Incidentally Speaking ?>
Be Well

Incidentally Speaking

by John Swartzberg, M.D.  

Your doctor orders an imaging test because you have unexplained back pain, but the results come back showing a “spot” on your kidney—an unexpected finding totally unrelated to the reason you had the test in the first place. Should your doctor now order follow-up testing to see what that spot might be? Or is this so-called incidental finding (sometimes dubbed an “incidentaloma”) a harmless irregularity, with further test­ing simply a chase down the rabbit hole?

Whether the initial test was imaging, as with this example, or a blood test or some other type of screening test, what to do about incidental findings is one of mod­ern-day medicine’s most vexing questions, since often there is no clear answer.

To follow up—or not?

To illustrate the dilemma, consider the results of a survey com­pleted by 376 U.S. internists, published in JAMA Network Open in October 2019, in which they described their experiences with inci­dental findings on various health screenings. More than 90 percent reported that incidental findings led to further testing that yielded clinically important information that could be used to improve their patients’ health. But more than 90 percent of the doctors also reported that there were instances where further testing provided no clinically significant information whatsoever.

Over the last half-century of medical technology, our ability to detect what’s going on inside the body through imaging tests has exceeded our understanding of how best to use initial test results. We’re still fine-tuning—and in some cases struggling with—how to interpret the findings.

The problem is that doing more testing after an initial test is not just time-consuming: It can also have considerable costs, physically, mentally, and financially. Indeed, 68 percent of the physicians in the above-mentioned survey reported that the ensuing “cascade” of tests triggered by incidental findings led to psychological harm (think of the anxiety that comes with being told you need a biopsy, say, or just waiting for more test results); 58 percent mentioned the increased financial burden; and 16 percent referred to physical harm.

How can further testing harm you? Let’s say a CT scan of the abdominal area, done to find the cause of ongoing pain there, shows a spot at the base of a lung. If, to rule out a serious lung problem, the doctor then orders a bronchoscopy (which involves passing a scope down the windpipe) or a needle biopsy, complications can arise. A biopsy that doesn’t go right, for instance, could result in bleeding in the lung or a partially collapsed lung. Even having just a repeat CT scan means being exposed to more radiation on follow-up. At the other end of the spectrum is to do nothing—and risk missing some­thing that could be deadly if not diagnosed and treated.

A shared decision

So what’s the answer? It depends. I don’t want to suggest that fol­low-up tests for incidental findings are not a good idea. Undoubtedly, they sometimes save lives. And physicians should know to use their accumulated knowledge and experience when considering testing decisions. Importantly, that includes evaluating the necessity of a test in the first place. All too often, tests are ordered at the drop of a hat. A study last September in the Journal of the American Medical Associa­tion found that rates for CT, MRI, and other scans continue to rise in the U.S. despite campaigns by medical societies to reduce their overuse.

Physicians shouldn’t be making these decisions on their own, however. You, the patient, need to be involved in the process, in which you are provided with the best available evidence and are encouraged to consider the options in collaboration with your doctor, rather than having the doctor direct what you will do in a top-down manner. The “doctor knows best” approach of an earlier era is outdated.

That doesn’t do away with the uncertainty of whether further testing will bear fruit, and no one likes uncertainty. But that’s the world we live in. If you discuss incidental findings with your doctor and participate in the decision of what to do about them, you’re participating in your health care with your eyes open.

This article first appeared in the UC Berkeley Wellness Letter.

Also see Reducing Radiation from Health Scans.