In a move that could affect millions of current and former smokers, a highly influential, independent panel of medical experts is recommending yearly screening for healthy adults between the ages of 55 and 80 at high risk for lung cancer.
The screening would be done with low-dose computed tomography, commonly known as CT scans — and the panel’s recommendation could require new insurance plans to cover them under the Affordable Care Act.
“There are about 160,000 lung cancer deaths in the U.S. every year,” says Dr. Michael LeFevre, co-vice chair of the U.S. Preventive Services Task Force, whose recommendation is published today in the Annals of Internal Medicine. “More people die from lung cancer than the total combined deaths from breast cancer, prostate cancer and colon cancer.”
With the recommended screening, “As many as 20,000 lung cancer deaths a year could be prevented,” LeFevre told NBC News. “But lung screening is not an alternative to smoking cessation, and the best way to avoid lung cancer and death is to avoid smoking.”
Roughly 10 million people meet the task force’s definition of high risk: 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. Someone smoking one pack a day for 30 years or 2 packs a day for 15 years, for example, would have a 30 pack-year smoking history.
The task force says not everybody within that group should be screened. “Anybody who has a significant health problem that limits life expectancy or does not have the ability or willingness to have curative lung surgery should not be screened,” says LeFevre. In addition, the task force recommends discontinuing screening for anyone who has not smoked for 15 years.
In 2004, the task force had found inadequate evidence to recommend for or against lung cancer screening. It changed its mind based, in part, on the results of the National Lung Screening Trial, the largest randomized trial on the subject to date.
CT scans are computer-processed X-rays that create a cross-sectional image of bones and soft tissue. They can cost several hundred dollars and the cost of large-scale screening could be enormous.
The task force gives its new recommendation a B grade, which means it found with moderate certainty that annual screening is of moderate net benefit, in other words, the benefits outweigh harms.
And there are potential harms. They include overdiagnosis — in other words, finding cancers that would never have caused a problem; radiation exposure from the CT scan itself; and a high rate of false positives. In fact, research shows that 95 percent of people who have a positive low-dose CT scan do not have lung cancer. Most of those false positive results are resolved with a subsequent full-dose CT scan, not by an invasive biopsy.
The task force also strongly recommends that any screening take place in a facility with a program that combines screening with followup, counseling, smoking cessation and treatment. The standard treatment for early-stage lung cancer is surgery along with radiation and chemotherapy. At the moment, very few hospitals have such coordinated programs because they have been waiting for the task force decision.
“The task force recommendation is unbelievably important because it leads to insurance mandates,” says Dr. Peter Bach, a lung physician and health policy expert at Memorial Sloan Kettering Cancer Center in New York and an author of an editorial accompanying the task force recommendation.
The 2010 Affordable Care Act says that if the task force has given a preventive service an A or a B grade, private insurance companies participating in the new insurance exchanges must cover that service at no cost to the patient. Bach anticipates the government will include all newer A and B recommendations as well.
Medicare, the federal health insurance program for people 65 or older and certain younger people with disabilities, has more discretion. It can decide to cover everything the task force recommends, nothing the task force recommends, or something in between, says Bach. So, for example, it could decide to cover low-dose CT scans for lung cancer in only certain age groups or for only, say, three years. It could also decide not to cover the extra costs of tracking patients to make sure invasive biopsies are not done on benign nodules.
“I think it’s pretty unlikely that we’re going to see the same benefits that they saw in the randomized controlled study if insurance doesn’t cover all the pieces,” says Dr. Frank Detterbeck, a professor of thoracic surgery at Yale University and the co-author of a second editorial. “If insurance only pays for a piece, we may end up doing a lousy job at this.” Yale University has a low-dose CT screening program in place for high risk individuals up to age 74. There is no insurance coverage, and patients pay out-of-pocket.
Detterbeck also says that the real world is very different from a clinical trial, where people are recruited and watched. In the real world, the heaviest smokers — those who would benefit the most from screening — will be the hardest to reach. “Most of the people who smoke, they’re thinking, ‘Gee, I want a cigarette now,’ and they’re not thinking about what happens in five or 10 years if I continue to smoke,” says Detterbeck.
“Nevertheless, if we screen 25 percent of the people who need it, that’s better than screening nobody who needs it. We’re still doing some good,” says Detterbeck.
There also will be the opposite problem of low risk current and reformed smokers who will insist on being screened. “I speak from experience. It takes time talking with people to make them comfortable with what we’re doing, and that may not be screening,” says Detterbeck.
Bach would have liked to have seen the task force break down its recommendation into several, with different grades. “I find it a little frustrating that we have primary data from the National Lung Screening Trial that shows big difference within subgroups of this high risk population, and yet even with that information, everybody gets a B recommendation,” says Bach. Perhaps, he suggests, the heaviest smokers should have gotten an A recommendation. An A grade means the task force has high certainty that the net benefit is substantial.
“That would send a signal to doctors and health systems about where to put their priorities,” says Bach.
First published December 30 2013, 2:04 PM