Should People Who Are Eligible Have a Lung Cancer Screening?

Arguments For and Against Lung Cancer Screening

If you've watched the news over the past few years, you probably heard some of the debate about lung cancer screening. The discussion at first was whether or not Medicare should cover lung cancer CT screening in those who met specified criteria. In February of 2015, that decision was put to rest as Medicare now covers this testing. The reason for the arguments was the finding — in a large medical study called the National Lung Cancer Screening Trial — that low-dose CT (LDCT) screening could reduce lung cancer deaths by 20 percent, or 18,000 U.S. citizens each year.

 

It would seem all is well, yet a 2016 study found that less than half of family physicians agreed that lung cancer screening was a good idea and many were unaware of the specific recommendations. In addition, many of these physicians continue to order chest x-rays as a screening test for lung cancer. This, in turn, has resulted in a common question:

"Why won’t my doctor order a test that could save my life?"

What are the arguments for and against lung cancer screening, and what organizations support these arguments? Let's take a look at these positions and compare lung cancer screening to other cancer screening tests currently available.

*Medicare now covers lung cancer screening for those between the ages of 55 and 77, who continue to smoke or quit in the past 15 years, and have smoked for at least 30 pack-years. Screening requires a physician's signature (or non-physician who is qualified) and requires that a person who will be screened meets with their physician for counseling to take part in a shared decision-making visit before the order is written.

Who Benefits From Lung Cancer Screening?

After too many years without any effective screening test for lung cancer, the National Lung Cancer Screening Trial (NLST) found that low-dose CT (LDCT) screening can save lives among people who meet certain criteria. In people meeting these criteria, yearly LDCT screening can reduce lung cancer deaths by 20 percent - a number that translates into tens of thousands of Americans each year.

Based on study results the United States Preventive Task Force (USPSTF) has recommended screening for:

  • Adults between the ages of 55 and 80 who have a 30 pack-year history of smoking, and
  • Continue to smoke or quit smoking in the past 15 years

Screening may also be appropriate for other people, such as those who have been exposed to asbestos, a history of tuberculosis, radon exposure, BRCA2 gene mutations, and other conditions.

Reasons to be Excited About LDCT Lung Cancer Screening

  • Currently, at least 40 percent of people with lung cancer are diagnosed when the disease has already progressed to stage 4 lung cancer.
  • The 5-year lung cancer survival rate overall is just over 17 percent.
  • When lung cancer is found in the earlier stages, survival is higher.
  • Other forms of screening that have been evaluated to date, such as chest x-rays and sputum cytology, have not been found to reduce deaths.
  • Lung cancer is the leading cause of cancer deaths for both men and women in the United States. It kills close to twice as many women as breast cancer.
  • Recently it's also been found that some smokers who have LDCT screening are more likely to quit than if they did not have the test performed. Though it's too early to say, knowledge of other diseases caused by smoking suggests that, as an added perk, lung cancer screening may reduce the risk of heart disease, COPD, and more.
  • Among Medicare beneficiaries, it is thought that yearly LDCT screening could more than double the percent of early stage lung cancer diagnoses  (As a quick comparison, the 5-year survival rate for stage 1 non-small cell lung cancer is 60 to 80 percent. For stage 2 it is 40 to 50 percent. For stage 4 it is less than 5 percent.) It's thought that this screening would identify 54,000 additional lung cancers per year (32,000 at an early stage.)
  • If screening guidelines were implemented immediately, and if everyone who meets the criteria for screening would undergo screening, 18,000 lives could be saved each year.

    Potential Problems Associated with Screening

    Any screening test comes with some problems. Many of you likely know of someone who had a scare on a mammogram -- only to hear that it was only a scare. Some of the problems with lung cancer screening can include:

    When Is Lung Cancer Screening Covered?

    The United States Preventive Task Force (USPSTF) has recommended lung cancer screening as a Grade B procedure. Under the Affordable Care Act (ACA) private insurers are required to cover screening procedures with a Grade B or higher (see below). This is effective January 2015. Screening is covered by the Department of Energy, the Department of Veteran Affairs (thankfully, as veterans have an elevated risk of lung cancer,) and others.

    What About Medicare?

    In April, the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) voted against covering LDCT lung cancer screening for beneficiaries - in other words, it is not covered as an "essential health benefit" without cost. The reason is that they are not confident that benefits will outweigh the harms in this population. In contrast to private insurers, Medicare benefits are not covered under the Affordable Care Act. A final decision will not be made until February 2015.

    Who is In Support of Lung Cancer Screening?

    A quick review of the Web finds the following organizations to support lung cancer screening (are against Medicare's decision:)

    • The American Medical Association (AMA)
    • The American College of Radiology (ACR)
    • The Lung Cancer Alliance (LCA) - LCA has submitted a formal request for a National Coverage Determination for lung cancer screening.
    • The United States Preventive Services Task Force (USPSTF)
    • The American Society of Clinical Oncology
    • The American Cancer Society (ACS)
    • The Society of Thoracic Surgeons (STS)
    • Many Senators and State Representatives 

    Who Does Not Support Lung Cancer Screening

    As of October of 2016, the American Academy of Family Practice states that there is isufficient evidence to rule for or against screening.

    Arguments/Counterarguments in Support of Lung Cancer Screening - Comparing Apples to Apples

    • Evidence-based medicine. Lung cancer screening has been shown via evidence-based medicine to save lives. A recent study says that breast cancer screening does not.  A recent PLos One review found that screening mammograms have a modest effect on mortality in women aged 50 to 69, and non-significant effects for women over the age of 70. Lung cancer screening is expected to significantly lower lung cancer deaths in those in the Medicare age group. Despite this, Medicare pays for mammograms but does not pay for lung cancer screening.
    • Cost Issues - The cost to cover lung cancer screening for Medicare recipients is substantial, but translates to around $3 per month per beneficiary. The cost of breast cancer screening for Medicare beneficiaries translates to about $2.50 per month. Note that the $3 per month for lung cancer screening does include follow-up (for example to look for false positives,) but the $2.50 per month for breast cancer screening does not include follow-up tests and procedures. Looking at other numbers in other studies, it was thought to cost Medicare $2 billion a year to offer lung cancer screening vs the 1.08 to 1.36 billion for mammograms. Consider that both female and male beneficiaries would benefit from lung scans, but the majority of the time only women receive mammograms. I won't go into the cost of treatment. Screening, of course, would increase the number of lung cancer surgeries due to the increase in early-stage diagnoses, and of course, it is more expensive to cover costs of cancer survivorship and follow-up than death. We could weigh the costs of this treatment of early stage lung cancers with the costs of late-stage lung cancer management and end-of-life concerns, but I'd rather not go there. From the bedside, there is no comparison. Yes, I've seen pain as people recover from surgery, but it pales in comparison to end-of-life pain with bone metastases and shortness-of-breath.
    • Argument to focus on smoking cessation. Yes, this is important, however, it won't help those who are candidates for screening who quit in the past 15 years. It's interesting to again note, that as noted above, screening does improve the rate of smoking cessation in some people (and more effectively based on numbers than programs and aids we have available.) But very importantly - if we are to treat those at risk of lung cancer equally to those at risk of other forms of cancer we need to do one of 2 things. Either Medicare should cover LDCT screening for lung cancer, or use the same form of discrimination against people at risk of other forms of cancer screening. For example, if Medicare prefers to pay for smoking cessation instead of lung cancer screening, it logically follows that it should pay to educate women to breastfeed their children, rather than pay for mammograms. It would also follow that Medicare should focus on encouraging exercise rather than covering colonoscopies as colon cancer is associated with a sedentary lifestyle in some cases. (Yes, I'm being facetious, but it's important to continue to compare apples to apples, and this decision concerns me that the stigma of lung cancer may play a role in the decision.) In his world history class this year one of my children was asked this question. "What was the worst place to be a slave?' The answer was in the Caribbean, because instead of feeding and caring for the slave, it was cheaper to "use him up" and buy another. For some reason, that thought kept coming to mind as I scoured this argument.
    • False positives - Yes, lung cancer screening does result in false positives. So does breast cancer screening. False positives have been noted in up to 25% of people undergoing lung cancer screening, requiring further scans and sometimes invasive procedures. Of patients followed with yearly mammograms for 10 years, the incidence of false positives was 50 to 60%. In addition, of 90,000 patients followed for 25 years with mammogram screening, 22% were overdiagnosed or treated with unnecessary therapy. Yet mammography is a covered benefit under Medicare, but lung cancer screening is not as it's thought that harms (false positives, overdiagnosis) may outweigh benefits (a 20% improved rate of survival.) Does MEDCAC anticipate it would have to contend with a stampede of pink if they were to treat apples as apples and refuse to cover mammograms due to the risk of false positives?
    • Radiation exposure - We have learned that exposure to medical radiation is not without risks.
    • USPSTF Grade B - The United States Preventive Task Force issues "grades" which look at the benefit from providing a service to patients. Grade B means that the USPSTF recommends the service because there is a high certainty that the net benefit is moderate or that there is moderate certainty that the net benefit is moderate to substantial. For lung cancer screening, LDCT screening is ranked as Grade B for appropriate patients as discussed above. Breast cancer screening via mammography is also considered Grade B for women every 1 to 2 years after the age of 40.
    • Argument about what we've learned from prostate cancer screening - Another argument on the Web is that we should be cautious about lung cancer screening and use the example of prostate cancer screening as an example. For years, men have been encouraged to have prostate cancer screenings, and PSA tests have become a household word. A Cochrane review of many studies has now found that prostate cancer screening does not decrease prostate cancer-specific mortality (deaths) or overall mortality. In addition, harm (from overdiagnosis and overtreatment) was rated as common and moderate. The 5-year survival rate for prostate cancer is 99%. Is this comparing apples to apples?
    • Patients are savvy. In saying that they aren't sure that benefits outweigh risks in this population, Medicare is denying patients the right to make educated decisions themselves - decisions that are often made with the help of a physician who can in turn help patients interested in embarking on screening weigh the risks and benefits for their particular health and situation. People are required to make these decisions daily - some of which can be very important to a healthy life, such as having good tires for your car.
    • The poor will get poorer (or die) and the rich will get richer (or live). The cost of screening CT scans vary, but in general are in the range of $350. Some people on Medicare can afford to self-pay this amount, while others can't. Studies have found that people are less likely to pursue screening tests for early detection of disease when they have to pay for it out of pocket, and especially when the cost would require them to forego something else, for example, food.
    • Justice. It would seem an injustice based on the notes above, that those at risk for lung cancer are not being treated equally. As Martin Luther King once said, "Injustice anywhere is a threat to justice everywhere." What other threats lurk in the care of the health of our citizens?

    Summing it Up and Next Steps

    If you or a loved one meet the criteria for lung cancer screening, there is hope. Medicare has yet to make a final decision on coverage. If you have supplementary private insurance (or are a veteran, among other insurers) you are in luck. As noted above the Affordable Care Act requires that these screenings be covered. Options if you do not have a supplement include self-paying for the test. Though Medicare does not currently cover lung cancer screening, you have a right to have the test done and pay for it yourself. If a lung cancer is discovered when you self-pay for a screening test, Medicare would then be required to pay for your care.

    Sources

    Centers for Medicare and Government Services. Decision Memo for Screening for Lung Cancer with Low Dose Computed Tomography. Accessed 02/07/15. http://lungcancer.about.com/od/whatislungcancer/a/screeninglung.htm

    Ersek, J., Eberth, J., McDonnell, K., Strayer, S., Sercy, E., Cartmell, K., and D. Friedman. Knowledge of, Attitudes Toward, and Use of Low-Dose Computed Tomography for Lung Cancer Screening Among Family Physicians. Cancer. 2016. 122(15):2324-31.

    Gross, G. et al. The cost of breast cancer screening in the Medicare population. JAMA Internal Medicine. 2013. 173(3):220-6.

    IIic, D., Neuberger, M., Diulbegovic, M., and P. Dahm. Screening for prostate cancer. Cochrane Database of Systematic Reviews. 2013 Jan 31.

    Irvin, V., and R. Kaplan. Screening mammography & breast cancer mortality: meta-analysis of quasi-experimental studies. PLoS One. 2014 Jun 2.

    Tammemagi, M. et al. Impact of lung cancer screening results on smoking cessation. Journal of the National Cancer Institute. 2014. 106(6):dju084.

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