October 13th, 2014

Medicare Reimbursement for Lung Cancer Screening Provokes Debate

Although 160,000 people in the U.S. die each year from lung cancer, accounting for more than a quarter of all cancer deaths, screening for lung cancer remains controversial. Based on results from the National Lung Screening Trial (NLST) in 2011, the U.S. Preventive Services Task Force (USPSTF) issued a B recommendation in favor of low-dose CT screening for high-risk current and former smokers. Due to a provision in the Affordable Care Act, private insurance is now mandated. More recently, the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) concluded that there is only low to intermediate confidence that “there is adequate evidence to determine if the benefits outweigh the harms.” The Centers for Medicare and Medicaid Services (CMS) is expected to issue a final decision on national coverage in 2015.

In a special communication published in JAMA Internal Medicine, Douglas Wood writes that the NLST clearly established that the benefits of screening were greater than the risks: “the balance was not close, with a substantial improvement in lung cancer mortality among screened patients.” He argues that the “unintended consequences of screening… can be reasonably mitigated by well-constructed policies and disciplined control within screening programs.” Guidelines from professional societies will help ensure the safe and effective implementation of screening programs, he writes.

Wood further notes that 70% of lung cancer is found in the Medicare population — people who are 65 years or older. “CMS should cover low-dose CT,” he writes, “thus avoiding the situation of at-risk patients being screened up to age 64 through private insurers and then abruptly ceasing screening at exactly the ages when their risk for developing lung cancer is increasing.”

Steven Woolf, Russell Harris, and Doug Campos-Outcalt take the opposite perspective in a competing special communication. The 16% mortality reduction in NLST translated into an absolute reduction of only 0.3% from 21 to 18 deaths from lung cancer per 1000 people. Although the trial prevented 83 deaths among the 26,722 participants, “on the other side of the ledger, the screening caused 16 iatrogenic deaths from diagnostic workups, which included 10,246 imaging studies, 322 percutaneous biopsies, 671 bronchoscopies, 713 surgical procedures, and 228 complications (86 classified as major).”

Woolf et al also warn that “the lure of a vast consumer market of current and former smokers and mandated insurance coverage might entice a groundswell of companies and health systems” seeking to profit from the coverage with little commitment to “accuracy, minimizing radiation exposure, and responsible referrals.”

In an Editor’s Note, Robert Steinbrook  expresses concern about the scope of the intensive lobbying effort before the final CMS decision.  By June 2014, 45 U.S. senators and 134 House Representatives had written in support of reimbursement for low-dose CT scans. The final CMS decision should be “based on medical evidence, not lobbying or politics,” writes Steinbrook.



2 Responses to “Medicare Reimbursement for Lung Cancer Screening Provokes Debate”

  1. David Powell , MD, FACC says:

    I guess I have no idea how things happen. I thought CMS made decisions without political input, though it’s current abysmal state is consistent with political influence. I think it should be run more like the FDA is supposed to be, independent with multiple inputs from different physician groups.I am not sure which groups, but does the ACA specify the group which will run and/or interpret comparative effectiveness studies? The IOM? Who is the final arbitrator? Please fill me in.

  2. Lung cancer screening clearly works and saves lives. In the first 18 years of my practice, I found 0 surgically resectable cancers. I not have 12 subjects with a greater than 90% chance of being cured of lung cancer as it was found <1.5 cm in size, stage 1. I stumbled across these cancers while screening for coronary disease with EBT calcium imaging.

    The study showing a 16% reduction in lung cancer mortality was based on a poorly designed study where a CT every 6 months X 3 was compared to a chest x-ray every 6 month x 3, then followed for 10 years without subsequent screening.

    A prior study showed across the board an 84% long term survival from lung cancer when CT screening was used. (N Engl J Med 2006;355:1763-71.) That is a major departure from the 10% long term survival we normally see for lung cancer.