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Lung cancer screening of Medicare-eligible patients associated with greater benefits, risks
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Screen-detected lung cancer prevalence, as well false-positive results, were higher among Medicare-eligible individuals compared with younger participants, according to results of a secondary analysis of the National Lung Screening Trial.
Initial results of the National Lung Screening Trial (NLST) demonstrated a 20% reduction in the risk for lung cancer with annual low-dose CT compared with chest radiography in high-risk adults aged 55 to 74 years. The findings served, in part, as the basis for the US Preventive Services Task Force’s recommendation — issued in December 2013 — that high-risk individuals aged 55 to 80 undergo annual lung cancer screening with low-dose CT.
However, experts have debated whether the annual screens should be covered for Medicare beneficiaries, who comprised approximately 25% of the trial’s population (age 55 to 64 years, n=19,612; age 65 to 74 years, n=7,110). In April, the Medicare Evidence Development & Coverage Advisory Committee expressed low to intermediate confidence that the benefits of annual screening outweighed the potential risks in the Medicare population.
Paul F. Pinsky, PhD, MPH, acting chief of the Early Detection Research Group in the division of cancer prevention at the NCI, and colleagues sought to address this question through an age-stratified analysis of the NLST.
Results showed the aggregate false-positive rate was significantly greater in patients aged 65 years or older (27.7% vs. 22%;
Despite increased risks, screening in the older cohort was associated with a higher aggregate positive predictive value (4.9% vs. 3%;
Negative results with clinically significant abnormalities (9.2% vs. 6.9%;
Researchers further analyzed data about screen-detected lung cancer incidence in the older cohort by stratifying participants based on age at diagnosis (aged 65 to 69 years, n=136; aged ≥70, n=144).
Participants aged ≥70 years had a higher resection rate than those aged 65 to 69 years (77.9% vs. 68.8%;
Five-year all-cause survival was lower among participants aged ≥70 years compared with those aged 65 to 69 years (50% vs. 60.2%;
“It is difficult to predict how low-dose CT screening for lung cancer will disseminate in the Medicare-eligible population, regardless of whether it is covered by Medicare,” Pinsky and colleagues wrote. “Going forward, monitoring and assessing the relative performance of low-dose CT screening in older persons will be critical to more fully understand its risks and benefits when it is done outside the clinical trial setting and to modify recommendations on the basis of the evidence if needed.”
These data should support Medicare coverage of lung cancer screening, Michael K. Gould, MD, director for health services research and implementation science at Kaiser Permanente, wrote in an accompanying editorial.
“For policymakers, low-dose CT screening seems to involve similar tradeoffs for persons who meet NLST eligibility criteria in both the older and younger age groups,” Gould wrote. “Until there is new and direct evidence to the contrary, it does not seem reasonable to exclude persons aged 65 to 74 years from access to screening. For clinicians, it would be helpful to provide age-specific estimates of benefits and harms when engaging patients in a process of shared decision making that enables each to weigh the tradeoffs and make an informed choice.”
For more information:
- Gould MK. Ann Intern Med. 2014;doi:10.7326/M14-2006.
- Pinsky PF.
Ann Intern Med . 2014;doi:10.7326/M14-1484.
Disclosure: Gould was a guest (non-voting) member of the Medicare Evidence Development and Coverage Advisory Committee for lung cancer screening. Pinsky reports no relevant financial disclosures. See the study for a full list of the remaining researchers’ relevant financial disclosures.
Perspective
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Roy S. Herbst, MD, PhD
Although screening adults aged 65 years or older did find more cancers, there were a few more false-positives. This is to be expected in an older population of individuals who often have other abnormalities that can be detected by the screens. Despite the risk for false-positives seen in this study, my feeling is that lung cancer, once it spreads and metastasizes, is so difficult to treat — in fact, incurable — that finding it early is critical.I would not worry as much about the risks when finding these nodules and the limitations of subsequent therapies and surgery, as long as the patients are screened and treated at a top hospital with multimodality care that has experienced pulmonologists and thoracic surgeons. As long as these lesions can be addressed in a very careful way with minimally invasive techniques, patients as old as 80 years or even older can undergo video-assisted thoracic surgical (VATS) lobectomy.
At Yale, like at many other major centers, we combine screening with smoking cessation therapy. Finding a lung nodule during screening is a potentially teachable moment, when we can actually help people stop smoking.
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