Full article reprinted from "The Gray Sheet" - November 24, 2008
Find out how computed tomography colonography shows promise as a colorectal cancer screening tool comparable to optical colonoscopy, and could be covered under Medicare, but the price per procedure would have to be lowered, members of a CMS advisory panel agreed Nov. 19.
Full article reprinted from "The Gray Sheet" - November 24, 2008
CTC could be cost effective - and would provide additional years of life at the same cost per year as colonoscopy - at a price of $179-$237, according to an assessment by the Agency for Healthcare Research and Quality presented to the Medicare Evidence Development & Coverage Advisory Committee (MedCAC).
Currently, CTC costs $488 per test. AHRQ estimated this base cost by examining average CMS reimbursement for an abdominal CT, a pelvic CT and image processing.
CMS said May 19 it will consider providing national coverage for cancer screening with CTC, an idea that is supported by the American Cancer Society and the American College of Radiology ("1The Gray Sheet" May 26, 2008, p. 16). The proposed decision is due in January 2009.
In September, the National Cancer Institute and the American College of Radiology Imaging Network released results of a 2,600-patient study lending support for CTC as an alternative to visual colonoscopy for colorectal cancer screening. Researchers concluded that CTC may be the best modality for initial screening because it is less invasive than colonoscopy - now covered by Medicare for use as a colon cancer screening tool - and therefore more attractive to patients ("2The Gray Sheet" Sept. 22, 2008, p. 21).
Makers of CT machines or CT software for the colon procedure who might benefit if CMS allows national Medicare coverage include Vital Images Inc., iCAD, General Electric, Philips and Siemens.
AHRQ's cost-effectiveness analysis is based on the assumption that CT colonography is a two-step procedure, with patients who have 6mm or larger polyps referred to optical colonoscopy.
Also, in the event that colon cancer screening adherence is higher with CT colonography than with other tests, CTC could be an efficient strategy at costs of up to the current estimated cost of $488, AHRQ said.
Based on Medicare data, colonoscopy currently costs approximately $500 when polypectomy is not performed, and $650 when it is, according to AHRQ estimates. The estimates include the cost of sedation in colonoscopy, assuming it is not administered by an anesthesiologist.
The MedCAC meeting was notable for its explicit discussion of cost factors, which CMS typically tries to avoid during the coverage determination process. "It's nice to be able to talk about cost effectiveness," said MedCAC Vice Chair Steven Pearson, Harvard Medical School.
Panel Votes On CTC's Ability To Catch Small Polyps
The MedCAC panel voted that they have little or no confidence that CTC could catch polyps of 6mm or less, but moderate to high confidence that it could catch polyps of 6mm to 10mm, and very high confidence it could find polyps greater than 10mm.
They voted "low confidence" to the question, "At current Medicare prices, how confident are you that CTC has a similar ratio of cost per life years saved as optical colonoscopy?"
Part of that low confidence may have been because Dr. Ned Calonge, U.S. Preventive Services Task Force, said that in its systematic review of CTC for colorectal screening, AHRQ had to give the procedure a grade of "I" for insufficient benefit shown, because "we cannot estimate the magnitude of harm" from CTC.
In contrast, the risks of optical colonoscopy are well known. AHRQ said that some of the harms posed by optical colonoscopy come from complications of anesthesia and manipulation of the colon, with 0.7 patients per 1,000 suffering perforations; 0.3 per 1,000 suffering serosal burns; 0.4 per 1,000 suffering bleeding with transfusion; and 1.1 per 1,000 suffering bleeding without transfusion.
In comparison, with CT colonography, the chance of perforation was estimated at 0.045 per 1,000, but there is also radiation exposure with CTC, which could potentially cause 1 in 1,000 to develop leukemia, said Mary Barton of the Oregon U.S. Preventative Services Task Force.
- Sue Darcey
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