Computed Tomography Colonography (CTC)

CMS covers colorectal cancer screening for average risk individuals age 50 and older using fecal occult blood testing, sigmoidoscopy, colonoscopy, and barium enema (42 CFR 410.37). On March 5, 2008, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology issued new cancer screening guidelines, including a recommendation that computed tomography colonography (CTC) be considered an acceptable option for colorectal cancer screening for such individuals. CTC, also referred to as virtual colonoscopy, uses computed tomography (CT) to acquire images and advanced 2-dimensional (3D) -image display techniques for interpretation. Neither the Medicare law nor the regulations identify the CTC test as a possible coverage option under the colorectal cancer screening benefit. However, under 42 CFR 410.37(a)(1), CMS is allowed to use the NCD process to determine coverage of other types of colorectal cancer screening tests that are not specifically identified in the law or regulations as it determines to be appropriate, in consultation with appropriate organizations.

September 26, 2008

October 15, 2008

November 12, 2008

November 17, 2008

November 21, 2008

February 2, 2009

Barbara McNeil, MD PhD, Chair
Steve Pearson, MD, MSC, Vice-Chair
Steve E. Phurrough, MD, MPA, Coverage and Analysis Group
Maria Ellis, Executive Secretary

7:30 – 8:00 AM

8:00 – 8:15AM

8:15- 8:30 AM

8:30 – 9:15 AM

9:15 – 9:45 AM

9:45 –10:15 AM

10:15 – 10:30 AM

10:30 – 11:15 AM

Public attendees, who have contacted the executive secretary prior to the meeting, will address the panel and present information relevant to the agenda. Speakers are asked to state whether or not they have any financial involvement with manufacturers of any products being discussed or with their competitors and who funded their travel to this meeting.

11:15 – 11:35 AM

Public Attendees who wish to address the panel will be given that opportunity

11:35 – 12:35 PM

12:35 – 1:35 PM

1:35 – 2:45 PM

2:45 – 3:30 PM

The Chairperson will ask each panel member to state his or her position on the voting questions

3:30 – 4:25 PM

4:25 – 4:30 PM

4:30 PM

Download meeting minutes [PDF, 40KB].

MEDCAC Questions
Screening Computed Tomography Colonography (CTC) for Colorectal Cancer (CRC) for Average Risk Individuals

Use the following scale response for each of the questions below.

1. How confident are you that there is sufficient evidence to determine the sensitivity and specificity of screening CTC using at least 16 slice scanners for average risk individuals compared to optical colonoscopy for:
   

   1. Polyps < 6 mm
      
   2. Polyps 6 to < 10mm
      
   3. Polyps ≥ 10 mm

2. How confident are you that there is sufficient evidence to determine the health benefits of screening CTC using at least 16 slice scanners for average risk individuals compared to optical colonoscopy for:
   

   1. Polyps < 6 mm
      
   2. Polyps 6 to < 10mm
      
   3. Polyps ≥ 10 mm

3. How confident are you that previous evidence and modeling for the treatment of polyps discovered using other screening modalities can be applied to polyps discovered using screening CTC?

4. Based on the following discussion questions, how confident are you that the evidence demonstrates that screening CTC results in a net health benefit for Medicare beneficiaries similar to optical colonoscopy? (Net health benefits include the decrease in morbidity and mortality from the identification and removal of polyps balanced with the risks of the procedure and the identification of extracolonic abnormalities. It does not include costs.)

   Discussion questions:
   

   1. Does the health benefit depend upon polyp size, referral for colonoscopy and/or interval before subsequent screening? If so, what does the evidence demonstrate to be the appropriate recommendations for these factors?

      Note: All identified polyps are typically removed during optical colonoscopy regardless of their size. Guidelines for CTC must determine whether to refer all polyps or only those of certain sizes.

   2. Does the health benefit depend on the scanner resolution? If so, what does the evidence demonstrate to be the lowest resolution that should be used?

   3. Does the health benefit depend upon the skills of the individual performing and interpreting the screening CTC? What should be the minimal training and experience?

   4. How should extracolonic findings of CTC screening be reported and treated?

5. At the current Medicare prices, how confident are you that CTC has a similar ratio of cost per LYS (Life Years Saved) as optical colonoscopy? (Note: Interval for CTC screening and referrals for follow up by polyp size will be entered into the CEA modeling.)

6. How confident are you that the evidence demonstrates that the use of CTC screening in the average risk Medicare population will increase overall colorectal cancer screening rates in that population?

7. How confident are you that there is sufficient evidence to determine the appropriate CTC guidelines for referral for polyp removal and for frequency of screening?

Discussion question:
a. How can adherence to CTC guidelines and compliance with referrals for optical colonoscopy be monitored and maximized?

Download scoresheet [PDF, 77KB].