A Commitment to Doing It Right
The ACR advocates to bring lung cancer screening to patients in need.
Last December, the United States Preventive Services Taskforce (USPSTF) finalized its recommendation and gave a grade of B to lung cancer screening with low dose CT.
Officially, this means “the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.” Under the provisions of the Affordable Care Act, commercial insurers will have to pay for this service effective January 2015. At time of writing, CMS had referred the issue to a Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) to further consider the evidence before making a coverage decision.
There are potentially millions of people who will benefit from this new screening program. Lung cancer is the deadliest cancer and is far too often diagnosed too late for effective treatment. Many of those who are now at high risk started smoking when the real dangers of tobacco were known only to those selling cigarettes, when doctors were featured in cigarette ads and there was seemingly no place you could not smoke. Nonetheless, the stigma associated with this particular addiction as well as its disproportionate impact on the more challenged sectors of society have undoubtedly contributed to many avoidable deaths.
For cynics (and there are many) lung cancer screening is a huge new program that will refill the slots of CT scanners left empty by recent radiation concerns and will line the pockets of radiologists. It will impose more harm than good because of over-diagnosis and complications from follow-up procedures and should be subject to further evidence development before being covered by CMS.
I’m grateful, therefore, to have been part of the ACR team that prepared the submissions to CMS and the MEDCAC. I feel so proud of the commitment to our patients and to better health care that was evident all along. Nothing that the cynics can throw at us is true. The ACR, a leader in high-quality, high-value imaging screening through its work on mammography, has shown itself to be a standard bearer for how to do it right for lung cancer screening.
At every step of the process, our multidisciplinary group led by Ella A. Kazerooni, MD, FACR, from the University of Michigan, has looked to set up a program that will serve our patients and provide high value. Teams from across the College, from Quality and Safety to Economics to Education, worked collaboratively and quickly given the short turnaround time allowed for comments. Our ACR staff was phenomenal. They were a critical part of the submission, working long nights and weekends.
ACR’s leadership in supporting the National Lung Screening Trial was the essential first step in making sure that robust evidence was in place to justify a new screening benefit. Our team looked critically at every facet of how a screening program should work to make sure that benefits would be maximized and harms minimized. From patient selection to equipment maintenance and protocol selection, we wanted to ensure that the right patients are screened in the right way. We are espousing a structured reporting system called LUNG-RADS, based on that used at Lahey Clinic in Burlington, Mass., and updated by the committee to make sure that our reports are actionable and direct patients to the appropriate follow-up.
Are we setting a high bar for practices that will perform lung cancer screening? You bet. But as radiologists, we are more than capable of meeting high standards. We have a long history of setting them for ourselves. In formulating these standards, we were keenly aware that there must be easy access for patients, but once those patients get to a screening center we want to make sure they are imaged at the highest quality. Learn more about how to become a ACR designated lung cancer screening center at www.acr.org/lungcancerscreening.
The effort to develop a lung cancer screening program embodied every element of the Imaging 3.0™ philosophy and was so inspiring. The collaboration with other stakeholders, such as the Society of Thoracic Surgeons and the tireless patient advocates at the Lung Cancer Alliance, was important in building consensus and very impressive to policy-makers when we presented jointly at meetings. The reliance on evidence and our clinical experts’ ability to discuss the finer points at the most detailed level demonstrated ACR’s obvious leadership in this process. The focus on how to set reporting parameters to maximize the number of cancers diagnosed and minimize unnecessary biopsies could not have been further from the “fee-for-service mentality” of which we have sometimes been accused. Our decision to develop education products and recommend outcome tracking demonstrates a commitment to quality that is inarguable.
By Geraldine B. McGinty, MD, MBA, FACR, Chair