As Lung Cancer Screening Debate Continues, Study Projects Implementation Outcomes

Joshua A. Roth, PhD, MHA

In December 2013, the US Preventive Services Task Force (USPSTF) recommended that asymptomatic, high-risk individuals receive annual screening for lung cancer with low-dose computed tomography (LDCT). A new analysis projects that implementing this recommendation will increase detection rates, but only at a steep increase in Medicare costs.¹

The report comes at a heated moment in the national conversation on lung cancer screening. In late April, the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), in direct opposition to the USPSTF, recommended against Medicare covering lung cancer screening in high-risk individuals.

The MEDCAC vote caused a stir in the lung cancer community over the potential implication for screening coverage. Under the Affordable Care Act (ACA), medical exams receiving a grade “B” (moderate) or higher from the USPSTF (lung screening was given a “B” rating) must be covered by private insurers without a copay. However, the ACA does not stipulate that Medicare must follow the USPSTF rating. If the CMS follows MEDCAC’s recommendation, a screening disparity would be created between Medicare beneficiaries and the privately insured. The CMS will issue a draft decision in November, followed by a final decision in early 2015.

The lung screening implementation forecast, presented at a presscast held in advance of the 2014 ASCO Annual Meeting, is sure to stoke this conversation. In the analysis, lead author Joshua A. Roth, PhD, a postdoctoral research fellow at Fred Hutchinson Cancer Research Center, and colleagues projected 5-year clinical and cost outcomes of implementing the USPSTF’s lung cancer screening recommendation in high-risk Medicare patients as compared with a policy of no screening.

In its recommendation, the USPSTF defined “high risk” as individuals aged 55 to 80 years with a 30 pack—year smoking history who currently smoke or quit within the past 15 years. The panel recommends discontinuing screening when an individual stops smoking for 15 years or develops a health problem that significantly reduces life expectancy or the capacity/desire to receive curative lung surgery. Further, the panel warned that its analysis did not yield enough evidence to support screening low-risk individuals.

The USPSTF recommendation was largely based on the National Lung Screening Trial (NLST), which involved 53,454 high-risk patients aged 55 to 74 years who were randomized to 3 years of annual screening with either LDCT or standard chest x-ray.² Over 6.5 years of follow-up, patients screened with LDCT had a 20% reduction in mortality compared with those in the x-ray group (P = .004).

Roth and colleagues used Medicare data from the NLST, the NCI SEER database, and peer-reviewed literature for their forecast model. In Roth et al's model, the base-case or "expected" scenario assumed a gradual phasing of LDCT screening into clinical practice over 5 years, based on a prior study of the phasing in of breast cancer screening. The base-case scenario estimated that 50% of patients offered screening would undergo the procedure. Additionally, the expected scenario assumed a 20% annual increase in the number of patients being offered screening.

The base-case scenario projected that there would be 11.2 million more LDCT scans over the 5 years (2 million false positives) and 54,900 additional lung cancer diagnoses. Thirty-two percent of the lung cancers would be detected at a localized stage, compared with 15% currently, Roth said. Compared with 57% currently, 40% of lung cancers would be detected at a distant stage.

The accompanying base-case expenditure increases for LDCT imaging, diagnostic work ups, and treatment would be $5.6 billion, $1.1 billion, and $2.6 billion, respectively. The $9.3 billion expenditure increase translated into a $3.00 monthly premium increase per Medicare member, according to Roth.

“By implementing lung cancer screening, we could potentially have a stage shift in Medicare—patients diagnosed at a distant stage might be able to be diagnosed at an early stage,” Roth said, “But there’s going to be increased expenditure.”

The researchers also considered low- and high-use scenarios, in which 25% and 75% of individuals, respectively, were estimated to undergo the screening once it was offered. The low-use scenario resulted in fewer diagnoses and lower expenditure increases ($5.9 billion) versus the base case, and the high-use scenario resulted in more diagnoses and higher expenditures ($12.7 billion) compared with the base case.

The model did not include a cost effectiveness analysis. “There is this open question of value, and this study did not directly address that,” Roth said. “We’re really trying to forecast what will happen as far as clinical resource use and budget impact if this policy is implemented.”

ASCO President Clifford A. Hudis, MD, who also participated in the presscast, separately addressed the value of Roth et al’s research and lung cancer screening in general.

“This is a societal question. What we can provide and what Dr. Roth and his group have provided is an estimation of the expense side that bounces against the measurable concrete gains that we would hope to see. But [the] question of ‘What is this worth?’ is one that I think we have to engage with the policymakers, regulators, and others in order to arrive at a decision.”

References

1. Roth JA, Sullivan SD, Ravelo A, et al. Low-dose computed tomography lung cancer screening in the Medicare program: Projected clinical, resource, and budget impact. J Clin Oncol. 2014;(suppl; abstr 6501).
2. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395-409.

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