After a push led by a University professor, the Centers for Medicare and Medicaid Services finalized coverage guidelines this February for individuals at high risk for developing lung cancer, allowing them the ability to receive lung-screening CT scans with no co-pay.
CMS is the federal agency that administers Medicaid and Medicare.
Annual lung screenings will be available to patients ages of 55-77 and have an extensive smoking history. However, doctors will have the final say in deciding who are appropriate candidates to undergo the testing. If testing is considered appropriate, then patients must also undergo smoking cessation counseling.
Radiology Prof. Ella Kazerooni, the director of Cardiothoracic Radiology, has been on the forefront of the race to get these screening approved by the CMS.
“Lung cancer is the leading cause of cancer death in the United States, both for men and women,” Kazerooni said. “For the other common cancers, like breast, prostate and colon cancer, we have screening tests. So, there’s definitely a public health need to try and reduce mortality from lung cancer. Lung cancer screening with CT is aimed at doing that at the population health level.”
Kazerooni was an investigator for the 2011 National Lung Screening Trial that showed lung cancer screenings reduced mortality and proved cost-effective. Despite the finding, lung cancer screenings were voted down when originally presented to the CMS in 2014.
As the principal organizer of the coalition to advocate for CMS coverage, Kazerooni said a diverse group of medical professionals and advocacy groups was necessary to achieve their goal of screening coverage.
“When you bring in the voice of the patients through patient advocacy, it really tells the story in a way that’s very impactful for people who are not necessarily in the medical field,” she said.
Kazerooni also emphasized another important aspect of the lung cancer screening — smoking cessation. The requirement not only targets lung cancer, but also has secondary effects by reducing death from cardiovascular disease and chronic obstructive pulmonary disease, Kazerooni said. By including smoking cessation alongside these screenings, she said the system functions in a more cost-effective way as well.
Douglas Arenberg, associate professor of internal medicine and a member of the American Thoracic Society — a group involved with the coalition — also stressed the importance of smoking cessation.
“It is absolutely imperative for people interested in setting up a lung cancer screening program to make the center of gravity of that program offering and encouraging tobacco cessation amongst current smokers,” he said. “It is a far more efficient, far safer and a far less expensive way to achieve the goal of a lung cancer screening program, which is fewer people dying from lung cancer.”
Such cessation programs are part of what makes the new coverage not just a one-time test, but rather an ongoing process.
For smoking cessation to work, Arenberg said, several additional steps — including integrated cessation counseling, pharmacotherapy and follow-up phone calls with nurses, physicians and medical assistants — need to be implemented, not all of which are fully included under the coverage.
Arenberg said in a society consumed by instant gratification, quitting smoking can be a challenge. He said while it would be difficult to prove to individual former smokers that quitting saved their lives, smoking cessation programs have made a big difference for the population at large.
Overall, Arenberg said CMS should provide even more funding toward these kinds of programs.
“We, as a society, could invest in prevention by providing more robust reimbursement for tobacco cessation counseling,” he said.
However, despite the benefits of lung cancer screening, Arenberg also mentioned several problematic components.
Because a lung CT scan looks at the whole chest, as opposed to other cancer screenings that only look at certain tissues, he said issues in other areas can be discovered that seem medically significant, but really are not.
“This is a very different test,” he said. “And it has the potential for harm because a lot of these findings are just incidental and don’t represent significant disease, but in investigating them you sometimes have to put the patient at risk, including invasive procedures that have the potential for harm.”
Because of these complexities, Arenberg said a major goal of his, as well as other advocates for the lung screening policy, is to inform people about both the benefits and the risks of these screenings.
Moving forward, Kazerooni said one of the next steps is to spread public awareness. While many physician practices are currently in the process of educating patients about the importance of the scans, more work still needs to be done with local advocacy groups to educate those who could benefit from the screenings.
Another condition of the CMS lung screening coverage is building a clinical practice quality registry into the screening. This registry compares the progress of the screenings in relation to benchmarks and quality metrics.
Kazerooni also said there is interest in helping individuals at risk for lung cancer for reasons unrelated to smoking, such as radon exposure, asbestos exposure and a genetic history of lung cancer. Such efforts, she said, may be a future focus.
With many moving parts to lung cancer screenings, Kazerooni said that the biggest challenge in organizing the coalition was keeping everybody focused on the ultimate goal of bringing lung cancer screenings to those who needed them. Despite those difficulties, she said she was happy with the overall result.
“Bringing people together across disciplines for a common purpose was amazing to see as it started to fall into place,” she said.