www.baltimoresun.com/health/bs-hs-lung-cancer-screening-20130802,0,4983144.story

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Proposed screening guidelines could prevent lung cancer deaths, doctors say

CT scans may soon be recommended for high-risk patients

By Scott Dance, The Baltimore Sun

7:46 PM EDT, August 2, 2013

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An influential U.S. health care panel's recommendation for lung cancer screening of high-risk patients could fortify Baltimore-area hospitals' efforts to prevent deaths from the disease, which kills more each year than the next four deadliest cancers combined.

Patients ages 55-80 who are or have been heavy smokers will likely be able to get insurance coverage for preventive CT scans examining their lungs for abnormalities. Some patients have been paying up to $300 out-of-pocket for the procedures, and several local hospitals have invested in performing them more frequently as research indicated a possible benefit.

The U.S. Preventive Service Task Force, the same body that took a controversial stance against regular mammography for some women in 2009, suggested in a draft recommendation issued Monday that the benefit of lung cancer screenings likely outweighs any possible harms. Under the federal health reform law, insurers will be required to cover the procedure if the panel officially adopts the recommendation.

That could mean more broad screening of patients at high risk of lung cancer for the first time. While age-specific screenings for breast, cervical and prostate cancers, for example, have saved lives by detecting disease earlier, lung cancer often doesn't present itself with symptoms until it's too late to be treated, doctors said.

"We really haven't been able to move the needle in terms of finding lung cancer early for 45 years despite billions of dollars being spent on it," said Dr. William Krimsky, director of pulmonology at MedStar Franklin Square Medical Center. "The whole goal here is if we can find earlier lung cancers we can prevent the more serious lung cancers that present later."

Still, there are some concerns that the policy could lead to over-diagnosis and unnecessary surgeries.

The recommendation stems largely from the National Lung Screening Trial, a study whose results published in 2011 showed that CT scanning cut lung cancer deaths in high-risk patients by 20 percent, compared with no screening or with chest X-rays. The federally funded trial studied 53,000 current or former heavy smokers, thus far the largest lung cancer screening study.

The Preventive Services Task Force issued draft guidelines Monday that took the study results into account. They suggest that those ages 55-80 who have smoked the equivalent of a pack a day for 30 years undergo annual low-dose CT scans to test for lung tissue abnormalities, known as nodules.

The panel issues recommendations graded A to D on its confidence in certain preventive tests — the lung cancer screening was graded a B, which means officials are at least moderately certain the benefits of screening outweigh risks. The Affordable Care Act, the federal health reform law that becomes effective in 2014, requires insurers to cover preventive services that the panel grades a B or higher.

The intent is to reduce the 160,000 lung cancer deaths that occur each year in the U.S., a number that exceeds deaths from breast, prostate and colon cancers combined. About 2,700 Marylanders died of malignant tumors of the trachea, bronchus or lung in 2011, according to the state's health department.

As research including the National Lung Screening Trial and other studies have indicated likely benefit from testing, hospitals have moved toward offering the service to patients. But given that the procedure isn't covered by insurance, it isn't widely practiced, doctors said.

At Johns Hopkins Bayview Medical Center, a lung cancer screening clinic held each Monday for about the past 18 months attracts 12-15 patients weekly, said Dr. Phillip Dennis, an oncology professor and director of Bayview's Sidney Kimmel Comprehensive Cancer Center.

MedStar Health's Baltimore-area hospitals have established a lung cancer screening program within the past few months that has seen about a dozen patients, Krimsky said.

Saint Agnes Hospital meanwhile participated for seven years in a national study known as the International Early Lung Cancer Action Program, screening about 1,200 each year. That study ended in 2011, when the other major study was published, and Saint Agnes continues to screen a few hundred patients each year, said Dr. Enser Cole, chief of medical oncology at the hospital.

In each case, as with the panel's recommendation, screening is limited to patients with long smoking histories and often family history of lung cancer. Practices have been similar with other types of cancer, as after a certain age women are advised yearly mammograms and men prostate exams, but similar screening hasn't been practical for lung cancer.

"As with any screening tool, you want to find an approach that saves lives so that it catches the tumor or cancer early enough to intervene," said Dr. Charles White, a professor of radiology at the University of Maryland School of Medicine who specializes in lung cancer. "Up until now that's been a real difficult task to achieve with lung cancer."

The university medical system has been taking a slow approach toward offering lung cancer screening, White said, in part waiting to see if insurers step up to cover the procedure.

It's not clear yet whether they will, or if the government will force them to. The panel's draft recommendations are open to public comment until Aug. 26, after which they could become final and trigger the federal health reform law's coverage requirements.

Officials with CareFirst BlueCross BlueShield, the region's largest insurer, said they are considering whether to cover lung cancer screening and plan to address the issue in the fall.

"CareFirst has an established process for reviewing recommendations regarding new treatments and technologies," spokesman Michael Sullivan said in a statement. "We weigh the potential benefits to our members as well as the benefits and risks associated with any treatment."

Still, earlier and more frequent detection of lung abnormalities doesn't mean more cancer diagnoses. As with other types of cancers, more frequent screening could lead to more biopsies and surgeries.

Dr. Peter Bach, director of Memorial Sloan-Kettering Cancer Center's Center for Health Policy and Outcomes, who has studied the impact of lung cancer screening, said with the new guidelines, "over-diagnosis is guaranteed." Bach said he hopes doctors will view the "B" rating as an indication that the recommendation was weak. "They are not telling people you have to do it," he said.

With heavy smokers, red flags during screening can be common, but don't always mean cancer. In as many as 40 percent of the patients, nodules can appear, but 99 percent of those abnormalities are not cancer, Cole said.

The findings of the key study on lung cancer screening are only applicable to the group of older, heavy smokers that were included, but it's possible the screening recommendations could be expanded to more groups over time as more is learned about who is at highest risk for cancer, doctors said.

Screening guidelines for other types of cancer have similarly evolved over time. The Preventive Services Task Force recommended in 2009 that routine biennial breast cancer screening be limited to women older than 50 or with other known risk factors, leaving out women in their 40s. The panel found that for those younger women, routine screening was not shown to be worth it, a stance that stirred confusion and frustration from breast cancer advocates.

That episode underscores the importance of the lung cancer screening recommendation, said Hopkins' Dennis.

"This is a group that is very conservative in their recommendations," he said. "It speaks to the power of the data, the overwhelming evidence that lung cancer screening is effective for that population. The challenge for us as a society and as a government is to find a way to pay for it and to do it."

Reuters contributed to this report.

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