surely aware of that even if the question did not focus on PC. A more general reason might be the resistance of clinicians to guidelines developed outside their professional control. See also question no. 54.
It is interesting to note that experts regard published studies as the most reliable evidence to influence their willingness to refer a patient for imaging (see question no. 49). On the other hand, EBM guidelines resulting directly from scientific data review are perceived as less reliable than scientific society guidelines.
It is noteworthy that not a single panelist considers local healthcare recommendations as relevant. Once again, this result could relate to the composition of the panel, which is made up of clinicians selected on the basis of their international reputation. This means they may not be keen to adhere to local rules that often tend to limit access to expensive and innovative imaging methods.
3.3. Patients’ Preferences
Question number 51 was “Which part of patients’ preference are you considering when prescribing an imaging procedure?”, and panelists were asked to choose all that apply: results are reported in
Table 4.
The suggested answers to this question were slightly tricky because only the first four are genuinely related to patient preference and the fifth (accuracy of the procedure) relates to a scientific point of view. Indeed, it was this answer that received the largest majority of preferences (almost 82%), with the others being selected, but not to such a great extent. It is clear that this finding is related to the paternalistic approach of doctors to patients. When a final decision has to be taken, all patient preferences are duly taken into account, but the most relevant factor remains purely scientific evidence. In other words, the doctor is deciding in favor of the best diagnostic option, the value of which is more important than other factors.