Roxanne Nelson

May 15, 2014

While the decision on whether Medicare should cover lung cancer screening is still up in the air, a new study warns that such screening would increase costs.

Adding low-dose CT (LDCT) to the Medicare program, which covers people older than 65 year, could result in the detection of approximately 54,900 more lung cancer cases during a 5-year period, with most at an early and more treatable stage. However, this would extrapolate to a cost increase of $9.3 billion, according to lead study author Joshua A. Roth, PhD, MHA, a postdoctoral research fellow at the Fred Hutchinson Cancer Research Center in Seattle.

Dr. Roth was speaking at a presscast held in advance of the 2014 Annual Meeting of the American Society of Clinical Oncology® (ASCO), where he will present the findings.

"We predicted that over a 5-year period, LDCT would result in more lung cancers, a shift toward an earlier stage of diagnosis, and increased expenditure, particularly on scans themselves," he reported.

"With that in mind, if screening is covered, it is important for Medicare and contracted healthcare systems to plan for an increased demand for LDCT imaging and treatment capacity for a growing early-stage lung cancer population," he added. In addition, "Medicare should plan for increased expenditure in the budgeting process."

According to their model, approximately $5.6 billion more would be spent on LDCT imaging during the next 5 years, $1.1 billion more would be spent on diagnostic workups, and $2.6 billion more would be spent on cancer care expenditures. The total 5-year expenditure would amount to an increase in premiums of $3.00 per month per Medicare member.

The screening would yield 11.2 million more LDCT scans, and it is estimated that it would double the proportion of early-stage diagnoses from the current 15% to 33%.

Lung cancers diagnosed at distant stage would decrease, from the current 57% to 40%.

Costs Higher But Lives Saved

My take on this is that there is no such thing as a free lunch.

"This is an important analysis being conducted at the time of much confusion about the identity of low-dose CT screening in modern medicine," said Tawee Tanvetyanon, MD, associate member of thoracic oncology program at the H. Lee Moffitt Cancer Center in Tampa, Florida. "My take on this is that there is no such thing as a free lunch."

"It may be true that lung cancer screening will increase the cost of care, especially in the short term," said Dr. Tanvetyanon, who was approached by Medscape Medical News for independent comment. "However, as a physician, I feel that the issue of cost is secondary; the primary issue is about saving lives. The goal of healthcare should be to enhance our life and increase our longevity. Its goal should not be to save money."

The issue of cost is secondary; the primary issue is about saving lives.

Dr. Tanvetyanon noted that in the National Lung Screening Trial (NLST), about 1000 cancers were detected with CT screenings, and fewer people in the LDCT group than in the x-ray group died of lung cancer (250 vs 300).

"This means that for every 1000 cancers detected by CT screening, 50 people will be saved," Dr. Tanvetyanon said. "If an estimated 54,900 lung cancer cases are going to be detected in the next 5 years, we can estimate that 2745 lives will be saved. How much do we think these lives should cost us?"

Uncertainties Remain

However, Dr. Roth emphasized that the study was not about judging value, it was about forecasting a potential shift in staging and increased expenditure.

The US Preventative Services Task Force (USPSTF) recommends annual LDCT screening in people 55 to 80 years of age who have a 30 pack-year smoking history and who currently smoke or have quit in the past 15 years. These recommendations are largely based on findings from the NLST, which demonstrated a 20% reduction in lung cancer mortality with LDCT screening, compared with x-ray screening.

Currently, Medicare does not cover lung cancer screening. A draft decision on Medicare coverage will be posted in November, but an advisory committee recently voted against recommending national Medicare coverage for annual screening for lung cancer.

That advisory meeting discussed a number of uncertainties, such as the limited number of participants in the NLST who were older than 65 years, explained Dr. Roth. "There are also uncertainties about who will be screened when this comes into real clinical practice. For example, would lower-risk patients be screened? That would affect value as well."

Model Based on USPSTF Recommendations

This is the first study to look at a lung cancer screening model that is focused on the Medicare population, which has a high incidence of lung cancer and a large proportion of members who qualify for screening. Dr. Roth and his colleagues developed a model to forecast the 5-year incremental outcomes of implementing the USPSTF screening recommendations, and compared them with no screening. The model simulates a Medicare cohort that is consistent with 2013 enrollment and age distribution statistics.

Rates of lung cancer diagnoses and stage were derived from the NLST. Included in the model were the costs of LDCT screening and follow-up, confirmatory bronchoscopy/biopsy, and stage-specific lung cancer treatment (initial, continuing, terminal care). The model assumes that over a 5-year period, an additional 20% of high-risk patients will be offered screening each year.

The researchers estimated lung cancers detected, LDCT scans, and the impact on cost for 3 scenarios: an expected-use scenario based on historic experience with mammography (50% of patients who are offered screening undergo screening every year); a low-use scenario (25% of patients who are offered screening undergo screening every year); and a high-use scenario (75% of patients who are offered screening undergo screening every year).

"We assumed gradual diffusion of LDCT screening, much like the experience with mammography for breast cancer," Dr. Roth explained. "The rate of diffusion of the screening program has great influence on the degree of stage shift, as well as on downstream expenditures."

In the expected-use scenario, screening would yield 11.2 million more LDCT scans and result in 54,900 more lung cancers detected. In the low-use scenario, the total 5-year expenditure would be $5.9 billion, or a premium increase of $1.90 per Medicare member. In the high-use scenario, the 5-year expenditure would be $12.7 billion, or a premium increase of $4.10 per Medicare member.

For the model, the most influential inputs were the proportion of eligible patients who elected to undergo screening, the initial treatment cost of early-stage lung cancer, and the proportion of stage IV diagnoses in the no-screening strategy.

Putting the study into context, ASCO president Clifford A. Hudis, MD, FACP, noted that this is just a model that "makes assumptions."

He added that this study provides an "estimation of the expense side that bounces against the measurable concrete gains that we would hope to see."

This research was funded by Genentech. The authors have disclosed no relevant financial relationships.

2014 Annual Meeting of the American Society of Clinical Oncology. Abstract 6501. To be presented June 2, 2014.


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