Editorials suggest way forward for Medicare lung screening coverage

As the healthcare community awaits the decision from the Centers for Medicare & Medicaid Services (CMS) on whether low-dose CT screening for lung cancer will be covered for Medicare beneficiaries, two editorials published in the Sept. 24 issue of JAMA recommended ways to cautiously move forward with screening.

Robert J. Volk, PhD, and colleagues from the University of Texas MD Anderson Cancer Center in Houston, noted that the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), when it met in April, expressed low confidence that the benefits of screening in a Medicare-aged population would outweigh the harms. However, by engaging in a process of shared decision-making, Volk and colleagues wrote that patients and their physicians can make fully informed and values-based decisions about care.

“There is a pathway to achieving high-quality discussions, and CMS should offer national coverage for the fully informed patient who elects screening after completing the shared decision-making process with a clinician,” wrote Volk and colleagues. “Detailed documentation of the shared decision process could be a requirement for financial reimbursement.”

This process of shared decision-making is especially important for elderly patients due to their more limited life expectancy and increased risk of harm from screening and treatment, according to the authors. They recommended the use of decision aids to educate patients about options—which includes informing patients that the decision not to screen is acceptable—and to make clear the potential for harm as well as the benefits.

In an associated editorial, Harold C. Sox, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H., and also the Patient-Centered Outcomes Research Institute in Washington, D.C., agreed that shared decision-making would be a powerful tool for lung cancer screening, but the research community must work to close the evidence gap for Medicare patients.

“Whether it recommends coverage, Medicare patients do not have the evidence they need to make an informed, personal decision about lung cancer screening,” wrote Sox, noting that only 25 percent of the patient population in the National Lung Screening Trial was 65 year or older and just 9 percent was older than 70.

“A registry-based observational study could address a problem with current judgments about the balance of harms and benefits of screening, which are necessarily subjective because harms and benefits are typically measured in different units,” wrote Sox. Modeling benefits and harms in standardized units of quality-adjusted life-years could be a way of addressing this issue.

“No one wants to repeat the experience with prostate cancer screening, which became a de facto standard of practice long before evidence from randomized trials signaled caution,” concluded Sox. “The era of lung cancer screening begins with randomized trial evidence, but the potential for uncontrolled growth—and net harm—remains.”