Lung Biopsy Value, Costs Questioned

An appropriate reduction in the number of diagnostic lung biopsies "has the potential to reduce costs and improve patient outcomes," says a researcher who has studied diagnostic costs associated with Medicare beneficiaries who had abnormal chest CT scans.

A study presented in Chicago recently calls for a hard look at the value of biopsies in lung cancer diagnoses.

The research focused on a random sample of nearly 9,000 Medicare beneficiaries who underwent diagnostic tests after an abnormal chest computed tomography scan. The study found 43% of the total diagnostic workup cost after the abnormal CT scans was linked to biopsies with negative results for patients who ended up not being diagnosed with lung cancer.

The total diagnostic workup cost for patients in the study was pegged at $38.3 million, with Medicare spending at $16.5 million on biopsies for patients who did not have lung cancer.

The study was presented at the 2014 Chicago Multidisciplinary Symposium in Thoracic Oncology. The lead author of the report, Tasneem Lokhandwala, PhD, a research analyst at the Xcenda subsidiary of Chesterbrook, PA-based AmerisourceBergen Corp., drew a three-fold conclusion for the conference attendees:

• Biopsies are a significant proportion of the overall cost of diagnosing lung cancer
• To reduce lung cancer diagnostic costs, oncologists need to develop "more precise risk stratification tools to better identify patients who require referrals for lung biopsy"
• An appropriate reduction in the number of diagnostic lung biopsies "has the potential to reduce costs and improve patient outcomes"

Bearing Down on the Numbers

In an interview this week, Lokhandwala said her research team's data was drawn from Medicare beneficiaries across the country.

"This is a nationally generalized sample," she said of the 8,979 Medicare beneficiaries who had abnormal chest CT scans from January 2009 to December 2011. "They all could have been diagnosed with lung cancer."

She said more research would have to be conducted to determine the potential annual savings for the Medicare program if unnecessary lung biopsies could be eliminated. "You would need extensive analytical modeling to get that number," she said.

To conduct a study on the potential annual savings linked to elimination of unnecessary biopsies, Lokhandwala said researchers would have to consider focusing only on patients at high risk for lung cancer and weigh murky factors including cost estimates for new diagnostic tools.

Tradeoffs in High-Stakes Cancer Battle

The moderator of the conference, Laurie Gaspar, MD, MBA, a professor at the University of Colorado's School of Medicine in Denver and longtime clinical oncologist, says Lokhandwala's research highlights the benefits of improving lung cancer diagnostics.

"It is always possible to develop more precise risk-stratification tools for lung cancer so that we have more accuracy in our diagnosis of lung cancer as opposed to benign lesions."

"The areas that appear most promising are in the ability to diagnose early lung cancer from blood samples, referred to as liquid biopsies sometimes; the use of new imaging modalities such as new types of PET and CT scans; or the use of exhaled breath to detect chemicals that are correlated with early lung cancer," she says.

A key finding of Lokhandwala's research is relatively low utilization of positron emission tomography compared to biopsy in lung cancer diagnosis. PET scans were performed on less than 1% of patients. Lung biopsies were performed on about 19% of patients. This finding suggests oncologists are not following diagnostic guidelines for lung biopsies.

"From this analysis, it was found that the National Comprehensive Cancer Network (NCCN) lung cancer screening guidelines were not followed, which resulted in many patients who ultimately had a negative lung cancer diagnosis undergoing unnecessary biopsies. The NCCN guidelines call for low-dose computed tomography of the chest followed by a PET scan to identify patients for biopsy," says a statement accompanying the release of the report.

In Lokhandwala's study, the average cost to Medicare for a complication-free lung biopsy was $8,869 and the average cost of a PET scan was $624. She notes that the average cost of a PET scan in her study only covered the procedure, but Medicare spending on lung biopsies included all incidental costs.

"It's not just the cost of the procedure," she says. The incidental costs for biopsies in her study accounted for "everything that could happen" such as length of stay in a hospital and the cost of managing adverse events linked to a biopsy.

Gaspar says oncologists and researchers will have work carefully as they seek to refine lung cancer diagnostics.

Developing more cost-effective diagnostic tests involves a large measure of uncertainty and "the cost of these tests is not yet known. The ultimate cost depends on whether the new tests replace the traditional biopsy or are just done to avoid some biopsies. The latter sounds more likely at this point."

Lung cancer is among the most deadly diseases afflicting the Medicare population, so the stakes will be high in any effort to reduce the number of lung biopsies, Gaspar says. "Money would be saved as long as we are not missing the early detection of lung cancer in the vast majority of patients."