Despite a recent recommendation from the U.S. Preventive Services Task Force (USPSTF) to screen high-risk older adults for lung cancer using low-dose CT, the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) recently recommended against covering the procedure(www.cms.gov) for this patient group based on a lack of evidence to support the benefits of the screening.
MEDCAC's action is congruent with the AAFP's lung cancer screening recommendation, which states: "The AAFP concludes that the evidence is insufficient to recommend for or against screening for lung cancer with low-dose computed tomography (LDCT) in persons at high risk for lung cancer based on age and smoking history."
Both the MEDCAC and AAFP recommendations diverge from the USPSTF's recommendation(www.uspreventiveservicestaskforce.org) to perform annual LDCT screening "in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years."
The USPSTF gave its recommendation a "B" grade(www.uspreventiveservicestaskforce.org), which means that in accordance with the Patient Protection and Affordable Care Act (ACA), marketplace plans and many other private plans would be required to cover the screening with no out-of-pocket obligation to plan members. But the ACA doesn't specify that Medicare must provide full coverage for its beneficiaries. So the draft MEDCAC recommendation could affect screening coverage for Medicare participants if CMS accepts the committee's recommendation.
- The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) recently recommended that CMS not cover low-dose CT (LDCT) screening for high-risk older smokers, despite a U.S. Preventive Services Task Force (USPSTF) recommendation that annual LDCT screening be performed in this patient population.
- The AAFP disagreed with the USPSTF in its own screening recommendation and outlined its concerns during the MEDCAC meeting.
- A final decision from CMS is expected in the fall and will open a public comment period.
Doug Campos-Outcalt, M.D., M.P.A., of Phoenix, the AAFP liaison to the USPSTF, spoke during the MEDCAC committee meeting to explain the Academy's position regarding LDCT screening for high-risk older smokers.
In his presentation, Campos-Outcalt pointed out five major concerns with the USPSTF recommendation, not the least of which was that it was based largely on one study, the National Lung Screening Trial(www.nejm.org) (NLST). Specifically, he said, the conditions of that study were unlikely to be replicated in community settings.
The NLST found a 20 percent reduction in lung cancer mortality, according to Campos-Outcalt, which means that 80 percent of current lung cancer mortality will persist. And it is very likely that this is a best-case scenario, he added.
In addition, all-cause mortality was reduced by only 6.7 percent in the NLST and, in some other studies, was not reduced at all. "With widespread community screening, there are likely to be more complications and deaths, raising more doubts about all-cause mortality," Campos-Outcalt told AAFP News. "The AAFP was concerned that if future research shows a 20 percent reduction in the mortality rate was optimistic, and complications end up being more prevalent, they didn't want to recommend the screening."
Also of concern is increased exposure to radiation with repeat screening, Campos-Outcalt said, noting that a current smoker in the targeted group could possibly get 25 CT scans during his or her lifetime. In its comments on the draft version of the USPSTF recommendation, the AAFP suggested that the task force consider better risk/benefit patient profiling to minimize the number of CT scans.
Another apprehension Campos-Outcalt outlined to the panel was that the modeling used by the USPSTF to extend the NLST data to include different screening intervals, age ranges, smoking histories and times since quitting might not have accurately reflected data for the targeted group. The model predicted the outcomes of continuing the screening program used in the NLST through age 80, but Campos-Outcalt noted that another presentation made during the MEDCAC meeting showed how the modeling used to extrapolate the study's findings has not been proven reliable, which supported the AAFP's concern.
According to Campos-Outcalt, several panelists mentioned that in addition to agreeing with many of the previously stated arguments against coverage, they also didn't want to approve coverage if screening was later found to not be effective. That possibility can't be counted out, they contended, given that a number of LDCT screening studies are currently still in progress.
Finally, Campos-Outcalt said that even though MEDCAC recommended against coverage, he suspects the final decision by CMS could very well include some form of coverage. That decision is expected in the fall and will spark another public comment period on the recommendation's merits.
Related AAFP News Coverage
Evidence Lacking to Support or Oppose Low-dose CT Screening for Lung Cancer, Says AAFP
Inability to Make Harms/Benefits Comparison Precludes Definitive Recommendation