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Nationwide screening would increase lung cancer detection as well as costs
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Lung cancer screening conducted according to US Preventive Services Task Force guidelines would increase the number of detected cancers, particularly those in early stages, but it also would come at a considerable cost to Medicare, according to study results.
The USPSTF recommended annual lung cancer screening with low-dose CT for adults aged 55 to 80 years with a 30 pack-year smoking history who are current smokers or who quit within the past 15 years.
Joshua A. Roth
A draft decision regarding Medicare coverage of CT screening for lung cancer will be posted in November; however, the Medicare Evidence Development & Coverage Advisory Committee recently recommended against CMS coverage of annual screening, researcher Joshua A. Roth, PhD, MHA, a postdoctoral research fellow at Fred Hutchinson Cancer Research Center in Seattle, WA, said during a press conference.
“With those recent developments in mind, we designed this study to project the 5-year clinical resource use and budget impact of implementing CT screening in the Medicare program,” Roth said. “We hope our findings can inform these ongoing debates about coverage.”
Roth and colleagues developed a model to evaluate 5-year incremental outcomes of annual screening based on USPSTF guidelines compared with no screening in a Medicare cohort. The researchers based the model on 2013 enrollment and age distribution statistics.
They calculated lung cancer detection rates and diagnosis stage based on data from the National Lung Screening Trial (NLST). Results of the trial, which provided the basis for the USPSTF guidelines, showed annual screening with low-dose CT reduced lung cancer deaths by 20%.
Researchers projected costs in three participation scenarios, each of which assumed an additional 20% of high-risk adults would be offered screening per year. The expected-use scenario predicted 50% of eligible adults would undergo screening according to mammography experience, the low-use scenario predicted 25% of adults would undergo screening, and the high-use scenario predicted 75% would undergo screening.
According to the expected-use scenario, annual screening would result in 11.2 million more low-dose CT scans and 54,900 more detected lung cancers compared with no screening. The proportion of detected lung cancers that are in the early stage would increase from 15% to 32% in this scenario.
Five-year Medicare costs — which include included low-dose CT screening and follow-up, bronchoscopy/biopsy workup and stage–specific lung cancer treatment — were $9.3 billion with the expected-use scenario, $5.9 billion with the low-use scenario, and $12.7 billion with the high-use scenario.
The expected-use scenario would result in a $3 monthly premium increase per Medicare member. The low-use scenario was associated with a $1.90 increase, and the high-use scenario was associated with a $4.10 increase.
“If we can diagnose lung cancers at an earlier stage, patients can be treated far more effectively and survival prognosis is much better,” Roth said in a press release. “However, the key to the success of this screening program is ensuring that those who are at high risk actually undergo screening and subsequently receive appropriate treatment.”
Further analyses are planned to evaluate the demand for scanner and technologist resources vs. availability of existing facilities, the researchers said.
For more information:
Roth JA. Abstract #6501. Scheduled for presentation at: 2014 ASCO Annual Meeting; May 30-June 3, 2014; Chicago.
Disclosure: The study was funded by Genentech. The researchers report no relevant financial disclosures.
Perspective
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Clifford A. Hudis, MD, FACP
ASCO’s guideline supports the UPSTF recommendation with regard to screening and, if anything, extends them just a little bit. This study uses a model and not actual data. It makes assumptions, for example, that over a 5-year period about 20% of the high-risk patients would be offered screening each year.
These investigators considered three different screening-use scenarios for the implementation of the USPSTF recommendations: an expected-use based on historic use of mammography, where 50% of those offered screening undergo screening; a low-use scenario where only a quarter do, and; a high-use one which goes up to 75% undergo screening. In the expected screening-use scenario, screening would yield about 11 million more low-dose CT scans and about 55,000 more lung cancers over 5 years as compared to the no screening situation. It’s estimated therefore that there would be an increase in the early stage diagnoses, from almost 15% to 32%. That’s somewhat similar to the shift we’ve seen historically when mammography was rolled out.
The total 5-year Medicare expenditure for low-dose CT imaging, diagnostic work-ups and cancer care would be about $9.3 billion. To place that in context, that is about an increase of $3 for each month for each Medicare member.
Roth and his group have provided an estimation of the expense side, which is a balance against the measurable concrete gains that we hope to see. But, what this information is worth is something that we have to engage with policy makers, regulators and others in order to arrive at a decision. It goes beyond this model.
Tobacco use continues to contribute far too much to the national cancer burden. While low-dose CT screening offers a long-awaited early lung cancer detection strategy, as doctors we must do everything possible to provide patients with the encouragement and resources they need to stop smoking and prevent the next generation of young adults from starting.
Perspective
Back to TopTawee Tanvetyanon, MD
This is an important analysis being conducted at the time of much confusion about the identity of low-dose CT screening in modern medicine. My take on this is that there is no such thing as a free lunch. It may be true that lung cancer screening will increase the cost of care, especially in the short term. However, as a physician, I feel that the issue about cost is secondary. The primary issue is about saving lives. The goal of our health care should be to enhance our lives and increase our longevity. Its goal should not be to save money.
In the National Lung Screening Trial, they detected about 1,000 cancers among those who had CT screenings. Of these, about 250 people died of lung cancer (compared with more than 300 people who died in the group of those who only had a chest X-ray). This means that, for every 1,000 cancers detected by CT screening, 50 people will be saved. So, if an estimated of 54,900 lung cancer cases are going to be detected in the next 5 years, we can estimate also that 2,745 lives will be saved. How much do we think these lives should cost us?
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