MEDCAC vote chills hopes for LDCT lung-cancer screening coverage

Lung and bronchus cancer is most frequently diagnosed among people aged 65-74, precisely a population for which Medicare is responsible, yet a CMS advisory panel gave low-dose CT lung-cancer screening a vote of low confidence in a meeting today in Baltimore.

The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) met at the request of CMS, in the wake of an endorsement for LDCT lung-cancer screening from the U.S. Preventive Services Task Force.  ACA requires that insurers cover procedures with a B or better recommendation, and the USPSTF gave LDCT lung-cancer screening in high-risk populations a B recommendation in December of 2013. Medicare, however, is not bound by that requirement.

The Medicare Improvement for Patients and Providers Act (MIPPA) of 2008 does authorize CMS to add new preventive services, provided that the service is reasonable and necessary for the prevention or early detection of disease; recommended with a grade of A or B by the USPSTF; and appropriate for individuals entitled to benefits under Medicare Part A or Part B.

Following a full day’s worth of presentations and testimony about and in support of lung-cancer screening, MEDCAC panelists were unconvinced, indicating a lack of confidence in the evidence for and benefits of screening in their responses to the following two questions (a score of 1 being low or no confidence and 5 representing high confidence), according to an early report from Aunt Minnie:

• How confident are you that there is adequate evidence to determine if the benefits outweigh the harms of lung cancer screening with LDCT [CT acquisition variables set to reduce exposure to an average effective dose of 1.5 mSv (please see footnotes)] in the Medicare population? Mean score of 2.2.

• How confident are you that the harms of lung cancer screening with LDCT (average effective dose of 1.5 mSv) if implemented in the Medicare population will be minimized? Mean score of 2.333

A score of 2.4444 indicated an intermediate level of confidence.

The committee cast its highest vote when queried about its confidence that clinically significant evidence gaps remain regarding the use of LDCT in the Medicare population outside a clinical trial: Mean score of 4.4444.

CMS is expected to publish a formal decision memo in November, followed by a second public comment period.

A Grim Toll

Nonetheless, lead medical officer for the panel, Joseph Chin, MD, MS, opened the meeting with a Power Point presentation that underscored the need to reverse the grim toll exacted by lung cancer: 159,480 estimated deaths in 2012, more than the three other most prevalent cancers combined, prostate (29,720 deaths), breast (39,620 deaths) and colon and rectum cancer (50,830).

Other salient facts culled from SEER data by Chin include the following:

• 31.4% of lung and bronchus cancer is diagnosed among people aged 65–74;

• 28.1% of lung and bronchus cancers are diagnosed among people aged 75–84;

• 30.5% of deaths due to lung and bronchus cancer occur among people aged 65–74;

• 57% of lung and bronchus cancers are diagnosed after cancer has metastasized; and

• 44% of Medicare beneficiaries are former smokers, while 14% are current smokers.

Shortly after the meeting, the American College of Radiology (ACR) issued a statement condemning the decision, suggesting that the lack of national Medicare coverage for CT lung cancer screening places many Medicare beneficiaries at a potentially lethal disadvantage.

“Without national Medicare coverage for CT lung cancer screening, seniors face a two-tier coverage system in which those with private insurance will be covered for these exams and many of their lives saved, while Medicare beneficiaries are left with lesser access to these exams and placed at increased risk of dying from lung cancer. CMS needs to move for full national coverage as the USPSTF recommendations would indicate,” said Ella Kazerooni, MD, chair of the ACR Lung Cancer Screening Committee in the statement.