NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo

Among the societal organizations making recommendations for the selection of individuals for lung cancer screening, the American College of Chest Physicians (CHEST) has two recommendations. 1. For asymptomatic individuals age 55 to 77 who have smoked 30 pack- years or more and either continue to smoke or have quit within the past 15 years, we recommend that annual screening with low-dose CT should be offered. (Strong recommendation, moderate-quality evidence). 2. For asymptomatic individuals who do not meet the smoking and/or age criteria in Recommendation #1, are age 50 to 80, have smoked 20 pack-years or more and either continue to smoke or have quit within the past 15 years, we suggest that annual screening with low-dose CT should be offered. (Weak recommendation, moderate-quality evidence) (Mazzone, Panel Report 2021). Thus, for the smoking history for persons who smoked 20 to 29 pack-years, the American College of Chest Physicians guidelines only suggest low dose CT since this is a weak recommendation, and so it is not recommended since it is not a strong recommendation.In the National Comprehensive Cancer Network (NCCN), Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Lung Cancer Screening Version 1.2021, the NCCN Lung Cancer Screening Panel defined the risk status of high risk as age  50 years and  20 pack-year history of smoking with these high-risk candidates for low dose CT (LDCT) screening (category 1) where shared patient/physician decision-making is recommended, including a discussion of benefits/risks (NCCN, 2020). The updates in the clinical pathway algorithms in the current Version 1.2021 (NCCN, 2020) of the NCCN Guidelines for Lung Cancer Screening from Version 1.2020 include high risk status being modified with the age range changed from 55 to 77 years to only  50 years and lowered from  30 to  20 pack-year history  of smoking (NCCN, 2020). Regarding lowering the pack-year smoking history criterion, the current NCCN guidelines Version 1.2021 reported that data suggest that the lung cancer risk for individuals with a 20 to 29 pack-year smoking history is similar to that of individuals with a 30 or more pack-year history (NCCN, 2020) which supports the current NCCN recommendation of low dose CT screening among persons with a 20 or more pack-year smoking history. The pack-year history criterion for high risk individuals remains unchanged in the updated NCCN recommendation (Wood, NCCN, 2021).Similarly, the American Academy of Family Physicians gives the clinical preventive services recommendation for lung cancer screening in adults a B grade recommendation. The AAFP supports the United States Preventive Services Task Force (USPSTF) recommendation for annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery (AAFP, 2021). Thus, the American Academy of Family Physicians recommends screening in adults who have a 20 pack-yearsmoking history.In summary of their recommendations, the American College of Radiology Appropriateness Criteria expert panel concluded that for Variant 1: Lung cancer screening with low-dose CT chest without IV contrast is usually appropriate in patients 55 to 80 years of age and 30 or more packs per year smoking history and currently smoke or have quit within the past 15 years. Variant 2: The panel did not agree on recommending lung cancer screening with low dose CT chest without IV contrast in patients 50 years of age or older and 20 or more packs per year history of smoking plus one additional risk factor. There is insufficient medical literature to conclude whether or not these patients would benefit from CT screening for lung cancer. Screening in this patient population is controversial but may be appropriate. Variant 3: Lung cancer screening is usually not appropriate in patients younger than 50 years of age or older than 80 years of age or in patients of any age with less than 20 packs per year history of smoking and no additional risk factors (Donnelly, 2018). Thus, the American College of Radiology could not agree on recommending lung cancer screening with low dose CT in patients with 20 or more packs per year history of smoking.The American Cancer Society 2013 guideline recommends that clinicians with access to high-volume, high-quality lung cancer screening and treatment centers should initiate a discussion about screening with apparently healthy patients aged 55 years to 74 years who have at least a 30 [or more]pack-year smoking history and who currently smoke or have quit within the past 15 years. (Wender, 2013). This American Cancer Society guideline was published around the time of the previous 2013 USPSTF lung cancer screening recommendation statement. Thus, the American Cancer Society recommends screening persons who have at least a 30 pack-year smoking history. However, the 2013 American Cancer Society guideline is being updated and, in the meantime, the American Cancer Society recommends yearly lung cancer screening with low dose CT scans for people who: are 50 to 80 years old and in fairly good health, currently smoke or have quit in the past 15 years, and have at least a 20 pack-year smoking.We find that the empiric evidence is sufficient to conclude that lung cancer screening with low- dose CT is reasonable and necessary for the prevention or early detection of illness or disability, for Medicare beneficiaries with the specific eligibility criterion for a smoking history of 20 or more pack-years. This approach to broadening the smoking history from 30 pack-years to 20 or more pack-years is consistent with the USPSTF grade B recommendation.Maintaining Quit Smoking History at Quitting Within Past 15 Years