the Medicare Evidence Development & Coverage Advisory Committee

 (MEDCAC) is both disappointing and discouraging. Its ruling, which will likely lead to non-coverage of lung cancer screening with low dose CT scans for Medicare and Medicaid beneficiaries, will inhibit our ability to make a dent in reducing the negative impact of the number 1 cancer killer in the US, and will have unattended health disparity consequences.

In regards to health disparity, under rules of the Patient Protection Affordable Care Act (ACA), private insurers are required to cover effective prevention measures graded A or B by the US Preventative Services Task Force (USPSTF) as part of an Essential Health Benefit. The USPSTF gave lung cancer screening for high risk patients with low dose CT a grade B. Therefore, under the rules of the ACA, private insurers will be required to cover patients aged 55-64. Centers for Medicare and Medicaid (CMS) beneficiaries without private insurance will not be able to obtain the same benefits of lung cancer screening.

I do understand the worries of MEDCAC, specifically:

		Lack of evidence based oversight (ala colonoscopy)

I believe an alternative final ruling should approve CMS coverage of lung cancer screening with low dose CT with the following caveats that would address the committees concerns:

		A lung cancer screening program that is repaid by Medicare can only be reimbursed if it fits CMS criteria for quality and comprehensiveness (e.g. specific low dose CT specifications, multidisciplinary oversight, smoking cessation counseling, upfront selection screening for USPSTF criteria, communication with PCP and patient, Continuous Quality Improvement oversight, etc.)

		Screening limited to centers that have the above resources, but encourage connection to rural and under-resourced centers through telemedicine

		Specific measures to prevent indication creep

Articles

The MEDCAC ruling will likely lead to non-coverage of lung cancer screening with low dose CT scans for Medicare and Medicaid beneficiaries.

MEDCAC Ruling on Lung Cancer Screening

The section of General Thoracic Surgery at UC Davis is offering Robotic Thoracic Surgery to further enhance our top regional minimally invasive thoracic surgery program.  

	Robotic surgery is performed in much the same way that minimally invasive thoracic surgery (VATS) is performed.  It involves the use of small incisions, a video camera and a surgical robot.  The surgical robot is under the control of your surgeon at all times.  One of the many advantages of the surgical robot is the ability to have wristed articulation inside the chest, almost like having a surgeon’s hand inside your chest (without having a large incision).  The robot also provides exceptional optics, surgeon control of all instruments and is ideal for visualization in tight spaces like the middle of the chest.

  Additionally, robotic lung resection is associated with a shorter need for narcotic pain medication after surgery and an earlier return to usual activities when it is compared to traditional VATS lung resections.

  When compared to VATS, robotic surgery has been found to have similar complication and death rates, as well as similar long-term survival for cancer patients undergoing cancer resections.

	For what surgeries is the robot being used?

	We are currently using the surgical robot for:

		Mediastinal tumors (tumor in the middle

		Lung lobectomy (removal of parts of the lung)

	The UC Davis Robotic Thoracic Surgery Program offers unprecedented new value and quality to our patients

			Cerfolio EJ, Bryan AS, Minnich DJ.  Operative techniques in robotic thoracic surgery for inferior or posterior mediastinal pathology.  . J Thor and CV Surgery 2012; 143 (5) 1138-43.

			Louie BE, FarivarAS, Aye RW et al. Early Experience with Robotic Lung Resection Results in Similar Operative Outcomes and Morbiditiy When Compared with Matched Video-Assisted Thoracoscopic Surgery Cases.  Ann Thor Surg 2012 May Vol 93 (5) 1598-1605.

			Park BJ, Melfi F, Mussi A et al. Robotic lobectomy for non-small cell lung cancer (NSCLC): Long-term oncologic results. J Thor and CV Surgery 2012; 143 (2) 383-9.

Learn More About Robotic Thoracic Surgery Offered at UC Davis

UC Davis Comprehensive Lung Cancer Screening Program

		UC Davis CLSP is a multidisciplinary program for comprehensive lung cancer screening.  The innovative program provides low-dose chest computed tomography (LDCT) technology to detect lung cancer early in its most treatable form in those individuals at the highest risk for lung cancer.   The groundbreaking National Lung Screening Trial (NLST) clearly shows that screening with LDCT scans reduces the risk of dying from lung cancer in heavy smokers by 20% compared to screening with simple chest X-rays.  (N Engl J Med. 2011).

		The UC Davis Comprehensive Lung Cancer Screening Program addresses the recent recommendations released on July 29, 2013 by the United States Preventive Services Task Force (USPSTF) for annual LDCT scans to screen individuals who are at high risk for lung cancer.  To serve our patients in the program, we use a multidisciplinary team of Radiologists, Thoracic Surgeons, Pulmonologists, Pathologists, Medical Oncologists and Radiation Oncologists to develop a best-practice, patient-centered plan.

		      UC Davis CLSP serves a specific high-risk population for lung cancer.  This population is defined by the results of the multi-institution NLST, the USPSTF recommendations and the National Comprehensive Cancer Network (NCCN) and includes the following:

		 i.   Current or former smokers 50-80 years of age;

		ii.   Smoked the equivalent of one pack of cigarettes a day for at least 30 years;

		iii.   If a former smoker, he/she should have quit within the previous 15 years.

		i.     Current or former smokers 50-80 years of age;

		ii.    Smoked the equivalent of one pack of cigarettes a day for at least 20 years;

		iii.   Have one additional lung cancer risk factor.  Risk factors include the following:   personal lung cancer history (>5 years), family history of lung cancer (first degree relative), chronic lung disease, and carcinogen exposure (excluding second hand smoke exposure).

We will need a referral from your Primary Care Provider or PCP

		We would be happy to assist you with lung cancer screening or answer additional questions through our Radiology Department. 

Their phone number for scheduling is 916-734-0655

. The referral can be faxed to 916-703-2254.

Insurance does not currently pay for lung cancer screening, and an out-of-pocket price for the exam is $375.

		The results will be reported back to your PCP. Should an abnormality be found which requires further evaluation; our UC Davis CLSP Practitioners, including Pulmonologists and/or Thoracic Surgeons, will assist you, if your PCP wishes to consult them.

In addition if interested, we can offer you advice and help on strategies to stop smoking.

Thank you again for choosing UC Davis CLSP!

UC Davis CLSP is a multidisciplinary program for comprehensive lung cancer screening.

 Comprehensive Lung Cancer Screening at UC Davis

		Brought to you by the UC Davis Section of General Thoracic Surgery: PulmaCalc PPO is a predicted post-operative pulmonary function calculator.  This unique point of care app, is ideal for health care providers, trainees and patients interested in patient centered medicine to easily calculate predicted post-operative (PPO) pulmonary function based on known pulmonary function test (PFT) values and knowledge of the extent of anatomic lung tissue removed.

		The easy to use, intuitive interface allows the user to determine the PPO pulmonary function after segmentectomy, lobectomy or pneumonectomy, using known values for Forced Expiratory Volume in 1 second (

) and Diffusing Capacity of the Lung for Carbon Monoxide (

		For segmentectomy and lobectomy, the user may utilize the anatomic graphic feature or the slide bar to input the number of anatomic segments removed for calculation.

		For pneumonectomy a slide bar for the fraction of lung perfusion measured by quantitative radionuclide ventilation/perfusion (V/Q) scan can be used to determine 

		Additional tabs describe the role for calculating PPO pulmonary function and the evidence-based medicine behind it.

		This application is for informational purposes only and is not intended as a substitute for medical care, advice or professional services.

https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewSoftware?id=670782795&mt=8

		To trouble shoot or additional questions contact:

Brought to you by the UC Davis Section of General Thoracic Surgery: PulmaCalc PPO is a predicted post-operative pulmonary function calculator

New Point-of-Care App, PulmaCalc PPO, Predicted Post-operative Pulmonary Function Calculator

	In July 2009 a new lung cancer staging system was revealed: The 7

 edition of the Tumor/LymphNode/Metastasis (TNM) classification. The 7

 edition TNM classification is a result of the International Staging Committee (ISC) created by the International Association for the Study of Lung Cancer (IASLC), resulting in the IASLC Lung Cancer Retrospective Staging Project.

	The ISC compiled clinical data on over 100,000 patients diagnosed with NSCLC and SCLC between 1990 and 2000, making the patient population examined 20 times the size of the 1997 analysis.  All components of the staging system were considered for upgrading, with the majority of changes occurring in the T and M components.

 staging edition divided tumors into two size groups: T1 < 3cm in diameter, and T2 ≥ 3cm in diameter.  However, most thoracic surgeons and medical oncologists can anecdotally attest that the biologic behavior of node negative tumors that are 6-7cm, behave differently then 3cm node negative tumors, despite both being in the same broad T2 grouping.  The ISC confirmed this assumption.  Results suggested that new size groupings should be created of 2, 3, 5 and 7cm.  5 year survival rates for the pathologic groupings with negative nodes and no metastasis were 77% for T1 ≤ 2cm, 71% for T1 > 2cm and ≤ 3cm, 58% for T2 > 3cm and ≤ 5cm, 49% > 5cm and ≤ 7cm and 35% for T2 > 7cm.  Subsequently, the ISC recommended subclassifying T1 into T1a (≤ 2cm) and T1b (>2cm and ≤3cm) and subclassifying T2 into T2a (> 3cm but ≤ 5cm or tumor with any other T2 descriptors, but ≤ 5cm) and T2b (> 5cm but ≤ 7cm), and reclassify T2 tumors > 7cm to T3.

	No formal changes were recommended for nodal staging.  Malignant pleural effusion was reclassified to M1a.  The ISC found that extrathoracic metastasis had poorer prognosis than intrathoracic metastasis.  M1 was therefore sub-classified to M1a for additional tumors in the contralateral lung, malignant pleural and pericardial effusions, and nodular pleural dissemination, and M1b for extrathoracic metastasis.

	The new stage groupings are as follows:  T2b tumors ((> 5cm but ≤ 7cm) that are N0M0 are upstaged from IB to IIA; T2a tumors (≤ 5cm) that are N1M0 are down staged from IIB to IIA, and T4 tumors that are N0/1 are down staged to IIIA.  Restaging the patient population in the study based on the proposed 7

 TNM edition, found a pathologic 5 year survival rate 73% for IA, 58% for IB, 46% for IIA, 36% for IIB, 24% for IIIA, 9% for IIIB and 13% for IV.

 edition TNM staging system for NSCLC is an exciting accomplishment, and will help the clinician to better understand the outcomes of lung cancer and offers an exciting advance to our specialty. 

			Rami-Porta R, Crowley JJ, Goldstraw P.  The revised TNM staging system for lung cancer. 

			Rami-Porta R, Ball D, Crowley J, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. 

			Rusch VW, Crowley J, Giroux DJ, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the N descriptors in the forthcoming seventh edition of the TNM classification for lung cancer. 

			Postmus PE, Brambilla E, Chansky K, et al.  The IASLC Lung Cancer Staging Project: proposals for revision of the M descriptors in the forthcoming (seventh) edition of the TNM classification of lung cancer.  

			nbsp; Goldstraw P, Crowley J, Chansky K, et al.  The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours.  J Thorac Oncol. 2007 Aug;2(8):706-14. Erratum in: 

			Rusch VW, Asamura H, Watanabe H, et al.  The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer.  

The 7th edition TNM staging system for NSCLC is an exciting accomplishment, and will help the clinician to better understand the outcomes of lung cancer and offers an exciting advance to our specialty. 

What is the New Lung Cancer Staging System?

 is an interactive meeting of learning and support for patients, families, friends and caregivers affected by lung cancer.

		This support group is proudly sponsored by the UC Davis Comprehensive Cancer Center.

 provides a time for education, sharing and an opportunity to connect face-to-face with people who can relate the realities of lung cancer. Special guest speakers are invited to give presentations on topics of interest to patients. Educational and support materials are provided.

		For more information about this group, please contact Jena Cooreman, LCSW at 916-734-5198

		Director of Cancer Pain, Division of Pain Medicine

		Section Head of General Thoracic Surgery

Lung Cancer Surgery: When is it Necessary?

Minimally Invasive Lung Cancer Surgery: What Are We Doing Now, What’s on the Horizon?

		Associate Director of Clinical Research

		Marlene von Friederichs-Fitzwater, PhD, MPH

Personalizing Lung Cancer Therapy: How Tumor Molecular Testing Can Help Your Cancer Care

The UC Davis Lung Cancer Chat Room is an interactive meeting of learning and support for patients, families, friends and caregivers affected by lung cancer.

Introducing the UC Davis Lung Cancer Chat Room

	“What is Thoracic Surgery?” is a good question. Often times the term Thoracic Surgery is used interchangeably with Cardiothoracic Surgery, Adult Cardiac Surgery, Cardiovascular Surgery, Congenital Cardiothoracic Surgery, and General Thoracic Surgery. But for the layperson, Thoracic Surgery should be synonymous with General Thoracic Surgery.

	A General Thoracic Surgeon takes care of patients with surgical diseases of the chest, generally excluding the heart and great vessels. About 80% of Thoracic Surgery involves surgery for some sort of cancer. This includes such tumors as lung cancer (which kills more people in the United States than colon, prostate and breast cancer combined), esophageal cancer, tumors of the chest wall (rib cage, sternum, etc…) and tumors of the mediastinum, or the space around the heart.

	But a lot of Thoracic Surgery involves curing or helping people with disease processes that are not cancer related. This includes such procedures like thymectomy for Myasthenia Gravis, sympathectomy for hyperhidrosis or “sweaty palms”, first rib resection for thoracic outlet syndrome, myotomy for Achalasia, esophagectomy and reconstruction for end stage benign esophageal disease, plication of the diaphragm for diaphragm paralysis, resection of esophageal diverticulum, removal of cysts of the chest, lung transplantation, and providing tissue or biopsies of the lung and chest tissue to diagnose problems such as interstitial lung disease.

	Much of Thoracic Surgery is now done minimally invasively by using small incisions, a thin camera and high definition monitors.  This is called Video-Assisted Thorascopic Surgery or (VATS).

	A Thoracic Surgeon should always be either already board certified or in the process of being board certified by the American Board of Thoracic Surgery (ABTS). In addition to ABTS certification, many thoracic surgeons are also board certified by the American Board of Surgery (ABS). There is data that demonstrates that patients who have complex thoracic surgical disease, such as lung and esophageal cancer, have better outcomes when operated on by Thoracic Surgeons as opposed to non-Thoracic Surgeons (Birkmeyer JD et al., NEJM, 2003; Schipper PH et al., Ann Thorac Surg 2009). Also, research shows that patients may not do well after esophagectomy (removal of the esophagus) because of failure of their hospital to “rescue” them from complications (Ghaferi AA et al., Ann Surg, 2009). This fact underscores the importance that some operations should be performed by Thoracic Surgeons at high volume academic medical centers.

	So what is Thoracic Surgery? Now you know!

"What is Thoracic Surgery?" is a good question.

What is Thoracic Surgery?

Welcome to UCD ChestHealth, the official blog of UC Davis Thoracic Surgery. This exciting new outlet, the first of its kind for a UC Davis Health System clinical service, will allow patients, physicians, students, residents, allied health professionals and anyone else who is interested or curious to learn about what we do and the important and not so publicized disease processes that affect thousands of individuals each day such as Lung Cancer, Esophageal Cancer, Emphysema/COPD and Hyperhidrosis.

Most of all, this blog will help answer that age old question “What is Thoracic Surgery?” My mother asks me that question all of the time! So feel free to comment, enjoy, and please suggest content. You can contact or follow us on twitter: 

Welcome to UCD ChestHealth, the official blog of UC Davis Thoracic Surgery.

David Tom Cooke, MD, FCCP, FACS