Lung CT scan use expected to swell

Three years ago, Gordon Green, then 55, rejected his primary-care doctor's suggestion that he get screened for lung cancer.

But Green's history of smoking a pack a day for 30 years and his doctor's insistence changed his mind. And when his low-dose CT scan (LDCT) identified an early stage tumor in his left lung, Green underwent surgery at Lahey Hospital & Medical Center, a teaching affiliate of the Tufts University School of Medicine, Burlington, Mass. He has been cancer-free since. “It wasn't so long ago that lung cancer was a death sentence,” he said.

Green's experience reinforces the medical community's growing belief that annual CT screens of current or former smokers at high risk for lung cancer will save lives through early detection. The CMS has proposed covering screening for millions of eligible Medicare beneficiaries, which is expected to create a lucrative market for hospitals and medical manufacturers. Some CT scanner manufacturers are already marketing consulting services and technology to hospitals to help them develop their lung-cancer screening service lines. “Almost every one of our customers is looking at this,” said Michael Cwalinski, a product manager for the CT business at medical-imaging system manufacturer Siemens Healthcare North America.

But experts say setting up screening programs is complex. Hospitals also must train primary-care doctors on how to identify which patients should be screened, establish navigators to track and work with patients, and purchase or develop radiology workflow systems.

Using LDCT to screen these patients is “one of the greatest advances that the field of thoracic oncology has seen in decades,” said Dr. Andrea McKee, chair of Lahey's radiation oncology department.

Most health insurers are legally required to cover the screenings on a first-dollar basis in the wake of the U.S. Preventive Services Task Force giving the exams a “B” recommendation in 2013. And last year, the CMS proposed covering screening of Medicare beneficiaries between ages 55 and 74 who smoked a pack a day for at least 30 years, excluding patients older than 75.

However, a study published last year in the Journal of Clinical Oncology found the task force's recommendations would hike Medicare spending by $9.3 billion over five years. That total included $5.6 billion for scans, $1.1 billion for biopsies and other tests, and $2.6 billion more for cancer treatments.

Hospitals that offer lung cancer screening charge from $99 to $450 for a chest CT exam. The CMS proposal, by limiting beneficiaries' out-of-pocket costs, likely will lead to millions more people undergoing exams. About 9 million people meet the task force's recommendation for lung cancer screening. Proponents say the reduced-mortality benefit is at least equal or greater to mammography screening for women.

But some clinicians caution that the benefits of aggressive screening of lifelong smokers using LDCT scans are exaggerated. Writing last February in JAMA Internal Medicine, independent researchers who evaluated the study used by the task force and the CMS concluded that “more than 18% of all lung cancers detected by LDCT scans in the National Lung Screening Trial seem to be indolent and ... clinically insignificant.” In other words, improved survival in the screened arm of the trial might be attributable to overdiagnosis.

The critics have little influence over the hospitals and clinicians preparing for a surge of new patients with a long history of smoking. At least 350 providers have applied for a lung cancer screening accreditation program established by the American College of Radiology.

Philips Healthcare, which markets imaging systems, announced at the Radiological Society of North America's annual meeting in December that it would begin marketing consulting services and software systems to hospitals to help them with their lung cancer screening programs. Radiologists can use Philips' Web portal to find examples of chest CT exams with early stage cancers, as well as clinical education materials to give to patients. Siemens is also working with hospitals as they develop screening programs.

But executives at both companies say they do not expect the anticipated number of patients coming in for screening to lead to higher sales of CT machines. Most hospitals that are considering screening programs already own low-dose CT systems, they say.

The American College of Radiology in May launched the Lung Imaging Reporting and Data System (Lung-RADS), which seeks to standardize lung cancer screening, CT reporting and interpretations. But there is not yet a standard way to report lung cancer screening exams. “There's still a huge learning curve,” Lahey's McKee said. “Radiologists have to learn to use Lung-RADS.” Lahey launched its program in January 2012 and has screened 2,700 high-risk patients, 45 of whom were diagnosed with lung cancer.

The CMS is expected to issue its final coverage decision in February, with payment rates to be announced after that. If the agency sets low rates, many hospitals may decide against offering the screenings, McKee said.

Follow Jaimy Lee on Twitter: @MHjlee