ACR asks CMS to revise proposed guidelines for LDCT lung cancer screening

The American College of Radiology (ACR) has asked the Centers for Medicare and Medicaid Services (CMS) to revise its guidelines for low dose CT (LDCT) lung cancer screening for the Medicare population.

Last month CMS issued a  proposed decision memo approving LDCT screening for Medicare patients, but with restrictions that concern lung cancer screening advocates.

For example, under the proposed CMS guidelines screening participants must be between the ages of 55 and 74. Last year, however, the United States Preventive Services Task Force (USPSTF) issued recommendations supporting screening for persons between the ages of 55 and 80.

In a joint comment letter signed by ACR CEO William Thorwarth, MD, the ACR, along with the Lung Cancer Alliance and the Society of Thoracic surgeons, said they “strongly oppose” the decision to restrict screening access to high risk patients 74 and younger.

“The median age of diagnosis for this particular disease is 70 years and a cap of 74 would exclude a large patient group where this exam is medically necessary and appropriate,” the letter stated. The three societies urged CMS to adopt the USPSTF recommendation, stating that the USPSTF “provided robust mathematical modeling” justifying a broader age range for screening.

The groups also argued that excluding 75-80 year old patients from LDCT screening coverage would create a lack of uniformity among governmental recommendations and disproportionately impact lower income elderly Americans.

The three groups also asked CMS to:

• Revise the definition of asymptomatic patients to ensure that those with medically appropriate indications who may be exhibiting signs suggestive of lung cancer (e.g., COPD, smoking cough, asthma, emphysema, and other pulmonary symptoms) can still qualify for an annual LDCT screen.
• Clarify that patients only need a written order and to complete a shared-decision making visit for the initial LDCT screen (not subsequent screenings or visits).
• Recognize for payment those sites previously accredited and designated as "accredited providers of chest CT and LCS designation."
• Delete the 15-year threshold by which patients must have ceased use of tobacco products.

As for the last recommendation, the three societies asked CMS to “weigh the unintended consequences" of this smoking cessation threshold. The groups wrote that they are specifically concerned that this arbitrary time period will incentivize patients to restart their smoking habit in order to become eligible for screening or retain their screening eligibility.

"While we recognize the 15-year smoking cessation threshold was part of the [National Lung Screening Trial] inclusionary trial criteria, there is no evidence that lung cancer risk falls offs substantially after 15 years smoking cessation,” the letter stated. “We ask that CMS implement their final decision based on the broader impact of a public policy decision. The final lung cancer screening [national coverage determination] must utilize language and standards that ultimately prevent, rather than encourage smoking.”

The comment period on the proposed decision ended last week and CMS is expected to issue a final decision after the first of the year.