Pumping the brakes on Medicare lung cancer screening

When the U.S. Preventive Services Task Force (USPSTF) recommended last December that annual screening with low dose CT (LDCT) be provided to asymptomatic adults aged 55-80 who had a 30 pack-year history of smoking, it seemed like the first step toward full national coverage of LDCT screening. Under the Affordable Care Act, the grade “B” recommendation meant that all private insurers had to cover the procedure, and all that would be left is for Medicare to sign off on coverage.

Things can change quickly. The Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) met this week to hear arguments for Medicare coverage of LDCT lung cancer screening, and despite impassioned pleas from organizations like the Lung Cancer Alliance and the American College of Radiology, the MEDCAC panel expressed a lack of confidence in the evidence that the benefits of screening the Medicare population outweighed the harms.

A central issue was the fact that the USPSTF recommendation was based largely on a single trial, the National Lung Screening Trial, which demonstrated a 20 percent mortality benefit with screening. While many at the meeting acknowledged that trial was well constructed, it alone would not be enough to convince the panel to expand coverage.

“We have never relied on a single randomized control trial to set national policy on cancer screening,” said Steven H. Woolf, MD, MPH, of Virginia Commonwealth University, who sat on the panel.

Moreover, within the National Lung Screening Trial population, only 25 percent were in the Medicare eligible age group, 12 percent were over 70 and none were older than 74. Some speakers wondered whether the results of the trial, which was conducted at academic medical centers, would translate to the community setting.

All of these questions led the panel to vote for a lack of confidence that the current evidence is adequate to determine if the benefits outweigh the harms of lung cancer screening with LDCT in the Medicare population.

The Centers for Medicare and Medicaid Services will issue a draft coverage decision in November, with a final national coverage determination to follow early next year.

The MEDCAC meeting didn’t officially settle the matter, but it did show that supporters of expanding screening coverage to Medicare patients have an uphill battle to fight.

-Evan Godt
Editor – Health Imaging