Medicare's 2015 Coverage Of CT Lung Cancer Screening: Who Is Eligible And Why?

Issue 25 Summer/Fall 2015

Lung cancer remains the leading cancer killer, and is responsible for more cancer deaths in the United States than breast, prostate and colorectal cancer combined.1,2

Early detection of lung cancer has been tested for decades, but only recently did the National Lung Cancer Screening Trial (NLST), published in 2011, show that lung cancer deaths can be prevented through screening with low dose helical computed tomography (LDCT).

No other study before or since has shown a benefit of any type of screening, so this was a breakthrough moment in lung cancer prevention.

However, not everyone – or even every smoker – stands to benefit. The NLST result only pertains to high-risk patients who are age 55 to 74 years old and have a heavy smoking history of 30 pack years or more.3

In this group, screening prevented about 3 deaths for every 1,000 people screened.

The United States Preventive Services Task Force (USPSTF) gave lung cancer screening a Grade B recommendation, meaning that there is moderate certainty that the net benefit is at least moderate.4

Radiology image of the lungs

Why such a cautious recommendation? That’s because there are also downsides to widespread screening.

For example, one in every four lung CT scans shows something worrisome that turns out not to be cancer. Results like those can take a psychological toll on patients, since studies have shown that when people are told they have anything abnormal in a screening result, they can become distressed.5,6

CT scans also expose people to significant amounts of harmful radiation: About one out of every 2,500 people screened for three years will get cancer from the testing, about one-tenth as many as who will have benefited.7

The Centers for Medicare and Medicaid Services (CMS) – the agency that runs the federal Medicare program – has now determined that annual screening with LDCT should be available to certain Medicare patients. These include people who are age 55-77 years; asymptomatic (meaning no signs or symptoms of lung cancer); have a tobacco smoking history of a minimum of 30 pack-years (one packyear is the equivalent of smoking one pack per day for one year); still smoke or, if a former smoker, he or she quit within the past 15 years.

Screening should stop once a former smoker is beyond 15 years since quitting, CMS has ruled.

The agency’s rules closely follow the multi-society statement outlining nine components necessary for a high quality LDCT lung cancer screening program.8 CMS recognized the importance of shared decision making, too.

Not all people who are at highrisk for lung cancer may want the risks of screening for its benefits, the agency noted.

Then there is the proficiency of the person who reads the CT scan result. CMS requires that the radiologist interpreting the LDCT be boardcertified or eligible and have read a minimum of 300 chest CT scans over the past 3 years.

Smoking-cessation services must be also made available to the patient, radiation doses should be kept to a minimum, and the reporting of findings must be standardized.

Lastly, CMS requires that screening facilities collect and submit data to an approved registry for each screening test.

There is no doubt that lung cancer screening works when offered in the correct population and done carefully. But, as with all cancer screening technologies, there are both benefits and harms that must be considered when deciding to be screened.

REFERENCES:

  1. Cancer facts and figures. Atlanta, GA: American Cancer Society, 2013
  2. Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol 2007; 2:706-714
  3. National Lung Screening Trial Research T, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365:395-409
  4. Moyer VA. Screening for Lung Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2013
  5. Wiener RS, Gould MK, Woloshin S, et al. What do you mean, a spot?: A qualitative analysis of patients' reactions to discussions with their physicians about pulmonary nodules. Chest 2013; 143:672-677
  6. Slatore CG, Press N, Au DH, et al. What the heck is a "nodule"? A qualitative study of veterans with pulmonary nodules. Ann Am Thorac Soc 2013; 10:330-335
  7. Bach PB, Mirkin JN, Oliver TK, et al. Benefits and harms of CT screening for lung cancer: a systematic review. Jama 2012; 307:2418-2429
  8. Mazzone P, Powell CA, Arenberg D, et al. Components necessary for high-quality lung cancer screening: american college of chest physicians and american thoracic society policy statement. Chest 2015; 147:295-303
Peter B. Bach, MD

Peter B. Bach, MD
Director, Center for Health Policy and Outcomes
Memorial Sloan Kettering Cancer Center
New York, NY

Nichole T. Tanner, MD
Assistant Professor of Medicine
Medical University of South Carolina
Charleston, SC