Munden: CMS decision on lung cancer screening a win-lose—but more win than lose

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 - Reginald Munden MD

Last week’s decision by CMS to cover low-dose CT for lung cancer screening was widely hailed by medical associations that have a dog in the fight. Rooters included the ACR, the Lung Cancer Alliance and the American Thoracic Society. But critics quickly weighed in—from both sides of the debate.

On one side were those who said the coverage criteria for patients and facilities are overly restrictive. Douglas Wood, MD, immediate past president of the Society of Thoracic Surgery, told MedPage Today that CMS had stopped too short, “rather than extending the age for screening beyond that of the enrollment criteria of the National Lung Screening Trial (NLST)—as the U.S. Preventive Services Task Force had done based on modeling—and including risk factors beyond age and smoking pack-year history.”

On the other side were those who amplified the thinking of the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC), which last April voted against recommending the coverage. “The benefits of this have been overestimated, and the harms have been underestimated,” said Russ Harris, a professor of medicine at the University of North Carolina, as quoted in several outlets.  

Count Reginald Munden, MD, in the first camp. “It’s a win-lose,” the chair of radiology at Houston Methodist and NLST principal investigator told “There are some parts that may hinder or prevent people from getting screened, but it’s better than not funding at all.” He then took a few additional questions. How will the decision affect the screening program you’ve set up at Houston Methodist?

Munden: It really hasn’t made a difference to our screening program whether you are insured or not insured, 55 or 70 years old. We screen according to NLST criteria, which is basically what CMS adapted. The only thing I think we will have to adjust to is do more government paperwork. We probably will have to dump more stuff onto our coordinator personnel to make sure we put the data into the database, for example. Do you serve a substantial Medicare population?

Munden: We do not, really. We probably are average for most nonprofit hospitals in large cities. We have two county hospitals, and we have regional hospitals that have a higher population of Medicare and Medicaid patients. I would guess we’re pretty much average. It’s going be interesting to see how this plays out in more regional areas rather than the larger cities. What are your concerns with the particulars of the decision?

Munden: First, I think it’s fantastic that they agreed to pay for lung cancer screening. We’ve been fighting to get this through CMS, particularly since the MEDCAC ruling. So this is great for patients and great for those of us in the lung cancer prevention business, trying to make a dent in this disease. Because the only thing that’s had any real benefit against lung cancer, other than smoking cessation, is screening. Obviously, if people didn’t smoke we wouldn’t even be talking right now. But that’s not been successful so far.

As far as specific concerns, my concern has always been requiring a patient or participant to get an order to be screened. In most states you can’t refer yourself; you have to have a physician’s order. Self-referral, to me, is very important for screening. You can do it in mammography, but we can’t do it in lung cancer screening. I suspect there are several reasons for this. One is the fear of the radiation from the CT, but that’s not really a concern nowadays with the low dose and everything else. And CMS speaks to that, saying you have to have a less than 1.5 mSv [scanner], although I don’t know anyone who’s doing any more than that anyway. That’s an appropriate response to a legitimate concern, and industry and our profession responded to it.

And then on the shared decision-making, I’ve been involved in that and I’ve actually worked with some of my former colleagues over at M.D. Anderson [Cancer Center of the University of Texas]. We’ve developed an educational videotape presentation on shared decision-making that has been very well received. So I think shared decision-making is an important part of this. Whether that needs to be done at a different office or can be done when you walk in to get your screening, I think, is part of the issue. The wording in the CMS decision is that, if you have to go to another physician’s office and have a consultation and