Medicare and lung CT screening of smokers

Medicare just came out with their formal decision on low dose CT scans (LDCT) for lung cancer screening in smokers (see lung cancer CT screen medicare 2015in dropbox, or http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274 )​. These are somewhat between the USPSTF recommendations, recommending screening 55-80 year olds annually, and the actual criteria for the National Lung Screening Trial (NSLT) which was only 3 annual screens for the age range of 55-74 (and was the study upon which USPSTF based their recommendations). For Medicare, eligibility criteria are:

• Age 55 – 77 years;
• Asymptomatic (no signs or symptoms of lung cancer);
• Tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
• Current smoker or one who has quit smoking within the last 15 years; and
• Receives a written order for LDCT lung cancer screening that meets the following criteria:
  • For the initial LDCT lung cancer screening service:  a beneficiary must receive a written order for LDCT lung cancer screening during a lung cancer screening counseling and shared decision making visit, furnished by a physician or qualified non-physician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist).  A lung cancer screening counseling and shared decision making visit includes the following elements (and is appropriately documented in the beneficiary’s medical records): 
    • Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;
    • Shared decision making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure;
    • Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment; 
    • Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions; and
    • If appropriate, the furnishing of a written order for lung cancer screening with LDCT.  
  • For subsequent LDCT lung cancer screenings:  the beneficiary must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non-physician practitioner. If a physician or qualified non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the criteria described above for a counseling and shared decision making visit.
  • Written orders for both initial and subsequent LDCT lung cancer screenings must contain the following information, which must also be appropriately documented in the beneficiary’s medical records: 
    • Beneficiary date of birth;
    • Actual pack - year smoking history (number);
    • Current smoking status, and for former smokers, the number of years since quitting smoking;
    • Statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and
    • National Provider Identifier (NPI) of the ordering practitioner. 

so, the decision has arrived. as noted in my prior blogs, there are several very important issues. the extent of radiation exposure by doing the LDCT scans is perhaps the most important, and there are a few salient points with the Medicare recommendation:

    ​--patients could get up to 22 annual LDCTs done, if they continue to smoke or stop after age 62.

    --in NSLT, the average individual's radiation exposure was essentially the same as with the regular (high-dose) CT, when one adds in the additional radiation from follow-up studies from positive LDCTs (the vast majority of which were false positives)

    --the NSLT was mathematically projected to create one cancer death per 2500 screened in just 3 years!!  Medicare only noted that there is a radiation risk but felt that we needed to study/quantify the effects of the radiation exposure.

see my prior blogs for more detailed critique at http://gmodestmedblogs.blogspot.com/2014/10/uspstf-lung-cancer-screening-revisited.html