Is the lung cancer test worth the cost?


CT scanST. LOUIS, Mo. - Jim Boyd smoked for 40 years before quitting this summer. Both of his parents died of smoking-related illnesses.

Boyd, 61 and a resident of Wentzville, Mo., hopes to avoid their fate by participating in a multinational research study through St. Joseph Health Center in St. Charles, part of the SSM Health Care System. The study aims to catch lung cancer early by using spiral CT scans to find tiny cancerous lesions in patients' lungs.

Early results, published last month in the New England Journal of Medicine, found the process was able to detect lung cancer in its earliest stage, when surgery could be most successful.

However, Boyd's insurance company will not cover the $300 cost of the test.

Many physicians, most insurers and even some patient groups say there's not enough evidence to use the CT scans to detect lung cancer. That's particularly true, they say, when the cost, anxiety and risks of the scans and follow-up procedures are weighed against the less-than-definitive results of the study.

"There's a limited supply of cash out there," said Dr. Ann O'Malley, a preventive-medicine specialist and a senior researcher at the Center for Studying Health System Change, a think tank in Washington. "We have to decide - hopefully based on evidence - what to cover."

CT scans of smokers' lungs can be difficult to read, so additional scans and biopsies often are necessary for a diagnosis. Studies show 25 percent to 60 percent of smokers' lungs have abnormalities that mimic lung cancer, but in most cases are not.

Dr. Wayne Meyer, medical director at Anthem Blue Cross Blue Shield of Missouri, estimated a patient could be exposed to 250 times as much radiation during a CT scan as during a traditional chest X-ray.

CT, or computerized tomography, scans use special X-ray equipment to obtain image data from different angles of the body. A computer then processes the information to show a cross-section of body tissues and organs.

The scans could find many tiny tumors - benign or cancerous - that might never lead to death, but if caught early will prompt potentially needless surgeries and the accompanying risks for complications.

Proponents of early testing say treating cancer early can save $3,000 to $10,000 per surgery. But those who are opposed say it also can lead to dozens of unnecessary procedures per patient, leading to costs that easily could creep into the tens of thousands of dollars.

No one contacted for this story could provide information comparing the total cost of caring for someone diagnosed early versus someone diagnosed later.

"The simple calculation is, do the benefits outweigh the costs?" said Timothy McBride, a professor of health management and policy at St. Louis University. "It turns out that's pretty difficult to measure."

Researchers involved in the study say the scans are worth the costs and risk. Finding lung cancer earlier, they say, will be the only way to save lives.

"CT scans can detect tumors that are smaller than a grain of rice," said Dr. Daniel Luedke, an oncologist and St. Joseph's principal investigator in the study. "Often, by the time a tumor is large enough to be viewed on a chest X-ray, the cancer is too far along to be cured."

On average, 95 percent of people with lung cancer die from the disease. Only 15 percent live longer than five years after being diagnosed. More people die of lung cancer each year than cancers of the breast, prostate, colon and pancreas combined, according to the American Cancer Society.

But critics of the study say the results published in the New England Journal of Medicine did not prove the patients had better outcomes than they would have with traditional chest X-rays or if they had never been screened. That's because the study did not include patients who did not have a CT scan, or a control group.

"You have to have a randomized, controlled study for it to be a really valid study," Meyer said.

Meyer sits on the medical-policy committee for Blue Cross parent Wellpoint Inc. The committee, which is made of up Wellpoint physicians and outside experts, slipped the debate onto its December calendar as a last-minute, urgent addition. The committee will review recommendations by its research staff, which reads medical literature and asks for input from speciality societies.

"If it's medically accepted, we want to do the right thing, regardless of cost," Meyer said. "In this particular case, we want to save lives."

Meyer and much of the medical community are waiting for the results of another study that probably won't be released for two or three years. That study, by the National Cancer Institute, is a randomized, controlled study of more than 50,000 people. Some are being given CT scans while others are given chest X-rays.

"I think that will really tell the story," Meyer said.

But in St. Charles, Luedke says waiting for those findings could result in hundreds of thousands of needless deaths.

"I don't think that based on the information that we have ... that we can wait," Luedke said. "The data are very strong and I think they demand that we start taking action."

The study at St. Joseph was launched by a team of researchers at New York-Presbyterian Hospital/Weill Cornell Medical Center in 1993. Called the International Early Lung Cancer Action Project, it has expanded to 38 institutions in seven countries. St. Joseph Health Center is the only Missouri hospital participating.

None of the patients from St. Charles was included in the results released last month. The hospital signed up about a year ago, after that data had been collected.

Those results showed that among the 31,567 people in the study, the screening found 484 people with lung cancer, 412 of whom were diagnosed at the earliest stage. The overall estimated 10-year survival rate for the diagnosed patients was 80 percent.

O'Malley said it's important to put the numbers into perspective.

For example, if the patients were diagnosed five years later and then lived for five years, they would still be alive for 10 years. She questions whether the 10-year survival rates are only higher because the patients are diagnosed earlier, not living longer. "It all depends when you start counting," O'Malley said.

source - St. Louis Post-Dispatch


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