Health for life

Testing for hidden early lung cancer

Remember this article on screening for lung cancer? 

More than 54,000 former and current tobacco users who looked like they were free of cancer were randomly assigned to a yearly cheapo chest x-ray vs. a yearly pricey low-radiation-dose CAT scan. Over 5 to 7 years of follow-up, the CAT scan was better at picking up early lung cancer (119 cases) which translated into a small but statistically significant survival advantage of 62 lives saved per 100,000 patient years.

Does this mean that Medicare, Medicaid and all commercial insurers should "cover" a baseline and yearly follow-up screening CAT scan for tobacco smokers at risk for lung cancer?  According to actuary Bruce Pyenson and colleagues writing in the latest issue of Health Affairs, the answer may be yes.

The Disease Management Care Blog thinks the answer may still be no. 

Is it being a heartless curmudgeon?  Read on and decide for yourself.......

In the Health Affairs article, the authors assumed current and former tobacco smokers comprise about 30% of persons aged 50-64 years.  They further assumed that about 50% of persons at risk would agree to the CAT screening exam.  Based on prior studies, they estimated that 21% of the baseline scans and 7% of the follow-up yearly scans would require additional testing and figured lung cancers would be present in 0.6% and 0.2% of the baseline and follow-up scans. They used a fee rate of $247 per screening for both the scan and included the cost of a counseling session on smoking cessation.  

Spread over a population, the cost of the screening would amount to 76 cents per member per month (PMPM). On a nationwide basis, there would be 130,000 additional lung cancer survivors.  The cost per life-year saved in 2012 dollars would range between $11,708 and $26,016.  To put things in perspective, it costs more per life-year saved to use current screening approaches to cervical cancer with pap smears (more than $50,000), colon cancer with colonoscopies ($18,000 to $29,000) and mammography ($31,000 to $51,000).

Much of the high costs of these other cancer screening procedures are the result of more persons being eligible for the testing.  In the Health Affairs study, the only persons getting the scan are smokers who are at high risk.

What did the DMCB learn?

One important lesson in this study is that cancer screening is not free.  Its too easy to assume that the early detection provided by mammography, colonoscopies and pap smears pays for itself.  Thats simply not true.  What is true is that cancer screening is good value, but itll still cost you for each life saved.

The second lesson is that good value still represents incremental cost.  As a result, the 76 cents PMPM is in addition to the money already being spent by health insurers.  While the extra pennies doesnt seem like a lot of money, the health insurance dollar is comprised of coverage of similarly priced goods and services, and all those pennies are continuing to add up.  The DMCB thinks were getting to the point where the U.S. would need to ask what coverage of which service should be cut to pay for lung cancer screening.

Both of these issues make it unlikely that insurers will willingly include coverage of screening CAT scans in their health insurer benefit.  They can also argue that it would be highly unusual to decide to cover a new screening procedure based on a single study that hasnt even been reviewed yet by the U.S. Preventive Health Services Task Force.

Last but not least, the DMCB is willing to bet that there wont be much consumer demand for coverage by insurers because of bias against the victims of tobacco-associated illnesses as well as the argument that smokers should self-pay based on the comparative cost of a years worth of cigarettes.

It remains to be seen if, under their ability to define a minimum insurance benefit as part of the Affordable Care Act, the Feds will require lung cancer screening.

Stay tuned!

Image from Wikipedia

National guidelines recommend that at-risk women be screened for elevated cholesterol levels to reduce their chances of developing cardiovascular disease. But who is ‘at risk?’ The results of a study by investigators at the Centers for Disease Control and Prevention (CDC) to estimate the proportion of women young and old who have cholesterol levels that meet the definition of being at-risk are reported in an article in Journal of Women’s Health, a peer-reviewed publication from Mary Ann Liebert, Inc., publishers. The article is available on the Journal of Women’s Health website.

In "Cholesterol Screening for Women: Who is At Risk?" Cheryl Robbins, Patricia Dietz, Shanna Cox, and Elena Kuklina, from the CDC, Atlanta, GA, analyzed data for a representative sample of 1,781 U.S. women not previously diagnosed with elevated cholesterol.

More than half (55%) of younger women (ages 20-44 years) and 74.2% of older women (>45 years) were at-risk for high cholesterol as defined by U.S. Preventive Services Task Force guidelines. Nearly all of the women in both age groups had at least one risk factor that would make them candidates for cholesterol screening according to the American Heart Association risk definition. The authors suggest the need for future research to determine whether screening and treatment of young women with high cholesterol will help to decrease subsequent deaths due to cardiovascular disease.

“The high prevalence of dyslipidemia reported in this study even among younger women is striking and supports the need for increased education about the risks for cardiovascular disease in women,” says Susan G. Kornstein, MD, Editor-in-Chief of Journal of Women’s Health, Executive Director of the Virginia Commonwealth University Institute for Women’s Health, Richmond, VA, and President of the Academy of Women’s Health.

Michael Baum, Professor emeritus of surgery at University College London says that, while deaths from breast cancer may be avoided, any benefit will be more than outweighed by deaths due to the long term adverse effects of treatment.

He estimates that, for every 10, 000 women invited for screening, three to four breast cancer deaths are avoided at the cost of 2.72 to 9.25 deaths from the long term toxicity of radiotherapy.

These figures contrast with an independent report on breast cancer screening, led by Sir Michael Marmot and published in November last year. Marmot and his committee were charged with asking whether the screening programme should continue, and if so, what women should be told about the risks of overdiagnosis.

They concluded that screening should continue because it prevented 43 deaths from breast cancer for every 10,000 women invited for screening.

The downside was an estimated 19% rate of overdiagnosis: 129 of the 681 cancers detected in those 10,000 women would have done them no harm during their lifetime. However, those women would have undergone unnecessary treatment, including surgery, radiotherapy and chemotherapy.

But despite this higher than previous estimate of overdiagnosis, they concluded that the breast screening programme should continue.

The report also judged that screening reduces the risk of dying from breast cancer by 20%. But Professor Baum disputes these figures, saying the analysis takes no account of improvements in treatment since these trials were done, which will reduce the benefits of screening. Nor does it make use of more recent observational data.

With these data included, estimated rates of overdiagnosis as a result of screening increase to up to 50%, he argues.

This is important because it can change the decisions women make when invited for screening. In a study also published today, researchers at the University of Sydney explored attitudes to screening in a sample of 50 women. Many of the women were surprised when they were told about overdiagnosis and most said they would attend screening if overdiagnosis rates were 30% or lower, but a rate of 50% made most of them reconsider.

An accompanying editorial points out that the harms of screening will reduce as more effective diagnostic processes develop to inform less harmful and more personalised treatments. In the meantime, it says women need up to date and transparent information about the benefits and harms of screening to help them make informed choices.