Jennifer Lewis, MD
Much of the controversy surrounding the implementation of lung cancer screening has focused on cost and whether Medicare will cover the procedure. Now, a new study suggests a knowledge gap in Primary Care Providers’ (PCPs) familiarity with screening guidelines could also be a barrier to successful implementation.
In a survey analysis presented at the 2014 Multidisciplinary Symposium in Thoracic Oncology, PCPs who knew at least three of six key guideline components for lung cancer screening with low-dose computed tomography (LDCT) were more likely to order the procedure.1
However, fewer than 50% of PCPs surveyed were aware of at least three guideline components, and a quarter of PCPs were unaware of any components.
“The results of this survey highlight an essential need for provider education on the effectiveness of low-dose CT screening for lung cancer, on lung cancer screening guideline recommendations, and the potential benefits and harms of screening,” said Jennifer Lewis, MD, lead study author and an assistant chief of Medicine in the Department of Internal Medicine at Wake Forest Baptist in Winston-Salem, North Carolina.
In December 2013, the US Preventive Services Task Force (USPSTF) recommended that asymptomatic, high-risk individuals receive annual screening for lung cancer with LDCT. The USPSTF defined “high risk” as individuals aged 55 to 80 years with a 30 pack–year smoking history who currently smoke or quit within the past 15 years. The panel recommended discontinuing screening when an individual stops smoking for 15 years or develops a health problem that significantly reduces life expectancy or the capacity/desire to receive curative lung surgery.
To examine provider knowledge of the guidelines, Lewis et al sent an online survey to 488 PCPs affiliated with the Wake Forest Baptist Health Medical Center. Specifically, the survey assessed awareness of six screening guideline components: frequency, age to start screening, age to no longer screen, relevant pack years, that current and former smokers should both be screened, and that the guideline does not apply to individuals exposed to second-hand smoke only.
Of the 60% (n = 293) of PCPs who responded, 48% (n = 102) knew three or more of the six components, and 24% (n = 51) did not know any of them. Twelve percent (n = 25) of PCPs reported ordering LDCT screening, with 21% (n = 45) having ordered screening with a chest x-ray and 3% (n = 6) with sputum cytology. Logistic regression analysis showed that the odds of PCPs ordering LDCT screening were higher if they knew three or more of the guideline components (odds ratio = 5.0; 95% CI 1.9-12.9).
The survey also questioned PCPs on barriers to LDCT screening in lung cancer. The most commonly perceived barriers were patient cost (87%), risk of harm from a false-positive (83%), lack of patient awareness (81%), harm resulting from incidental findings (81%), and a lack of insurance coverage (80%).
The majority of PCPs (80%) were interested in receiving additional education about lung cancer screening. Patient education is also critical to proper implementation of lung cancer screening, noted Lewis. “It is…important to provide additional education for patients so that they can participate with their primary care provider in making informed decisions about lung cancer screening.”
The USPSTF lung cancer screening recommendation was largely based on the National Lung Screening Trial, which involved 53,454 high-risk patients aged 55 to 74 years who were randomized to 3 years of annual screening with either LDCT or standard chest x-ray.2
Over 6.5 years of follow-up, patients screened with LDCT had a 20% reduction in mortality compared with those in the x-ray group (P
The lung cancer community is now awaiting a decision on whether the CMS will cover screening based on the USPSTF recommendation. In April, the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), in direct opposition to the USPSTF, recommended against Medicare covering lung cancer screening in high-risk individuals.
The MEDCAC vote caused some controversy over the potential implication for screening coverage. Under the Affordable Care Act (ACA), medical exams receiving a grade “B” (moderate) or higher from the USPSTF (lung screening was given a “B” rating) must be covered by private insurers without a copay. However, the ACA does not stipulate that Medicare must follow the USPSTF rating. If the CMS follows MEDCAC’s recommendation, a screening disparity would be created between Medicare beneficiaries and the privately insured.
The CMS will issue a draft decision in November, followed by a final decision in early 2015.