In what is seen as a key step in broadening insurance coverage for lung cancer screening with low-dose CT, the U.S. Preventive Services Task Force (USPSTF) has issued a grade B recommendation in favor of the test for current and former heavy smokers age 55 to 80. Under the Affordable Care Act, any preventive services given an A or B grade recommendation by the USPSTF must be reimbursed by insurers.
The USPSTF based its recommendation largely on the National Lung Screening Trial, and it recommends the test only for patients that closely match the patients enrolled in that study. Those are patients with a heavy smoking history that is equivalent of smoking a pack a day for 30 years.
The recommendation is for annual screening and includes those who have quit within the past 15 years. However, the USPSTF also added that screening should be stopped after age 80, after the patient has been smoke free for 15 years, and if the patient develops a serious health problem that “substantially limits life expectancy or the ability or willingness to have curative lung surgery.”
Because the USPSTF’s recommendations by law form the basis for most private payor and Medicare coverage decisions, the task force’s decision could create a potential new revenue stream for imaging centers, along with broadening access to a group of patients that previously had no good screening option. The task force had earlier come out against X-ray screening for lung cancer, the only insurance-covered test for the disease, because researchers found that simple chest X-rays could not detect cancers early enough to make a difference in survival rates.
In its recommendation, the USPSTF noted that although risks of false positives, radiation exposure and complications from follow-up testing are big concerns with this test, the fact that lung cancer is fatal in nearly 90% of cases and has no other testing option that has been shown to detect cancers early enough to make a difference in survivability tips the balance of benefit vs. harm in the test's favor.
The Lung Cancer Alliance, a national patient advocacy group, hailed the decision as a big step forward in improving survival rates for people at high risk for developing lung cancer. “Today the tide has turned in our battle against lung cancer,” said Laurie Fenton Ambrose, president and CEO of Lung Cancer Alliance in a statement.
Now advocacy efforts will shift toward improving access to the test by getting all payors to cover the cost of the test and spreading best practices in follow-up care for patients whose low-dose CT indicates the need for further testing for cancer. The USPSTF noted in its decision that it saw a need for studying what happens to patients when low-dose CT lung cancer screening becomes more common in diverse community setting where there may be greater variability in follow-up protocols. Poor follow-up care could, according to the USPSTF, result “in a different balance of benefits and harms” than those observed in the studies the task force based its recommendation on.
The National Comprehensive Cancer Network, as well as the American Cancer Society and the Lung Cancer Alliance, have developed guidelines for follow-up care when a nodule is detected by low-dose CT. However, practice guidelines from the ACR that speak directly to radiologists are still under development.