CT test for hidden lung cancer is cost-effective but not covered for many likely to benefit

Beverly Merz

Executive Editor, Harvard Women's Health Watch

Lung cancer is a fact of life for some smokers. About 1 in 7, or 14%, develop this potentially  difficult-to-treat and deadly cancer. Quitting lessens the risk. Having tests to detect hidden lung cancer can help find it early, while it is still treatable.

The best test for finding hidden lung cancer is a low-dose CT scan. Its use has been endorsed by the U.S. Preventive Services Task Force (USPSTF), an independent panel that makes recommendations for screening tests. Most insurers follow the recommendations of the task force, and pay for those services. But some opposition to lung cancer screening using low-dose CT scans by a Medicare advisory board may mean that the test isn’t covered for some of the people who could benefit from it the most.

Who should be screened for lung cancer?

Checking seemingly healthy people for a hidden condition is called screening. The USPSTF recommends screening with low-dose CT for men and women between the ages of 55 and 80 who currently smoke or who have quit within the past 15 years, and who have a 30 pack-year smoking history. That means a pack a day for 30 years, two packs a day for 15 years, etc.

The task force says to stop screening once a person has not smoked for 15 years or develops a health problem that substantially limits his or her life expectancy or the ability or willingness to have curative lung surgery.

A detailed analysis of low-dose cancer screening, published in today’s New England Journal of Medicine, showed that the cost of adding one good year to a person’s life through CT screening is around $80,000. Tests or procedures that cost less than $100,000 per year added are considered cost effective.

In the NEJM analysis, researchers identified two groups for whom screening is the most cost-effective: current smokers and people ages 60-74. “This article talked about the populations that did the best—those with the highest risks and older people,” says Dr. Christopher Lathan, assistant professor of medicine at Harvard Medical School and a thoracic oncologist at Dana Farber Cancer Institute. But he also notes that many of those people may not be able to afford screening.

Who can afford to be screened?

Under the Affordable Care Act, insurers are required to provide services recommended by the USPST, so people with private insurance who fit its criteria can get screening at no cost. But an advisory committee to the Center for Medicare and Medicaid Services (CMS) came out against covering screening last spring. “What this means is that the people with the highest rate of lung cancer are the very ones who may not be able to take part in the screening,” Dr. Lathan says. “This group is likely to be on Medicaid or Medicare and they aren’t likely to be able to spend $350-$400 out of pocket for the test.”

Lung cancer screening in 2014 is a lot like mammography 30 years ago. Although medical organizations began to recommend regular mammograms in 1979, Medicare didn’t cover them. And because most insurers marched to the beat of the Medicare drum, health plans weren’t likely to cover mammography, either. After a decade of protests from consumer advocates and health professionals, Congress responded by attaching a mandate that Medicare cover mammography into the Omnibus Reconciliation Act of 1990.

“There has been something of a populist uprising over lung cancer screening, too,” Dr. Lathan says. A survey of the comments posted on the CMS website indicates that the populists are healthcare professionals—doctors, nurses, and medical groups who posted hundreds of testimonials urging CMS to override the panel’s advice and extend coverage. Many reminded the CMS that the reduction in deaths from lung cancer with CT screening is larger than the reduction in deaths due to mammography for breast cancer. The CMS is expected to publish a draft of its decision within the next few days and come to a final decision in early 2015.

Dr. Phillip Boiselle, professor of medicine at Harvard Medical School and a thoracic radiologist at Beth Israel Deaconess Medical Center, and colleagues filed a comment at CMS and followed up with an editorial in the September 2014 Journal of Thoracic Imaging. “The lack of Medicare coverage would prevent many seniors from benefiting from CT screening…and the lifesaving benefit of screening won’t be realized without this critical coverage,” he wrote.

If you’re considering screening

Like any screening test, this one is worth discussing with your doctor, who can help you determine whether or not it is for you.

During the discussion, consider the following:

  • False alarms. In the New England Journal of Medicine study, about a quarter of people who had low-dose CT screening for lung cancer had positive tests, which set them up for additional CTs, bronchoscopies, or biopsies. Ultimately, only about 5% actually had lung cancer. False alarms can be quite stressful, and the additional testing can cause problems.
  • Radiation exposure. Although the risk is low, some people develop radiation-induced cancers.
  • The test could pick up a cancer that is unlikely to cause problems in your lifetime.
  • Availability of quality testing. It’s important to have CT screening at a medical center that has experience in lung cancer screening and treatment and that offers follow-up counseling based on your results.

If you’re a smoker, keep in mind that screening won’t prevent lung cancer. It’s even more important talk to your doctor about enrolling in a program to help you quit, which will be covered by your insurance.

Related Information: How to Quit Smoking


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