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Screening for Lung Cancer

Screening for Lung Cancer

Low-dose CT scans offer early detection and improved survival rates. And CMS will pay for them.

"He wouldn't have lung cancer if he hadn't smoked ." Well, not necessarily.

This most voracious and lethal cancer has been unfairly stigmatized as a cancer people inflict on themselves via poor habits. "We are now seeing about 18% of lung cancer occurring in nonsmokers," countered John Maurice, MD, director of the thoracic oncology program at St. Joseph Hospital in Orange, Calif. "When 1 out of 5 patients walking through your door never picked up a cigarette, you have to do away with this idea that lung cancer is the result of avoidable behaviors. Some of it is, but not all of it. There are environmental issues, genetic issues and more."

One problem with this notion that lung cancer is "your own fault" is found in the fact that there has been little public proactivity around the disease, as there has been with other cancers. "You don't see them closing the Golden Gate Bridge for a Lung Walk," Maurice noted.

So when the Centers for Medicare and Medicaid Services (CMS) approved reimbursement for the use of low-dose CT screening scans to detect early lung cancer in high-risk patients in 2015, Maurice was overjoyed about the progressive step that comes none too soon.

"This is huge news. This is a big change. This is an overarching message of hope," Maurice proclaimed with real conviction.

According to information on the CMS website (, "Lung cancer is the third most common cancer and the leading cause of cancer deaths in the United States. It is an important issue for the Medicare population due to the age at diagnosis and at death. In 2013, more than 220,000 cases of lung cancer were diagnosed, with a median age at diagnosis of 70 years, the National Cancer Institute reported. Cancer of the lung and bronchus accounted for over 150,000 deaths in 2013 (more than the total number of deaths from colon, breast and prostate cancer combined) with a median age at death of 72 years."

Prior to Reimbursement
Clinicians at St. Joseph Hospital have long been advocates of low-dose CT screening for lung cancer, even before CMS gave its stamp of approval. In 2002, some 45 care providers- pulmonologists, oncologists, radiologists, pathologists, research coordinators, cancer specialists, respiratory therapists, nurses, palliative care specialists, internists and family practitioners-came together during a weekly lung cancer conference at the hospital and agreed that diagnosing patients with Stage IV lung cancer was a disheartening task.

They determined the best way to find and treat early lung cancer, instead of highly progressed lung cancer, was through the use of low-dose (about 1/5th the dose of a regular CT scan) CT screening.

Since it was not approved for reimbursement by insurers, these providers decided they would have to make it happen through their own diligence. They appealed to the hospital and staff radiologists to allow deeply discounted CT scans to be conducted on Saturdays (imaging suite "downtime"). The program began in 2004 and developed traction.

"St. Joseph has been ahead of the curve for many years and has been offering the screening CT to at-risk patients at extremely minimal cost (about $125). We willingly lost money on the venture because we believed it to be so important to public health," Maurice said.

The big payoff to the hospital clearly has not been in revenue; it has been found in a different kind of currency: saving lives. Since the program's inception in 2004, it has resulted in the scanning of 1,100 patients and the discovery of 21 lung cancers, many in early stages. In 2015 alone, three lung cancers were found on screening-one in Stage I, one at Stage IIIA and one now being scheduled for resectioning, according to Ray Casciari, MD, who was instrumental in the creation of the screening program. Although he has retired from his former position as chief medical officer the hospital, Casciari remains on staff as a pulmonary physician and a member of the hospital's thoracic oncology team.

CMS Reimbursement
"Before paying for this, CMS wanted a good, randomized, controlled trial done," Maurice explained. In 2011, the results of the National Cancer Institute-sponsored National Lung Screening Trial (NLST) were published. The NLST showed that people aged 55 to 74 years with a history of heavy smoking are 20% less likely to die from lung cancer if they are screened with low-dose helical CT than with standard screening chest x-rays.

"Last year CMS reviewed the lung cancer screening trial data, and all other available trial data, which revealed that low-dose CT screened patients showed a 20% improvement in survival rates over patients who were not screened. I can tell you this-and I treat lots of lung cancer-20% is unheard of. It's the single biggest innovation in any intervention that I've seen in the last three decades," he emphasized.

"This is so dramatic for patients. Everyone knows lung cancer is a tough cancer. But now there is a ray of hope. All smokers who have a high risk for lung cancer can now get the screening CT and have a potential for 20% improvement in their survival," Maurice said. To be clear, CMS did drill down on high-risk criteria. "To qualify for CMS reimbursement for the CT lung screening, an individual must be between the ages of 55 and 77, be asymptomatic, have a 30 pack-year history."

Empowering Care Providers
Maurice said he is taking the message of this development to healthcare providers through workshops, radio shows, conferences, articles-any trumpet he can find to sound a clarion call.

"This is a call to primary care physicians, nurse practitioners, physician assistants in the community to discuss the screening with patients they may be treating for emphysema, or patients who have a history of smoking. Now they can say, 'You know, you're 60 and you've never had a CT scan to check for lung cancer. You've smoked for 35 years. Let's get you checked out. And don't worry, CMS will pay for it.' That's the message practitioners need to get out there.

"Now you can actually make a difference in your patient's life that is bigger than anything I do as a thoracic surgeon," Maurice said. "That is a meaningful statement for care providers. And that is why CMS is willing to pay billions of dollars for scans-they now know they will improve the health of Americans."

Maurice sees this reimbursable deployment of screening scans as moving lung cancer to a new level of care. "No longer must a patient wait until he develops a cough and spits up blood to determine if he has lung cancer. Those of us specializing in lung cancer are going crazy over this development," Maurice said. "Even the best molecular treatment can't offer a 20% improvement. This is a major headline."

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