Dissertation Abstract

Ethics and policy issues in the diffusion and marketing of computed tomography (CT) screening exams

Background . Screening exams using computed tomography (CT) were marketed and provided to patients before conclusive evidence and professional agreement about their benefit. The early diffusion of these exams raises ethical questions about how physicians should balance promoting innovation, protecting patients from harm, and respecting patient autonomy during periods of uncertainty about the utility of a screening test.

Methods . This study used a self-administered mailed survey designed to collect data on the practices and attitudes of US radiologists regarding CT screening tests, including coronary artery calcium scoring (CACS), lung cancer screening CT, and whole body screening CT. The survey was sent to one thousand diagnostic radiologists who were randomly sampled from the American Medical Association's (AMA) Masterfile Physician Database. Findings were incorporated into an ethical analysis of how referring physicians and radiologists ought to behave during periods of uncertainty about the utility of a CT screening test.

Results . One-third of a nationally representative sample of radiologists reads CT screening exams, the most common being CACS, followed by lung screening and whole-body screening. Most radiologists believed that CACS and lung CT screening may be appropriate for particular patients, while a minority believed whole-body CT screening appropriate; those reading CT screening were significantly more likely to think it appropriate. Most radiologists believed direct-to-consumer advertising is inappropriate, while they were divided in their beliefs about the appropriateness of patient access to screening, the extent of their involvement in decision-making, and the need for informed consent.

Conclusions . A substantial proportion of radiologists in the US read CT screening exams of the heart, lungs, and whole body. The favorable attitudes of many radiologists toward CACS and lung CT screening may allow for the premature diffusion of new screening tests into practice. Individual radiologists and the field should more actively appraise the evidence behind screening and educate referring physicians and patients about the risks, benefits, and uncertainties of exams. Generally, physicians should discourage screening tests with low levels of evidence of benefit. However, there are specific circumstances under which it may be appropriate to refer patients for screening, given that certain safeguards are in place.

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