Congress should pass proposed legislation requiring Medicare to pay for "virtual" CT colonography screening because it is just as accurate as colonoscopy, but has lower distension rates, extremely low chance of perforation, and is less expensive and faster, the American College of Radiology says.
After all, if the procedure was good enough to be part of President Obama's physical in February, it should be good for people age 65 and older, the organization says.
"The ACRIN trial, which had 2,600 patients, showed that CTC has equal sensitivity compared to colonoscopy for clinically significant or pre-cancerous polyps. And other multi center trials in Europe are showing the same thing," says Judy Yee, MD, vice chairman of the Department of Radiology at the University of California San Francisco and chief of Radiology at the San Francisco VA Medical Center.
Besides, she says, "One would think that the President of the United States would have access to the best test." She adds that major insurance companies such as Cigna, UnitedHealthcare, and Anthem BlueCross BlueShield now cover screening as well as diagnostic CTC for their beneficiaries, so there's no reason why the federal government shouldn't do it as well.
The ACR is pushing for approval of the Virtual Screening for Colorectal Cancer Act of 2010 (H.R. 5461), which was introduced last week by Rep. Danny Davis, D-IL.
However, the Centers for Medicare & Medicaid Services has held back on issuing a national coverage decision for CTC, suggesting that the procedure needs another clinical trial and more research. Also, the U.S. Preventive Services Task Force says there is insufficient evidence to determine whether its benefits outweigh potential harms, primarily because the technique is not as good as colonoscopy at detecting polyps or smaller lesions.
Yee and the ACR argue that the task force is using statistics that are not current. What's really behind the opposition to approve this, she says, is "kind of a turf battle that's going on right now. Colonoscopy is the bread and butter of what gastroenterologists make their living off of. And this alternative, done by another specialty, is being visualized as a threat."
An estimated 1.2 million colonoscopies are done annually by gastroenterologists, with another 300,000 to 400,000 by other healthcare providers.
CT colonography uses low-dose X-ray technology to produce three-dimensional images obtained when the patient lies for 10 seconds on the back, and then again on the belly. The preparation is the same, but there is no need for sedation, which both the ACR and Yee believe will encourage more people to have the potentially life-saving exam. Patients return to normal activities immediately after the procedure.
Some people just don't want to accept the idea of a 6-foot scope being inserted.
Yee says that Medicare's reluctance to approve the scan is not universal, because she says in a few states local Medicare Administrative Contractors will pay for the screening in people 65 and older, but in most other states, MACs will not. "One of the investigators forced the issue in Wisconsin and was able to get approval," she says.
"But maybe there is concern (on the part of Medicare) that they don't want to open the floodgates, with the potential that there would be so many more people who would want screening at a time when there is so much uncertainty about healthcare reform."
She says that Medicare's rationale "doesn't make any sense," especially when considering the cost, which for people paying out-of-pocket, amounts to $800 to $1,000 compared to colonoscopy, which costs $3,000.
John Patti, MD, chair of the ACR Board of Chancellors, said in a statement that the current payment system "creates a two-tiered approach to screening coverage for this deadly and preventable disease: one for those who have private insurance (or the ability to pay out of pocket), and lesser coverage for Medicare beneficiaries."
He added: "It's time for all patients who want a CT colonography to be covered for this lifesaving exam. All the relevant clinical questions have been answered."
One downside, however, is that because CT colonography is less invasive than standard colonoscopy, patients who do have clinically significant polyps will have to have another procedure to have them removed whereas during a colonoscopy, polyps are usually removed during the exam. But Yee says that would only be required in a relatively small number of patients.
Colon cancer causes an estimated 50,000 deaths a year in the U.S. and is said to be one of the most common preventable types of cancer, if it is caught early enough.