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Waiting for CMS to Rule on Lung Cancer Screening

By Jim Knaub

The Centers for Medicare and Medicaid Services (CMS) will approve or deny low-dose CT lung cancer screening for Medicare patients at high risk of lung cancer—possibly as soon as next month. Both sides in the debate are waiting for that clarity.

Medicare coverage of screening would provide seniors coverage similar to what the Affordable Care Act (ACA) requires for individuals covered by private insurance. In 2013, the United States Preventive Services Task Force (USPSTF) gave CT lung cancer screening a “B” recommendation for people between the ages of 55 and 80 with a minimum 30-pack-year history of smoking, which led to the coverage requirement by the ACA. However, the USPSTF’s recommendation does not mandate CMS coverage.

While waiting for that decision, both camps are advocating for their positions. The proscreening side reinforces the evidence that supports their key points:

  • Low-dose screening already has shown a better cost-benefit ratio than breast cancer screening.
  • The USPSTF recommended screening for people with a minimum 30-pack-year history of smoking.
  • The National Lung Screening Trial (NLST) reported 20% mortality reduction for individuals with a minimum 30-pack-year history of smoking who were screened using CT.
  • Screening could save thousands of lives. Lung cancer claims more lives than breast, colon, pancreatic, and prostate cancers combined.
  • An analysis of NLST data found that screening produced a similar mortality reduction in patients over age 65 as it did for those under 65.

More than 70 cancer organizations and medical societies, including the ACR, urged CMS to cover screening for people at high risk of lung cancer.

“CT lung cancer screening is cost-effective and significantly reduces lung cancer deaths,” said Ella Kazerooni, MD, FACR, in the ACR’s statement on lung cancer screening last month. Kazerooni chairs ACR’s Lung Cancer Screening Committee. “Published results show no undue or lasting patient anxiety from the screening process. It is time for Medicare to cover CT lung cancer screening,” she added.

Like many debates over screening, there are views on both sides of the issue. Here are some of the common arguments against screening.

  • The NLST is just one study. In an editorial in American Family Physician, Dean A. Seehusen, MD, MPH, wrote: “This [USPSTF] recommendation is based largely on the results of a single study, the National Lung Screening Trial (NLST). Although the NLST was a large and well-conducted investigation, the participants were younger, more educated, and more likely to be current smokers than the general population. The population at greatest risk of lung cancer, those 70 years and older, comprised less than 9% of NLST participants. From 2004 to 2006, more than one-half of lung cancer cases in the United States occurred in this population.”
  • The Medicare Evidence Development and Coverage Advisory Committee issued a vote of low confidence in low-dose CT scans for lung cancer screening, citing concerns of insufficient evidence of screening benefit, and that screening harms may outweigh its benefits in older people.
  • Which populations will be screened? A series of editorials for and against screening in this month’s JAMA Internal Medicine mentioned concerns about which patients would be covered, how often at-risk individuals should be scanned, and how to minimize false-positive results.
  • Screening brings potential harms. Commonly listed concerns about the potential harm of screening include false-positives, additional radiation exposure, patients’ anxiety, and overtreatment and its resulting complications.
  • There is pressure to expand screening to populations without proven benefit.

Medicare coverage of CT lung cancer screening may make it more widely available, but like most debates about screening, insurance coverage alone won’t end the debate.

— Jim Knaub is editor of Radiology Today.