Mara B. Antonoff, MD
4 min read
Key Points
  • Following the US Preventive Services Task Force announcement expanding the inclusion criteria for lung cancer screening, STS joined forces with the American College of Radiology and the GO2 Foundation for Lung Cancer in urging Medicare coverage for this larger population.
  • The Centers for Medicare & Medicaid Services responded on May 18, 2021, by reopening its National Coverage Determination for low-dose computed tomography lung cancer screening and currently is accepting public comments. 
  • Dr. Mara Antonoff describes the importance of the revised guidelines and addresses two key challenges that remain: financial coverage and awareness. 

(June 1, 2021) — Lung cancer is the #1 cancer killer of men and women in the United States, taking more lives than breast, prostate, and colorectal cancers combined. Survival from lung cancer is highly dependent on the stage at diagnosis, with earlier staged disease much more likely to be curatively treated. As most symptoms of lung cancer don’t occur until later stages of disease, detection of lung cancer through screening processes—before symptoms develop—greatly improves our ability to save lives.  

On May 18, 2021, the Centers for Medicare & Medicaid Services (CMS) announced the reopening of the National Coverage Determination (NCD) for lung cancer screening with updated screening risk criteria. This action occurred in response to a formal request from STS, the GO2 Foundation for Lung Cancer, and the American College of Radiology (ACR). 

CMS currently is soliciting public comments that may be relevant to the reconsideration, and this is an important opportunity for scientists, clinicians, advocates, and patients to take action. By providing evidence-based support for this crucial change, we can help expedite progress, detect more cases of lung cancer at earlier stages, and start to narrow the demographic disparities in detection and treatment of this disease. 

The initial decision from CMS, published on February 5, 2015, provided lung cancer screening counseling, shared decision-making visits, and annual screening with low-dose computed tomography (CT) as a preventive benefit for eligible individuals who met very specific criteria. Most notably, these criteria included patients aged 55 to 77 years, with a smoking history of at least 30 pack-years. 

In March 2021, the US Preventive Services Task Force (USPSTF) published updated recommendations. The revised guidelines recommend annual CT lung screening for adults aged 50 to 80 years, with at least a 20-pack year smoking history. With these changes, the lives of many more patients could be improved and saved, particularly those of specific demographic groups. 

However, in order for the revised recommendations to be employed, it is critical that these services are covered and reimbursed by Medicare and Medicare contractors. Thus, STS, along with GO2 and ACR, urged CMS to reopen the NCD for lung cancer screening. 

These changes will enable more people to get screened overall, and, importantly, have particular implications for certain groups of individuals. The revised guidelines provide screening to more women and black patients, who are known to smoke less than white men.  

Of key relevance, these also are groups that have been previously shown to develop lung cancer at a younger age and after less tobacco exposure. By facilitating screening at earlier ages and after shorter duration of cigarette smoking, we can increase the likelihood of identifying malignancies in these patients before they reach advanced stages. Moreover, this would improve our chances of diagnosing lung cancer in these groups of patients at stages when treatment strategies tend to be more easily tolerated, carry less risk of adverse events, and are more frequently successful at providing durable cure. 

Racial and sex-based disparities in care are highly prevalent in the diseases managed by cardiothoracic surgeons. While there have been substantial recent efforts to identify and address differential outcomes from our surgical interventions, it is absolutely necessary for us to recognize that our surgical procedures do not stand alone as the sole components of overcoming disease. Deliberate endeavors to mitigate discrepancies in access to diagnosis and screening are a crucial upstream component. Likewise, we need to ensure that appropriate, effective survivorship strategies for postoperative patients exit to support the diverse range of individuals who are diagnosed with cardiothoracic disease. 

The updated USPSTF recommendations represent much-needed progress in achieving successful lung cancer screening in the US. However, two key challenges remain: financial coverage and awareness. 

We must ensure that these changes are reflected in patients’ abilities to afford screening services. Now is the time to provide comments to encourage CMS to cover screening for younger individuals with shorter smoking history. As a surgeon, I am proud to be a member of organizations such as STS, which has taken important actions to encourage CMS to reopen the NCD. As CMS solicits comments relevant to reconsideration of the NCD, I’d encourage everyone to share their support for this important update.  

Even with availability of service coverage, screening is of no use to patients who are not aware that they qualify. Lung cancer screening is extremely underutilized, and efforts to inform patients, caregivers, and primary care providers of updated recommendations are in strong need. While there is still much work to be done, enormous progress has been made, and can continue to be made, with sustained dedication to fighting this disease.

Mara B. Antonoff, MD, is an Associate Professor and Program Director of Education in the Department of Thoracic and Cardiovascular Surgery at The University of Texas MD Anderson Cancer Center in Houston, TX.