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…