title: Use of bone scan during initial prostate cancer workup, downstream procedures, and associated Medicare costs.
abstract: OBJECTIVE
  For patients with a high likelihood of having metastatic disease (high-risk prostate cancer), bone scan is the standard, guideline-recommended test to look for bony metastasis. We quantified the use of bone scans and downstream procedures, along with associated costs, in patients with high-risk prostate cancer, and their use in low- and intermediate-risk patients for whom these tests are not recommended.
  
  
  METHODS
  Patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with prostate cancer from 2004 to 2007 were included. Prostate specific antigen (PSA), Gleason score, and clinical T stage were used to define D'Amico risk categories. We report use of bone scans from the date of diagnosis to the earlier of treatment or 6 months. In patients who underwent bone scans, we report use of bone-specific x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans, and bone biopsy within 3 months after bone scan. Costs were estimated using 2012 Medicare reimbursement rates.
  
  
  RESULTS
  In all, 31% and 48% of patients with apparent low- and intermediate-risk prostate cancer underwent a bone scan; of these patients, 21% underwent subsequent x-rays, 7% CT, and 3% MRI scans. Bone biopsies were uncommon. Overall, <1% of low- and intermediate-risk patients were found to have metastatic disease. The annual estimated Medicare cost for bone scans and downstream procedures was $11,300,000 for low- and intermediate-risk patients. For patients with apparent high-risk disease, only 62% received a bone scan, of whom 14% were found to have metastasis.
  
  
  CONCLUSIONS
  There is overuse of bone scans in patients with low- and intermediate-risk prostate cancers, which is unlikely to yield clinically actionable information and results in a potential Medicare waste. However, there is underuse of bone scans in high-risk patients for whom metastasis is likely.
authors: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors: Aaron D
authors: AD
authors: Falchook
authors: Department of Health Services Policy and Management, University of South Carolina, Columbia, South Carolina.
authors: Ramzi G
authors: RG
authors: Salloum
authors: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors: Laura H
authors: LH
authors: Hendrix
authors: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Electronic address: ronald_chen@med.unc.edu.
authors: Ronald C
authors: RC
authors: Chen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy / Q000191:economics / Q000706:statistics & numerical data; D001859:Bone Neoplasms / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology / Q000473:pathology / Q000556:secondary*; D001842:Bone and Bones / Q000000981:diagnostic imaging / Q000473:pathology; D003362:Cost-Benefit Analysis; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D006278:Medicare / Q000191:economics*; D060787:Neoplasm Grading; D011467:Prostate / Q000473:pathology; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000097:blood / Q000191:economics / Q000473:pathology; D012306:Risk; D018426:SEER Program; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000706:statistics & numerical data; D014481:United States; D019564:Unnecessary Procedures / Q000191:economics* / Q000706:statistics & numerical data
chemical_list: D017430:Prostate-Specific Antigen