Cost analysis reveals need to reduce biopsy use in the diagnosis of lung cancer

With the November 8 deadline looming for a CMS decision on coverage of lung-cancer screening for Medicare patients, several studies presented earlier this week at the 2014 Chicago Multidisciplinary Symposium in Thoracic Oncology underscored the need for a disciplined approach to lung cancer diagnosis in the Medicare population.

One study undertaken by data analysts at Xcenda, a consultant in managed healthcare, underscored the need to reduce the use of biopsy and increase the use of PET in the diagnosis of lung cancer.  The study looked at utilization rates in a 5% sample of Medicare beneficiaries from 2009 to 2011 and estimated the cost of lung cancer diagnosis using Medicare reimbursement. Patients were excluded from the study if they had a diagnosis of cancer, pneumonia, atelectasis or tuberculosis the six months period prior to their abnormal CT.

A total of 8,979 patients were identified as having an abnormal chest CT scans between July 1, 2009 and December 31, 2010. The total diagnostic workup cost was $38.3 million, with 43.1% attributed to biopsy costs for the 761 patients in the sample with negative biopsy results. The mean age of the patients was 69.3 and 56.4% were women, and during a 12-month period, 13.9% were diagnosed with lung cancer.

The diagnostic tests used to arrive at the diagnosis included chest CT (in 32.9% of patients) chest x-rays (54.4%), lung biopsies (19.4%) and PET scans (0.4%). The average cost of a lung biopsy was $3,784, with a mean cost of $14,634.  (Average cost of a lung biopsy with complications was $37,745, and adverse events were reported ion 19.3% of patients with biopsies.

The researchers concluded that the National Comprehensive Cancer Network lung cancer screening guidelines were not followed, which calls for a low-dose CT of chest followed by PET to identify patients for biopsy.

“These results suggest that since NCCN guidelines are not being followed, there is a need to develop more precise risk stratification tools to better identify patients who require lung biopsies,” said Tasneem Lokhanbdwala, MS, PhD, lead author and data analyst at Xcenda, Palm Harbor, Fla. Reducing the number of patients who are referred for lung biopsies has the potential to decrease Medicare costs and ultimately improve patient outcomes.”

A second study emphasized the need to educate primary care providers on lung-cancer screening guidelines to ensure that high-risk patients receive screening. Undertaken by a group of clinicians at Wake Forest Baptist Medical Center, Winston-Salem, NC, a survey was sent to 488 primary care providers, including physicians, physician assistants and nurse practitioners affiliated with medical center.

The survey instrument measured the provider’s use of lung-cancer screening in the previous year, the perceived effectiveness of the test in reducing mortality, knowledge of the consensus guidelines, and interest in further education about them. Of the respondents, 212 cared for patients older than 40 and were eligible for the study.

Almost half of the respondents (48%) knew three of the six guidelines; 30% were unsure of the effectiveness of low-dose CT lung cancer screening (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.

“The results of this survey highlight an essential need for provider education on the effectiveness of low-dose CT screening for lung cancer, on lung cancer screening guideline recommendations and the potential benefits and harms of screening,” said Jennifer Lewis, MD, lead study author and an assistant chief of medicine in the Department of Internal Medicine at Wake Forest Baptist in Winston-Salem, North Carolina. “It is also important to provide additional education for patients so that they can participate with their primary care provider in making informed decisions about lung cancer screening.”