CMS approves CT Lung Cancer Screening

The Centers for Medicare and MedicaidServices on February 6, 2015 issued its final decision approving Medicare coverage for lung cancer screening by low-dose CT.  Medicare will cover annual screenings for beneficiaries aged 55-77 who are current smokers or who quit in the last 15 years, and who have a history of at least 30 “pack years.”   According to the American Cancer Society, lung cancer kills nearly 158,000 patients a year.

Increase in the cost of breast cancer screening results in no benefit for older women

Killelea et al in their paper published by the JNat Cancer Inst report that cost for breast cancer screening have increased dramatically since the introduction of newer imaging technologies such as digital mammography, computer aided detection, MRI and image guided biopsies, but the outcomes remain undefined, particularly among older women.

The authors used the Surveillance, Epidemiology, and End Results-Medicare linked database, and constructed two cohorts of women without a history of breast cancer, which they followed for 2 years. They compared the use and cost of screening mammography including digital mammography, CAD, and adjunct procedures such as CAD, breast ultrasound, MRI, and biopsies between the period of 2001 and 2002 and the period of 2008 and 2009.

There were 137150 women (mean age = 76.0 years) in the early cohort (2001-2002) and 133097 women (mean age = 77.3 years) in the later cohort (2008-2009). The use of digital image acquisition for screening mammography increased from 2.0% in 2001 and 2002 to 29.8% in 2008 and 2009 (P < .001). CAD use increased from 3.2% to 33.1% (P < .001). Average screening-related cost per capita increased from $76 to $112 (P < .001), with annual national fee-for-service Medicare spending increasing from $666 million to $962 million. There was no statistically significant change in detection rates of early-stage tumors (2.45 vs 2.57 per 1000 person-years; P = .41).

The authors concluded that although breast cancer screening-related costs increased substantially from 2001 through 2009 among Medicare beneficiaries, a clinically significant change in stage at diagnosis was not observed.

Malpractice Reform does not Affect ED Utilization

Waxman et al report in NEJM their findings regarding the effect legal reform had in the practice of medicine, in three states, Texas, Georgia, and South Carolina, which between 2003 and 2005, enacted legislation that changed the malpractice standard for emergency care to gross negligence.  

Using a 5% random sample of Medicare fee-for-service beneficiaries, they identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. They compared patient-level outcomes, before and after legislation, in reform states and control states. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.

For eight of the nine states–outcome combinations tested, they found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction in per-visit emergency department charges.

They conclude that legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates.

Surgical Biopsies for Breast Cancer are Overused in the United States

Ebert et al in an article published by JCO report their findings from a review of Medicare data from 89,712 patients with breast cancer and 12,405 surgeons, regarding three outcomes: surgeon consultation before versus after biopsy, use of needle biopsy, and number of surgeries for cancer treatment.

Surgical biopsy was the standard for breast diagnosis before the 1990s, when most patients with breast cancer presented with clinical symptoms. The growth of mammographic screening in the 1980s significantly increased the number of non-palpable lesions found that required diagnostic work-up with either needle biopsy or surgical biopsy following needle localization. In their analysis the  authors looked at factors associated with surgeon consultation before biopsy, Medicaid coverage, rural residence, residence more than 8 miles from a radiologic facility performing needle biopsy, and no mammogram within 60 days before consultation. Among patients with surgeon consultation before biopsy, factors such as absence of board certification, training outside the United States, low case volume, earlier decade of medical school graduation, and lack of specialization in surgical oncology were negatively correlated with receipt of needle biopsy.

Overall, 68.4 percent had a needle biopsy and 31.6 had a surgical biopsy. If the patient's initial appointment was with a surgeon instead of a radiologist, the surgical biopsy rate grew to nearly 50 percent.  Surgeons less likely to refer patients for a needle biopsy were those without board certification, trained outside the U.S., graduated from medical school before 1980 or not specialized in surgical oncology.

The study found that 70 percent of patients who had an excisional biopsy required multiple surgeries while only 33 percent of patients who had needle biopsies did.

As in some countries like the United Kingdom diagnosis for breast cancers is now made with needle biopsy in 95% of the cases, the authors conclude that surgical biopsy is overused in the United States, and is having a negative impact on breast cancer diagnosis and treatment.