The tests found 22 colorectal cancers (1 in every 500 patients examined) and 36 other cancers (1 in every 300 patients.)  More than half were found at an early stage I.  After an average follow-up time of 30 months, only 3 patients had died of cancer.

Renal cell cancer was the most frequent extracolonic cancer, discovered in 11 patients who didn’t have symptoms.  Eight lung cancers were also found along with six cases of non-Hodgkins lymphoma and eleven cancers in other sites.  More specific information about patients, their cancers, and their survival is part of the report in Radiology.

CT colonography allows radiologists limited views of the body outside of the colon, particularly in the pelvis, abdomen, and part of the lungs.  About 6 percent of the time, the exam leads to additional testing for other diseases, although more than half of that testing will eventually prove benign.

If polyps or suspected colorectal cancer is found during CTC screening, referrals are necessary for a traditional optical colonoscopy where polyps can be removed and biopsied.

During an exam patients are exposed to about 10 millisieverts (mSv) of radiation, about the same amount they receive from normal background radiation in three years.

In a news release from the Radiological Society of North America (RSNA), lead author Perry J. Pickhardt, M.D., professor of radiology and chief of GI Imaging, at the University of Wisconsin School of Medicine & Public Health, noted,

We are finding that virtual colonoscopy screening actually identifies more unsuspected cancers outside of the colon than within it. As with asymptomatic colorectal cancers identified by virtual colonoscopy screening, these cancers are often detected at an early, curable stage.

However, he points out that CT colonography does find benign conditions that nevertheless need follow-up.

Although extracolonic evaluation at screening CT colonography does carry some disadvantages, such as patient anxiety, inconvenience, or the potential for benign biopsy, our results suggest that early detection of asymptomatic extracolonic cancer represents an additional benefit of screening CT colonography that is not available with optical colonoscopy

Reporting their results in the April issue of Radiology, Pickhardt and his colleagues concluded,

The overall detection rate of unsuspected cancer is approximately one per 200 asymptomatic adults undergoing routine screening CT colonography, including about one invasive CRC per 500 cases and one extracolonic cancer per 300 cases. Detection and treatment at an early presymptomatic stage may have contributed to the favorable outcome.

SOURCES:  Pickhard et al., Radiology, Volume 255, Issue 1, pages 83-88, April 2010.

RSNA News Release: Virtual Colonoscopy Allows Detection of Unsuspected Cancers Beyond Colon, March 23, 2010.

“The President completed all age-appropriate screening tests, to include colorectal cancer screening.  A CT-colonography was performed with normal results.  Follow-up colorectal cancer screening is recommended in 5 years for routine colon cancer screening.”

Screening is just one important way to prevent colorectal cancer.  Take a few minutes to read more about preventing colorectal cancer.

About one in six older patients was referred for an optical colonoscopy based on findings from the scans.

There were no major complications including colon perforations or bleeding, from either the CT procedure or the follow-up colonoscopy.

Researchers at the University of Wisconsin reviewed results of 577 people from 65 to 79 tested in the university’s CT colonography screening program and found either an advanced adenoma or cancer in 44 (7.6 percent).  There were 5 cancers detected.

The rate of advanced neoplasia (advanced adenoma or cancer) for all the patients screened in the program, young and old, was 3.2 percent.

The percentage of older patients who were referred for an optical colonoscopy was about twice that of those under 65 — 15.3 percent of patients 65 and older, 7.6 percent of younger people.  Optical colonoscopy confirmed the positive CT findings in all but 4 percent of cases, not verifying 3.6 percent of smaller polyps measuring 6 to 10 mm and 2.1 percent of those larger than 10 mm.

The scans also found potential problems outside the colon in 89 patients, 45 of whom needed additional medical studies.  Workups discovered 21 previously undetected abnormalities including a lung cancer and 18 aneurysms.

The authors point out the the study was retrospective, looking back at experience in their program, and that negative findings were not verified by an optical colonoscopy.

Last year, the Centers for Medicare and Medicaid Services (CMS) declined coverage of screening colonoscopy for Medicare beneficiaries, stating lack of evidence for its effectiveness in people 65 and older.  CMS was also concerned that CT colonography identifies issues outside the colon which require additional medical follow-up and may not be serious medical problems.

David H. Kim, MD and his colleagues at the University of Wisconsin concluded,

CT colonography is a safe and effective screening modality for the older population.

SOURCE:  Kim et al., Radiology, Volume 254, pp 493-500, February 2010.

In other headlines, shut-down of a Canadian nuclear reactor threatens the supply of medical isotopes used in many cancer tests.  Free drug samples may do more harm than good, and CT colonography finds cancers and other serious conditions outside the colon in about 2 or 3 out of 100 tests.  Finally, we provide a link to a Cancer.Net podcast with information about what to expect from your colonoscopy.

Research Reports

• Patients with cancer cachexia or loss of weight, muscle mass, and fat due to cancer had lower blood levels of fentanyl two and three days into using a fentanyl patch for pain management than did normal weight patients.  Cachectic patients had significantly thinner upper arm folds with less fat but there was no difference in local blood flow, sweating, or skin temperature.  Pain clinic researchers in Helsinki concluded that, “Absorption of transdermal fentanyl is impaired in cachectic patients compared with that of normal weight cancer pain patients.” Tarji Heiskan and team reported their research in Pain online May 13, 2009.
• People with Down Syndrome are rarely diagnosed with solid tumor cancers, and researchers at Children’s Hospital in Boston have found a reason.  Children with Down Syndrome are born with an extra copy of chromosome 21, and additional protein controlled by an extra DSCR1 gene acts within cells themselves to suppress VEGF (vascular endothelial growth factor) preventing potential cancers from developing the blood supply they need to grow and spread.  Both cell and mouse studies confirm the activity of DSCR1 proteins to block angiogenesis.  The discovery is reported in a letter from lead author to the journal Nature published online May 20, 2009.  More detailed information about the study is available from Science Daily, May 21, 2009.

Other Headlines

• The shut-down of a Canadian nuclear reactor in Chalk River, Ontario to repair  leaking heavy water has imperiled millions of medical imaging tests in the United States.  The reactor supplies the radioactive isotope molybdenum-99, injected into patients during nuclear medicine studies.  The Canadian reactor is one of only five worldwide that produce medical isotopes, and it provides them for half of hospitals and clinics in the United States.  Nuclear medicine experts predict that costs will rise, patients will have to be switched to less accurate testing, and some patients will not be able to have testing at all.  The reactor closure is expected to last at least a month and probably longer. Julie Steenhuysen has written about the reactor problems on Reuters Health.
• Health policy researchers Susan Chimonas and Jerome P. Kassirer discuss the negative impact of free drug samples in an essay on PLoS Medicine.  They review research that shows only a third of samples go to low-income patients and patients in the highest income categories were most likely to receive free samples.  Many samples are diverted for personal use by health professionals.  Low-income patients given starter packs of medicines frequently do not fill prescriptions to continue them and have no oversight by a pharmacist.  Samples raise the cost of health care with patients who receive them having higher out-of-pocket costs than those who don’t.  Estimates are that free samples are worth about $16 billion retail dollars annually in the US.  The complete essay by Chimonas and Kassirir is available on PLoS Medicine, published May 12, 2009.
• CT colonography can find cancers outside of the colon.  In fact, in a study of over 10,000 people who were screened with CTC, 38 non-colorectal cancers were discovered — more than the 21 colorectal cancers.  Most were in the kidney, but lung cancer and lymphomas were also found.  Such discoveries are rare.  Dr. Perry Pickhardt, discussing them at the  2009 International Symposium on Multidetector-Row CT, pointed out that they occur about once in every 300 CTC procedures.  In addition, other serious medical conditions can be seen including unsuspected abdominal aneuryms.  However, while a suspicious problem occurs in about 1 out of 10 CTC exams, only 2 or 3 of them will actually be something serious needing treatment.
• Wonder what happens during a colonoscopy?  Cancer.Net, the patient and consumer information web site of the American Society of Clinical Oncology, has a podcast that can help. Colonoscopy — What to Expect.

Dr. Brawley points out that randomized clinical trials have shown the CTC option as effective as traditional optical colonoscopy in finding early cancers and precancerous polyps.  He also concerned that there is not a sufficient supply of trained specialists providing colonoscopy to meet the need for screening and that new options are needed.

The American Cancer Society believes, Brawley says, that a full battery of testing for colorectal cancer screening should be available, particularly to the Medicare population who are at higher risk of developing and dying from colorectal cancer.

Dr. Brawley’s statement:

I am disappointed in this decision, as randomized clinical trials clearly show CT colonography (CTC) is as effective as optical colonoscopy for the early detection of early cancers and pre-malignant lesions. Medicare coverage for CTC, also known as virtual colonoscopy, would have provided an additional option for colorectal cancer screening. Additional options are absolutely necessary as the supply of gastroenterologists and other trained specialists is currently inadequate to supply optical colonoscopy to all of those who need it, and many people are unwilling to undergo colonoscopy or other currently reimbursed tests. It is our belief that by increasing the proportion of Americans 50 and over who get colorectal cancer screening, we could increase the number of lives saved from this devastating disease and decrease long term medical costs. Providing access to all proven screening options is even more important for those in the Medicare population, most of whom are at even greater risk of developing and dying from colorectal cancer due to their advanced age. The American Cancer Society still believes that a battery of different tests for colorectal cancer screening should be available to the American people. This includes optical colonoscopy, virtual colonoscopy, stool blood testing, as well as sigmoidoscopy.

Despite an overwhelming number of comments urging that CMS overturn their provisional determination not to cover the test, the agency remained unconvinced that there was sufficient evidence to conclude that CT colonography was appropriate to screen for colorectal cancer.

Almost 95 percent of 357 comments supported CT colonography screening, including comments from the American Cancer Society and C3:Colorectal Cancer Coalition.

Briefly,

The Centers for Medicare and Medicaid Services (CMS) concludes the following:

The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test under § 1861(pp)(1) of the Social Security Act.  CT colonography for colorectal cancer screening remains noncovered.

Free colonoscopies are available through a Connecticut program, the FDA and FTC warn the public to be wary of websites or ads promising treatments for 2009 H1N1 influenza, and people in remote areas of Arizona were able to have CT colonoscopy screening with teleradiology.

Research Reports

• Ostarine or GTx-024, the first of a new drug class called selective androgen receptor modulators (SARMS) increased lean muscle mass in patients with cancer cachexia. Patients were also stronger, as shown by improved performance on a stair climbing task.  They didn’t gain weight because fat tissue was replaced with muscle.   Cancer cachexia or wasting causes significant weight loss and reduced lean muscle leaving patients tired, weak, and with little appetite.  Merely eating more — or trying to eat more — doesn’t help patients gain weight or strength.  In the study, nearly 160 patients were randomized to a placebo or two different strengths of ostarine.  Before beginning the trial, patients with a number of different cancers had lost an average of almost ten percent of their body weight.  There was no difference in serious side effects among the three groups.  Read more about the study in a news release from GTx, the company developing the drug.
• The number of circulating tumor cells (CTCs) can predict both how long it will take for colorectal cancer to get worse (progression-free interval) and overall survival time.  Both progression-free interval (PFS) and overall survival (OS) were shorter when three or more CTCs were found in the blood.  Those with fewer than three CTC  had median PFS of 7.8 months compared to 4.4 months for those with three or more. Overall survival was 20.6 months with fewer than three CTCs compared to 9.4 months for three or more.  The study, led by Dr. S.J. Cohen, was published in Annals of Oncology in advance online March 26,2009.

Other Headlines

• Connecticut has a free screening colonoscopy program for the uninsured and people whose insurance doesn’t cover screening colonoscopy. Working with the Community Health Center Association of Connecticut, the University of Connecticut, and gastroenterologists statewide, the program refers Connecticut residents, ages 50 through 64, for colonoscopy screening and follow-up.  Find telephone numbers of participating community health centers.
• Teleradiology is helping bring virtual colonoscopy to remote areas of Arizona.  While physicians and equipment for optical colonoscopy screening often is not available in rural areas, CT colonography can be performed by technologists and information be uploaded to a workstation and interpreted by an off-site radiologist.  During a study at the University of Arizona, 86 patients were screened with CT colonography in two rural health centers. Radiologist Arnold Friedman, MD, FACR, who led the study, reported its results at the American Roentgen Ray Society meeting in Boston
• The FDA and the Federal Trade Commission warn consumers against websites or products that offer to prevent, treat, or cure the 2009 H1N1 influenza virus.   FTC Chairman Jon Leibowitz said, “The last thing any consumer needs right now is to be conned by someone selling fraudulent flu remedies. The FTC will act swiftly against companies that resort to deceptive advertising.” The FDA provides information about buying medicine online and has a web page dedicated to influenza information, including H1N1 updates.

A CED would enable CMS to determine if CT colonography is safe and effective in the older Medicare population and which patients might benefit from screening using CTC rather than optical colonoscopy.

We believe that older patients should have a choice for colorectal cancer screening methods after a discussion of the risks and benefits of each method with their doctors.  And we want good information available for those patient decisions. 

Recognizing the difference in screening guidelines from the American Cancer Society developed in consensus with the Multi-Society Task Force on Colorectal Cancer and the American College of Radiology which include CTC as a test that can prevent colorectal cancer and those of the United States Preventive Services Task Force (USPSTF) which found “insufficient evidence to assess the balance of risks and benefits of CTC“, C3 urges coverage that could provide more information to clear up this confusion.

C3 comments included:

Therefore, C3 strongly urges CMS to gather the evidence by approving coverage of CTC, and implement the new coverage through a Coverage with Evidence Development (CED) process. A CED will generate additional safety and efficacy data in people over the age of 65, a population that is typically under-represented in clinical research. CED can also generate information that will help to identify patients who can benefit from CTC as opposed to optical colonoscopy.

A complete denial of coverage is akin to “throwing the baby out with the bathwater.” Thus, we urge CMS to use its unique ability to generate data from its consumer base, and determine whether CTC is appropriate for people over age 65.

Background information supporting our comments included:

• Studies that showed CTC equivalent to optical colonoscopy in finding large polyps and colorectal cancers with fewer colon perforations and other complications.
• The need to reach additional people who are not now being screened and who might agree to be tested if CTC were covered by Medicare.
• Confusing and conflicting guidelines that don’t provide clear guidance to balance  risks and benefits for Medicare patients who are deciding on a screening method.

In conclusion,

C3 urges reconsideration of the non-coverage decision by CMS, and strongly urges CMS to gather the evidence by approving coverage of CTC, and implementing the new coverage through a Coverage with Evidence Development (CED) process.

Click here to read the entire comment.

C3: Colorectal Cancer Coalition Comments Regarding the Centers for Medicare and Medicaid Services National Coverage Analysis on Computed Tomography Colonography and the Proposed Decision Memo for Screening Computed Tomography Colonography for Colorectal Cancer (CAG-00396N)

March 9, 2009

Download a copy of the C3 comments.

These comments are submitted by C3: Colorectal Cancer Coalition (C3), a non-profit, nonpartisan advocacy organization committed to the fight against colon and rectal cancer. We appreciate the opportunity to comment on the Centers for Medicare and Medicaid Services (CMS) National Coverage Analysis (NCA) on Computed Tomography Colonography (CTC) and the Proposed Decision Memo for Screening Computed Tomography Colonography (CTC) for Colorectal Cancer (CAG-00396N).

After careful review of the Proposed Decision Memo for Screening Computed Tomography Colonography (CTC) for Colorectal Cancer (CAG-00396N)[i], our past comment on this issue[ii], and the many references available, C3 believes that there is sufficient evidence to recommend CTC to screen for colorectal cancer in the Medicare population. While we agree with CMS that there is limited data in the Medicare population, we believe that the existing data supports coverage of CTC by CMS.

No one disputes that colorectal cancer screening saves lives and saves money. At the same time, almost every article about screening acknowledges that it is under-utilized. CTC provides the unique option of a whole-bowel, non-invasive visualization of the colon and rectum. This option is important for people who will not or cannot undergo optical colonoscopy[iii].

C3 recognizes that CMS and the US Preventive Services Task Force[iv] (USPSTF) disagree with our conclusion. Both CMS and USPSTF want to see additional supportive data prior to adopting CTC for screening.

C3 Recommendation

Therefore, C3 strongly urges CMS to gather the evidence by approving coverage of CTC, and implement the new coverage through a Coverage with Evidence Development (CED) process. A CED will generate additional safety and efficacy data in people over the age of 65, a population that is typically under-represented in clinical research. CED can also generate information that will help to identify patients who can benefit from CTC as opposed to optical colonoscopy.

A complete denial of coverage is akin to “throwing the baby out with the bathwater.” Thus, we urge CMS to use its unique ability to generate data from its consumer base, and determine whether CTC is appropriate for people over age 65.

Background for C3 Recommendation

Evidence that CTC is an Effective Colorectal Cancer Screening Tool

In March 2008, the American Cancer Society in collaboration with the Multi-Society Task Force on Colorectal Cancer and the American College of Radiology consensus guidelines (ACS-MSTFCC-ACR consensus[v]) found that “Based on the accumulation of evidence . . . the expert panel concludes that there are sufficient data to include CTC as an acceptable option for [colorectal cancer] screening.” CTC is included in their recommendations as one of the “tests that are effective at detecting cancer and premalignant adenomatous polyps.”

Since the release of the ACS-MSTFCC-ACR consensus guidelines, results from the American College of Radiology Imaging Network (ACRIN) National CT Colonography Trial have been published[vi]. These results found similar sensitivity between CTC and optical colonoscopy to find polyps over 1 cm. CTC in the National CT Colonography trial found 90 percent of larger polyps over 1 cm and 78 percent of those 6 to 9 mm. The nationwide, 15-site study supported earlier research with similar results.[vii] [viii][ix]

In October 2008, we believe that the USPSTF confused the screening issue for patients and advocates by dissenting from the ACS-MSTFCC-ACR consensus. They concluded, “The evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. (I statement)”. As a result, their recommendations for screening methods include only fecal occult blood testing, sigmoidoscopy and colonoscopy.

However, neither FOBT nor sigmoidoscopy has the single-test sensitivity of CTC, and false positives from FOBT lead to unnecessary colonoscopy in about one-third of cases[x]. Furthermore, sigmoidoscopy alone offers only partial bowel screening, and misses proximal polyps and tumors. Women are significantly more likely to have proximal polyps (42.2% vs 31.5%, P < 0.001)[xi], further limiting the usefulness of sigmoidoscopy.

As C3 reviewed the material supporting the CMS national coverage decision, we found that the USPSTF recommendations and the computer simulations that supported it were strongly influential at the MEDCAC meeting. We urge fuller reconsideration of the supporting evidence for the ACS-MSTFCC-ACR guidelines and the results of the ACRIN trial.

Reaching Screening Candidates Who Refuse Optical Colonoscopy

We regularly hear from people who adamantly refuse colonoscopy screening. They relate personal stories of family or friends who experienced excessive pain or perforation of the colon. Some worry that surgery or heart conditions might make them more vulnerable to colonoscopy complications. While bowel preparation is the most frequently given reason for avoiding colonoscopy, patients also are concerned about the invasiveness of the procedure, the size and length of the scope, being sedated, having to miss work, and needing a ride home.

While anecdotal information has limited usefulness, we believe that the relatively low uptake of colorectal cancer screening illustrates public concern with existing methods of screening.

The ACS-MSTFCC-ACR consensus guidelines point out that, “CTC surveillance could be offered to those patients who would benefit from screening but either decline CSPY (colonoscopy) or are not good candidates for CSPY for one or more reasons.”

The American Society for Gastrointestinal Endoscopy, a member of the US Multi-Society Task Force on Colorectal Cancer, does not recommend CTC for “widespread screening” but points out in their 2008 Screening Recommendations, “However, it may be useful for patients who refuse colonoscopy or who have had an incomplete colonoscopic examination.”

Patients Need Clear Guidance

C3 is concerned that there is an important difference in the screening recommendations between ACS in collaboration with the Multi-Society Task Force on Colorectal Cancer and the American College of Radiology and the guidelines from the US Preventive Services Task Force. While the ACS-MSTFCC-ACR consensus includes CTC as a screening option to prevent colorectal cancer, the USPSTF does not. In an environment where several different screening options are available, choices with varying benefits, risks, and payment coverage can confuse patients and physicians.

CMS coverage with evidence development of CTC will generate data that can resolve this confusion and provide significant public benefit.

Conclusion

C3 urges reconsideration of the non-coverage decision by CMS, and strongly urges CMS to gather the evidence by approving coverage of CTC, and implementing the new coverage through a Coverage with Evidence Development (CED) process.

About C3

C3 pushes for research to improve screening, diagnosis, and treatment of colorectal cancer; for policy decisions that make the most effective colorectal cancer prevention and treatment available to all; and for increased awareness that colorectal cancer is preventable, treatable, and beatable. More information can be found at www.FightColorectalCancer.org.

C3 believes in fully disclosing sources of financial support, per our disclosure policy which can be viewed at www.FightColorectalCancer.org/sponsors. C3 has received no financial or in-kind support from manufacturers of CTCs. None of our other corporate supporters have influenced our comments on this issue.

[i] Available at https://www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?from2=viewdraftdecisionmemo.asp&id=220&

[ii] Available at http://www.cms.hhs.gov/mcd/publiccomment_popup.asp?comment_id=18470

[iii] Levin B, Lieberman DA, McFarland, 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. Published online March 5, 2008. CA Cancer J Clin. 2008;58:

“CTC surveillance could be offered to those patients who would benefit from screening but either decline CSPY (colonoscopy) or are not good candidates for CSPY for one or more reasons.”

The American Society for Gastrointestinal Endoscopy, a member of the US Multi-Society Task Force on Colorectal Cancer does not recommend CTC for “widespread screening” but points out in their 2008 Screening Recommendations, “However, it may be useful for patients who refuse colonoscopy or who have had an incomplete colonoscopic examination.”

[iv] U.S. Preventive Services Task Force (USPSTF). Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627-637. Available at http://www.ahrq.gov/clinic/uspstf08/colocancer/coloartwhit.htm

[v] Levin B, Lieberman DA, McFarland, 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. Published online March 5, 2008. CA Cancer J Clin. 2008;58

[vi] Johnson CD, Chen MH, Toledano AY, Heiken JP, Dachman A, Kuo MD, et al. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med 2008;359:1207-17.

[vii] Johnson CD, MacCarty RL, Welch TJ, Wilson LA, Harmsen WS, Ilstrup DM, Ahlquist DA. Comparison of the relative sensitivity of CT colonography and double-contrast barium enema for screen detection of colorectal polyps. Clin Gastroenterol Hepatol 2004;4:314-321.

[viii] Kim DH, Pickhardt PJ, Taylor AJ, Leung WK, Winter TC, Hinshaw JL, et al. CT Colonography versus colonoscopy for the detection of advanced neoplasia. N Engl J Med 2007;357:1403-12.

[ix] Pickhardt PJ, ChoiRJ, Hwang I, Butler JA, Puckett ML, Hildebrandt HA, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191-200.

[x] Ronsohoff DF, Lang CA. Screening for colorectal cancer with the fecal occult blood test: a background paper. Ann Intern Med. 1997;126:811-22.

[xi] Koo et al. Improved Survival in Young Women With Colorectal Cancer. The American Journal of Gastroenterology (2008) 103, 1488-1495

The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test under §1861(pp)(1) of the Social Security Act. CT colonography for colorectal cancer screening remains noncovered.

The national coverage decision will not be final until 30 days after February 11 to allow for public comments.  Individuals and organizations concerned about the proposed decision can submit a comment online. However, CMS does not now cover screening CT colonography.

IMPORTANT: If you want to submit a comment to CMS online, you MUST click on and open the CMS PHI Posting Policy and then check off that you have read it.  If you don’t click on the underlined link, you cannot enter a check mark, your personal information, or your comment.

The decision was based on a review of medical literature, information presented during a meeting of MEDCAC (Medicare Evidence Development and Coverage Advisory Committee) in November, and public comments submitted since May.

In March of 2008, the American Cancer Society in collaboration with the US Multi-Society Task Force on Colorectal Cancer and the American College of Radiology, included CT colonography in its updated colorectal cancer screening guidelines.

However, in October, the US Preventive Services Task Force  (USPSTF) found insufficent evidence to add CT colonography to their colorectal cancer screening guidelines.  They were also concerned about lifetime radiation exposure and the ability of CT colonography to find problems outside the colon that needed further, perhaps unnecessary, medical testing.

The results of a randomized national study of CT colonography were published in the New England Journal of Medicine in September 2008 showing no difference between optical colonoscopy and CTC in finding large polyps, uncovering 90 percent of those over 10 millimeters.  CTC was less sensitive for intermediate-sized lesions, finding 78 percent of them.

Based on the revised ACS guidelines and C3′s policy that reimbursement should include all ACS recommended screening tests, C3: Colorectal Cancer Coalition submitted comments  in June 2008 calling for Medicare payment for CT colonography during the comment period for the National Coverage Analysis on Computed Tomography Colonography.

Medicare should provide coverage for CTC that is consistent with all colorectal cancer screening tests recommended by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Their recommendation includes tests such as fecal occult blood tests (FOBTs), barium enemas, flexible sigmoidoscopy and colonoscopy which are already covered under Medicare.

During the initial comment period in May and June of 2008, CMS received 100 comments. Of the 100, 79 supported payment for CT colonography, 20 opposed it, and 1 commentor offered no opinion.  While many comments came from professional societies and medical professionals, one-third (34) were submitted by the general public including patients, screening candidates, their families and other people with an interest in the prevention and early detection of colorectal cancer.  Of those, 32 supported paying for CTC, 1 opposed it, and 1 person offered no opinion.  A full discussion of the content of those comments is part of the material supporting the proposed coverage decision.

Medicare now covers colorectal cancer screening for beneficiaries over 50 with fecal occult blood testing, flexible sigmoidoscopy, barium enema, and colonoscopy.  There is no minimum age for screening colonoscopy.

Since Medicare began providing full coverage of screening colonoscopies in 2001, there has been a significant increase in the rates of screening colonoscopies for people covered by Medicare.  There are also been an increase in the percentage of Medicare patients whose cancer was detected at an early, highly curable stage I.