ASCO paper overestimates Medicare cost of LDCT lung-cancer screening

The ACR issued a swift response to a paper presented this morning at the annual meeting of the American Society of Clinical Oncology (ASCO) that overestimates the potential costs of low-dose CT (LDCT) lung-cancer screening to the Medicare program by using an outdated definition of a positive screening study.

Basing their cost estimates on the 4mm threshold used at the outset of the National Lung Screening Trial, the authors estimated the cost of screening to the Medicare program at $8.80PMPM and $5.70PMPM, based on two different scenarios, one in which all eligible patients would be screened and one in which 20% of eligible patients would be added to the program each year.

“Published scientific evidence shows that a 6mm threshold significantly reduces false positive exams and subsequent diagnostic testing,” said Ella A. Kazerooni, MD, chair of the American College of Radiology Lung Cancer Screening Committee, in a prepared statement.  “The NLST began enrollment in 2002 and used the 4mm size threshold to define a positive screen based on scientific knowledge at the time.”

“Since then, our knowledge has increased through multiple published papers from the NLST and iELCAP, and the positive threshold has evolved,” she continued. “Use of the 6mm size threshold reduces positives screens from over 1-in-4 exams to 1-in-10, reducing diagnostic testing and without delay in lung cancer diagnostics. This results in lifesaving screening that is incredibly cost-effective compared to other widespread screening measures.”

This exchange illustrates both the slow uptake of research in the medical community and the rapidly changing standard of care in LDCT lung-cancer screening. Some researchers are already suggesting that a threshold higher than 6 mm could be used, but 6mm is the current threshold used in the American College of Radiology’s recently released Lung-RADS™ quality assurance tool, part of a broader infrastructure the college is developing to ensure that screening exams are delivered in a standardized, safe and effective way.

Many private health insurance plans across the country are already covering LDCT lung cancer screening, considered an essential health benefit under ACA since receiving a B recommendation from the United States Preventive Services Task Force. The ACA requirement applies only to private payors.

CMS initiated a National Coverage Analysis on LDCT lung-cancer screening in February, and convened a Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) meeting on April 30th.  That meeting resulted in a low-confidence vote in the evidence for and benefits of lung-cancer screening in the Medicare population. CMS is expected to publish a formal decision memo in November, followed by a second public comment period.