Posts Tagged screening
Wow, you could have had a CPT code and $60. While fee-for-service is widely excoriated for excessive cost what is CMS doing? They want primary care providers or someone to have another fee-for-service. The fee is for “counseling” about lung cancer CT screening and “counseling” about weight loss. Both things that are currently part of an office visit with no additional CPT code — just good patient care.
Both topics could easily be covered on YouTube in several languages but NO — lets do this the old fashioned way and spend a zillion dollars for each provider to reinvent the discussion each time. CMS: don’t be so lazy — make the patient education video and tell primary care providers the URL! And, update the video every 6 months.
The bottom line:
- Lung Cancer CT Screening:
- Don’t do it if the patient can’t have surgery
- Don’t do it until the patient has 30 pk yrs accumulated (number of packs per day times number of years)
- Don’t do it if the patient is less than 55 or over 80 years old.
- Don’t do it if the patient quit smoking more than 15 years ago.
- Weight-loss counseling:
- Say in a loud voice “you weigh too much” then say “eat less”. (that was not so hard!)
- Doctors have been doing this for decades without sustained results.
- There are 20,000 books about diets to loose weight without sustained results.
- This is not going to work — at least be honest.
Follow the money:
Counseling fees for CT scans is an incentive to do the CT scans. The primary care provider makes money, the x-ray office makes money and the radiologist makes money. A better idea is to have the radiology office pay the primary care provider for the counseling out of CT revenue so this is a no-sum-gain. Better yet — make it a provided service under an ACO plan!
Counseling fees for intensive weight-loss is an incentive for lots of repeat visits or a referral. The Primary care provider makes money (and changes from a primary care provider to a specialty provider). The incentive reduces the pool of available visits for primary care with little if any benefit to the vast majority of obese people. A better idea is not to add another CPT code. If the patient needs more time — make another appointment!
You smoked 2 packs a day for 20 years. Your doctor orders the low-dose CT screening (above). Your doctor says you have a lung nodule, now what? That’s a lot to think about but before anxiety builds too much you need to know that of all the people with a nodule on their first scan 19 times out of 20 it is NOT lung cancer.
By asking some questions it is possible to work through the complicated logic of what to do next.
What if I am that unfortunate 1 out of 20?
If you know for sure the nodule is cancer you would get that nodule removed. Sure it’s a big surgery, hurts for weeks (sometimes longer), in the hospital for several days, and tons of risks the surgeon will recite. No walk in the park but the odds of a cure are better at an early stage. Lung cancer is a killer so it is easy to conclude: get rid of that nodule
What if that nodule is a bad type called “small cell” cancer?
Most specialists agree that chemotherapy is the treatment of choice. Surgery for small-cell cancer is not helpful and may actually shorten your life. A biopsy before surgery may help to avoid surgery for this type of cancer.
What if I am one of the lucky 19?
If all 19 get surgery there would be a lot of discomfort only to be told after surgery the nodule was just a scar or a harmless irritation. Biopsy or follow-up x-rays are sometimes helpful to avoid surgery.
What if I get a needle biopsy of the nodule?
A shot of numbing medicine, a long needle between the ribs, a tiny bit of tissue removed, and finally the pathologist sends a report. Such biopsies are 95% accurate. The wheel of fortune lands in one of 5 major categories:
- No cancer found
- Small-cell lung cancer
- Non-small-cell lung cancers
- Squamous cell carcinoma
- Large cell carcinoma
- Other cancers (much less common)
- Something which is not cancer
A needle biopsy answers critical questions. If it shows non-small-cell lung cancer surgery is the next step. If it is small-cell cancer the next step is chemotherapy. If it is something else, like tuberculosis, then entirely different treatment is needed. If it is “no cancer found” then you are back to square one — meaning a nodule is present and the cause is unknown (possibly a cancer that was missed by the needle).
I am willing to take some risk to avoid procedures.
We started this discussion with a 1 out of 20 chance of cancer. Is there some way to improve on the accuracy of that prediction? 1 out of 20 does not sound so good. But, if the odds of cancer in your situation are 1 out of 100 that would be more favorable.
Improved risk assessment
Canadian Annette M. Williams, MB and others reported in the New England Journal of Medicine in September 2013 an improved mathematical prediction method. Most pulmonary doctors and radiologists can readily provide the statistic. Basically, if the calculated risk score is below 5% then the chance of cancer is about 1 out of 100 .
If the risk is low you might just choose to get a CT scan every few months. If the size of the nodule does not change for 2 years then it is harmless. One sure thing, cancers grow. No growth means no cancer. But, if the nodule does grow you could change the plan and get the biopsy or surgery — there is a risk to letting a cancer grow for a few months (it could spread) but there are risks to biopsies and surgery as well.
If the cancer risk is high you might want to go ahead with a biopsy.
The above are the outlines of nodules 1) round 2) lobulated 3) irregular and 4) spiculated. Cancerous nodules can take any shape but tend toward the spiculated (spiny) form.
The improved statistical method is based on a few details about the nodule. Sex (women are more likely to have malignant nodules), size (the larger the nodule the more likely it is malignant), location (upper lobe nodules are more likely malignant) and spiculation (see diagrams).
If you want to calculate the risk statistic yourself, have a calculator and know the details listed above then click this: Calculate Risk. But, be warned, this calculation only applies to people who have a risk for cancer to begin with, not the incidental nodule found in a lifetime non-smoker or someone who only smoked a few years.
The forgoing material is intended as education, not a substitute for the evaluation and advice of your health care provider. If it seems helpful print it and take it to your provider for discussion. Medical care changes with time so always get up to date information.