Lehigh County Health & Medicine Spring 2020 - 11

L C M E D S O C .O R G

LDCT SCREENING: JUST FOR
HEAVY SMOKERS
When LDCT scans were introduced as
a way to screen for lung cancer, there were
some drawbacks. Since the screening itself
A SLOW ROAD TO DETECTION
does not detect cancer, but only nodules
Lung cancer is most often asymptomatic in the lungs, further testing needs to be
in its early stages, which leads to a delayed done to determine whether the nodules
diagnosis. More than half of patients already are cancerous. The initial false-positive rate
have metastatic disease by the time the disease among patients, and the possibility of causing
is diagnosed.** After studies showed that the patients undue worry, gave many providers
cancer is curable, with a five-year survival and institutions pause about wide scale
rate at 56 percent for cases detected when LDCT screening. This led to development
the disease is still localized (within the lungs) of guidelines as to which patients might be
according to the American Lung Association, most helped; these are endorsed today by
early detection became of paramount interest the U.S. Preventive Services Task Force, the
for health care researchers and providers. American Cancer Society, and the Centers
Studies involving the chest x-ray as a scan- for Disease Control and Prevention (CDC),
ning tool began in the 1960s, with a large among others (see side bar).
randomized trail conducted in London. Trials
in the United States followed in the 1970s
The guidelines focus on heavy smokers.
at the National Cancer Institute, Memorial Although non-smokers can develop lung
Sloan Kettering Cancer Center, and Johns cancer, there is not enough evidence to know
Hopkins. The results were consistent for all whether screening them would be helpful
of them: cumulative lung cancer incidence or harmful, according to the American
and mortality rates were similar between Cancer Society. Statistics show that cigarette
groups, showing no real benefit of chest smoking is the number one risk factor for
radiographic screening for the disease.
lung cancer. In the United States, cigarette
smoking is linked to about 80% to 90% of
By the late 1990s, computed tomography lung cancer deaths as reported by the CDC.
(CT) had been introduced and had evolved
to the point of producing good images in COST STILL A FACTOR IN
the span of a single holding of the breath. ACCESSIBILITY
Its next generation, low-dose CT (LDCT),
Cost can be a significant detriment to
provided an even better tool as it reduced LDCT screening. Patients initially had to
radiation exposure (to 1.6 millisieverts), bear the cost of the scan, averaging $300,
and offered high-resolution images of until major insurers and Medicare decided in
nodules as small as 0.5 cm to 1 cm. Studies 2015 to provide coverage for those patients
that followed through institutions such who meet the guidelines above. However,
as Mayo Clinic produced outcomes with according to the American College of
LDCT that were far superior to the early Radiology, CMS has since slashed Medicare
attempts at detection with chest x-rays. The reimbursement to less than half the Medicare
most convincing was the National Lung provider reimbursement for a mammogram.
Screening Trial in 2011, which showed a Such cuts have restricted the number of
20% reduction in lung cancer mortality in facilities financially able to provide scans, and
patients who received LDCT. (Learn more have impacted the motivation for providers
at bit.ly/Lungtrial.) Based on the study, the to recommend screenings.
U.S. Preventive Services Task Force made
lung cancer screening with LDCT a public
Medicaid beneficiaries are disproportionhealth recommendation in 2013.
ately affected by lung cancer, yet standard
Medicaid programs are one of the only health
care payers not required to cover lung cancer
screening. If screening is covered, Medicaid
early detection. In this latter category, we are
seeing encouraging outcomes that could be
made even better with increased awareness
about the value of screening.

programs may use different eligibility criteria,
require prior authorization or charge individuals for their scans. As of January 2019,
31 state Medicaid fee-for-service programs
covered lung cancer screening for those at
high risk, 12 did not, and seven had no
information available. In states where feefor-service Medicaid plans covered screening,
4.8 percent of those at high risk had been
screened, compared to 2.6 percent in states
that did not cover screening.*
EDUCATION, PROGRAMS, AND
FOLLOW-UP ARE KEY
While we have made progress, the majority
of the estimated 8 million eligible Americans
are not enrolled in a screening program.***
Lung cancer screening with low-dose CT
scans has been recommended for those at
high risk since 2013, but only 4.2 percent
of those eligible were screened in 2018.*
These numbers suggest awareness is a
formidable obstacle to early detection
through screening. Much of the public
does not understand the role of lung cancer
screening, and CT scans for heavy smokers
are not yet embedded in providers' work
flows. A patient's primary care physician
must approve an LDCT scan for a patient
after a shared decision-making visit (unlike
breast or colorectal screenings). This will
only take place if the PCP is informed and
aware of the value of the LDCT, and is
willing to recommend the screening with
equal encouragement to breast and colon
cancer screens.
As more providers and health system
administrators are exposed to the statistics,
and recognize that today's tools can potentially detect lung cancer early with increased
success, there is more movement toward
promotion of LDCT as the lifesaver it can
be. Many U.S. institutions have been taking
steps to create programs and incorporate CT
scans into their medical best practices. The
same is occurring locally, such as at Lehigh
Valley Health Network based in Lehigh
County, where currently 20% of adults are
smokers.****
Continued on page 12
SPRING 2020 | Lehigh County Health & Medicine 11

http://www.LCMEDSOC.ORG http://www.bit.ly/Lungtrial

Lehigh County Health & Medicine Spring 2020

Table of Contents for the Digital Edition of Lehigh County Health & Medicine Spring 2020