How to Manage Incidental Findings: Today’s Radiologists Turn to a Mix of Society Guidelines and Trusting Their Instincts

It’s a question that comes up time and time again in medical imaging: How should incidental findings be handled by the radiologist? Should they be included in the radiology report or just ignored? While radiologists don’t want to alarm patients, they also realize that not reporting a finding could have devastating results for the patient and involve the radiologists in malpractice litigation. There also are potential cost savings to consider. At a time when quality is being emphasized over quantity, reducing the number of unnecessary follow-up exams is a priority throughout all of radiology.

Of course, the challenge has only been exacerbated as imaging technology has improved to the point that many cysts, masses and other types of incidental findings, once too small to be seen, are now imaged routinely. So while radiologists try to make these decisions, they have to weigh their options with more findings today than ever before.

So what is the medical imaging industry doing to address this ongoing dilemma? Quite a lot, it turns out.

Building a Consensus

In recent years, more and more has been done throughout the medical imaging industry to help specialists handle incidental findings appropriately. The American College of Radiology (ACR), for example, has worked toward developing a standardized approach and building a consensus on how to address incidental findings. The ACR’s Incidental Findings Committee (IFC) has published a series of white papers containing specific algorithms on how to best manage such findings on a number of modalities. And in 2017, the committee published its findings on how to best manage incidental adrenal masses, incidental pancreatic cysts, incidental kidney masses and incidental liver lesions.

How does the IFC reach its conclusions? They start with the evidence, says Pari V. Pandharipande, MD, MPH, a radiologist at Massachusetts General Hospital in Boston and chairperson of the IFC. The Committee begins with the evidence on how to manage a given finding. When there is no evidence, Committee members pool experts in the area and come to a consensus on how to manage that finding, using an algorithm-based approach. The algorithms are designed to cover the vast majority of findings, though there may always be exceptions to any given rule. 

Lincoln L. Berland, MD, professor emeritus at the University of Alabama at Birmingham and chair of the ACR’s Commission on Body Imaging, says developing these guidelines was a big step for radiologists. He remembers how things were before the white papers existed, and says there has certainly been an improvement. “In the past, many radiologists were inconsistent in their reporting when dealing with incidental findings,” Berland says. “There was a tendency to report just about every incidental finding. But that was not good since many of the findings were benign.” He added that knowledge of the findings would just add to patients' anxiety and risk, and to costs for both patients and the facility.

But the IFC’s guidelines, he says, help specialists provide the best possible care while also providing a needed level of consistency to radiology reports. “The point of the white papers is to cut down on the number of examinations and procedures that are done on patients that have common, unimportant incidental findings,” Berland says, adding that ACR surveys have indicated radiologists learn from the recommendations and recommend fewer unnecessary follow-up exams.

Rajan T. Gupta, MD, associate professor of radiology at Duke University Medical Center in Durham, N.C., applauds the IFC’s efforts, noting that improved efficiency is always important for radiologists, especially now that more attention is being paid to wasteful imaging. “As a profession, standardizing our approach to how we address incidental findings will help us be more aware of cost in this era of value-based care,” he says. 

He notes, however, that it’s not as if every radiologist will suddenly follow the ACR’s guidance. “Adherence to guidelines can be a little challenging,” Gupta says. “These are not rules, and radiologists may not agree with all of them. Factors that complicate the picture can arise.”

Berland adds that other reasons may come up that lead to specialists not following the information contained within the IFC’s white papers. Sometimes people do not have time in a busy environment to refer to each individual paper, he says. Another problem occurs when radiologists who are not experts in a particular organ system read scans specific to that system, he says. Radiologists working out of their specialty may make mistakes, even as they sincerely try their hardest to do the right thing.

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Striking a Balance

Pandharipande says radiologists have a lot to consider when reporting an incidental finding. Discovering something that could potentially be harmful should be viewed as a good thing that could possibly impact patient care, but there are obviously other factors in play as well. “The workups that radiologists may pursue for findings not likely to be harmful can be associated with drawbacks for the patient, such as inconvenience, anxiety, risks and high costs,” she says. “We want to make sure that we best balance the risks and benefits for the patient’s best interest.”

Pandharipande adds that precision is key when radiologists are writing their reports. It’s crucial to be as precise as possible, she says, and be clear about each finding to avoid referring physicians, or even patients, getting the wrong idea. “We want to be objective and as uniform and precise as we can be,” she says. “If we are not, we may end up causing undue anxiety and other problems.” 

Pandharipande believes that more imaging providers are now standardizing the management of incidental findings. “Radiologists should follow a systematic method that draws from what we know about the evidence related to the finding,” she says. “It can be challenging when the evidence is not perfect. That’s when radiologists have to use their clinical judgment.” 

Gupta believes a radiologist’s gut feelings still have a place in the management of incidental findings. His or her clinical expertise and experience will always play a role in whether they follow recommendations exactly or go with what they, in the moment, think is right. “It’s important to balance expertise with established guidelines,” Gupta says. “The key issue for radiologists is to put clinical findings into context around a patient’s clinical history and then communicate with the referring doctor to decide whether there is a need for the next step of imaging. There must be that direct communication between the radiologist and referring physician.”

Connecting with Patients

Some specialists encounter another issue related to incidental findings: making sure their voices are heard by patients. Physicians at Penn State University Milton S. Hershey Medical Center in Hershey, Pa., discovered that ED patients were not always receiving follow-up recommendations for various incidental findings. And even when they did receive the recommendations, patients weren’t following through.

Radiologists became aware that some emergency department patients had not received the recommended follow-up care for their incidental findings. Many patients were not following-up with their physicians even when told to. “We were satisfying the standard of care by transmitting our results in a timely way to the referring physician,” says Michael A. Bruno, MD, professor of radiology and medicine and vice chair for quality and safety at the medical center. “But there wasn’t any way to ensure the referring physician would act on them.”

Bruno responded by helping develop the center’s Failsafe program, which helps radiologists use letters and phone calls to inform ED patients about incidental findings, urging them to follow up with their primary physicians. Bruno says there was a concern that they could be frightening patients by taking this step, but he quickly determined that wasn’t the case. “We thought we were over-scaring people, but we were under-scaring them,” Bruno says. “Many patients were totally unconcerned and unengaged.”

Bruno says he thinks Failsafe has been a success for his department. More patients are now agreeing to go in for follow-up exams than before and communication about patient care has increased. “Our end goal is to get the patient to talk to his or her doctor about the recommendation,” Bruno says. “With Failsafe, we are trying to reach the primary care physician. The patient is the messenger.”