ORIGINAL ARTICLE
Computed Tomography Screening for Lung Cancer A Survey of Society of Thoracic Radiology Members Jan M. Eberth, PhD,*w Rebecca Qiu,z Suzanne K. Linder, PhD,y Nancy R. Gallant, MS,*w and Reginald F. Munden, MD, DMD, MBA, FACR8
Purpose: This study aimed to determine the availability, attributes, and hindrances of current and developing US lung cancer screening programs. Materials and Methods: An electronic questionnaire was sent to the membership of the Society of Thoracic Radiology in August 2013 and remained open for 4 weeks. Of the 225 US-based members, we received 140 responses representing 82 unique health care institutions. Descriptive statistics were used to characterize the responding health care institutions’ LDCT screening availability and components. Results: A majority of responding institutions reported having an active LDCT screening program (65.9%). Of the responding institutions without an active program, 89.3% reported they were considering having an LDCT screening program in the future, and 35.7% (n = 10) indicated the developing status of screening recommendations as a motivating factor in not offering a screening program. Forty-four percent of participating LDCT screening centers reported that their services were self-pay only, and nearly half charged a rate of $200 to $500 for screening. Conclusions: In our sample, we found that a majority of respondents were engaged in LDCT screening programs. Growth of such programs is expected in the coming years. Finalizing screening guidelines and insurance reimbursement will likely remove barriers that inhibit further growth of LDCT lung cancer screening programs. Key Words: lung neoplasms, spiral computed tomography, early detection of cancer, health plan implementation, smoking
(J Thorac Imaging 2014;29:289–292)
L
ung cancer is the leading cause of cancer-related deaths in the United States.1 Treatment is minimally effective during the cancer’s last stages, resulting in a dismal 5-year survival rate of 17%.1 In August 2011, results from the National Lung Screening Trial were published, showing a 20% reduction in lung cancer–related mortality from annual screening with low-dose computed tomography (LDCT) compared with traditional chest radiography.2 As a result, many federal, professional, and nonprofit organizations with a stake in cancer prevention research and From the *Department of Epidemiology and Biostatistics, Arnold School of Public Health; wCancer Prevention and Control Program; zCollege of Nursing, University of South Carolina, Columbia, SC; ySealy Center on Aging, The University of Texas Medical Branch, Galveston; and 8Department of Radiology, Houston Methodist, Houston, TX. The authors declare no conflicts of interest. Correspondence to: Jan M. Eberth, PhD, Cancer Prevention and Control Program, University of South Carolina, 915 Greene St., Room 234, Columbia, SC 29208 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
J Thorac Imaging
Volume 29, Number 5, September 2014
practice have updated their recommendations for lung cancer screening. For example, in December 2013, the US Preventive Services Task Force updated their screening recommendations to include annual LDCT screening for persons aged 55 to 80 years who have a Z30 pack-year smoking history and currently smoke or have quit within the past 15 years.3 LDCT screening has the potential to detect lung cancer at its early, curative stages and may also be useful for identifying other CT findings such as coronary artery calcification in heavy smokers.4 However, risk of overdiagnosis and an abundance of false-positive findings are known limitations of LDCT screening.1 An increasing number of organizations have issued recommendations for annual LDCT screening, and utilization is expected to increase as reimbursement becomes available; however, LDCT screening programs have been slow to develop. The purpose of this study is to determine the availability and characteristics of LDCT lung cancer screening programs in the United States and to identify barriers to program development and implementation.
MATERIALS AND METHODS The availability and characteristics of LDCT screening centers in the United States was determined by gathering survey data from members of the Society of Thoracic Radiology (STR), an international organization of radiologists dedicated to cardiopulmonary imaging.5 The surveys were structured to elicit information about respondents’ respective health care institution’s characteristics and LDCT screening practices. A formal request sent to the STR Board of Directors to survey their membership electronically was approved on July 22, 2013. Eligibility for survey participation included that respondents be engaged in medical practice in the United States and possess a thorough understanding of the radiologic practices at their respective institution. Qualtricst, an online survey platform, was used to develop and disseminate the survey. An email containing the link to the survey was sent to the STR membership directory (US members only) on August 15, 2013. Four weeks were allocated for the completion of the survey. After 2 weeks, a follow-up email was delivered to nonrespondents on August 29, 2013 to promote survey participation. The survey closed on September 15, 2013. A total of 140 responses were received, with respondents representing 82 unique screening programs from an aggregate of 225 US institutions; this yielded an institutional response rate of 36.4%. Because no personal information or potentially identifying data were collected in this study, institutional review board approval was unnecessary. Surveys that excluded the name of their represented institution (n = 21) were removed from data analysis, and duplicate surveys representing the same screening program www.thoracicimaging.com |
289
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Eberth et al
were also discarded. Specifically, multiple responses from individuals practicing at the same LDCT screening program were identified and flagged (35 surveys representing 30 duplicate institutions). In these instances, the respondent that provided the most complete information in the survey was selected to represent his/her institution in the analysis phase. After the respondent was chosen in the above manner, any missing information was imputed from the discarded respondent(s) survey. Discrepancies in responses between respondents of the same institution were addressed by telephone inquiry to the radiology program at the respective institution. Such discrepancies included a difference in the reported cost of screening, numbers of patients screened in 2012, and types of insurance accepted by the institution. Responses from this secondary telephone inquiry took precedence over the respondents’ original survey responses. In addition, 14 surveys deemed too incomplete were discarded from the initial 140 surveys received. This process resulted in a total of 82 surveys representing unique LDCT screening programs across the United States. Finally, the data were extracted from Qualtricst and imported into IBM SPSS Statistics Version 21 for further data management and analysis.
RESULTS There were 82 unique LDCT screening programs represented in the study. California had the highest number of screening programs (10), whereas 14 states (Alaska, Arkansas, Delaware, Idaho, Maine, Mississippi, Nebraska, Nevada, New Hampshire, North Dakota, Oklahoma, Rhode Island, West Virginia, and Wyoming) had no responding screening programs. The majority of respondents (65.9%, n = 54) reported having an active LDCT screening program (Table 1). The majority of active screening programs (70.4%, n = 38) identified themselves as academic/research hospitals, followed by private/group practice. Despite recommendations by professional and nonprofit organizations to offer smoking cessation counseling in concert with lung cancer screening, only 77.8% (n = 42) of active screening programs indicated offering smoking cessation directly or through a referral to another program. Whereas the cost to the patient for lung cancer screening ranged from free of charge to $2500, 48.1% (n = 26) of active screening programs indicated that their cost of screening averaged from $200 to $500. Nearly half of the active screening programs (44.4%, n = 24) stated that they would only accept patient self-pay. We found that demand for services was low, with only 11.1% (n = 6) of programs reporting screening >100 patients in 2012. From the 28 responding institutions that did not have an active LDCT screening program, only 3 (10.7%) reported that their center was not considering implementing a lung cancer screening program in the future (Table 2). The most common reason that affected organizations’ screening decisions was the current, tentative status of screening guidelines in the United States (35.7%, n = 10). Other reported factors for not offering screening were staffing shortages and a lack of reimbursement from insurance companies (n = 5, 17.9%, and n = 4, 14.3%, respectively).
DISCUSSION Overall, a majority of responding institutions indicated having an active LDCT lung cancer screening
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program, whereas nearly all responding institutions without an active screening program are presently considering it. Of the 54 institutions with an LDCT screening program, 10 sites were National Lung Screening Trial sites. Incomplete screening guidelines and lack of coverage from insurance companies are the most cited barriers to lung cancer program implementation. Nearly half of respondents also stated that patient self-payment is the most common form of accepted payment, which may have contributed to the low demand for services observed to date. With professional and federal advisory committees making recommendations in favor of annual LDCT screening for high-risk patients, health care institutions are increasingly interested in offering screening. This is evidenced by a doubling in the number of programs offering LDCT screening (32% in 2012 to 64% in 2013), according to the Oncology Roundtable Lung Cancer Screening Quick Poll, a brief survey of Oncology Roundtable members regarding the characteristics of their respective lung cancer screening programs, conducted in 2012 and 2013.6,7 Similarly, in our survey of STR members’ institutions, we found that 66% of the 82 distinct health care institutions represented in our survey reported having an active LDCT screening program in 2013. There were other similarities between our survey results and those of the 2013 Oncology Roundtable Lung Cancer Screening Quick Poll, including low demand for services (average of 41 patients in 2013), payment method (83% paid out-of-pocket), and average cost to patient for screening ($169/screening): the majority of institutions in our study reported screening 21 to 50 patients in the past year, self-payment only for 44.4% of screening programs, and costs per screening ranging from $200 to $500, which showcases data congruent to the 2013 Quick Poll results. Finally, 87% of the 2013 Quick Poll respondents with no screening program reported planning on offering this service in the future, nearly identical to the 89% observed in this study. In addition, a majority of respondents in a survey of leading academic medical centers conducted by Boiselle et al8 reported a payment range of $300 to $400 per LDCT screening, which is similar to this study’s results. However, 93% of their sites reported a smoking cessation program onsite, in comparison to the 61.1% of institutions in this study.8 Although these results may serve as a baseline for future evaluations of screening adoption, there are some inherent limitations to note. Firstly, because of the voluntary nature of our study, potential participants without an active LDCT lung cancer screening program at their institution may have been reluctant to respond to the survey, incurring a nonresponse bias. Secondly, our survey was solely distributed to the membership base of STR, resulting in data that may have been overrepresented by academic centers and, thus, not representative of all US medical institutions. A survey delivered to all possible screening centers would ensure the most comprehensive evaluation of screening adoption. Moreover, institutions without a screening program 6 months ago at the start of the survey may now have implemented their program. A follow-up survey to the STR membership is planned for late 2014 to assess changes in screening implementation over time. In the coming years, a likely surge in the availability of LDCT lung cancer screening programs appears to be imminent. With the US Preventive Services Task Force finalizing their recommendations for LDCT screening in December 2013,3 we expect both the development of screening programs, and the respective utilization of those programs will continue to grow. Reimbursement for LDCT r
2014 Lippincott Williams & Wilkins
J Thorac Imaging
Volume 29, Number 5, September 2014
Adoption of LDCT Lung Cancer Screening
TABLE 1. Characteristics of Institutions With Active LDCT Screening Programs Institution status Academic teaching/research hospital Private/group radiology practice Community-based health center Group model HMO and other Types of services provided to patients Risk assessment or screening evaluation Discussion/information about the risk/benefits of screening Smoking cessation counseling/treatment Referral to a smoking cessation program Findings report mailed directly to the patient Findings report mailed to the patient’s primary care provider Cost of LDCT screening at self-pay rate No charge $200 or less > $200-$500 $500-over $1000 Not sure No response Billing methods Medical insurance accepted Self-pay only Not sure No response No. patients that received screening in 2012 None < 5-20 21-50 51-100 > 100 Not sure No response
screening in high-risk patients will be covered by private insurers, through provisions of the Affordable Care Act, which states that US Preventive Service Task Force– recommended screenings with an A or B grade are eligible for reimbursement without cost-sharing.9 However, at a recent Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) meeting on April 30, 2014, the panel recommended against coverage for lung cancer screening by the Center for Medicare and Medicaid
Response (N = 54)
%
38 8 1 7
70.4 14.8 1.9 13
41 39 33 31 23 44
75.9 72.2 61.1 57.4 52.6 81.5
3 16 26 2 4 3
5.6 29.6 48.1 3.7 7.4 5.6
15 24 12 3
27.8 44.4 22.2 5.6
5 3 14 9 6 3 14
9.3 5.6 25.9 16.7 11.1 5.6 25.9
services.10 The final decision on CMS coverage will not be made until early 2015 following posting of a draft recommendation in November 2014, and the outcome of this decision could have significant impact on screening programs for people over 65 years of age.11 On the basis of the results of our survey, removing these barriers will likely entice more health care institutions to develop and broaden the scope of their lung cancer screening programs, which has been quite limited to date.
TABLE 2. Characteristics of Institutions With No Active LDCT Screening Program Scenario Considering a screening program in the future Factors that contributed to institute’s decision not to offer screening Legal concerns Screening guidelines in development Insufficient evidence to warrant screening Lack of support by peers and professional organizations Not enough staff to conduct screening Not enough machine time available to conduct screening Other (open-ended responses) Not sure Institution status Academic teaching/research hospital Private/group radiology practice Community-based health center, HMO, or other
r
2014 Lippincott Williams & Wilkins
Response (N = 28)
%
25
89.3
2 10 2 3 5 1 13 2
7.1 35.7 7.1 10.7 17.9 3.6 46.4 7.1
16 5 7
57.1 17.9 25
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ACKNOWLEDGMENTS The authors thank the members and Board of Directors of the STR for approving the distribution of our survey to the STR membership. REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63:11–30. 2. National Lung Screening Trial Research Team, Church TR, Black WC, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980–1991. 3. US Preventative Services Task Force. Screening for Lung Cancer, Topic Page. January 2014. Available at: http://www. uspreventiveservicestaskforce.org/uspstf/uspslung.htm. Accessed January 30, 2014. 4. Shemesh J, Henschke CI, Farooqi A, et al. Frequency of coronary artery calcification on low-dose computed tomography screening for lung cancer. Clin Imaging. 2006;30:181–185. 5. Society of Thoracic Radiology. Society of Thoracic Radiology. 2011. Available at: http://www.thoracicrad.org/. Accessed February 26, 2014. 6. The Advisory Board Company. The results are in-see what we learned from the 2013 Lung cancer Screening Quick Poll. Available at: www.advisory.com/Research/Oncology-Roundtable/ExpertInsights/2015/The-results-are-in-Lung-Cancer-Quick-pol. Accessed February 13, 2014.
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7. The Advisory Board Company. The latest fact? Why 32% of members offer long CT screening. Accessed May 5, 2014. 8. Boiselle PM, White CS, Ravenel JG. Computed tomographic screening for lung cancer: current practice patterns at leading academic medical centers. JAMA Intern Med. 2014;174: 286–287. 9. American College of Radiology. ACR lead effort to meet with CMS on proposed low-dose CT Lung Cancer Screening Program. January 17, 2014. Available at: http://www.acr.org/ Advocacy/eNews/20140117-Issue/ACR-Leads-Effort-to-MeetWith-CMS-on-Proposed-CT-Lung-Cancer-Screening-Program. Accessed February 26, 2014. 10. Helio Hematology/Oncology. CMS advisory panel rejects Medicare coverage for lung cancer screening. April 30, 2014. Available at: http://www.healio.com/hematology-oncology/ practice-management/news/online/%7Be90ef7a1-f0d2-4e2c91c5-1438273f6a10%7D/cms-advisory-panel-rejects-medicarecoverage-for-lung-cancer-screening. May 12, 2013. 11. MEDCAC failure to support Medicare coverage for CT lung cancer screening may place many seniors at risk: college continues to recommend full national coverage of these lifesaving exams. April 30. 2014. Available at: http://www. acr.org/About-Us/Media-Center/Press-Releases/2014-PressReleases/MEDCAC-Failure-to-Support-Medicare-Coverage-forCT-Lung-Cancer-Screening-May-Place-Seniors-at-Risk. Accessed May 12, 2014.
r
2014 Lippincott Williams & Wilkins
Computed Tomography Screening for Lung Cancer A Survey of Society of Thoracic Radiology Members Jan M. Eberth, PhD,*w Rebecca Qiu,z Suzanne K. Linder, PhD,y Nancy R. Gallant, MS,*w and Reginald F. Munden, MD, DMD, MBA, FACR8
Purpose: This study aimed to determine the availability, attributes, and hindrances of current and developing US lung cancer screening programs. Materials and Methods: An electronic questionnaire was sent to the membership of the Society of Thoracic Radiology in August 2013 and remained open for 4 weeks. Of the 225 US-based members, we received 140 responses representing 82 unique health care institutions. Descriptive statistics were used to characterize the responding health care institutions’ LDCT screening availability and components. Results: A majority of responding institutions reported having an active LDCT screening program (65.9%). Of the responding institutions without an active program, 89.3% reported they were considering having an LDCT screening program in the future, and 35.7% (n = 10) indicated the developing status of screening recommendations as a motivating factor in not offering a screening program. Forty-four percent of participating LDCT screening centers reported that their services were self-pay only, and nearly half charged a rate of $200 to $500 for screening. Conclusions: In our sample, we found that a majority of respondents were engaged in LDCT screening programs. Growth of such programs is expected in the coming years. Finalizing screening guidelines and insurance reimbursement will likely remove barriers that inhibit further growth of LDCT lung cancer screening programs. Key Words: lung neoplasms, spiral computed tomography, early detection of cancer, health plan implementation, smoking
(J Thorac Imaging 2014;29:289–292)
L
ung cancer is the leading cause of cancer-related deaths in the United States.1 Treatment is minimally effective during the cancer’s last stages, resulting in a dismal 5-year survival rate of 17%.1 In August 2011, results from the National Lung Screening Trial were published, showing a 20% reduction in lung cancer–related mortality from annual screening with low-dose computed tomography (LDCT) compared with traditional chest radiography.2 As a result, many federal, professional, and nonprofit organizations with a stake in cancer prevention research and From the *Department of Epidemiology and Biostatistics, Arnold School of Public Health; wCancer Prevention and Control Program; zCollege of Nursing, University of South Carolina, Columbia, SC; ySealy Center on Aging, The University of Texas Medical Branch, Galveston; and 8Department of Radiology, Houston Methodist, Houston, TX. The authors declare no conflicts of interest. Correspondence to: Jan M. Eberth, PhD, Cancer Prevention and Control Program, University of South Carolina, 915 Greene St., Room 234, Columbia, SC 29208 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
J Thorac Imaging
Volume 29, Number 5, September 2014
practice have updated their recommendations for lung cancer screening. For example, in December 2013, the US Preventive Services Task Force updated their screening recommendations to include annual LDCT screening for persons aged 55 to 80 years who have a Z30 pack-year smoking history and currently smoke or have quit within the past 15 years.3 LDCT screening has the potential to detect lung cancer at its early, curative stages and may also be useful for identifying other CT findings such as coronary artery calcification in heavy smokers.4 However, risk of overdiagnosis and an abundance of false-positive findings are known limitations of LDCT screening.1 An increasing number of organizations have issued recommendations for annual LDCT screening, and utilization is expected to increase as reimbursement becomes available; however, LDCT screening programs have been slow to develop. The purpose of this study is to determine the availability and characteristics of LDCT lung cancer screening programs in the United States and to identify barriers to program development and implementation.
MATERIALS AND METHODS The availability and characteristics of LDCT screening centers in the United States was determined by gathering survey data from members of the Society of Thoracic Radiology (STR), an international organization of radiologists dedicated to cardiopulmonary imaging.5 The surveys were structured to elicit information about respondents’ respective health care institution’s characteristics and LDCT screening practices. A formal request sent to the STR Board of Directors to survey their membership electronically was approved on July 22, 2013. Eligibility for survey participation included that respondents be engaged in medical practice in the United States and possess a thorough understanding of the radiologic practices at their respective institution. Qualtricst, an online survey platform, was used to develop and disseminate the survey. An email containing the link to the survey was sent to the STR membership directory (US members only) on August 15, 2013. Four weeks were allocated for the completion of the survey. After 2 weeks, a follow-up email was delivered to nonrespondents on August 29, 2013 to promote survey participation. The survey closed on September 15, 2013. A total of 140 responses were received, with respondents representing 82 unique screening programs from an aggregate of 225 US institutions; this yielded an institutional response rate of 36.4%. Because no personal information or potentially identifying data were collected in this study, institutional review board approval was unnecessary. Surveys that excluded the name of their represented institution (n = 21) were removed from data analysis, and duplicate surveys representing the same screening program www.thoracicimaging.com |
289
J Thorac Imaging
Eberth et al
were also discarded. Specifically, multiple responses from individuals practicing at the same LDCT screening program were identified and flagged (35 surveys representing 30 duplicate institutions). In these instances, the respondent that provided the most complete information in the survey was selected to represent his/her institution in the analysis phase. After the respondent was chosen in the above manner, any missing information was imputed from the discarded respondent(s) survey. Discrepancies in responses between respondents of the same institution were addressed by telephone inquiry to the radiology program at the respective institution. Such discrepancies included a difference in the reported cost of screening, numbers of patients screened in 2012, and types of insurance accepted by the institution. Responses from this secondary telephone inquiry took precedence over the respondents’ original survey responses. In addition, 14 surveys deemed too incomplete were discarded from the initial 140 surveys received. This process resulted in a total of 82 surveys representing unique LDCT screening programs across the United States. Finally, the data were extracted from Qualtricst and imported into IBM SPSS Statistics Version 21 for further data management and analysis.
RESULTS There were 82 unique LDCT screening programs represented in the study. California had the highest number of screening programs (10), whereas 14 states (Alaska, Arkansas, Delaware, Idaho, Maine, Mississippi, Nebraska, Nevada, New Hampshire, North Dakota, Oklahoma, Rhode Island, West Virginia, and Wyoming) had no responding screening programs. The majority of respondents (65.9%, n = 54) reported having an active LDCT screening program (Table 1). The majority of active screening programs (70.4%, n = 38) identified themselves as academic/research hospitals, followed by private/group practice. Despite recommendations by professional and nonprofit organizations to offer smoking cessation counseling in concert with lung cancer screening, only 77.8% (n = 42) of active screening programs indicated offering smoking cessation directly or through a referral to another program. Whereas the cost to the patient for lung cancer screening ranged from free of charge to $2500, 48.1% (n = 26) of active screening programs indicated that their cost of screening averaged from $200 to $500. Nearly half of the active screening programs (44.4%, n = 24) stated that they would only accept patient self-pay. We found that demand for services was low, with only 11.1% (n = 6) of programs reporting screening >100 patients in 2012. From the 28 responding institutions that did not have an active LDCT screening program, only 3 (10.7%) reported that their center was not considering implementing a lung cancer screening program in the future (Table 2). The most common reason that affected organizations’ screening decisions was the current, tentative status of screening guidelines in the United States (35.7%, n = 10). Other reported factors for not offering screening were staffing shortages and a lack of reimbursement from insurance companies (n = 5, 17.9%, and n = 4, 14.3%, respectively).
DISCUSSION Overall, a majority of responding institutions indicated having an active LDCT lung cancer screening
290 | www.thoracicimaging.com
Volume 29, Number 5, September 2014
program, whereas nearly all responding institutions without an active screening program are presently considering it. Of the 54 institutions with an LDCT screening program, 10 sites were National Lung Screening Trial sites. Incomplete screening guidelines and lack of coverage from insurance companies are the most cited barriers to lung cancer program implementation. Nearly half of respondents also stated that patient self-payment is the most common form of accepted payment, which may have contributed to the low demand for services observed to date. With professional and federal advisory committees making recommendations in favor of annual LDCT screening for high-risk patients, health care institutions are increasingly interested in offering screening. This is evidenced by a doubling in the number of programs offering LDCT screening (32% in 2012 to 64% in 2013), according to the Oncology Roundtable Lung Cancer Screening Quick Poll, a brief survey of Oncology Roundtable members regarding the characteristics of their respective lung cancer screening programs, conducted in 2012 and 2013.6,7 Similarly, in our survey of STR members’ institutions, we found that 66% of the 82 distinct health care institutions represented in our survey reported having an active LDCT screening program in 2013. There were other similarities between our survey results and those of the 2013 Oncology Roundtable Lung Cancer Screening Quick Poll, including low demand for services (average of 41 patients in 2013), payment method (83% paid out-of-pocket), and average cost to patient for screening ($169/screening): the majority of institutions in our study reported screening 21 to 50 patients in the past year, self-payment only for 44.4% of screening programs, and costs per screening ranging from $200 to $500, which showcases data congruent to the 2013 Quick Poll results. Finally, 87% of the 2013 Quick Poll respondents with no screening program reported planning on offering this service in the future, nearly identical to the 89% observed in this study. In addition, a majority of respondents in a survey of leading academic medical centers conducted by Boiselle et al8 reported a payment range of $300 to $400 per LDCT screening, which is similar to this study’s results. However, 93% of their sites reported a smoking cessation program onsite, in comparison to the 61.1% of institutions in this study.8 Although these results may serve as a baseline for future evaluations of screening adoption, there are some inherent limitations to note. Firstly, because of the voluntary nature of our study, potential participants without an active LDCT lung cancer screening program at their institution may have been reluctant to respond to the survey, incurring a nonresponse bias. Secondly, our survey was solely distributed to the membership base of STR, resulting in data that may have been overrepresented by academic centers and, thus, not representative of all US medical institutions. A survey delivered to all possible screening centers would ensure the most comprehensive evaluation of screening adoption. Moreover, institutions without a screening program 6 months ago at the start of the survey may now have implemented their program. A follow-up survey to the STR membership is planned for late 2014 to assess changes in screening implementation over time. In the coming years, a likely surge in the availability of LDCT lung cancer screening programs appears to be imminent. With the US Preventive Services Task Force finalizing their recommendations for LDCT screening in December 2013,3 we expect both the development of screening programs, and the respective utilization of those programs will continue to grow. Reimbursement for LDCT r
2014 Lippincott Williams & Wilkins
J Thorac Imaging
Volume 29, Number 5, September 2014
Adoption of LDCT Lung Cancer Screening
TABLE 1. Characteristics of Institutions With Active LDCT Screening Programs Institution status Academic teaching/research hospital Private/group radiology practice Community-based health center Group model HMO and other Types of services provided to patients Risk assessment or screening evaluation Discussion/information about the risk/benefits of screening Smoking cessation counseling/treatment Referral to a smoking cessation program Findings report mailed directly to the patient Findings report mailed to the patient’s primary care provider Cost of LDCT screening at self-pay rate No charge $200 or less > $200-$500 $500-over $1000 Not sure No response Billing methods Medical insurance accepted Self-pay only Not sure No response No. patients that received screening in 2012 None < 5-20 21-50 51-100 > 100 Not sure No response
screening in high-risk patients will be covered by private insurers, through provisions of the Affordable Care Act, which states that US Preventive Service Task Force– recommended screenings with an A or B grade are eligible for reimbursement without cost-sharing.9 However, at a recent Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) meeting on April 30, 2014, the panel recommended against coverage for lung cancer screening by the Center for Medicare and Medicaid
Response (N = 54)
%
38 8 1 7
70.4 14.8 1.9 13
41 39 33 31 23 44
75.9 72.2 61.1 57.4 52.6 81.5
3 16 26 2 4 3
5.6 29.6 48.1 3.7 7.4 5.6
15 24 12 3
27.8 44.4 22.2 5.6
5 3 14 9 6 3 14
9.3 5.6 25.9 16.7 11.1 5.6 25.9
services.10 The final decision on CMS coverage will not be made until early 2015 following posting of a draft recommendation in November 2014, and the outcome of this decision could have significant impact on screening programs for people over 65 years of age.11 On the basis of the results of our survey, removing these barriers will likely entice more health care institutions to develop and broaden the scope of their lung cancer screening programs, which has been quite limited to date.
TABLE 2. Characteristics of Institutions With No Active LDCT Screening Program Scenario Considering a screening program in the future Factors that contributed to institute’s decision not to offer screening Legal concerns Screening guidelines in development Insufficient evidence to warrant screening Lack of support by peers and professional organizations Not enough staff to conduct screening Not enough machine time available to conduct screening Other (open-ended responses) Not sure Institution status Academic teaching/research hospital Private/group radiology practice Community-based health center, HMO, or other
r
2014 Lippincott Williams & Wilkins
Response (N = 28)
%
25
89.3
2 10 2 3 5 1 13 2
7.1 35.7 7.1 10.7 17.9 3.6 46.4 7.1
16 5 7
57.1 17.9 25
www.thoracicimaging.com |
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Eberth et al
ACKNOWLEDGMENTS The authors thank the members and Board of Directors of the STR for approving the distribution of our survey to the STR membership. REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63:11–30. 2. National Lung Screening Trial Research Team, Church TR, Black WC, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med. 2013;368:1980–1991. 3. US Preventative Services Task Force. Screening for Lung Cancer, Topic Page. January 2014. Available at: http://www. uspreventiveservicestaskforce.org/uspstf/uspslung.htm. Accessed January 30, 2014. 4. Shemesh J, Henschke CI, Farooqi A, et al. Frequency of coronary artery calcification on low-dose computed tomography screening for lung cancer. Clin Imaging. 2006;30:181–185. 5. Society of Thoracic Radiology. Society of Thoracic Radiology. 2011. Available at: http://www.thoracicrad.org/. Accessed February 26, 2014. 6. The Advisory Board Company. The results are in-see what we learned from the 2013 Lung cancer Screening Quick Poll. Available at: www.advisory.com/Research/Oncology-Roundtable/ExpertInsights/2015/The-results-are-in-Lung-Cancer-Quick-pol. Accessed February 13, 2014.
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7. The Advisory Board Company. The latest fact? Why 32% of members offer long CT screening. Accessed May 5, 2014. 8. Boiselle PM, White CS, Ravenel JG. Computed tomographic screening for lung cancer: current practice patterns at leading academic medical centers. JAMA Intern Med. 2014;174: 286–287. 9. American College of Radiology. ACR lead effort to meet with CMS on proposed low-dose CT Lung Cancer Screening Program. January 17, 2014. Available at: http://www.acr.org/ Advocacy/eNews/20140117-Issue/ACR-Leads-Effort-to-MeetWith-CMS-on-Proposed-CT-Lung-Cancer-Screening-Program. Accessed February 26, 2014. 10. Helio Hematology/Oncology. CMS advisory panel rejects Medicare coverage for lung cancer screening. April 30, 2014. Available at: http://www.healio.com/hematology-oncology/ practice-management/news/online/%7Be90ef7a1-f0d2-4e2c91c5-1438273f6a10%7D/cms-advisory-panel-rejects-medicarecoverage-for-lung-cancer-screening. May 12, 2013. 11. MEDCAC failure to support Medicare coverage for CT lung cancer screening may place many seniors at risk: college continues to recommend full national coverage of these lifesaving exams. April 30. 2014. Available at: http://www. acr.org/About-Us/Media-Center/Press-Releases/2014-PressReleases/MEDCAC-Failure-to-Support-Medicare-Coverage-forCT-Lung-Cancer-Screening-May-Place-Seniors-at-Risk. Accessed May 12, 2014.
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2014 Lippincott Williams & Wilkins
