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Let's talk a little about the lung cancer

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screening guidelines.

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What makes people eligible for lung cancer screening,

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and importantly, insurance coverage to make sure

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that they can get their lung cancer screening exams.

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It's a little complicated.

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It's a quilt, as I call it,

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of healthcare coverage based on guidelines, eligibility,

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and insurance plans.

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So we'll look at the evidence supporting lung cancer

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screening, very foundational knowing

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why we screen who we do.

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We'll look at our US Preventative Services Task force

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recommendation, the CMS National Coverage Decision,

0:31

and talk about how these play into insurance coverage.

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We'll talk a little bit about billing

0:36

and coding documentation for lung cancer screening.

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As this can be challenging, we'll talk about the most recent

0:43

American Cancer Society updated guideline from

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November, 2023.

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Importantly, we'll talk about what the differences

0:49

between lung cancer screening versus lung cancer

0:53

surveillance in patients who've already been diagnosed

0:55

with lung cancer and are now surviving.

0:59

The fundamental underpinnings of the evidence

1:01

and why we screen for lung cancer today is the National Lung

1:04

Cancer Screening trial performed here in the United States,

1:07

which remains the largest randomized controlled trial

1:11

comparing low dose chest CT performed annually

1:14

to chest X-Ray in looking

1:16

to see if we can reduce cancer mortality.

1:19

This study published in the New England Journal

1:21

of Medicine in 2011 demonstrated a 20% reduction in lung

1:26

cancer specific mortality,

1:28

and a 7% reduction in all cause mortality,

1:31

which may be related to some

1:32

of those incidental findings like coronary arterial

1:35

calcification and cardiovascular disease, or COPD.

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The number needed to screen is 320 individuals

1:43

to save one person from a lung cancer death.

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This study randomized 50,000 subjects

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and looked at them over eight years with extended followup.

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To make this determination, the study entry criteria were 55

1:57

to 74 years of age

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and a 30 pack year threshold of pack year calculation.

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It's important to pay attention to this information

2:07

as you'll see how it's impacted the guidelines.

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The study was designed to be able

2:11

to follow people over a long period of time, and

2:15

therefore they needed to be healthy enough to survive,

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yet have a high enough risk cancer to be screened.

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And so these age impact years were designed based on having

2:24

a population that the theory could be tested on.

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Does lung cancer screening reduce mortality,

2:29

but that they would be surviving long enough by age

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and their comorbidities to be able

2:35

to evaluate them at long-term Follow-up.

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The cost effectiveness

2:40

of screening was also published in the New England Journal

2:42

of Medicine from the National Lung Screening Trial

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and comes out at $81,000 per quality adjusted life year.

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This is very similar to other cancers that we screen for

2:53

and other medical care that we deliver.

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The second largest trial published in the

2:58

England Journal in 2020 was the Dutch Belgian trial,

3:02

which similarly demonstrated a reduction in lung cancer

3:05

mortality of similar magnitude

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to the National Lung screening trial.

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These two together have driven guidelines

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and recommendations such

3:14

as the US Preventative Services Task Force guideline.

3:17

The U-S-P-S-T-F makes evidence-based recommendations about

3:21

preventative health services such as screenings,

3:23

preventative medications, and even behavioral counseling.

3:26

And these recommendations are created specifically

3:29

for primary care professionals and practices.

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If we look at the history of the U-S-P-S-T-F guideline

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for lung cancer screening in 1996,

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they gave it a grade D recommendation,

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which is a non recommendation.

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Neither x-ray

3:44

or sputum cytology,

3:46

which had been studied in several trials in the 1970s were

3:49

found to be of benefit in reducing lung cancer mortality.

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In their update eight years later in 2004,

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they mentioned low dose CT in their wording,

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but they don't actually execute on low dose CT

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because there was not substantive evidence at that time.

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So they gave it an I or inconclusive recommendation.

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In 2013,

4:10

for the first time they gave lung cancer screening a

4:13

positive recommendation or grade B,

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they recommended low dose CT in individuals aged 55

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to 80 years of age,

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a slightly wider age group than was used in U-S-P-S-T-F

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because this was discerned.

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Using modeling studies to know

4:28

that those patients would be at increased cancer risk.

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30 pack years was used as the cigarette smoking criteria,

4:34

either those who currently smoke

4:36

or quit within the last 15 years.

4:39

That last part in the last 15 years, we'll discuss later.

4:42

Screening, importantly should be discontinued if a person

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hasn't smoked for 15 years or more,

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or develops health problems

4:49

that substantially limit their life expectancy

4:51

to see the benefit of screening, they should also be willing

4:55

to undergo curative intent treatment.

4:58

Why screen for a lung cancer if a person is not interested

5:01

or willing to undergo the treatments?

5:03

That would then ensue in 2021?

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The U-S-P-S-D-F extended their lung cancer screening

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guideline, dropping the lower bound to 50 years

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and dropping the pack years to 20.

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This increased the number of people who were eligible

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for lung cancer screening from about 8 million using the

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2013 criteria to approximately 14 million people

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with a 2021 criteria.

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Importantly, by reducing age

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and by reducing the pack your criteria,

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it doubled the number of people eligible,

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particularly including African American individuals

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or black Americans and women.

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These individuals are known to have a higher risk

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of lung cancer at a younger age

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and may have slightly different smoking habits

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that contribute.

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So this was an important adjustment that was necessary

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to make sure that we were reaching in a more equitable

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manner the patient population high risk for lung

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Cancer.

5:58

Unfortunately, what this did was increase the size

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of the pool, but didn't really increase the concentration

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of individuals at risk.

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So it increased both the number of women

6:08

and black Americans elder screening,

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but it also increased the number of others, white Americans,

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Hispanics, and so on who are at risk for lung cancer.

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So it raised the bars for everybody.

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It increased the number of people,

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but it didn't increase the proportion of individuals

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of different racial and ethnic backgrounds

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who are eligible for screening.

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We're hopeful that in the future we'll have individual

6:30

risk-based tailored screening, such like they used

6:33

for cardiovascular disease risk assessments today.

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Now, these U-S-P-S-T-F guidelines are very important.

6:39

They publish their research in the published literature.

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The most recent update was published in jama, for example,

6:46

and are available usually

6:47

with open access for people to read.

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These guidelines are used by primary care

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and adapted by organizations.

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For example, after the 2020 upgrade,

6:57

the American Association of Family Physicians started

7:00

to recommend lung cancer screening.

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Now what's in A grade?

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Why is it important that it's grade A or B?

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Well, in the nomenclature of the U-S-P-S-T-F-A, great A

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or B means the test either has a high certainty

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that the benefit is moderate or a moderate certainty.

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The net benefit is moderate to substantial,

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that the service should be provided.

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And importantly for insurance coverage, anything

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with a grade A or B recommendation

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because of language in the Affordable Care Act is required

7:30

to be covered by private payers with no copay for patients.

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That makes lung cancer screenings more available

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and accessible to individuals without having to

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worry about the cost of the copay for the screening test.

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So this applies to private payers, doesn't apply to Medicare

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or Medicaid where decisions are made at a different level.

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Medicare has its own national coverage decision policy,

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which came out first in 2015

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and was updated in 2021 to reflect the lower pack years

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and lower age bound that the

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U-S-P-S-D-S started to recommend.

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Medicaid is a state-based program,

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and so that means lobbying at the state level

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to make decisions about whether lung cancer screening is

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available in your state for people who are on Medicaid,

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and that it gets updated as evidence progresses.

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And then we have large populations, for example,

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who receive their care

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through the Veterans' Health Administration, the Department

8:26

of Defense, and suddenly they make their own decisions.

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So as I mentioned, we have a quilt of healthcare coverage

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and how you get your healthcare depends on whether lung

8:35

cancer screening is accessible to you.

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But now we have broad coverage across all the populations,

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independent of any of their healthcare coverage.

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That has occurred now because of developments in science

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and advocacy over the years.

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When Medicare updated its decision in 2022,

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it did some things to make it easier

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For radiology practices

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and lung cancer screening programs

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to deliver lung cancer screening.

9:00

For example, one of the obstacles

9:02

that people had mentioned was a counseling

9:04

and shared decision making visit being

9:06

required for the first screen.

9:08

This means talking to a person about the risk

9:10

and benefits of lung cancer screening

9:12

and if it's right for them.

9:13

And specifically they require it be done using decision aids

9:17

such as video decision aids

9:20

in their initial coverage decision.

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It could only be done by a provider, a physician,

9:25

or an advanced practice professional, such

9:26

as a nurse practitioner or pa.

9:28

But in their updated guideline, they extended the ability

9:32

of staff within people's teams who are trained to do this

9:36

and under the supervision of providers to be able

9:39

to deliver this important component

9:42

of lung cancer screening.

9:44

So this has reduced one of the obstacles, for example,

9:47

the primary care physicians had when

9:50

delivering lung cancer screening.

9:53

One important thing for you to be aware

9:54

of is the BRAIDWOOD versus be case in the state of Texas

9:59

in 2023.

10:01

Judge O'Connor granted Braidwood management.

10:04

Its request to block a section

10:05

of the Public Health Services Act that had been amended

10:08

by the Affordable Care Act.

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And that language is what created the linkage

10:13

between the Grade B recommendation of lung cancer screening

10:16

and no copay for patients.

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This affects all of the preventative health recommendations

10:23

that U-S-P-S-T-F has since 2010.

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And they made this recommendation

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because they said the U-S-P-S-D-F recommendations are

10:32

unconstitutional as the task force is not appointed

10:35

by the president or confirmed by the Senate.

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This is immediately, uh,

10:40

within short timeframe put under appeal

10:42

by the Biden administration is on stay as we wait to hear

10:45

what the final results are.

10:47

But if this were to stay, it would mean

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that copays would now be required for all

10:51

of these preventative services including

10:53

lung cancer screening.

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Fortunately, research indicates that over 80%

10:57

of employers have decided they won't impose cost sharing

11:01

even if this were to stay in place.

11:03

And so that's good to know.

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But that means for 20% of people,

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and this usually affects the people with the lowest means,

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they are less likely to be able

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to get cancer screenings including lung cancer screening

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because of not being able to afford those copays.

11:19

We put together a A one pager

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for economics at the American College of Radiology

11:23

to help understand some of these pieces

11:26

of information about lung cancer screening,

11:29

who can do shared decision making, for example,

11:32

what the requirements are around smoking cessation as well

11:35

as importantly the billing codes

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and what the recommended codes are, both

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for the tests we perform, as well as the indications

11:43

for the test smoking cessation counseling, for example,

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screening cts versus interval diagnostic cts.

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And this information is available on the ACRs lung cancer

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screening resource webpage along with a lot of other content

11:56

that's important to you in your practice.