Debate over Medicare coverage of CT lung cancer screening begins

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 - panel debate

The Medicare Evidence Development & Coverage Advisory Committee (MedCAC) convened today and representatives from organizations such as the American College of Radiology and the Lung Cancer Alliance went before the committee to contend for national Medicare coverage of low dose CT (LDCT) screening for patients who are at a high risk for lung cancer.

While the Centers for Medicare and Medicaid Services (CMS) will not post a draft coverage decision until November, the MedCAC panelists at today's meeting did not have high confidence that current evidence supports the notion that the benefits of LDCT lung cancer screening in the Medicare population would outweight the harms.

Last December, the U.S. Preventive Services Task Force (USPSTF) recommended that annual screening with LDCT be provided to asymptomatic adults between the ages of 55 and 80 who have a 30 pack-year history of smoking and currently smoke or have quit within the last 15 years. According to the recommendation, screening should be discontinued once a patient has ceased smoking for 15 years or develops a health problem that drastically limits his or her life expectancy or willingness to undergo curative lung surgery. This recommendation was designated grade “B,” meaning that private insurers must cover the procedure without a co-pay under the Affordable Care Act. However, the healthcare reform law does not force Medicare to provide full national coverage for the recommendation.

Paul Pinsky, MD, of the National Cancer Institute and National Institute of Health in Bethesda, Md., began the meeting’s featured speaker section by discussing the design of the National Lung Screening Trial (NLST), which played a large role in the 2013 USPSTF recommendation regarding LDCT screening. Pinksy noted that while LDCT demonstrated efficacy for lung cancer screening with a 20 percent mortality benefit, there was extreme variability in the radiologists’ false-positive rates. The false-positive rates ranged from 10 percent to as high as 50 percent, and most of the centers involved in the study were academic. Significant abnormality was higher in the older population at 8.7 percent versus 6.9 percent for those between the ages of 55 and 64. “Models that extrapolate benefit must be taken with caution,” Pinksy remarked.

“This genie certainly won’t be able to be stuffed back into the bottle if we don’t deal with this now,” said  Peter Bach, MD, MAPP, of the Memorial Sloan-Kettering Cancer Center in New York City, in reference to the current lack of Medicare coverage for LDCT screening. Bach branched off of Pinksy’s points about the NLST’s design by bringing attention to the underrepresentation of people in the older age band. Moreover, about only 25 percent of the subjects were in the Medicare eligible age group, and most participants were overeducated in relation to the typical population of tobacco users. Thus, Bach argued, the population was not correctly represented.

In addition to the trial’s study population, Bach also focused on the atypical care settings involved, which included those with particular expertise at academic medical centers. These factors made the situation appear to be more efficacious to the community, said Bach. Additionally, fewer than 12 percent of the subjects were over the age of 70 at the time of study entry and none were older than 74. This is especially problematic, as the risk of lung cancer rises with age, he said. Bach then pointed to the reality that every guideline recommends shared decision making, and asked Medicare to consider this truth when moving forward in making their decision.

Laurie Fenton Ambrose, President and CEO of the Lung Cancer Alliance in Washington D.C., then took the podium, pledging to ensure that the people behind the numbers are heard. She emphasized the Lung Cancer Alliance’s support for national coverage for lung cancer screening in the Medicare population, as 27.5 percent of all cancer deaths are attributed to lung cancer. Ambrose emphasized that the vast majority of lung cancer cases are detected at late stages and continue to occur in people over the age of 65. “There is no other proven way to detect lung cancer than screening,” she said.

Ambrose pointed to the rigorous testing and review of lung cancer screening that has taken place over the past 30 years, which is far more than any other screening method. She emphasized key elements of responsible screening, which she listed as educating those at risk, implementation