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Limiting surveillance imaging for patients with lymphoma in remission: a mixed methods study leading to a Choosing Wisely recommendation
  1. Ora Paltiel1,2,
  2. Galor Raviv Sharabi3,
  3. Reut Tzemach4,
  4. Talya Rechavi1,
  5. Estherina Trachtenberg5,6,
  6. Neta Goldschmidt2,
  7. Eldad J Dann5,6,
  8. Rachel Bar-Shalom7
  1. 1 Braun School of Public Health and Community Medicine, Hadassah-Hebrew University of Jerusalem, Jerusalem, Israel
  2. 2 Hematology, Hadassah Medical Center, Jerusalem, Israel
  3. 3 Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
  4. 4 Rheumatology, Tel Aviv Ichilov-Sourasky Medical Center, Tel Aviv, Israel
  5. 5 Hematology, Rambam Hospital, Haifa, Israel
  6. 6 Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
  7. 7 Nuclear Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
  1. Correspondence to Professor Ora Paltiel, Braun School of Public Health and Community Medicine, Hadassah-Hebrew University of Jerusalem, Jerusalem 91120, Israel; orap{at}


Background Under the ‘Choosing Wisely’ (CW) framework, professional organisations internationally have advocated limiting imaging for asymptomatic patients following curative cancer therapy, based on limited value and high cost. F18-fluorodeoxyglucose (FDG) positron emission tomography-CT (PET/CT) was widely adopted locally for surveillance lymphoma imaging after 2004.

Objectives Prior to ratification of a local CW recommendation to limit surveillance imaging in lymphoma, we aimed to assess: (A) performance characteristics of surveillance FDG-PET/CT; (B) rates, clinical consequences and costs of false positives (FP); and (C) patients and professionals’ attitudes towards overuse.

Methods Mixed methods (quantitative and qualitative) study. We analysed surveillance FDG-PET/CT results of two patient cohorts (n1=215 Hodgkin lymphoma and non-Hodgkin lymphoma; n2=203 Hodgkin lymphoma only). FPs were defined by negative biopsy or clinical follow-up. We held focus group discussions and in-depth interviews eliciting attitudes of 26 patients and 11 clinicians, respectively.

Results FPs were observed in 25.1% (95% CI 20.5 to 30.5) per scan—cohort 1, and 41.7% (95% CI 37.9 to 45.6) per patient—cohort 2, engendering frequent additional testing. Specific characteristics and location of findings altered the FP rate. The estimated cost per relapse detected was $50 000 (cohort 2). Patients sought reassurance via surveillance imaging, which they considered highly accurate, yet stressful. Aware of radiation risks, they were largely unconcerned about consequences of FPs. Confidence in the treating physicians was an important factor in patients’ acceptance of forgoing imaging. Clinicians, frequently under patient pressure to order imaging, generally believed that it did not affect prognosis (with important exceptions), welcomed professional guidelines, but rejected regulatory restrictions on its use.

Conclusion Acceptance of CW recommendations to limit overuse may be enhanced by quantitative data on consequences and costs of surveillance imaging, supplemented by qualitative data on patient and physician attitudes.

  • qualitative research
  • clinical practice guidelines
  • attitudes

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  • EJD and RB-S contributed equally.

  • GRS and RT contributed equally.

  • Contributors OP, NG and EJD conceived the study, provided patient data and helped analyse the quantitative data. GRS and RT performed data collections for Aim 1, and data analysis. The study partially fulfilled the requirements for their MD theses at the Hadassah-Hebrew University Faculty of Medicine. TR and ET performed focus group discussions. TR analysed the qualitative sections. RBS interpreted PET/CT scans and extensively revised the manuscript. All coauthors contributed to the writing of the manuscript and approved the final versions.

  • Funding This study was funded by the Israel National Institute for Health Policy Research.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by participating institutions’ ethical review boards (0188-14). For cohort 1 informed consent was waived as data were anonymised and analysed retrospectively. Patients in ccohort 2 signed written informed consent and the study was additionally approved by the Health Ministry. Requirement for written consent was waived for the FGDs and IDIs, as participation was deemed to indicate voluntary informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.