FEATURE: Experts stunned by proposed CTC ruling

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Image courtesy of TeraRecon

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) issued a proposed decision memo stating that available evidence was inadequate to conclude that CT colonography (CTC) is an appropriate colorectal cancer screening test, leaving many radiologists and medical imaging professionals shocked.

According to the proposed decision memo, the evidence is not sufficient for CMS to conclude that "screening CTC improves net health benefits for asymptomatic, average risk Medicare beneficiaries." CTC for colorectal cancer will remain uncovered until the agency issues its final decision after a 30-day comment period closes in April.

"My initial response was one of disbelief," Abraham H. Dachman, MD, told Health Imaging News. "It is very hard to believe their specific concerns based on the science; and I think the scientific concerns raised are a veil for what boils down to economic issues and perhaps to the current economic crisis."

Dachman, professor of radiology and director of fellowship programs in the department of radiology at the University of Chicago, has been a member of the American College of Radiology's task force on CTC since 2006.

"Even with the current economic conditions, there are strong scientific data to support a positive decision as three large payors have done--payors who wouldn't be reimbursing for a procedure if they didn't think it was cost-effective," said Dachman.

CMS has created a state of bewilderment with its proposal that should it determine that CTC is clinically effective, the agency would still need further analysis into whether CTC is cost effective.

At the 2008 RSNA meeting, keynote lecturer Elizabeth McFarland, MD, called for increased CTC utilization, even in the face of a restrictive reimbursement and economic climate. She addressed some of the challenges, including defining the target lesion size for polyp detection, issues surrounding radiation dose, and the need to create standards for extracolonic findings—challenges that CMS has echoed in its proposed decision.

The cost of the exam is one reason CMS is holding off making a ruling, said Karen M. Horton, MD, professor of radiology at the Johns Hopkins Medical Institutions in Baltimore. Not just because of the cost of the exam, but the cost of the extracolonic findings as well.

"Personally, I think there are enough data out there showing CTC's similar accuracy to conventional colonoscopy to warrant that it be covered in a screening population," Horton said. "Certainly when you compare it with other studies, such as barium enema or flexible sigmoidoscopy, which are covered by CMS, CTC is much better. It just doesn't make sense."

Studies, such as that by Hassan et al in the April 2008 Archives of Internal Medicine, have reviewed the cost-effectiveness of CTC, taking into account extracolonic findings.

The study found that when "detection of extracolonic findings such as abdominal aortic aneurysms and extracolonic cancer are considered in addition to colorectal neoplasia in our model simulation, CT colonography is a dominant screening strategy (i.e., more clinically effective and more cost-effective) over both colonoscopy and colonoscopy with 1-time ultrasonography."

"This is smoke and mirrors," Dachman said. "And if I were a consumer, I would be writing a letter to CMS, saying they need to reimburse for CTC screening."

Individuals interested in commenting on the proposed decision can do so here.