Since the publication in 2011 of the National Lung Screening Trial (NLST) that found that screening for lung cancer with low-dose spiral CT imaging resulted in a 20 percent reduction in lung cancer deaths among 55-or-older heavy smokers, diagnostic imaging providers have watched and waited to see how the research might change the screening recommendations of the American Cancer Society. On Friday, the ACS came out in cautious favor of the test.
Because many payors look to the ACS’s recommendations for which tests to cover, the decision could open the door to greater coverage for low-dose spiral CT screening for lung cancer, one of the deadliest cancers among U.S. patients.
Patient advocacy group the Lung Cancer Alliance stated that it was pleased at the change in recommendations from the ACS and said it would now work on issues such how to deploy lung cancer screening responsibly and equitably, how to determine who else will benefit beyond the NLST population of older, heavy smokers, and how to get policymakers to include coverage for the test in federal and state health coverage. The Department of Veterans Affairs agreed to move forward on CT screening for veterans at high risk for lung cancer in 2012, but Medicare and Medicaid have not acted, and the test is not an “essential benefit” under the health plans created by the Affordable Care Act (aka, Obamacare).
“This is important because we have already seen improvements in imaging and protocols since the screening rounds in the NLST were completed,” said James Mulshine, MD, LCA Board member and Associate Provost for Research at Rush University in the organization’s statement.
The American College of Radiology (ACR) said in its statement about the ACS recommendations that it is working on scientifically-based appropriate guidelines and practice standards. This will include guidelines on personel, equipment protocols and follow-up to ensure patients nationwide have uniform, quality care that will indeed save lives.
As ACS chief medical and scientific officer Otis W. Brawley, MD, FACP noted in his comments on the recommendation change, there is a significant risk that patients referred for follow up tests like invasive bronchoscopy or needle lung biopsy may be harmed by the follow up tests. In addition, patients could be harmed by treatment for small tumors that are technically cancer but are not the kind that would pose a threat to their health.
“Some have interpreted the NLST as showing that for every 5 to 6 lives saved from lung cancer, 1 life was lost due to screening and the additional diagnostic procedures,” Dr. Brawley noted.
Many imaging providers are of course already offering the test following the guidelines of the NSLT and the recommendations of the National Comprehensive Cancer Network (NCCN) and the American Association of Thoracic Surgeons (AATS) — early endorsers of the test.
Wellpoint was the first private payor to begin covering the test after the publication of the NSLT results, and patients willing to pay cash have long been able to get discounted CT lung cancer screening for as little as a few hundred dollars plus the radiologists reading fee from well-respected hospital systems. (A 2011 Kaiser Health News article criticized the practice as being potentially self-serving as the hospital systems did stand to benefit from any needed follow-up testing or cancer treatment.)According to the LCA,160,000 people a year are dying of lung cancer, which is close to a third of all cancer deaths in the United States. There is clearly a significant opportunity in providing a test that could reduce this number, but the ACR urges patience and responsibly offering the test only in accordance with strict, research-based guidelines that may take up to a year for the College to develop.
“CT lung cancer screening is appropriate when performed in the context of careful patient selection and follow-up,” it stated. “We urge patience and support while the guidelines and standards infrastructure to create a safe, sustainable, and effective lung cancer screening program is created and put in place.”