Australasian Radiology

(2003)

47

, 268–273

Diagnostic Radiology

Are radiologists meeting the needs of Australian medical oncologists? Results of a national survey

B Koczwara,

1

M Tie

2

and A Esterman

3

1

Department of Medical Oncology and

3

Clinical Epidemiology and Health Outcomes Unit, Flinders Medical Centre and

2

Division of Medical Imaging, North West Adelaide Health Service, Adelaide, South Australia, Australia

SUMMARY

Although radiological evaluation plays an integral role in the management of oncology patients, little is known aboutwhich elements of such evaluation are most important or about how satisfied clinicians are with the quality ofradiology services in cancer patients. We have developed a 36-item anonymous survey evaluating availability of andsatisfaction with radiology services to medical oncologists. The survey was distributed to members of the MedicalOncology Group of Australia resident in Australia. We received 124 responses (51%). Most respondents (76.9%) weresatisfied with their radiology services. Satisfaction correlated closely with the availability of standardized reportingand promptness of reporting (

P

< 0.001). Oncologists in private practise were more likely to receive prompt reports(

P

< 0.0001). Oncologists in public practice were more concerned about availability of CT scanning (

P

= 0.02). Servicesthat were reported as less frequently available, despite being ranked as very important, included measurements of keylesions and comparison to previous studies. Standardized reporting was considered helpful by 91% of respondents.Only 32.5% of respondents reported receiving such a summary in more than 50% of cases and 21% never received sucha summary. Our findings highlight the need for closer collaboration between oncologists and radiologists in order toaddress specific needs and develop optimal patterns of practise. Consideration should be given to standardization ofreporting of radiology studies in oncology.

Key words:

oncology; radiology; service provision.

INTRODUCTION

Accurate interpretation of radiological studies is essential in the

management of patients with cancer. Radiological studies are

used for staging of tumours, assessment of end-organ function

prior to planning therapy, evaluation of response to treatment

and investigation of complications. Frequently, assessment is

based on serial evaluation using the same imagining modality

and, at times, cross-referencing between two different modali-

ties is required. There is evidence that clinical information

provided to radiologists influences reporting of radiological

studies,

1

but there is little data on how radiological reporting

impacts on patient decision-making. It is possible that mis-

understandings can occur as expressions used by radiologists

and referring clinicians might not be the same,

2

and the vari-

ability in interpretation of radiological finding might impact on

clinical decision-making. This is particularly important in the

area of assessment of response to treatment because the

definitions of response to treatment might vary between oncol-

ogists and radiologists.

While there have been attempts to standardize reporting in

the field of pathology and in some areas of radiology, notably

mammography and obstetric ultrasound, there is no standard-

ized approach to radiological reporting in other areas of

diagnostic radiology. This observation might seem somewhat

surprising as the process of radiological assessment of

tumours involves a number of specific items (tumour size,

organ involvement, etc.) that lend themselves to standardized

reporting approach.

Anecdotal observations suggest that the level of detail and

of radiological reports and the quality of the service varies

between different radiologists and between public and private

radiology services. There is also suggestion of variability in

B Koczwara

MB BS, MBioethics, FRACP;

M Tie

MB, BCh, FRANZCR;

A Esterman

PhD.

Correspondence: Dr Bogda Koczwara, Department of Oncology, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia 5042,

Australia. Email: bogda.koczwara@flinders.edu.au

Submitted 7 May 2002; resubmitted 10 April 2003; accepted 24 April 2003.

RADIOLOGY SERVICE NEEDS IN ONCOLOGY

269

access to services between public and private settings, and

between city and rural areas.

3

To assess any potential impact

of any such variability on oncological practice, we designed

a questionnaire evaluating the needs of Australian medical

oncologists with regards to access to radiological studies,

quality of reporting and oncologists’ satisfaction with radiology

services. In addition, questions regarding the potential utility of

standardized reporting were included.

METHODS

A 36-item anonymous questionnaire was designed (Appendix I)

and pretested for validity and reliability. The questionnaire was

mailed to all medical oncologists practising in Australia using

the database of Medical Oncology Group of Australia. Medical

oncologists residing overseas were excluded. Oncologists

were given an option of identifying themselves or answering

the questionnaire anonymously. Respondents were invited to

provide individual comments at the end of the questionnaire.

Statistical analysis

Because many items were highly skewed, medians are pro-

vided with the interquartile range (IQR). Differences between

groups were assessed by Exact Kruskal–Wallis

H

-test. Correla-

tions between variables was measured by the Spearman rank

correlation.

RESULTS

A total of 241 questionnaires were sent out and 124 responses

(51%) were received. Demographic characteristics of respond-

ents are summarized in Table 1. Preferences of oncologists

regarding public versus private radiology practice are sum-

marized in Table 2.

Service needs and satisfaction

The most commonly ordered studies were CT scans with a

median ordering rate of 5.5 studies per week (IQR 3.5–10.0)

and plain films with a median ordering rate of 5.0 studies per

week (IQR 3.0–10.0). Median time of waiting for a non-urgent

study varied from 0.5 days (IQR 0.0–1.0 day) for plain films to

7.0 days (IQR 2.0–14.0) for MRI.

Oncologists considered the majority of radiological services

identified in the questionnaire as important and usually avail-

able (Table 3). Services identified as important, yet less

available, included measurements of key lesions and compari-

sons to previous studies.

Availability of films electronically was considered desirable.

Availability of positron emission tomography (PET) scanning

was considered less important than other services.

There were differences between private and public serv-

ices. Oncologists in private practice and those using private

practice radiology were more likely than those in public practice

to state that prompt reporting was usually available (

P

≤

0.001).

Oncologists in public practice stated that access to CT scans

was less available (

P

= 0.024). Rural oncologists reported

less access to PET scans (

P

= 0.021) than their city-based

counterparts.

Table 1.

Responder’s characteristics

n

%

Age (years)

<36 34 27.6

36–45 44 35.8

46–55 33 26.8

56–65 11 8.9

>65 1 0.8

Location of oncology practice

Mainly private 22 22.6

Mainly public 62 35.5

Both private and public 40 41.9

Rural 7 5.7

City 100 81.3

Both rural and city 16 13.0

Radiology service used

Mainly private radiology 28 22.6

Mainly public radiology 44 35.5

Both private and public radiology 52 41.9

Table 3.

Importance and availability of specific services

Very important

or important

Usually or

sometimes

available

Access to all studies 99 99

Access to CT 99 100

Access to MRI 98 89

Access nuclear medicine 98 99

Access to positron emission tomography 70 63

Prompt reporting 98 90

Measurement of key lesions 93 70

Comparison to previous studies 99 74

Correlation of CT with previous studies 89 64

Mention of normal structures 72 86

Discussion with radiologist 98 91

Phone contact 96 81

Discussion at clinical meeting 94 90

Table 2.

Practice patterns: Private versus public

Radiology service used (%)

Private Public Either

Private oncology 86.4 – 13.6

Public oncology 4.8 66.1 29.0

270

B KOCZWARA

ET AL

.

The majority of oncologists (97.6%) liked to review radiology

films personally, and 88.4% usually reviewed films in addition to

reading the report. The most important barriers to reviewing

films included lack of time, difficulty accessing studies, and lack

of access to films on computer. Lack of training in film reading

was considered less important than other variables.

The majority of respondents (97.6%) were very satisfied

or satisfied with radiology services. Overall, satisfaction cor-

related closely with the promptness of reporting (

r

= 0.407,

P

< 0.001).

Standardized reporting

Standardized reporting was considered most helpful or helpful

by 91% of respondents. Only 32.5% of respondents reported

receiving such a summary in more than 50% of cases, and 21%

of respondents never received such a summary. How often a

summary was present was closely correlated with overall satis-

faction with radiology services (

r

= 0.431,

P

< 0.0001).

Response criteria

Only 15.1% of responders used Response Evaluation Criteria

in Solid Tumours Group (RECIST)

4

criteria for evaluation of

response, 74.8% used either World Health Organization criteria

with a small proportion using WHO or RECIST and 10.1%

used neither. Some respondents suggested that standardized

response criteria are useful in evaluation of clinical trial results

but less in clinical practice.

Oncologists’ comments

The individual comments at the end of the questionnaire were

added by 40% of respondents. These comments highlighted

some of the issues identified in the questionnaire, namely differ-

ences between public and private radiology as well as issues

not captured in the questionnaire including individual variation

between radiologists, importance of interventional radiology

and the frustration associated with film loss.

DISCUSSION

Our study demonstrates high levels of satisfaction with private

and public radiology services both in private and public

oncology practices. The greatest predictors of satisfaction iden-

tified in our survey, that is, prompt reporting and availability of

a written summary, are consistent with the known determinants

of customer satisfaction: reliability, responsiveness and assur-

ance.

5

Our study also highlights the high level of oncologist

involvement in interpretation of studies as shown by prefer-

ences for conference reviews and phone contact as well as the

high rate of personal reviewing of films. This is not surprising

considering how important radiological interpretation is in

clinical decision-making in oncology and is consistent with

other medical specialities with similar radiological involvement,

for example, emergency medicine physicians who consider

their own interpretation of a radiological study important in

clinical decision-making.

6

Other studies indirectly support

oncologists’ competence when it comes to radiological evalua-

tion.

7

Literature also supports the practice of clinical radiological

consultations, which Australian oncologists seem to favour.

Such consultations, although time consuming, add further to

clinical decision-making.

8

The survey demonstrated differences in services between

public and private sectors with speedier reporting in the private

sector and less access to CT for public oncologists. While this

finding might reflect the service attitudes, it might also be a result

of differences in workload and complexity of clinical cases

managed especially as to date, the majority of oncology tertiary

referral centres operate within the public sector. It is interesting

that although our study showed a difference in services provided

between private and public sectors in terms of access, this did

not seem to impact too much on the satisfaction. Furthermore,

oncologists seem to access both public and private radiology

services irrespective of their own area of practice: it might be

that this flexibility explains their satisfaction. Lower access to

PET in rural areas is not considered a problem probably as this

modality is not routinely used yet in oncology practice. Also, as

the majority of oncologists practice in metropolitan areas, this

lack of access is only a problem to a minority of oncologists and

indirectly, a minority of patients. It is possible that as the utility of

PET scanning increases, the demand for service and need for

better access will become more of an issue.

Some of the problems of access, as well as concerns

regarding film loss and access to films and reports via computer

might be addressed in the future by the change to filmless

reporting and teleradiology initiatives.

9

While the majority of services that were considered

important by oncologists were seen as usually available, meas-

urement of the lesions and comparison to previous studies

appeared to be less available than others. This might be

because they are the most time-consuming aspect of radio-

logical interpretation and might require a degree of additional

expertise, especially with lesion measurement. While our

survey was not designed to quantify the proportion of radio-

logical reports omitting measurements or comparisons to

previous studies and we have not been able to identify such

data in radiology literature, this might be an important finding

that warrants further exploration. This is because the compari-

son to previous studies and (indirectly) lesion measurements

are arguably the two most important elements or radiological

assessment in oncology. It is not possible to assess response

to treatment and make further treatment decisions without com-

parison to previous images. Furthermore, if information relating

to response to therapy or progress since the previous study

were to be included in the standardized report, such a report

would not be possible without comparison to a previous study

or without lesion measurements.

RADIOLOGY SERVICE NEEDS IN ONCOLOGY

271

Therefore, it might not be surprising that, similarly to these

two services, we have found that standardized reporting was

not frequently available despite its strong correlation with oncol-

ogist satisfaction with services.

Within the field of radiology, standardized reporting has

been mainly developed in obstetric ultrasound and mammog-

raphy. These are both high-risk areas where diversion from

standardized reporting can have serious consequences. Both

areas deal with a limited range of diagnostic variables and the

importance of measurements recognized. The same could be

said for oncological reports, especially where staging of cancer

or assessment of response is the goal of the study. It is possible

that the lack of standardized reporting in these settings stems

from the lack of radiological understanding of the importance

of measurements and the radiological criteria for response or

presupposition that these are responsibility of the oncologists

rather than radiologists. In order to, for example, provide stand-

ardized reporting of tumour responses, radiologists would need

to become familiar with the criteria of response measurement.

It is possible that such familiarity is not widely prevalent at

present, especially as our survey demonstrates that not all

oncologists use standard response criteria. No data is available

on how competent radiologists are in assessing response

according to standard response criteria. The diagnostic radiol-

ogy syllabus does not contain knowledge of response criteria

as a specific learning goal, and there is no oncology module in

the syllabus.

10

In a number of institutions, it is a common

practice to nominate a designated radiologist to interpret

response in a setting of oncology clinical trials, indicating that it

is not a common skill. Until sufficient competence in standard

response criteria is achieved, standardized reporting might be

perceived by radiologists as an additional, time-consuming

burden. These questions, currently unanswered, might warrant

further exploration.

The interpretation of the findings of this survey is limited by

the responses rate to the questionnaire, which reflect the views

of just over half of the oncologists. Furthermore, not all the

service needs were explored, for example, nuclear medicine

services were not addressed specifically in the survey (with the

exception of PET scanning) and no questions referred to the

interventional radiology services despite their increasing impor-

tance in oncology.

CONCLUSIONS

While the majority of Australian oncologists are satisfied with

the radiology services they receive, gaps in service remain.

Close ongoing collaboration between oncologists and radiol-

ogists to address specific needs and develop optimal patterns

of practice is required.

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ET AL

.

APPENDIX I: SURVEY INSTRUMENT

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273