The Royal Australian and New Zealand College of Radiologists
Recommendations from the Royal Australian and New Zealand College of Radiologists on early-stage breast cancer, low risk prostate cancer, palliation of bone metastases, and brain metastases. The Royal Australian and New Zealand College of Radiologists (RANZCR) is a not-for-profit association of members who deliver skills, knowledge, insight, time and commitments to promote the science and practice of the medical specialties of clinical radiology (diagnostic and interventional) and radiation oncology in Australia and New Zealand.
3.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
Pulmonary embolism (PE) affects 2-3 per 1000 adults per year. It can be fatal if untreated, more often in hospitalised people than outpatients. The symptoms and signs of PE (chest pain, cough, dyspnoea, and tachycardia) are non specific and so imaging is required to make the diagnosis.
PE is diagnosed by direct (CT pulmonary angiogram) or indirect (ventilation/perfusion or “V/Q” lung scanning) demonstration of the emboli within the pulmonary arterial tree. PE can be excluded in low risk patients by a negative result on whole blood D dimer. Some low risk patients (“Pulmonary Embolism Rule-out Criteria [PERC] negative”) are at such low risk they require no diagnostic testing, including D dimer.
Clinical decision rules (CDRs) are more specific than clinical gestalt in determining which patients are unlikely to have PE, and thus can prevent unnecessary imaging in these groups.
Validated risk assessment strategies are not applicable to pregnant women and D dimer is physiologically elevated early in pregnancy. Ventilation perfusion lung scanning is the test of choice in the presence of a normal chest radiograph in a pregnant woman with suspected PE as the radiation dose to the breast is much lower than for CT pulmonary angiography and the fetal dose is very small and comparable for both imaging tests.
Recommendation released April 2015
Supporting evidence
- Lucassen W, Geersing GJ, Erkens PM, Reitsma JB, Moons KG, Buller H, et al. Clinical decision rules for excluding pulmonary embolism: A meta-analysis. Ann Intern Med. 2011; 155(7): 448-60.
- Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a Simple Clinical Model to Categorize Patients Probability of Pulmonary Embolism-Increasing the Models Utility with the SimpliRED D-dimer. Thromb Haemost. 2000; 83(3): 416-20. Stuttgart.
- Gibson NS, Sohne M, Kruip MJ, Tick LW, Gerdes VE, Bossuyt PM, et al. Further validation and simplification of the Wells clinical decision rule in pulmonary embolism. Thromb Haemost. 2008; 99(1): 229-34.
- Le Gal G, Righini M, Roy P, Sanchez O, Aujesky D, Bounameaux H, et al. Prediction of pulmonary embolism in the emergency department: The Revised Geneva Score. Ann Intern Med. 2006; 144(3): 165-71.
- Klok FA, Mos IC, Nijkeuter M, Righini M, Perrier A, Le Gal G, et al. Simplification of the Revised Geneva score for assessing clinical probability of pulmonary embolism. Arch Intern Med. 2008; 168(19): 2131-6.
- Douma RA, Gibson NS, Gerdes VE, Buller HR, Wells PS, Perrier A, et al. Validity and clinical utility of the Simplified Wells rule for assessing clinical probability for the exclusion of pulmonary embolism. Thromb Haemost. 2009; 101(1): 197-200.
- Kline JA, Nelson RD, Jackson RE, Courtney DM. Criteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: A multicenter US study. Ann Emerg Med. 2002; 39(2): 144-52.
- Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004; 2(8): 1247-55.
- Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, et al. Prospective multicenter evaluation of the Pulmonary Embolism Rule-out Criteria. J Thromb Haemost. 2008; 6(5): 772-80.
- Singh B, Parsaik AK, Agarwal D, Surana A, Mascarenhas SS, Chandra S. Diagnostic accuracy of Pulmonary Embolism Rule-out Criteria: A systematic review and meta-analysis. Ann Emerg Med. 2012; 59(6): 517-20.e4.
- McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, et al. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstet Gynaecol. 2012; 52(1): 14-22.
- Douma RA, Mos IC, Erkens PM, Nizet TAC, Durian MF, Hovens MM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism - A prospective cohort study. Ann Intern Med. 2011; 154(11): 709-18.
- Wolf SJ, McCubbin TR, Nordenholz KE, Naviaux NW, Haukoos JS. Assessment of the Pulmonary Embolism Rule-out Criteria rule for evaluation of suspected pulmonary embolism in the emergency department. Am J Emerg Med. 2008; 26(2): 181-5.
- Kline JA, Peterson CE, Steuerwald MT. Prospective evaluation of real time use of the Pulmonary Embolism Rule-out Criteria in an academic emergency department. Acad Emerg Med. 2010; 17(9): 1016-9.
- Penaloza A, Verschuren F, Dambrine S, Zech F, Thys F, Roy P-M. Performance of the Pulmonary Embolism Rule-out Criteria (the PERC rule) combined with low clinical probability in high prevalence population. Thromb Res. 2012; 129(5): e189-93.
How this list was made
Clinical radiology recommendations 1-6 (April 2015)
A team of five Lead Radiologists were nominated to guide RANZCR's Choosing Wisely contribution. These Lead Radiologists analysed previous work completed by RANZCR, in particular a series of Education Modules for Appropriate Imaging Referrals.
These modules had been developed from an extensive evidence base and with multiple stakeholder input. Using the evidence from the Education Modules, the Lead Radiologists developed a draft recommendations list, which was then further developed and endorsed by RANZCR's Quality and Safety Committee, before being circulated to the RANZCR membership for consultation with a request for alternative recommendations. Member feedback was reviewed by the Lead Radiologists prior to ratification of the final recommendations by the Faculty of Clinical Radiology Council. The final six items selected were those that were felt to meet the goals of Choosing Wisely, i.e. those which are frequently requested or which might expose patients to unnecessary radiation.
Due to the fundamental role of diagnostic imaging in supporting diagnosis across the healthcare system, RANZCR worked closely with other Colleges throughout the project via the Advisory Panel. Following identification of two common recommendations with the Australasian College for Emergency Medicine, it was agreed by both Colleges to present these items jointly.
Radiation oncology recommendations 7-10 (September 2021)
Recommendations relating to radiation oncology from the Choosing Wisely and Choosing Wisely Canada were circulated around the Faculty of Radiation Oncology Council to determine which recommendations were applicable to the Australian and New Zealand context. The selected recommendations were then put to the Quality Improvement and Economics and Workforce Committees, with each being asked to rank the recommendations. The five highest ranked recommendations were then put to the radiation oncology membership for consultation prior to being formally approved by the Faculty of Radiation Oncology Council. Recommendations 7-10 are adapted from the American Society for Radiation Oncology (ASTRO) 2013 and 2014 lists. Recommendation 11 is adapted from Choosing Wisely Canada’s Oncology list. Each organisation was approached for—and subsequently granted—approval to adapt these recommendations as part of the Choosing Wisely Australia campaign.
This initial list has now been reviewed with recommendations 7, 8 & 10 remaining unchanged, recommendation 9 has been updated based on the advice of the Faculty of Radiation Oncology Quality Improvement Committee and Recommendation 11 has been replaced based on the feedback of the Quality Improvement Committee and the Policy and Advocacy team.
- 1 Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules (localised bone tenderness or inability to weight-bear as defined in the Rules).
- 2 Don’t request duplex compression ultrasound for suspected lower limb deep venous thrombosis in ambulatory outpatients unless the Wells Score (deep venous thrombosis risk assessment score) is greater than 2, OR if less than 2, D dimer assay is positive.
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3
Don’t request any diagnostic testing for suspected pulmonary embolism (PE) unless indicated by Wells Score (or Charlotte Rule) followed by PE Rule-out Criteria (in patients not pregnant). Low risk patients in whom diagnostic testing is indicated should have PE excluded by a negative D dimer, not imaging.
- 4 Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain.
- 5 Don't request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.
- 7 Don’t initiate whole-breast radiation therapy as a part of breast conservation therapy in women age ≥50 years with early-stage invasive breast cancer without considering shorter treatment schedules.
- 8 Don’t initiate management of low risk prostate cancer without discussing active surveillance.
- 9 Don’t routinely use more than one fraction for palliation of non-complex bone metastases.
- 10 Don't routinely add adjuvant whole-brain radiation therapy to stereotactic radiosurgery for limited brain metastases.
- 11 Do not proceed with any treatment for localised prostate cancer unless the man has been offered a consultation with a urologist and a radiation oncologist, and taken time to consider the advantages and disadvantages of each treatment option.