USPSTF Issues Draft Recommendation for Low-Dose CT Lung Cancer Screening
The influential U.S. Preventive Services Task Force (USPSTF) has issued a draft grade “B” recommendation in favor of annual screening for lung cancer with low-dose CT in current or former heavy smokers between the ages 55 of 79. Unless the recommendation is downgraded during the 30-day comment period, it will virtually guarantee Medicare and private payor coverage for the test. Eight medical groups and societies — including the American Cancer Society and the American College of Chest Physicians — had already issued favorable recommendations for lung cancer screening with low-dose CT, but the Centers for Medicare & Medicaid Services (CMS) and most private payors primarily turn to the USPSTF for guidance on what benefits to cover because it is the only screening body that carries a legal mandate. Under the Affordable Care Act, Medicare and private insurers must provide coverage of all medical exams or procedures that receive a grade of “B” or higher from the USPSTF. The USPSTF draft recommendation is based on the same National Lung Screening Trial (NLST) data that all the other favorable recommendations have been based on and only recommends the test for patients that match the specific patient population examined by the NLST. Keeping the test from earning an “A” rating was the fact that the benefit of the test must be balanced against some risks. Beyond the additional radiation exposure patients would undergo with annual chest CTs, there is risk of harm in the course of investigating possible lung cancers found on the initial screening test. In the NLST, approximately 2.5% of positive tests required additional invasive diagnostic procedures, such as bronchoscopy, needle biopsy or thoracoscopy. A small number of these resulted in complications and six study participants did die after a diagnostic procedure. Also, some lung cancers found with low-dose CT screening in the study were slow-growing and may not have presented a significant risk to the patient for years. If the test is offered to patients at less risk of developing cancer than the current and former heavy smokers in the NLST study, the risks involved could easily overwhelm the benefits. The ACR is working on a practice guideline and an official Appropriateness Criteria, but could not say when exactly these would be forthcoming. In a June statement, Ella Kazerooni, M.D., chair of the ACR Thoracic Imaging Panel, had counseled patience. “These standards need adequate time to be finalized to support a robust screening program that will provide the life-saving results that everyone wants and expects,” she stated. The College was very supporting of the USPSTF draft recommendation and promised to both submit comments on the draft recommendation and work with the U.S. Department of Health and Human Services (HHS), the National Cancer Institute, Congress and other key stakeholders creating a CT lung cancer screening process. Lung cancer is one of the deadliest cancers, in part because it is typically detected too late to be effectively treated. According to the non-profit Lung Cancer Alliance, only 15 percent of people diagnosed with lung cancer will live 5 years or longer. Low-dose CT screening, despite its risks, is the only test scientifically shown to be able to detect cancers in time to improve survivability. “Today’s USPSTF draft recommendation marks a dramatic shift in views towards diagnosing and treating lung cancer. Expanded use of CT lung cancer screening in high-risk patients is a landmark step in the battle to defeat this terrible disease. The ACR is pleased that the USPSTF recognizes the benefits of these lifesaving exams. The College looks forward to completing the CT Lung Cancer Screening Appropriateness Criteria development and practice guideline and standards process to help ensure, safe, effective diagnostic care for those at high risk for lung cancer,” said Paul Ellenbogen, MD, FACR, chair of the American College of Radiology Board of Chancellors in a statement issued after the release of the draft recommendation. He went on to congratulate the lung cancer advocacy groups, particularly the Lung Cancer Alliance, for their “success in bringing the need for, and scientific efficacy of CT lung cancer screening to the forefront.” Lung Cancer Alliance president Laurie Fenton said in a statement that her group’s next steps would be to educate the public about the risk and direct them toward responsible screening providers. “We are here to answer questions about lung cancer risks and provide information to those who need it most,” she stated. Anticipating that current and former heavy smokers will hear news about the new recommendation and have questions, the LCA launched an online Risk Navigator tool – and expanded the hours of its support line – (800) 298-2436 – to 8 a.m. to 7 p.m. EST. A LCA national educational advertising campaign will also launch in September to encourage the public to know their risk for lung cancer. Public awareness may well add pressure on payors to cover the test more quickly. In particular, Medicare and Medicaid coverage is key because most of the patients that would benefit from the test are covered by these programs. (Heavy smoking is more common among the poor and nearly everyone opts for Medicare coverage after age 65 because of the substantial savings involved.)