To the Editor: Although evidence-based, cost-effective medicineis an important concept and a goal to strive for, these conceptsmust be applied in a way that is cognizant of the needs of real-worldpatients. The decision by the Centers for Medicare and MedicaidServices (CMS) to deny Medicare beneficiaries access to computedtomographic (CT) colonography, as discussed in the Perspectivearticle by Dhruva et al. (June 25 issue),1 will adversely affecttens of thousands of America's seniors. Contrary to statementsmade by the CMS, data that are specific to a population overthe age of 65 years exist and show that CT colonography is clinicallyeffective and cost-effective for this population subgroup.2These data were presented to the CMS before its recent ruling.The CMS also argues that access to CT colonography does notguarantee increased screening rates, yet the National NavalMedical Center has seen a 70% increase in colon screening sinceCT colonography was offered as an option. Respected medicalprofessionals and associations, including the American CancerSociety, stand behind the value of CT colonography for the Medicarepopulation,3 and 97% of the public comments on this decisionfavored coverage.4 Beyond this CMS decision, there are potentiallyserious repercussions associated with the authors' proposedrigid and unrealistic data requirements. Placing such requirementson all coverage decisions would severely curtail patients' accessto lifesaving technologies.
Brooks D. Cash, M.D. Walter Reed National Military Medical Center Bethesda, MD
The views expressed in this letter are those of the author and do not necessarily reflect the official policy or position ofthe Department of the Navy, the Department of Defense, or theU.S. government.
Dr. Cash reports having served as the director of a continuing-medical-educationcourse sponsored by the American Gastroenterological Associationto introduce gastroenterologists to the use of CT colonographyand having served as an uncompensated consultant to Colon HealthCenters of America. No other potential conflict of interestrelevant to this letter was reported.
References
Dhruva SS, Phurrough SE, Salive ME, Redberg RF. CMS's landmark decision on CT colonography -- examining the relevant data. N Engl J Med 2009;360:2699-2701. [Free Full Text]
Pickhardt PJ, Hassan C, Laghi A, Kim DH. CT colonography to screen for colorectal cancer and the aortic aneurysm in the Medicare population: cost-effectiveness analysis. AJR Am J Roentgenol 2009;192:1332-1340. [Free Full Text]
Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin 2008;58:130-160. [Free Full Text]
The authors reply: The analysis of CT colonography that Cashcites used a model that was validated in younger adult populations,1and the CMS's final decision memo noted that this model hadbeen neither well tested nor previously used.2 Furthermore,the memo acknowledged that this analysis combined outcomes fromscreening for colorectal cancer and abdominal aortic aneurysm.The Preventive Services Task Force recommends performing suchscreening only once in men who are 65 to 75 years of age andwho have a history of smoking; the task force does not recommendsuch screening in women.3 Thus, less than one sixth of Medicarebeneficiaries would be expected to have any benefit. Althoughthe CMS reviewed other data showing that CT colonography iscost-effective only at reimbursement levels that are much lowerthan current rates,4 its decision was based primarily on theinadequacy of the evidence of benefit for this test and notits cost-effectiveness.2
The CMS covers what is "reasonable and necessary."5 It wouldbe irresponsible to cover services for which there are no clinicaldata showing benefits among its beneficiaries, since such servicesmay be associated with harm — from additional unnecessarytesting and procedures, anxiety about "incidentalomas," andadditional diagnoses of uncertain clinical implications. Itis essential that the CMS make decisions on the basis of high-qualityclinical trials that reflect the effects on its elderly population.
Sanket S. Dhruva, M.D. Rita F. Redberg, M.D. University of California, San Francisco San Francisco, CA
References
Pickhardt PJ, Hassan C, Laghi A, Kim DH. CT colonography to screen for colorectal cancer and aortic aneurysm in the Medicare population: cost-effectiveness analysis. AJR Am J Roentgenol 2009;192:1332-1340. [Free Full Text]
Centers for Medicare & Medicaid Services. Decision memo for screening computed tomography colonography (CTC) for colorectal cancer (CAG-00396N). (Accessed September 3, 2009, at https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=220.)
Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2005;142:203-211. [Free Full Text]
Vijan S, Hwang I, Inadomi J, et al. The cost-effectiveness of CT colonography in screening for colorectal neoplasia. Am J Gastroenterol 2007;102:380-390. [CrossRef][Web of Science][Medline]
Social Security Act, 1862, 42 U.S.C. 1395y(a)(1)(A)(1965).
1862, 42 U.S.C. 1395y(a)(1)(A)(1965).
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