A screening recommended last summer to detect early stage lung cancers in chronic smokers has not gained the awareness level it merits, given that lung cancer is America’s most deadly cancer.* That was the assessment from Dr. Corey J. Langer, professor of medicine, Abrahamson Cancer Center, University of Pennsylvania, who took part in a panel discussion on non-small cell lung cancer convened by The American Journal of Managed Care.
(For the full discussion, click here.)
Breast cancer has the pink ribbon and a monthlong campaign every October to get women screened. Colonoscopies experienced the “Katie Couric effect,” an upsurge attributed to the popular former host of the Today Show, who had an onscreen exam after losing her husband, 42-year-old lawyer Jay Monahan, to colon cancer in 1998.
But according to Langer, screenings for lung cancer, which each year kills more Americans than colon, breast, and prostate cancer combined, did not see a similar surge last summer when it was recommended for the roster of tests for which insurance must pay under the Affordable Care Act. On December 31, 2013, the U.S. Preventive Services Task Force finalized its recommendation for annual lung cancer screenings with low-dose computed tomography in adults ages 55 to 80 years who have smoked 30 “pack years.” A pack-year means the person has smoked at least a pack a day for a year; a person who smoked two packs a day for 15 years would have 30 pack-years.
The draft recommendation, based on results from the National Lung Screening Trial, received plenty of press attention when it came out July 29, 2013. Yet, “It’s amazing how few patients or family members are aware of this,” Langer said. “The impact and the general notice of the NLST has not penetrated.”
Langer’s comments were part of a wide-ranging discussion on treatment strategies for non-small cell lung cancer, including new and emerging agents, the need for precision in pathology to identify the characteristics and stage of the disease, and the use of molecular-level tests and agents.
Michael Chernew, PhD, a health economist at Harvard University and co-editor-in-chief of The American Journal of Managed Care, led the discussion that also included Dr. David J. Sugarbaker, chief of thoracic surgery at Brigham and Women’s Hospital in Boston, and Dr. Steven Peskin, senior medical director, Horizon Healthcare Innovations, Horizon Blue Cross Blue Shield New Jersey.
Langer did not offer a reason for the lack of awareness. On its Web site, the American Lung Association said the stigma associated with cigarette smoking has clouded efforts to promote lung cancer screening. That’s quite a shift from the state of affairs in 1964, when the U.S. Surgeon General unveiled its landmark report that showed cigarettes cause lung cancer in men and “probably” in women. At that time, 46 percent of Americans smoked; today fewer than half that share do.
Some questions about who should be screened and how often come down cost-effectiveness. Overuse of scans generally has been a hot topic in cancer care, with the American Society of Clinical Oncology recommending against some scans in its Choose Wisely initiative.
Sugarbaker noted that the costs of screening for lung cancer had to be weighed against the expense of end-of-life care for a patient with stage IV lung cancer, which Chernew said can easily exceed $100,000 a year. Too often, he said, lung cancer is diagnosed after surgery is no longer possible, and a patient’s only options are expensive chemotherapy or targeted therapy treatments. “Early detection and early resection … saves a lot of money,” Sugarbaker said.
But when the evidence clearly supports screening, it makes sense for everyone, said Peskin. “The issue of imaging and early detection certainly resonates with payers, including myself, and not only for economic but also ethical considerations.”
Both Langer and Sugarbaker said screening and payment protocols are still evolving at major academic centers, with some centers offering the baseline screening for free for chronic, long-term smokers. Some patients don’t quite fit the 30 pack-year criteria, or may not be old enough, but does waiting make sense. Langer, who said he had doubts about the NLST when it began, noted that one-quarter of the high-risk population it targeted “had some abnormalities on their scan.”
The USPSTF recommendations call for ending annual scans once the patient has quit for more than 15 years, or if the patient develops some other medical condition that would make him or her unable or unwilling to be treated for lung cancer. Unlike the initial trial, scanning goes on to age 80
*According to the American Lung Association Web site, 160,340 people in the United States were expected to die from lung cancer in 2012.