Coalition Urges U.S. Panel to Approve CT Colonography for Routine Screening

A growing body of evidence supports the use of CT colonography for colon cancer screening, and a U.S. panel should reverse its decision to not endorse the procedure, according to the CT Colonography Coalition.

Currently, the U.S. Preventive Services Task Force (USPSTF) gives CT colonography (CTC) an "I" grade, meaning more research is needed before the panel can recommend the test. The CTC Coalition wants that to change.

Colon cancer is the second leading cause of cancer death in the U.S., which makes it essential that patients and doctors utilize the most effective services available to detect cancer early and prevent deaths, said Andrew Spiegel, CEO of the Colon Cancer Alliance.

"Data show that when CTC is offered in addition to other colorectal screening options, screening compliance rates increase dramatically. That is why we believe the USPSTF should endorse CTC," he said.

The CTC Coalition submitted its comments in response to an announcement in the Federal Register asking for preventive health topics that should be considered by the USPSTF. The coalition is not the only one saying there is already enough clinical evidence to prove CTC's effectiveness.

"There is definitely enough evidence to recommend CT colonography for colon cancer screening," said Judy Yee, MD, vice chair of radiology and biomedical imaging at the University of California, San Francisco and chief of radiology at the San Francisco Veterans Affairs Medical Center.

Dr. Yee cited several studies in favor of CTC, most notably a landmark American College of Radiology Imaging Network National CTC Trial (New Engl J Med 359:1207-1217, 2008).

"Results showed excellent sensitivity and specificity for the detection of the large, clinically significant polyps," she said. "Based on this study, as well as others, the American Cancer Society revised guidelines in 2008 and now includes CTC as a valid screening test option for colorectal cancer."

In addition to several U.S. studies, there is also evidence from other countries showing CTC's effectiveness.

"It is beginning to seem rather irresponsible to continue to offer routine double contrast barium enema examinations.... More than 90 Canadian radiology departments have bought the necessary CO2 insufflators, so there is clearly great interest," said the authors of a Canadian trial (Can Assoc Radiol J 59:174-82, 2008).

CTC is less invasive and therefore safer compared with colonoscopy, Dr. Yee said. No sedation is required, so patients avoid the risks and costs of anesthesia.

"Even with the older colon cancer screening tests, about 50% of the population who needed screening for colon cancer did not come in to get screened," Dr. Yee said. "There clearly is a need for a more appealing test."

Even though Medicare doesn't cover CTC and the USPSTF has yet to recommend it, about 30% to 40% of hospitals offer the procedure. "As we wait for national reimbursement by CMS, private payers are increasingly covering screening over the past two years," Dr. Yee said. "Patients need to request coverage by their insurance companies and at a state level."

There are also local coverage determinations in almost every state that allow reimbursement for diagnostic CTC, she said. That is an indication CTC is performed in almost all states. "Academic centers and larger private practices typically offer CTC," she said. "Smaller sites may not offer onsite CTC, but they could direct patients to places that do offer it."

Earlier this year, President Barack Obama opted for a virtual colonoscopy screening over traditional colonoscopy for his screening study. "If the president has the option to choose a CTC screening, then surely U.S. seniors should have the option available to them, too," Mr. Spiegel said.

Patients set cap on CTC pricing

Most patients who have been offered colorectal cancer screening but turned it down are willing to undergo CT colonography as long as out-of-pocket fees are reasonable, according to a study.

Wendy Ho, MD, and colleagues at Boston's Massachusetts General Hospital analyzed the barriers to CTC for colorectal cancer screening in a nonadherent urban population.

Of 68 patients who participated in the questionnaire, 83% said they would be willing to undergo CT colonography. However, 70% said they would not be willing to pay out-of-pocket fees if insurance did not cover the study.

Among the 30% who said they would pay the fees, the average amount they were willing to pay (mean: $244; median: $150) was well below currently charged rates (AJR Am JRoentgenol 95:393-397, 2010).

Although the values may have been influenced by the study's small size, they are consistent with the cost-effectiveness analysis by the Agency for Healthcare Research and Quality performed for CMS, the authors wrote. CMS found CT colonography could become a cost-effective screening strategy if its cost were $200 or less.

CTC review

Italian gastrointestinal specialists defined the role of CTC now and in the future, in a recent editorial.

Andrea Laghi, MD, and colleagues from the University of Rome-Sapienza and Nuovo Regina Margherita Hospital wrote that the present role of CTC in screening programs is to replace barium enema in the case of incomplete colonoscopy.

"The potential role is the proposal of CTC as a first-line CRC screening modality," they wrote "In this setting, CTC has clear advantages, such as accuracy, safety, and subject acceptance. Further research should be warranted to clarify, in particular, two aspects: The uptake rate of the general population and the real cost and benefits derived from a CTC screening program" (World J Gastroenterol 16:3987-3994, 2010).

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