Should Virtual Colonoscopies Be Covered by CMS?

Earlier this month, the Centers for Medicare & Medicaid Services announced that it would not cover computed tomographic colonography or virtual colonoscopy. CMS said in a memo that while the "technology was promising," there was insufficient evidence on the performance of CT colonography in Medicare aged individuals to "conclude that screening CT colonography improves health benefits for asymptomatic, average risk Medicare beneficiaries."

Advocates of CT colonography blasted CMS' decision saying that wider use of screening could save 20,000 lives annually.

Colorectal cancer is the third most common cancer among both men and women in the United States and accounted for nearly 50,000 deaths in 2008, according to the American Cancer Society. The majority of these deaths could be prevented by the early detection of colorectal cancer through screening, but only half of people age 50 or older, for whom the test is recommended, have received the screening. The reasons vary. Some people lack education about the importance of screening, others don't have health insurance coverage, and some just procrastinate or avoid taking the test because it is an invasive procedure and requires the unpleasant task of cleansing the colon.

Some experts believe that computed tomographic colonography or virtual colonoscopy, which is an imaging procedure that offers a detailed, cross-sectional, 2- or 3-dimensional view of the entire colon and rectum, could boost screening for colon cancer because it's less invasive than traditional colonoscopies. A traditional colonoscopy uses a thin tube equipped with a video camera that is pushed through the large intestine to view the lining. If a polyp is found, physicians can remove it by passing a wire loop through the colonoscope and using an electric current to cut the polyp from the wall of the colon. There is a higher risk of complications like bowel tears or bleeding, especially when a polyp is removed.

Although CT colonography still requires a bowel cleansing, it does not require sedation, has no recovery time, and usually takes about 10 to 15 minutes to complete. Patients with polyps or other abnormal test results would be referred for colonoscopy. Ideally they could receive the colonoscopy the same day to avoid the necessity of a second bowel preparation. Studies have shown that virtual colonoscopy detects about 96% of invasive colorectal cancer and has similar sensitivity compared with colonoscopy for large polyps.

One of CMS' chief concerns, however, is that CT colonography doesn't detect smaller polyps as well as other tests, and if a polyp is found, a regular colonoscopy would need to be performed anyway.

Did CMS make the right decision? Even gastroenterologists are split on the issue. CMS received comments opposing the decision from the American Cancer Society, the American College of Radiology, the American Gastroenterological Association, the Advanced Medical Technology Association, and UnitedHealthcare. CMS also received letters supporting the decision from the American College of Gastroenterology, the American College of Preventive Medicine, the American Society for Gastrointestinal Endoscopy, and American's Health Insurance Plans.

What do you think? Does the increased number of patients who would be willing to have a virtual colonoscopy screening outweigh concerns that the test is good, but not quite as good as a traditional colonoscopy? When colorectal cancer is found early and treated, the 5-year relative survival rate is 90%, according to statistics by the Centers for Disease Control and Prevention. That is a pretty powerful statistic in support of making colorectal cancer screenings as accessible as possible.