The following letter is adapted from comments made to the Centers for Medicare and Medicaid Services (CMS) by the American College of Radiology, the GO2 Foundation for Lung Cancer, and the Society of Thoracic Surgeons.
“The American College of Radiology, the GO2 Foundation for Lung Cancer, and the Society of Thoracic Surgeons appreciate the opportunity to submit comments on the National Coverage Analysis for Screening for Lung Cancer With Low-Dose Computed Tomography (LDCT). Our organizations fully support CMS revising its lung cancer screening coverage to reflect the updated U.S. Preventive Services Task Force (USPSTF) grade B recommendation that expands the low-dose CT lung cancer screening risk criteria and appreciate CMS’ prompt response to our National Coverage Determination (NCD) reconsideration request. In their comprehensive analysis, the USPSTF outlined that confirmatory mortality reduction benefit was reported by a second major randomized control study in a lower risk tobacco smoke–exposed cohort, with modest morbidity and greater study management efficiency. As CMS considers the extensive scientific evidence relevant to the Medicare population, we also request CMS to review our previous joint letter, which outlined specific areas of concern associated with the existing February 2015 NCD. The information presented below builds on these recommendations to further improve the early detection of lung cancer and foster equitable care.
“We agree directionally with the USPSTF’s recommendations to revise eligibility criteria for lung cancer screening coverage and strongly urge that Medicare coverage must also be updated to reflect the most recent guidelines and clinical standards, which aim to remove barriers that keep at-risk populations from accessing these lifesaving exams. The arc of evidence published since the last CMS NCD has supported the mortality benefit of this service while outlining many screening management refinements, which have reduced morbidity while improving screening workup efficiency. Based on this improving benefits-to-harms ratio, we urge CMS to revise and lower the screening eligibility age to 50 and smoking history criteria to 20 pack-years for Medicare beneficiaries, which would align with the recently published National Comprehensive Cancer Network (NCCN) 2021 Lung Cancer Screening Clinical Practice Guidelines in Oncology and the American Academy of Family Physicians updated March 2021 recommendation.1,2 In addition, the final USPSTF recommendations to lower the initial age and smoking history requirements for lung cancer screening reconfirm the lifesaving ability of these tests and present an opportunity for providers to re-engage screening-aged patients to save more lives, including Black individuals and women, who tend to smoke fewer cigarettes than White men. The growing evidence for scientific benefit relevant to the Medicare population builds on our recommendations to CMS during the initial 2015 NCD and brings into sharp focus that the principal challenge at hand—to ensure equitable access of screening to all communities that can benefit by reducing barriers to implementation.
“We also strongly urge CMS to revise the following key areas to mitigate known barriers for LDCT lung cancer screening uptake in the Medicare population:
- Eliminate the annual screening eligibility criteria: 15-year smoking cessation quit date.
- Eliminate the annual screening eligibility criteria: upper age limitation of 77 years.
- Eliminate the “Counseling and Shared Decision Making (SDM)” NCD criteria to ensure the current language and requirements do not act as a barrier to screening uptake.
- Formally instruct all Medicare Administrative Contractors to cover/reimburse LDCT performed in all facilities, including independent diagnostic testing facilities.
- Review the reading radiologist and imaging facility eligibility criteria to determine whether changes are needed.
“Lung cancer kills more people each year than breast, colon, and prostate cancers combined. Annual lung cancer screening with LDCT in high-risk patients greatly reduces lung cancer deaths. Less than 15% of Americans who met previous USPSTF screening criteria are tested each year. More widespread screening could save 30,000 to 60,000 lives in the United States each year.3 Lack of coverage for those who need it and paradoxical barrier to access (eg, SDM requirements) have contributed to severe underuse of lung cancer screening, which has undoubtedly cost lives. Several studies confirm that annual screening with LDCT provides greater benefit in decreasing lung cancer mortality and in life-years gained. Although Medicare and nearly all private payers cover lung cancer screening, public awareness of this life-saving screening benefit is woefully low. We believe a public health awareness campaign targeted to patients and providers would make a profound difference in lung cancer screening uptake. We believe CMS has a unique responsibility and opportunity to increase public awareness of LDCT screening benefits and encourage its adoption.”
—William T. Thorwarth, Jr, MD, FACR
Chief Executive Officer
American College of Radiology
—Laurie Fenton Ambrose
Co-Founder, President and CEO
GO2 Foundation for Lung Cancer
—Sean C. Grondin, MD
President
Society of Thoracic Surgeons
REFERENCES
1. Wood DE, Kazerooni EA, Aberle D, et al: NCCN Clinical Practice Guidelines in Oncology: Lung Cancer Screening, version 1.2021. Available at https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf. Accessed June 24, 2021.
2. American Academy of Family Physicians: AAFP updates recommendation on lung cancer screening. April 6, 2021. Available at https://www.aafp.org/news/health-of-the-public/20210406lungcancer.html. Accessed June 24, 2021.
3. American Cancer Society: Key statistics for lung cancer. Available at https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html. Accessed June 24, 2021.
