Conway: The implications of USPSTF's draft guidelines for lung cancer screening

Lindsay ConwayThe Daily Briefing's Hanna Jaquith spoke with Lindsay Conway, the Oncology Roundtable's practice manager, about the U.S. Preventive Services Task Force's (USPSTF) first-ever recommendation for annual lung cancer screening in high-risk individuals, which could save more than 20,000 lives annually.

Q: A number of other organizations have recommended lung cancer screening for current and former smokers. What is the significance of the USPSTF guidelines?

Conway: One of the key obstacles to lung screening right now is that most insurers do not reimburse for the service. So many hospitals have been offering it for free or for a reduced cost, which patients pay out of pocket.

If the USPSTF's draft guidelines are finalized with a "B" rating, then under the Affordable Care Act, Medicare and private insurers would have to begin to pay for the service.

Q: What impact will that have on screening rates?

Conway: By removing cost as a barrier, more high-risk patients will likely be able to access lung cancer screenings.

But there's still a lot of work to be done. There needs to be more public education about which individuals are considered high-risk and therefore are candidates for lung cancer screening. (Peter Bach has developed a great online tool to help people determine whether they should be screened.) And there needs to be more education for PCPs.

Q: Yesterday, the Daily Briefing ran a story about overhauling cancer terminology in an effort to deter patients from opting for aggressive treatment for diagnoses that are unlikely to cause harm. How do the guidelines fit into the larger debate about overtesting and unnecessary treatment?

Conway: Overdiagnosis is absolutely a concern. The big problem is that we can't reliably distinguish between fast growing cancers that are deadly and slower growing cancers that are unlikely to cause harm. So patients often undergo treatments that carry risks and serious side effects unnecessarily.

That's a risk for lung cancer, too. The good news is that these screening guidelines are already starting with a narrowly defined population—only patients with a history of 30+ pack years of smoking are advised to get screened.

The bad news is that there is a high rate of false positives associated with lung screening, and there's debate over how big a lung nodule needs to be to justify follow up testing, which leads to anxiety for patients and their physicians.

Q: What does this mean for providers?

Conway: Many hospitals have already invested in lung cancer screening programs, and their numbers are growing. According to a recent survey we conducted, 64% of Oncology Roundtable members offer the screening—double what we found in 2012.

Yet, the number of patients screened at each program was relatively low, just 47 on average in 2012, which suggests that there are some formidable barriers to access. Lack of reimbursement is a big one. So is awareness. I think the USPSTF guidelines can help on both fronts.

That said, I think the new guidelines are likely to fuel investment in new lung cancer programs, which could depress volumes per program.

Q: What steps should providers take to establish their own lung screening program?

Conway: First, you'll want to estimate the number of patients in your market who are candidates for screening. Just about 3% to 5% of the population meets the requirements. Then you'll need to make sure that you have sufficient capacity to do the scans and radiologists with the time to read them.

Next you need to ask yourself about physician engagement: Are doctors in your community willing to refer high-risk patients for screening? If there's a suspicious finding, who will be responsible for follow-up care?

You also have to figure out the operations: If insurance doesn't cover the screening, will you charge patients? How much? Will you require a referral? How will you manage communicating the results to patients? To their PCPs? How do you ensure patients get follow-up tests, when appropriate?

Finally, you need to figure out a strategy for promoting the program in the community.

Q. Does the Oncology Roundtable offer any resources to aid these efforts?

Conway: We've written about the crucial components of a successful lung CT screening program on our blog. We've also featured advice from two providers who have instituted programs of their own: Andrea McKee, director of the Rescue Lung, Rescue Life program at the Lahey Clinic, and Jared Christensen, Duke Medicine's director of radiology.


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