Individual Health Assessment using CT – UK perspective

Dr Giles Maskell

WHO consultation

Munich October 2014

Declaration of interests

• Member COMARE 2005-2013

• Chair, Dept of Health (England) working party on justification of CT for IHA 2010-2014

• President, Royal College of Radiologists

• Employer – Royal Cornwall Hospitals NHS Trust

• Expenses - personal

2007

2014

https://www.gov.uk/government/uploads/system/uploads/

attachment_data/file/304607/COMARE12thReport.pdf

COMARE 12th report

Recommendation 2:

COMARE 12th report

Recommendation 5:

https://www.gov.uk/government/uploads/system/uploads/

attachment_data/file/326572/IHA_-_June_Report.pdf

Terms of reference

• Consider the recommendations of the COMARE 12th report and the evidence on which they were based

• Consider any new evidence, specifically for the use of CT in lung disease, colonic and coronary heart disease in asymptomatic individuals

• Advise on the circumstances in which CT scanning for IHA can be justified on currently available evidence

• Alert the DH to areas in which the evidence base is uncertain or incomplete and early review of any recommendations is likely to be needed

Working party membership

• Dr Giles Maskell (chair)

• Dr David Baldwin chest physician

• Mr Steve Ebdon-Jackson physicist

• Dr Chris Gibson physicist

• Prof Fergus Gleeson chest radiologist

• Dr Steve Hughes gastroenterologist

• Dr John Reid cardiac radiologist

• Dr Nick Summerton GP

• Prof Stuart Taylor GI radiologist

• Mrs Helen Warner lay member

• Dr Mark Westwood cardiologist

The importance of language

“screening”

versus

“Individual Health Assessment”

“Screening”

• Public Health

• Part of an organised programme

• A national or regional body has assessed the potential benefits for the population as a whole and compared them with any detriments and costs

• A strong evidence base is required for the net positive effect of the programme

• Processes are put in place to ensure that quality is maintained

• Information from the programme is included in any subsequent care pathway for the detected disease, for the population and for the individual

“Individual Health Assessment”

• Individual not population

• Outside mainstream healthcare system

• Evidence base, quality assurance, arrangements for transfer of information into established care pathways and assessment regarding net benefit not conducted to same level

Other issues for IHA

• The extent of information provided to clients before examination (including rates of false positives etc)

• Detail provided of risks associated with further investigations

• Support provided when scans are positive or indeterminate

• Potential reinforcement of unhealthy lifestyles when scan is negative

• Arrangements for transfer of data into health record

• Mechanisms in place to develop an evidence base for justification of CT in IHA

• Relationship between referrer and practitioner who justifies examination

• Impact on the wider healthcare system

The problem with the evidence

Most of it comes from population screening programmes and it is generally unclear how or whether it can be translated to IHA

Lung disease

Colonic disease

Cardiac disease

Lung disease – special considerations

• CT screening for lung cancer has been shown to reduce mortality in the USA but the case for screening in the UK has not yet been accepted (pending results of further studies)

• Trials of lung cancer screening have included only individuals with a higher than average risk of having cancer

• High but variable prevalence of pulmonary nodules

• Costs of follow-up investigation

• integration into healthcare records and co-ordination of follow-up

• Radiation dose 0.5-1.5 mSv

IHA CT for lung disease - recommendations

1. Should not be offered to people under age of 55

2. Should not be offered to people who have never smoked or those with a pack history of less than 20 years with no other risk factors

3. Individual risk prediction models should be used. IHA CT may be used if the risk of lung cancer is 5% in 5 years.

4. Should only be offered by expert clinicians, able to explain the risks and benefits

5. information on the limitations, risks and benefits should be provided in lay person’s language to clients before undergoing CT scanning

IHA for colonic disease – special considerations

• NHS BCSP uses FOBt followed by colonoscopy. CT only for those unfit or unsuitable for colonoscopy.

• Considerable evidence for utility of CTC in detecting polyps >6mm in unselected asymptomatic individuals

• 2008 joint guideline from American Cancer Society, ACR and US Multi-society Task Force on Colorectal Cancer recommends CTC every 5 years in asymptomatic average risk individuals over age 50.

• Impact of extra-colonic findings remains uncertain

• Radiation dose 5-7 mSv

IHA CT for colonic disease - recommendations

6. CTC for IHA should not be undertaken below age 45

7. Individuals with negative CTC or polyps less than 6mm in size should not undergo further CTC for IHA in less than 5 years

IHA CT for coronary heart disease – special considerations

• CT calcium scoring and CT coronary angiography have established roles in risk stratification of patients presenting with chest pain

• There are no trials assessing utility of these tests in a formal screening programme

• Incidental findings – frequent but very rarely significant

• Radiation dose highly variable. With optimal equipment and technique 1-2 mSv is achievable

IHA CT for cardiac disease - recommendations

8. A clear pathway should be in place to deal with both the consequences of identification of cardiovascular risk and the possibility of incidental findings. The pathway should preferably be overseen by a cardiologist.

9. CT coronary angiography for IHA should not be offered without the involvement of a cardiologist

10. CTCS could be offered to asymptomatic individuals over age 45 with a pre-test risk of significant coronary artery disease of greater than 10% (based on NICE CG 95 2010)

11. Repeat assessment should not be performed within 5 years of a previous normal scan

Final thoughts

• There is very little evidence specific to IHA

• What level of evidence should be required?

• The recommendations presented here are the result of expert opinion

Thank you very much