JAMA editorialists hit the brakes on Medicare LDCT lung cancer screening

Private insurers will soon have no choice but to cover low-dose CT (LDCT) lung cancer screenings for high-risk patients, but a fight is brewing over whether Medicare should follow suit.

After the U.S. Preventive Services Task Force (USPSTF) gave the LDCT lung cancer screening the greenlight late last year, dozens of groups led by the American College of Radiology, the Society of Thoracic Surgeons, the Lung Cancer Alliance, the American Thoracic Society and the American Cancer Society’s Cancer Action Network have weighed in on the affirmative side. The coalition sent CMS a 43-page letter in September specifying patient selection and screening protocols.

This side has the weight of bipartisan support in both chambers of Congress. Ella Kazerooni, MD, chair of ACR’s lung cancer screening committee recently summed up the case for screeing in a brief conversation with RadiologyBusiness.com.

Not so fast, say the authors of an editorial published this week in JAMA.

“The USPSTF’s recommendation and the anticipated national coverage determination by CMS have fueled calls by advocacy organizations for widespread implementation,” write the editorial’s authors, led by Steven H. Woolf, MD, MPH, of the department of family medicine and population health at Virginia Commonwealth University. “In the past, it was at this critical juncture when screening tests were prematurely introduced into practice without adequate consideration of potential harms. The CMS should scrutinize the evidence before setting a coverage policy.”

The authors justify their opinion with reasoning based on four main points: 

• the magnitude of benefit from widespread LDCT screening is uncertain;
• the potential harms of LDCT screening are concerning and could affect a large population;
• whether the benefits of LDCT outweigh the harms and confer net benefit is a matter of judgment; and
• the specific participants, clinical centers, and protocol that produced the NLST (National Lung Screening Trial) results would rarely exist under less controlled conditions, and less control should be expected in routine practice.

Woolf, et al., recommend that CMS postpone its coverage decision “until better data become available.”

“Our call for prudence is not a display of insensitivity to the approximately 160,000 people in the United States who die annually from lung cancer,” they write. “Saving their lives is urgent, and tobacco control remains the top public health priority: Fully 18% of adults in the United States continue to smoke cigarettes. It is fair to ask whether low-dose CT screening would add incremental benefit over tobacco control and would save enough additional lives to offset the harms it would cause.”

The ACR issued a sharp rebuttal before the ink of the editorial was dry, calling the piece “inaccurate and misleading.” The editorial “ignores available evidence, relies on unsubstantiated or ambiguous claims and fails to accurately portray the current state of CT lung cancer screening,” the group said in prepared remarks.

“Questions regarding CT lung cancer screening effectiveness, cost and patient acceptance are answered,” added Kazerooni. “Obfuscation of current screening capabilities and the lifesaving benefit of these exams is not helpful and may ultimately cost lives. It is time for Medicare to move forward with full coverage for low-dose CT lung cancer screening.”

The ACR noted studies showing that LDCT for lung cancer screening is as cost-effective as other major cancer screening programs and more cost-effective than automobile seatbelts and airbags.

In her conversation with RadiologyBusiness.com, Kazerooni deplored the policy prescription of mandating coverage for the privately insured only to cut patients off when they turn 65—“just as they’re going into their highest risk years for lung cancer.”

To which side will CMS ultimately listen come decision day, Nov. 10? All bets are off. The ACR pointed out to the media that the American Medical Association itself—the publisher of JAMA—has definitively endorsed coverage of LDCT for lung-cancer screening.