I recently posted a note about so-called incidentalomas, lesions often "accidentally" discovered during CT scans that have been ordered on the basis of other diagnostic concerns. You may want to refer to it to refresh your memory about the topic (see: How to Avoid the Risks of a CT Incidentaloma). Dr. Mark Pool who blogs over at The Daily Sign Out has posted a a well-thought-out note that extends this discussion in some interesting ways (see: Incidentalomas revisited). Below is an excerpt from it:
Dr. Bruce Friedman posted a thoughtful blog on Lab Soft News recently concerning "incidentalomas" ....This post happened to coincide with a new working committee at my hospital commissioned with developing a virtual clinic for following patients who have incidental lung nodules discovered. Perhaps unlike other sites, there are widely disseminated radiographic recommendations for following lung nodules (Fleishner criteria)....One issue that we will be challenged with is how to track these patients across multiple different providers for appropriate follow-up. One model we are considering is already in place: using a breast "navigator" to follow-up patients with abnormal mammograms. This issue arose recently because of a series of patients presented at our Tumor Board who had incidental lung nodules identified but were not followed appropriately and then were re-discovered with inoperable advanced stage disease months later....While I concur with the basic premise of the post (i.e. that one shouldn't jump into a full-blown diagnostic work-up of an incidental finding), I think we should also insist on developing evidence-based criteria for managing these types of findings such as Fleishner criteria for lung nodules.
Mark does a great job in his note of teasing out a key issue regarding incidentalomas that I had not considered. If an when an incidentaloma is discovered during a patient's care episode, how can his or her physicians ensure that the followup of the lesion is appropriate? Here's a brief description of the breast navigator program about which Mark makes mention above. Such individuals are assigned the specific task of ensuring continuity of care for breast patients (see: Breast Cancer Navigator Certification Program):
In 2008, the NCBC [National Consortium of Breast Centers] recognized the need for a standardization of the Breast Patient Navigator's role. Just as the breast care/cancer diagnosis and treatment process may differ from facility to facility, so do the definitions, activities, knowledge and job descriptions of a breast patient navigator. These disparities can adversely affect the breast care/cancer treatment provided to women across the nation and around the world. In an effort to minimize and eventually eliminate the variances in a breast patient's continuum of care and the definition/function of a breast patient navigator providing care within that continuum, the NCBC created this program.
I hate to admit this, but our heath system is so fragmented that I have little confidence that many/most incidentalomas would receive adequate followup after they are discovered, particularly if a patient changes providers. And by the way, these lesions occur frequently enough that this constitutes a real problem. My first idea was an "incidentaloma bracelet" that radiologists or clinicians could hand out to patients. However, this would only serve as an alert the next time that a patient was admitted to the hospital for an acute problem and not necessarily ensure proper followup. I am stumped. This is a generalized alert/followup challenge in our healthcare delivery system -- we can't just continue to patch specific problems.
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