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Publication Briefs

National Campaign Reduces Prostate Cancer Imaging in Sweden

Recently, the American Society of Clinical Oncology and the American Urological Association highlighted the need to reduce inappropriate imaging for low-risk prostate cancer in the Choosing Wisely campaign, a multi-disciplinary effort to reduce unnecessary medical testing, decrease overuse of healthcare resources, and improve quality of care. Since 2000, the National Prostate Cancer Register (NPCR) of Sweden also has engaged in an effort to reduce inappropriate diagnostic imaging. The NPCR collected data to generate local, hospital-level reports of the frequency of imaging use for patients with low-risk prostate cancer. These data, along with imaging guidelines from professional societies in Europe, the US, and Sweden, as well as important literature, are presented annually to Swedish urologists attending regional and national urology meetings, accompanied by the message that reducing inappropriate imaging is important. This retrospective cohort study assessed NPCR's effort to reduce inappropriate prostate cancer imaging by examining imaging trends over time across Sweden, taking into consideration clinical risk category (low, intermediate, high), geographic region, as well as patients' age and comorbidity. Analyses included 99,879 men diagnosed with prostate cancer from 1998-2009.


  • Overall, prostate cancer imaging decreased over time, particularly for men in the low-risk (inappropriate imaging) category, among whom the imaging rate decreased from 45% to 3%, but also for men in the high-risk (appropriate imaging) category, among whom the rate decreased from 63% to 47%.
  • Despite substantial regional variation, all regions in Sweden experienced significant decreases in prostate cancer imaging.


  • It is not possible to demonstrate that the NPCR intervention, and not secular trends, was responsible for the decrease in inappropriate imaging.
  • Differences across healthcare systems might reduce the generalizability of the approach described here for countries that do not have a uniform national healthcare system.


  • Many previous guidelines and policy efforts have failed to reduce inappropriate prostate cancer imaging in the U.S. These results may inform current efforts to promote guideline concordant imaging, especially in a coordinated healthcare system such as VA.
  • Efforts to curb inappropriate imaging may best be coupled with efforts to encourage appropriate imaging, so that improving care for low-risk patients is not at the expense of high-risk patients.

Dr. Makarov is supported by an HSR&D Career Development Award and is part of the VA New York Harbor Healthcare System.

PubMed Logo Makarov D, Loeb S, Ulmert D, et al. Prostate Cancer Imaging Trends Following a Nationwide Effort to Discourage Inappropriate Prostate Cancer Imaging. Journal of the National Cancer Institute September 4, 2013;105(17):1306-13.

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