Best Practice & Research Clinical Endocrinology & Metabolism
Volume 26, Issue 1 , Pages 3-8, February 2012

Incidentalomas – A “disease” of modern imaging technology☆

  • Jennifer Wagner, PhD

      Affiliations

    • Midwest-Mountain Veterans Engineering Resource Center, VA Nebraska Western Iowa Health care System, Omaha, NE, USA
    • ,
  • David C. Aron, MD, MS

      Affiliations

    • VA HSR&D Quality Enhancement Research Initiative Center for Implementation Practice & Research Support (CIPRS), Louis Stokes Cleveland, USA
    • Dept. of Veterans Affairs Medical Center 14(W), 10701 East Boulevard, Cleveland, OH 44106, USA
    • Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine, Cleveland OH 44106, USA
    • Corresponding Author InformationCorresponding author. Dept. of Veterans Affairs Medical Center 14(W), 10701 East Boulevard, Cleveland, OH 44106, USA. Tel.: +1 216 421 3098.

Article Outline

The evolution of new diagnostic techniques has revolutionized the practice of medicine and in fact, the nature of medicine itself. Technology has also expanded the “visual” field of medicine: the naked eye was assisted by the light microscope and then electron microscope to see smaller and smaller features while radiology has permitted “non-invasive” identification of internal structures. However, there are unintended consequences one of which is the discovery of an anomaly during the course of looking for something else – incidental findings and incidentalomas. Technology in general and imaging specifically offer much in service to physicians and their patients. However, it behoves physicians to ensure that technology supplements but does not replace good clinical judgment. This essay aims to put the issue of incidental findings related to advancing technology (especially imaging technology) into a broader context.

Keywords: imaging technology, magnetic resonance imaging, CT scanning, unintended consequences, social studies of medicine

 

In his famous book on diseases of the pituitary gland, written in 1912, Cushing described “Minnie G,” a patient thought to have a “peculiar polyglandular syndrome” now known to be the syndrome that bears Cushing’s name.1 Although within two decades such patients were thought to have basophilic adenomas of the pituitary, surgical exploration was the only reliable technique to confirm anatomic diagnosis in the living patient. Preoperative identification of the disease relied almost exclusively on the physician’s bedside skills and clinical acumen for diagnosis. Neuroradiology was in its infancy. A century later, the evolution of new diagnostic techniques has revolutionized the practice of medicine and in fact, the nature of medicine itself.

To quote Carl Mitcham, philosopher of technology: “Medicine is increasingly defined by the type and character of its instruments (from stethoscope to high-tech imaging devices) and the construction of special human–artifact interactions (synthetic drugs, prosthetic devices). Indeed, the physician-patient relationship, medical knowledge, and the concept of health are all affected by technological change”.2 (p.2477) Technology enables direct interventions so that medicine has changed from assisting the healing capacity of nature (and calling upon the power of nature) to controlling and manipulating bodily healing itself.*3, 4 An intensification of this process, termed biomedicalization by the sociologist Adele Clarke and her colleagues, involves increasingly complex processes and expansion of mechanical technologies to biotechnologies, especially those based upon genetics.5 Technology has also expanded the “visual” field of medicine: the naked eye was assisted by the light microscope and then electron microscope to see smaller and smaller features while radiology has permitted “non-invasive” identification of internal structures. Now, preclinical or subclinical ‘disease’ is being found owing to the extensive use of sophisticated technology; risk itself has been transformed into disease.6 This is further complicated by the discovery of an anomaly during the course of looking for something else – incidental findings and incidentalomas. The aim of this essay is to put the issue of incidental findings related to advancing technology (especially imaging technology) into a broader context.

Fueled by modern scientific advancements, Western culture holds to a belief in inevitable progress and that technological advancement is a major part of that progress. Bjorn Hofman, who has written extensively on technology in medicine, wrote that technology has become the bias of our culture.4 Technology has changed everything about human life: the way we travel, work, communicate, and enjoy leisure have all changed markedly in the last generation. Technology also appeals to Western ideals of freedom and choice as well as the penchant for novelty, innovation, and action. In Western society, new is better and nothing reflects “new” as well as the latest technology.

Corresponding to the rise of technology throughout society is a parallel in health care, a technological “mandate”.4 Medical professionals don’t attract patients with promises of “conventional treatments”. Rather, we look for products and services that are described as “state-of-the-art”, “the latest”, or “novel”. A critic of technology, Neil Postman pointed to an American character that embraces technological innovation which itself has become synonymous with progress and made technology the foundation of the medical profession.7 This has contributed to a medical arms race in which different health care systems, hospitals, and physician practices compete in the marketplace based on their use of the latest technique. The amount of technology in a given hospital is a factor in the US News and World Report Best Hospitals ranking methodology. The results of this rise in the use of medical technology means tests are more precise, surgeries less invasive, information more available, diagnostics more reliable, and treatments more targeted than in the past. How many of us would forgo these advances to live in earlier and “simpler” times?

Hofman provided an analytic framework highlighting medical technology’s five major features. He characterized technology in medicine as: interventive, expansive, defining disease, generalizing, and liberating.3 By providing the basic phenomena to be studied and manipulated in medicine, technology strongly influences the concept of disease, and hence medical action. It defines what is diagnosed and what is treated. As a general method for diagnosis and treatment with its ability to generate reproducible results, technology has contributed to making medicine more scientific. Finally, technology has made medical knowledge independent from the subjective experience of the patient. (It is arguable how “liberating” this is, since the patient experience is central to dis-ease, if not disease). However, despite remarkable technologic advancement, the practice of endocrinology and of medicine in general continues to involve uncertainty and this uncertainty along with faith in technology as well as other factors have contributed to increasing use of technology and technological development.

Imaging has become central to medical practice as it has to society. Recent improvement in image quality8 combined with visualization as a cultural preference9 have contributed to a belief that imaging is a superior diagnostic method for acquiring knowledge about the body.10 Expectations for medical technology in general and imaging in particular are high among ordinary people as well as medical professionals and the health care marketplace promotes the expectations. Illes et al. wrote that our society equates innovative medical technology with better care and supports market-based approaches to a range of services that emphasize consumer choice and responsibility.11 Full body scans and a variety of specialized imaging procedures are widely advertised and require no physician referral. Two typical web sites are shown in Fig. 1. It then comes as no surprise that patient requests and self-referrals are becoming increasingly commonplace. Kolber et al. surveyed patients seeking whole body scans.12 Only 20% of those surveyed heard about the scan from a physician. These patients had high expectations of the whole body scan in terms of personal benefit. Similarly, patients have high expectations for their physicians to order such imaging. For example, in a survey of radiologists from Norway, among the most common reasons cited for unnecessary testing was increased patient demands for certain knowledge about their own…body.13

Aside from societal norms, many factors have contributed to the rise of technology in health care. The Internet has played a role in putting information literally at one’s fingertips. This has affected the way that patients view their role in health care. Suddenly, patients can access virtually infinite although frequently incomplete or inaccurate information about medical conditions and treatments while in the comfort of their living rooms. Potential patients can use “symptom checkers” to enter their symptoms and get a preview of possible diagnoses. Then, because pharmaceutical commercials are streamed into homes via television (in the United States at least) and Internet advertising, instead of turning to physicians for advice on medications, patients offer their needs assessment to physicians and ask for specific medications: “Ask your doctor if XXX is right for you”. Instead of being viewed solely as the expert who directs care, physicians are also viewed as the avenue to an anonymously “recommended”, patient-defined course of action. Moreover, just as patients don’t always feel that providers are taking their complaints seriously if they don’t leave with a prescription, there is a tendency to equate laboratory work and body scans with quality care.14

Images have assumed an especially privileged role in medical technology. When testing is not ordered, the assumption often is not that it is not indicated, but rather that finances are somehow involved.*9, 10 The recent focus on improved cameras and picture viewing capabilities in the home shows similar bias toward video innovations in production of “the body as anatomical pictures”.*9, 10 The cultural influences even go as far as affecting the name “MRI.” What was once referred to as nuclear magnetic resonance now includes the word imaging in its name.*9, 10 (Hofmann) traces this to many characteristics that are implicit in technology: it satisfies our natural curiosity and ability to address the ambiguous and uncertain.4 Physicians are inevitably drawn into the process. “Medical technology has grown from being a tool to becoming a companion and, in some cases, the master of physician”.4

For all the countless positive changes technology has brought to our society, no technology is without unintended consequences, sometimes positive and sometimes negative. In some cases, these unintended consequences are foreseeable, though not desirable or predictable. For example, nuclear power plants bring the risk of plant meltdowns and man-made dams allow floods to be more destructive when they do occur. While foreseeable, these are not the intended outcomes. The risks would not exist without the technology. In other cases, potential effects come in the form of less foreseeable consequences. The Fukushima nuclear power plant was designed to withstand a major earthquake, but not the tsunami that could be triggered by the earthquake. Aspirin, first used as a pain reliever, has since been found to have other therapeutic uses, e.g., prevention and treatment of myocardial infarction. This is a positive development for many individuals with certain heart and blood conditions. However, negative consequences are also possible. For example, the development of antimicrobial resistance to antibiotics has followed their widespread and often beneficial use. Advances in diagnostic tests in general and imaging in particular are no exception to the rule.

While patients believe that more testing is better, there are times where the findings can have negative effects. Gilbert Welch called attention to the mid-course review of Healthy People 2010.15 While the data from 2001 to 2002 showed a slight increase in life expectancy as compared with 1999–2000, there was a decrease in “expected years free of selected chronic disease” of 1.2 years for women and 1.3 for men. Welch posits that this counter-intuitive finding is due to modern diagnostic practices: Americans are more likely to be told that they have a chronic disease. While the amount of money spent on personal health care in America doubled from 1998 to 2008 ($1 trillion to $2 trillion), the life expectancy grew by only 1.2 years (from 76.7 to 77.9 [2007] years). Disease is now diagnosed based on laboratory tests in the absence of clinical signs and symptoms. Moreover, the state of increased risk for a disease has become a disease itself, e.g., hypercholesterolemia. Furthermore, the very tests meant to improve patient’s health might actually cause harm, for example from exposure to radiation from multiple CT scans.12, 16 Although medical technology has brought great advances to the certainty in diagnostic abilities, it has also given rise to new areas of uncertainty. These are most evident in the case of incidental findings in imaging studies.

Human “abnormalities” are prevalent. So-called “abnormalities” are so common on MRI of the spine as to be viewed as normal variants possibly related to aging.17, 18, 19 In a cross-sectional study, 36% of asymptomatic persons aged 60 years or older had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc.20 A prospective study found that among patients with lumbar imaging abnormalities before the onset of low back pain, 84% had unchanged or improved findings after symptoms developed.21 Thus, there may be little correlation between “abnormalities” and symptoms attributed to those abnormalities. The “abnormalities might be considered incidental findings.

An incidentaloma is defined as an unsuspected finding (typically a mass lesion) discovered in the course of looking for something else. Incidental findings are very common. Furtado et al. (2005) reported that 86% of 1192 patients receiving a whole body CT scan had some type of finding.22 While most of these were benign, 37% of patients were referred for some type of follow-up treatment. Similarly, Morin et al. looked at abnormalities during whole body MRI scans; 59.2% of those identified were categorized as “low clinical significance”.23 Incidentalomas have also become an issue in clinical research studies. A review of recent studies indicates that, depending on technology being used, roughly one-third of participants can be expected to present with an incidental finding.23, 24, *25 What, if anything, can ethically be withheld from the participant? The risk that an incidental finding might be identified? The fact that an incidental finding was in fact identified in a given participant? Are our patients different from research subjects? One thinks not.*26, 27

As the latest technology identifies new diseases (or the potential for diseases), clinicians are faced with the dilemma as to whether or not to treat. There are many conditions or diseases that were previously undetectable, but with new technology, present themselves on films (or digitized screens) or in test tubes. In these cases, new technology is actually adding uncertainty to the diagnostic and treatment process. Consider the case of adrenal incidentalomas. Adrenal carcinoma is mercifully quite rare. However, the frequency of adrenal carcinoma in incidentalomas is relatively high. Yet so far, all the surgeries done for adrenal incidentalomas large enough for the diagnosis of adrenal carcinoma to be considered have not reduced the mortality rate from adrenal carcinoma. This raises the question of whether all lesions that have histologic features of adrenal carcinoma behave like those diagnosed clinically.28, 29 Nevertheless, once identified, there are pressures to relieve the uncertainty as to their significance.

The term incidentaloma has moved from professional jargon to the popular press. In a commentary in the New York Times, a case is presented of a patient who retrospectively was deemed low risk with regard to diseases associated with the serendipitously discovered mass.30 Many people then submitted comments relaying similar situations. However, additional testing following discovery of incidentaloma may result in further expense and harm as false-positive results are pursued, producing the cascade effect described by Mold and Stein as a “chain of events (which) tends to proceed with increasing momentum, so that the further it progresses the more difficult it is to stop”.31 This is a form of technological iatrogenesis, a term that Palmieri, Peterson, and Ford posited that needs to be included in a list that previously only contained clinical, social, and cultural, to describe adverse outcomes relating to medical interventions (or failure to intervene).32 Much has been made of the distancing between physician and patient brought about through technology, the atrophy of clinical diagnostic skills, and the lost art of taking a good history (see R.L. Sanders33 for an extended discussion). Even were these not true, subjecting patients to unnecessary testing and treatment carries its own set of risks. Technology in general and imaging specifically offer much in service to physicians and their patients. However, it behoves physicians to ensure that technology supplements but does not replace good clinical judgment.

Back to Article Outline

References 

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☆ The views expressed are those of the author and do not represent the views of any agency.

PII: S1521-690X(11)00103-5

doi:10.1016/j.beem.2011.08.006

Best Practice & Research Clinical Endocrinology & Metabolism
Volume 26, Issue 1 , Pages 3-8, February 2012

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