title: Imaging for appendicitis: should radiation-induced cancer risks affect modality selection?
abstract: OBJECTIVE
  To compare life expectancy (LE) losses attributable to three imaging strategies for appendicitis in adults-computed tomography (CT), ultrasonography (US) followed by CT for negative or indeterminate US results, and magnetic resonance (MR) imaging-by using a decision-analytic model.
  
  
  METHODS
  In this model, for each imaging strategy, LE losses for 20-, 40-, and 65-year-old men and women were computed as a function of five key variables: baseline cohort LE, test performance, surgical mortality, risk of death from delayed diagnosis (missed appendicitis), and LE loss attributable to radiation-induced cancer death. Appendicitis prevalence, test performance, mortality rates from surgery and missed appendicitis, and radiation doses from CT were elicited from the published literature and institutional data. LE loss attributable to radiation exposure was projected by using a separate organ-specific model that accounted for anatomic coverage during a typical abdominopelvic CT examination. One- and two-way sensitivity analyses were performed to evaluate effects of model input variability on results.
  
  
  RESULTS
  Outcomes across imaging strategies differed minimally-for example, for 20-year-old men, corresponding LE losses were 5.8 days (MR imaging), 6.8 days (combined US and CT), and 8.2 days (CT). This order was sensitive to differences in test performance but was insensitive to variation in radiation-induced cancer deaths. For example, in the same cohort, MR imaging sensitivity had to be 91% at minimum (if specificity were 100%), and MR imaging specificity had to be 62% at minimum (if sensitivity were 100%) to incur the least LE loss. Conversely, LE loss attributable to radiation exposure would need to decrease by 74-fold for combined US and CT, instead of MR imaging, to incur the least LE loss.
  
  
  CONCLUSIONS
  The specific imaging strategy used to diagnose appendicitis minimally affects outcomes. Paradigm shifts to MR imaging owing to concerns over radiation should be considered only if MR imaging test performance is very high.
authors.affiliation: From the Massachusetts General Hospital Institute for Technology Assessment, 101 Merrimac St, 10th Floor, Boston, MA 02114 (S.K., L.M., J.D.E., M.H., C.Y.K., P.V.P.); Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand (S.K.); Department of Radiology, Massachusetts General Hospital, Boston, Mass (L.L.A., C.Y.K., P.V.P.); and Harvard Medical School, Boston, Mass (C.Y.K., P.V.P.).
authors.forename: Sorapop
authors.initials: S
authors.lastname: Kiatpongsan
authors.forename: Lesley
authors.initials: L
authors.lastname: Meng
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Eisenberg
authors.forename: Maurice
authors.initials: M
authors.lastname: Herring
authors.forename: Laura L
authors.initials: LL
authors.lastname: Avery
authors.forename: Chung Yin
authors.initials: CY
authors.lastname: Kong
authors.forename: Pari V
authors.initials: PV
authors.lastname: Pandharipande
mesh_terms: D001064:Appendicitis / Q000175:diagnosis* / Q000453:epidemiology*; D003657:Decision Making; D003952:Diagnostic Imaging; D005260:Female; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D009381:Neoplasms, Radiation-Induced / Q000453:epidemiology* / Q000517:prevention & control*; D015995:Prevalence; D012306:Risk; D012680:Sensitivity and Specificity