Lung Cancer Screening SAG A R DA ML E , M D S P R ING CA R DI OLOGY SYM P OSI U M JA N UA RY 1 8 , 2 0 1 5
Objectives Understand the burden of lung cancer Identify screening tools of lung cancer Identify appropriate patient for lung cancer screening
Discuss necessary documentation for insurance coverage for LDCT
Epidemiology Leading cause of cancer death in US 220,000 new cases in 2014 180,000 deaths in 2014
5 year survival all-comers: 17% ◦ 70% of patients stage III or IV at time of diagnosis
Men vs. Women ◦ 3rd most common cancer in each
Epidemiology 94 million people still at increased risk for lung CA due to smoking Worldwide incidence increasing ◦ In US, plateau
Incidence of lung cancer variable ◦ ~1% in high-risk patients
Risk Factors Smoking Smoking Smoking
Radiation (XRT, radon) Asbestos (and other environmental toxins) Prior lung injury ◦ Hx TB, MAC, COPD etc.
History of Lung Cancer Screening Past ◦ Sputum Cytology ◦ CXR ◦ CXR with sputum cytology
Present ◦ CT Scan ◦ Low-dose CT Chest
Future ◦ LDCT ◦ Sputum/serum biomarkers
National Lung Cancer Screening Trial
NLCST Funded by NCI RCT Low-dose CT vs. CXR as screening in high-risk population
33 centers across US
NLCST Patients Enrolled from 8/2002-4/2004 Eligibility ◦ 55-74 yo ◦ 30 pyk yr hx of smoking at least ◦ Quit less than 15 years ago or still smoking
Exclusions ◦ Symptoms: Hemoptysis, weight loss, ◦ Hx of Lung CA ◦ Prior chest CT within preceding 18 months
Patients ◦ 53,454 patients => 26,722 for LDCT and 26,732 for CXR
NLCST Protocol 3 screenings ◦ ◦ ◦ ◦
T0 soon after randomization T1 1 year after randomization T2 2 yeas after randomization Patients found to have lung CA did not undergo further screening
Results ◦ Any scan with nodule > 4 mm or other findings could be “positive” ◦ Left to discretion of radiologist
◦ Follow-up for these nodules was not standardized b PCPs, but was by radiology recommendations
NLCST Results Median duration of follow-up was 6.5 (max 7.4 years) Good adherence to protocol: 95 and 93% Groups Identical
Results LDCT Found More Clinically Significant Nodules at all time points.
Results
Results: Lung Cancers Diagnosed
Results: Survival 20% Reduction!
Positive Conclusions More Lung Cancers Diagnosed Earlier Stage => improved resectability => improved survival Minimal adverse events from screening and diagnostic studies
Limitations F/u was usually decided by multi-disciplinary team Newer scanners may be more sensitive, so may be more specific or may lead to more false positives. Survival measured for only a limited time. Difference may be greater with more time or more screening.
Coverage… Several insurance carriers already cover LDCT
Couple months ago…
Key Elements Age 55-77 “Asymptomatic” (no signs or symptoms of lung cancer) TOBACCO Hx: 30 pyh
Smoking Status: Current smoker or quit within last 15 years Written order during lung cancer screening/counseling ◦ ◦ ◦ ◦ ◦
Determine eligibility Discussion of risks and benefits of LDCT Counseling on importance of adherence to yearly screen and willingness to get treatment Smoking cessation or abstinence counseling Written order with specific information
Elements for ordering LDCT “Smoking cessation” ◦ Can be separate code during other indicated E&M visit
Discussion of risks/benefits of screening ◦ ◦ ◦ ◦
Risks from radiation Risk from false positive Need for “sticking to it” Yearly if negative
Order: “Low-dose CT chest for lung cancer screening.”
Example of Order
Example (con/t)
Standardize Note “I discussed with the patient the need for smoking cessation as well as the myriad risks associated with continuance of tobacco use. We also discussed that since the patient has smoked more than a total of 30 pack-years and continue to smoke, they meet criteria for lung cancer screening using low-dose CT chest. We further discussed the minimal risks of CT scanning as well as the need for yearly CT screening.”
“The patient and I discussed the need for continued abstinence from smoking. We also discussed that since the patient has > 30 pack-year history of smoking, and quit less than 15 years ago, they still meet criteria for lung cancer screening with low-dose CT scans. We further discussed the minimal risks of CT scanning as well as the need for yearly CT screening.”
Billing/ Coding Can bill for smoking cessation counseling during other indicated E&M services (add -25 modifier) ◦ ◦ ◦ ◦ ◦
Asymptomatic, counseling 3-10 minutes: G0436 Asymptomatic, counseling > 10 minutes: G0437 Symptomatic, counseling 3-10 minutes: 99406 Symptomatic, counseling > 10 minutes: 99407 ICD-9 codes associated with these: ◦ 305.1 (non-dependent tobacco use disorder) ◦ V15.82 (history of tobacco use).
Can bill for smoking cessation counseling several times each year
Takehome Summary Lung Cancer is Still Deadly Cancer Screening now available for appropriate high-risk patients ◦ ◦ ◦ ◦
Age 55-74 30 pack-year hx of smoking Still smoking or quit less than 15 years ago ASYMPTOMATIC
DIAGNOSTIC CT ◦ CXR abnormalities ◦ Symptoms
For abnormal results ◦ Make sure you have a plan, or ◦ Refer to Lung Nodule Clinic
Thank you!
For example 65 yo gentleman comes in for yearly check-up. Has chronic HTN, DM and continues to smoke 2 packs per day x 30 years. You spend 10 minutes on smoking cessation and discuss LDCT screening. Codes to use:
Data for CXR Many small RCTs and series demonstrating no improvement. ◦ Significant contamination of control group ◦ Older studies ◦ Poor surgical outcomes as well
1 Large RCT…
55-74 yo volunteers with no hx of significant cancers ◦ No requirement for tobacco use
154K patients: screening protocol vs “usual care” Screening Protocol ◦ CXR @ T0, T1, T2, T3 ◦ Positive Results: Mass, nodule or infiltrate “suspicious for malignancy.” ◦ Further workup based on patient’s PCP.
Results: Lung Cancer Incidence
Survival: No Different
Conclusion
Since NLCST
Since NLST…