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In an environment where many practitioners are sensitive to the cost of veterinary care and creating efficiencies to lower the burden of veterinary professionals, it’s always a win-win when research can establish more efficient best practices. Dr. Thomas Bevelock, a small animal surgery resident at the University of Tennessee, took cost and staff efficiencies into consideration in his latest study, which was published in the Journal of Small Animal Practice. This retrospective study evaluates the medical records of 159 dogs with solid, soft tissue tumors. Researchers set out to compare the frequency of detection of clinically relevant findings and cost per clinically relevant finding for the restaging of solid, soft tissue tumors by abdominal radiography and ultrasonography.
What is the most important takeaway from this study?
Dr. Bevelock: It was the authors’ experience at multiple tertiary referral institutions that repeated abdominal radiographs are performed prior to any abdominal ultrasound exam. Abdominal radiography may also be routinely performed by primary care veterinarians for restaging purposes. The results of this study show that there is little clinical benefit to performing repeated abdominal radiographs alongside an abdominal ultrasound when restaging for solid, soft tissue tumors. In an age where our profession should be increasingly aware of all aspects of practice, such as radiation safety, cost burden to clients, and support staff workload, the information from this study will help maximize health benefits and improve hospital efficiency. This idea of restaging with abdominal ultrasound alone has been proposed anecdotally and even referenced in texts, however, to the authors’ knowledge, no peer-reviewed literature has previously evaluated this notion.
Specifically regarding the analysis of cost per clinically relevant finding, did anything surprise you?
Dr. Bevelock: We hypothesized that there would be fewer clinically relevant findings detected with abdominal radiographs; therefore, it was not surprising that the cost of performing that modality did not outweigh the benefits. We were surprised that only 1 clinically relevant finding was detected by abdominal radiographs alone, so the overall cost of radiographs for our population for only 1 additionally detected clinically relevant finding was substantial.
From the collected data, how would you compare the accuracy and effectiveness of abdominal radiography and ultrasonography for restaging solid, soft tissue tumors?
Dr. Bevelock: Defining a true diagnostic gold standard for restaging solid, soft tissue tumors could not be accomplished with this data. This study did, however, show more clinically relevant findings with abdominal ultrasound, suggesting that it may be a more sensitive diagnostic tool for restaging in comparison to abdominal radiographs. This information may save the clinic time and the client money but could also lead to earlier detection and treatment for disease. This also excludes further diagnostic costs for previously detected clinically relevant findings.
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What is the biggest limitation of this study?
Dr. Bevelock: The biggest limitation is its retrospective nature. We could not control certain aspects of the cases such as the consistency and frequency of restaging episodes. That limitation in adherence to follow-up recommendations for restaging is unfortunately common in veterinary medicine. However, it is suspected that follow-up adherence rates may be low due to financial limitations; eliminating unnecessary diagnostics may help improve patient follow-up. This study focuses on solid, soft tissue tumors, and the data may not be applicable to all tumor types. Individual tumor biology varies, so clinical judgment is necessary on an individual patient basis.
Because this study found abdominal radiographs to be of “minimal use beyond abdominal ultrasound for restaging,” what advice would you give primary care veterinarians involved with cases of restaging solid, soft tissue tumors?
Dr. Bevelock: If accessible and practical for clients, full abdominal ultrasonography would be a more effective modality to restage the majority of solid, soft tissue tumors of the abdomen. In our study, all restaging diagnostics were performed or interpreted by board-certified radiologists. Abdominal radiographs for these patients consume time, money, and energy in your facility. The authors would also emphasize the importance of client education regarding follow-up recommendations because early detection of disease may allow for the most, and potentially best, treatment options for a patient.
Is there anything we have not covered that you would like our readers to know from this study?
Dr. Bevelock: Clinical judgment should be used with this data. The study looks at a general overview of tumors involving the abdomen but does not evaluate each tumor type individually. There are certain tumor types, such as prostatic carcinoma, that have biologic behaviors that predispose them to metastasizing to bone. In situations such as those, abdominal radiographs would be a useful restaging tool. More studies evaluating individual tumor types for restaging effectiveness in a controlled manner need to be performed.
The Study
Radiographs are of limited use and low cost-effectiveness when combined with ultrasound for abdominal restaging in dogs with solid, soft tissue tumours.
Bevelock TJ, Skinner OT, Baumgardner RM, et al. J Small Anim Pract.
https://doi.org/10.1111/jsap.13791