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Balancing the Benefits and Harms of Low-Dose Computed Tomography Screening for Lung Cancer: Medicare's Options for CoverageBalancing the Benefits and Harms of LDCT Screening for Lung Cancer

Renda Soylemez Wiener, MD, MPH
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 24 June 2014.

From Boston University School of Medicine, Boston, and Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts.

Acknowledgment: The author thanks Peter B. Bach, MD, MAPP, of the Memorial Sloan Kettering Cancer Center, and Michael K. Gould, MD, MSc, of Kaiser Permanente Southern California, for graciously providing feedback on an early version of this manuscript.

Financial Support: By the National Cancer Institute (K07 CA138772) and the Department of Veterans Affairs.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1352.

Requests for Single Reprints: Renda Soylemez Wiener, MD, MPH, The Pulmonary Center, Boston University School of Medicine, 72 East Concord Street, R-304, Boston, MA 02118; e-mail, rwiener@bu.edu.

Author Contributions: Conception and design: R.S. Wiener.

Drafting of the article: R.S. Wiener.

Critical revision of the article for important intellectual content: R.S. Wiener.

Final approval of the article: R.S. Wiener.

Collection and assembly of data: R.S. Wiener.

Ann Intern Med. 2014;161(6):445-446. doi:10.7326/M14-1352
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On 30 April 2014, the Medicare Evidence Development&Coverage Advisory Committee issued a vote of low confi-dence about whether the benefits of low-dose computed tomography (LDCT) screening for lung cancer would out-weigh harms among Medicare beneficiaries in a community setting. This commentary discusses potential strategies to implement lung cancer screening with LDCT in a responsible manner that avoids overzealous screening.

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A Regionalized Approach to Early Detection and Treatment of Lung Cancer in a High Risk Population
Posted on October 6, 2014
Laura S Welch, MD, David Madtes, MD, Knut Ringen, DrPH
CPWR: The Center for Construction Research and Training and the Division of Pulmonary and Critical Care Medicine, Fred Hutchison Cancer Research Center and University of Washington
Conflict of Interest: None Declared
As described by Wiener, a Medicare advisory panel recommended against coverage of low dose computed tomography (LDCT) for Medicare beneficiaries. LDCT is recommended by many professional organizations provided that it is undertaken as a structured program in centers with considerable expertise in lung cancer care.(1-2) Wiener suggested that perhaps the optimal way for CMS to proceed would be to offer coverage for LDCT screening only when performed by facilities that are certified as comprehensive, patient centered programs.

The Building Trades National Medical Screening Program uses a regionalized approach to lung cancer screening, linking local providers with a regional cancer center of excellence. Under authorization from the US Congress, BTMed has been screening workers employed at Department of Energy atomic weapons facilities for occupational diseases since 1999. These are individuals who are at significantly increased risk for COPD and lung cancer mortality (3,4) and are also likely to live in rural areas which are not served by medical providers with the kinds of expertise recommended for LCDT screening.

BTMed partnered with the Seattle Cancer Care Alliance (SCCA), the Comprehensive Cancer Center for the Pacific Northwest, to provide early lung cancer detection for individuals from the Hanford Nuclear Reservation, located 200 miles from Seattle, while adhering to the NCCN guidelines for eligibility and diagnostic evaluation. (2). A local SCCA affiliate, Kadlec Regional Medical Center, administers the LDCT scan which is interpreted by a thoracic radiologist at the University of Washington (UW). Suspicious nodules are reviewed by a multi-disciplinary nodule board. Patients requiring evaluation beyond a repeat LDCT are invited to come to SCCA; any surgical resection is performed by the UW cardiothoracic surgeons. SCCA provides a smoking cessation program. To encourage care at SCCA, the program facilitates travel.
As of September 2014 we have enrolled 184 participants from Hanford; 37 had indeterminate nodules (2), 17 had suspicious nodules, five have been diagnosed with lung cancer, and 94 have been referred for evaluation of medical findings other than lung cancer. The individuals with lung cancer were generally agreeable to travel for specialty care; four Stage I A adenocarcinomas were removed with curative intent at UW. The 5th individual opted not to come to SCCA was eventually diagnosed with Stage IV squamous cell carcinoma.

We believe this model can be expanded to offer LDCT screening at comprehensive high quality regional cancer centers to all individuals at high risk for lung cancer.

(1) Humphrey LL, Deffebach M, Pappas M, Baumann C, Artis K, Mitchell JP, Zakher B, Fu R, Slatore CG. Screening for lung cancer with low-dose computed tomography: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med. 2013 Sep 17;159(6):411-20.
(2) National Comprehensive Cancer Network (NCCN). 2014. Clinical practice guidelines in oncology: Lung cancer screening, Version 1. 2015. http://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf
(3) Dement JM, Ringen K, Welch LS, Bingham E, Quinn P. Mortality of older construction and craft workers employed at department of energy (DOE) nuclear sites. Am J Ind Med 2009 Aug 7;52(9):671-82.

(4) Dement JM, Welch L, Ringen K, Bingham E, Quinn P. Airways obstruction among older construction and trade workers at Department of Energy nuclear sites. Am J Ind Med 2010 Mar;53(3):224-40.

Author's Response
Posted on November 12, 2014
Renda Soylemez Wiener, MD, MPH
Boston University School of Medicine
Conflict of Interest: None Declared
The authors are to be congratulated on their work to develop a regional lung cancer screening center serving high-risk individuals living in rural communities. In particular the incorporation of a smoking cessation program, the use of predetermined criteria for low-dose computed tomography (LDCT) screening eligibility and nodule evaluation, and the involvement of multiple disciplines in deciding evaluation of screen-detected nodules are to be applauded. However, these elements are not in themselves sufficient for a comprehensive LDCT screening program. Guidelines for LDCT screening also recommend shared decision-making about the benefits and harms of screening and the maintenance of a registry of individuals who have undergone screening (1, 2). Indeed, these additional elements are required under the draft policy for Medicare coverage of LDCT screening released by the Centers for Medicare & Medicaid Services (CMS) on November 10, 2014 (3). Careful design and implementation of comprehensive LDCT screening programs including all these elements should help optimize the balance of benefits to harms for those individuals undergoing screening for lung cancer (4). However, further study of these programs as they are implemented in the real world is essential to ensure that lung cancer screening is safe, effective, and cost-effective.


1. Detterbeck FC, Mazzone PJ, Naidich DP, Bach PB. Screening for lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e78S-92S.
2. Moyer VA. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330-8.
3. Centers for Medicare & Medicaid Services. Proposed decision memo for screening for lung cancer with low dose computed tomography (LDCT) (CAG-00439N). Accessed at: http://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=274 on November 11, 2014.
4. Mazzone P, Powell CA, Arenberg D, et al. Components Necessary for High Quality Lung Cancer Screening: American College of Chest Physicians and American Thoracic Society Policy Statement. Chest. 2014.

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