A Mighty Challenge Ahead

The news just arrived, and it was great news for Medicare-aged smokers and former smokers: CMS proposes to cover low-dose CT (LDCT) lung cancer screening for high-risk Medicare beneficiaries.¹ The agency wisely looked past the Medicare Evidence Development & Coverage Advisory Committee’s miserly no-confidence vote of last April, studied the evidence previously considered by the United States Preventive Services Task Force (USPSTF) and determined—as did the USPSTF—that the evidence is indeed sufficient to add lung cancer screening counseling and, if appropriate, yearly screening for high-risk individuals.

These are frugal times in medicine, and CMS could have hidden behind the MEDCAC vote and kicked the can down the road.  Instead, it has assured that a large segment of the most appropriate screening population will have access to the test.

Many people and organizations in radiology worked to make this happen. Denise Aberle, MD, and the other National Lung Screening Trial (NLST)² investigators, the American College of Radiology Imaging Network (ACRIN), and both the National Cancer Institute and the National Institutes of Health, which provided the funding, deserve special recognition. Aside from the grim demographics of this deadly disease, the NLST produced the primary evidence considered by the USPSTF and CMS, and researchers continue to sift through this treasure trove provided by 53,454 trial participants.

While ACRIN provided the infrastructure to get a multicenter lung cancer screening trial under way, there was minimal formal infrastructure in radiology for lung cancer screening when the USPSTF B-grade recommendation was made one year ago. The American College of Radiology (ACR) has worked with unprecedented speed and resolve to gain consensus for diagnostic and reporting protocols, practice parameters and technical standards, as well as an accreditation program for lung cancer screening center status.

The confetti has settled

Now comes the hard part.  After the confetti has settled, the work begins—and there is much to be done. Many radiologists working in the field of lung cancer screening compare these days to the early days of mammography, when what was known was far less than what would be learned. Staying current with an escalating standard of care will be an ongoing challenge.

Initially, however, the specialty has three important tasks. Radiology’s first challenge is simply to educate itself. To give patients the best care, radiologists must become fluent in lung cancer screening, beyond the 300 eligibility chest CT studies annually that Medicare proposes. Three excellent resources are the ACR, the National Comprehensive Cancer Network and the Lung Cancer Alliance, a patient advocacy organization led by Laurie Fenton Ambrose, a key figure in the campaign for coverage.

Second, radiology must help educate referring physicians. A study presented recently at the 2014 Chicago Multidisciplinary Symposium in Thoracic Oncology underscored this urgent need. A group  at Wake Forest Baptist Medical Center, Winston-Salem, NC, surveyed³ 488 primary care providers (physicians, physician assistants, nurse practitioners) to measure the provider’s use of lung cancer screening, its perceived effectiveness in reducing mortality, knowledge of the consensus guidelines and interest in further education.

Less than 50% knew three of the six guidelines; 30% were unsure of the effectiveness of LDCT; and 24% did not know any of them. The most knowledgeable providers were more likely to order LDCT screening for their high-risk patients and 80% of all respondents expressed interest in further education about lung cancer screening. It is important to note that all providers were affiliated with an academic medical center.

Third, radiology will need to meet what some NLST investigators have said is one of the greatest challenges—making sure patients come back after their initial screen. This will be a true test of patient centricity in radiology.

At long last, a positive coverage decision on LDCT lung cancer screening has arrived, representing a triumph of research, government funding and healthcare policy. This is an opportunity for radiology to further everything that healthcare needs more of: coordinated, efficient, patient-centered evidence-based care.

References

1. Proposed decision memo for screening for lung cancer with low dose computed tomography. CMS Web site. http://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=274. Accessed November 11, 2014.

2. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.

3. Lewis J, Petty WJ, Tooze JA, Miller DP, Chiles C, Miller AA, Weaver KE.  Low-dose CT lung cancer screening practices and attitudes among primary care providers at an academic medical center. Paper presented at: Chicago Multidisciplinary Symposium in Thoracic Oncology;  October 30, 2014; Chicago, IL.