Waiting to Exhale

CMS officially announced its coverage of lung cancer screening in February. How did we get here?


May 2015

Like a lot of stories, this one starts with a prologue, some background to remind us where we’ve been and how far we’ve come.

Lung cancer screening’s prologue begins with the ACRIN-sponsored National Lung Cancer Screening Trial (NLST), which studied the effects of low-dose CT (LDCT) screening on over 50,000 individuals who were at risk for lung cancer. The NLST found those patients who had received LDCT screening were 15 to 20 percent less likely to die from lung cancer. The trial was published in August 2011.

In 2013, due to the data in the NLST and other research on LDCT screening, the USPSTF gave LDCT lung cancer screening a new, higher grade “B,” recommending smokers ages 55–80 with a 30-pack-year history should be screened. Under the newly passed Affordable Care Act, private insurance companies were now required to cover LDCT screening for patients.

But what about the steadily increasing population of patients covered by Medicare? Following the USPSTF’s recommendation, CMS launched a decision process to determine the fate of screening for Medicare patients.

Dramatis Personae

“The College wanted to start a coalition for lung cancer screening because we knew that while private insurance coverage was good, Medicare coverage was an even bigger issue. Most Medicare patients fall into the age range in the USPSTF’s recommendation. That meant a vast number of patients should have been receiving screening and couldn’t,” says Chris Sherin, director of congressional affairs for the ACR.

The ACR brought together a group of organizations committed to fighting for screening, including the Society of Thoracic Surgeons and the patient advocacy group the Lung Cancer Alliance. “LDCT screening isn’t just about radiologists. It also impacts both the public and the other health care professionals involved in patient care. So it was vital we worked alongside other organizations that represent other parts of the health care team to get their perspectives,” says Ella A. Kazerooni, MD, FACR, chair of the ACR Committee on Lung Cancer Screening.

The majority of the work involved in advocating a decision for CMS consists of submitting comments and letters arguing your position. The coalition’s first letter provided 28 pages of guidance on how LDCT screening should be implemented. The coalition agreed with USPSTF’s recommendations, and so its subsequent recommendations to CMS followed the USPSTF’s as closely as possible. This first letter was signed by 40 organizations and delivered in March 2014.

What does it take to create a unified plan among three societies? “A lot of long days and nights,” laughs Anita McGlothlin, ACR economics and health policy analyst. “The coalition meant a lot of meetings, a lot of research, and a lot of coordination. Without the combined efforts of staff from the Government Relations, Economics, and Quality and Safety departments, we couldn’t have gotten it all accomplished.”

Storms Ahead

April 30, 2014, was dark and stormy in Washington, D.C. The deluge of rain seemed like an omen as the LDCT screening coalition gathered at an official hearing held by the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC). MEDCAC is a panel of experts selected by CMS to review medical evidence and testimonies in order to advise on coverage decisions.

During the testimonies, it was clear the outcome of the hearing would not be favorable. Andrea Borondy-Kitts, a patient advocate who came to testify on behalf of her husband who had lost his battle with cancer the previous year, remembers, “It was awful. I went to the MEDCAC meeting at my own expense and got barely a minute to make my case. How could I tell my husband’s story in that time?”

“We could tell from MEDCAC’s tone during the questions exactly where the decision would end,” says Kazerooni. “By the end of the day, our heads were hanging low.” And sure enough, MEDCAC ultimately recommended CMS not cover LDCT screening.

Note: Click on image below to enlarge

Silver Linings

“You’d think the meeting would have been discouraging for us, but really it had the opposite effect,” explains Kazerooni. “The questions MEDCAC asked told us exactly what we needed to answer in order to have LDCT screening passed by CMS, so we rallied. We created a roadmap and began marking off every action that we could.” Organizations such as the American Association of Physicists in Medicine (AAPM) created open-access radiation dose protocols for over 30 models of CT scanners. Having these protocols available makes it easy for radiology practices to set up CT scanners to perform LDCT. AAPM’s contribution helped eliminate MEDCAC’s concern these protocols were not widely available.

For the College’s part, rallying meant a lot of new projects. Following the USPSTF’s decision in 2011, the ACR had already begun working on a variety of resources to help make lung screening easier for clinicians. The College created a set of practice parameters for LDCT screening and continued developing Lung-RADS, a comprehensive lexicon for reading lung screening images. Lung-RADS is available now and will soon include an image-rich lexicon and user manual. The ACR also announced the Designated Lung Cancer Screening Center Program, which accredits institutions for lung cancer screening. As of press time, more than 500 practices have enrolled in the program.

On the Hill

Although MEDCAC seemed like a setback, other battles were fought that day in Washington. On the same day as the MEDCAC hearing, members of the ACR visited Capitol Hill as part of AMCLC’s Hill Day to discuss important topics with their legislators. That day, the goal for the ACR members was lung cancer screening. And after discussing the importance of LDCT with their members of Congress, ACR members were able to have a bipartisan letter of support for LDCT screening signed by hundreds of members of the U.S. House of Representatives and at least 40 senators. “We were able to show CMS that Capitol Hill was watching its decision and supported LDCT as a patient benefit. That’s why Hill Day is so important. We couldn’t have done it without our members,” says Sherin.

The movement seemed to be gaining steam. In September, the coalition sent another letter of support for LDCT screening to CMS — this time signed by 75 organizations. And then the waiting game began.

Endings and Epilogues

In February 2015, the wait came to an end when CMS issued the final rule announcing it would cover LDCT screening for smokers or former smokers ages 55–77 with 30 pack years. It was an emotional moment for Kazerooni. “I sat back in my chair and thought, ‘Oh my goodness. It’s really gone through,’” she says. “By the time I retire, I hope the face of lung cancer looks different than it does today because of what we’ve accomplished.”

Looking to the Future

For health care, coverage for lung cancer screening is only the first part of the story. Radiology practices should start implementing screening centers now, says Kazerooni. She notes, “The coverage decision is made, the research is out there, and the ACR now has a wealth of resources available. There are no excuses anymore.” To get started, visit the ACR Lung Screening page.

Learning More

Looking to find out more about lung cancer screening? Check out this webinar from the College. 




By Meghan Edwards, copywriter for the ACR Bulletin


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