Should insurance companies pay for double lung transplants for stage IV lung cancer

Yes insurers can behave poorly and peer to peer is an insult, but doctors still do crazy shit and make society pay

I want to begin this post by saying: I wish the nothing but the best to the patient, Carol, who has a diagnosis of lung cancer. I hope that our medicines are able to give her a long and rich life, and that a new discovery can eliminate this disease. This is a post about her doctors at Vanderbilt.

I also want to say that I am confident insurers can behave poorly, peer to peer is an insult, and prior auth is a broken system, but medicine has to be careful not to offer unproven and costly things to desperate people, not to waste a scare resource (donated lungs) and this story is about inappropriate care offered by transplant surgeons.

The story

Recently, on social media, a reporter made a plea for outraged people to write to the insurer Cigna. A young woman in Nashville has bilateral small cell lung cancer (which would be extensive stage), and Vanderbilt doctors said that if the disease was stable (did not spread to distant sites), she could get a double lung transplant.

Then, this week she was finally set to get the transplant, but at the 11th hour, the insurance company said no, and Vanderbilt did not proceed.

Aaron Goodman asks the key question:

Extended stage (ES) Small cell or Stage IV, non-small cell?

The original post said small cell lung cancer, and the patient said in the original post that her brother had it, and she has a mutation often found in the young.

Later, the story would change and the diagnosis would be stage IV, multifocal NSCLC, and no driver mutations (e.g. EGFR, ALK, ROS1, c-MET, exon20, KRAS, RET, TRK, HER2, BRAF, etc) would be present.

For the purpose of a medical analysis, it doesn’t matter if it is Extensive Stage (ES) small cell (SCC), or multifocal, stage IV, non driver mutation+, NSCLC— both are treated similarly when it comes to double lung transplants. Specifically: this procedure has no evidence to support it, and runs counter to biologic understanding of the disease.

Lung cancer

Lung cancer can be cured if a single spot is found in one lung, but when both lungs contain lung cancer— whether small cell or multifocal, non small cell— it is incurable. The reason is that ~100 percent of the time, there is microscopic disease outside the lung that hasn’t grown big enough to be seen on scans. Its just a matter of time before it grows, and immunosuppressant therapy may hasten that growth.

Lung transplants

Lung transplants are a brutal procedure. Often they require lifelong immunosuppression (which can fuel cancer growth). The treatment has a known fatality rate, and quality of life after transplant can be bad. Median survival after lung transplants is less than a decade when done for non-cancer purposes.

It is not clear that transplant will make this patient better off— it can even (and perhaps most likely will) hasten death.

What the insurance company did wrong

Cigna initially offered to cover the procedure, then declined at the 11th hour, and now has decided to cover it again if the patient’s cancer is still not visible elsewhere on scans. Obviously, agreeing to covering it and backing out at the last minute is despicable behavior. Cigna acted poorly by flip flopping. They should have always said no.

Case reports exist for lung transplant in NSCLC

Yes, other surgeons have done this before— unfortunately they have done it in a way that no credible data has been generated, and this procedure is still counter to medical practice, biology and evidence.

Double lung transplants for cancer should be done only as research, if at all

In medicine, we draw a distinction between research and practice. Insurers take money from everyone to provide evidence based care to all of us. That’s inherent to the social contract of insurance.

Researchers find grants to fund experimental ideas, and clear them with ethical and scientific committees. This protects patients from undue risk. IRBs don’t always do a good job but they are preferable to not having them.

Some of the people who underwent lung transplant for lung cancer may have done well, but all the selection pressures to decide who to operate on select for people who will do better than average. The question is whether they did well because of the surgery, or in spite of it.

What type of study is ideal for this?

First, I think an ethics and scientific committee should debate even doing this procedure. If they decide to, then I think step 1 is an uncontrolled phase 2 study with a futility rule for relapsed lung cancer. If relapse exceeds say 20% in 3 years, the intervention is halted. All patients need to be carefully monitored. If mortality for any reasons exceeds 40% in year 1, the study halted. These rules protect patients, while advancing new ideas.

Having said all this, I personally would not even permit the study until lung transplant can be done safer outside of cancer indications and until we have better predictive markers for patients with low propensity for distant explosive growth on immunosuppression.

Elsewhere, we have proposed other ideas for regular surgery (not transplant) in cases of metastatic cancer— but some principles can translate to this case (about growth rate of tumors).

Doctors should not criticize without knowing more

As a general rule I think this is true, but if I open a clinic offering head transplants, you could safely say that sounds bizarre, while you await more data. At the same time, if I cannot comment on this case, then crowdsourcing outrage to pressure Cigna to cover the procedure should not be done till we know more.

Do insurance companies make more money by denying procedures?

Most pundits don’t fully understand insurance companies. The affordable care act limits their profit on revenue to 20%. As such, they actually do not want to keep health care costs low. They want to grow costs over time. Currently we spend ~20% of GDP on health care, insurers want it to be 40%+ (then their 20% cut is larger). But they need to grow it slowly, over time, and in step with competitors. They don’t like one time costly things— like DLT— bc they did not budget for these in advance, but with time, they would happily pay for DLT— even if they did not extend life. There is no check in the system to halt unproven therapy in the long haul.

Inappropriate framing

In many instances the reporter frames this issue with wording that the intervention can only extend survival. That framing is false and misleading. The original sin are the doctors who offered a dying woman an unproven operation with false hope.

No winners

Ultimately, American medicine threatens to bankrupt society. We spend nearly 20% of US GDP on health care. Our path is unsustainable. Money spent on double lung transplants for metastatic lung cancer is money that could be spent on prenatal nutrition or better meals in schools.

The doctors at Vanderbilt are despicable in my opinion. They have sold a false promise to this woman. They don’t have the decency to apply for grant funding for their experimental idea, and instead want to bleed society to fund their whims.

America cannot pay for lung transplants in stage IV lung cancer— especially when they may not work, or even shorten life. Forcing insurers to cover procedures like this jeopardizes universal health care itself. It also means the organs— the lungs are squandered.

I feel ashamed to live in a country where children go to bed hungry, while people demand insurance companies pay for double lung transplants for bilateral lung cancer. Our priorities are so misplaced.

Our brains are working so poorly, it won’t be long before Vanderbilt doctors offer us a head transplant, and ask Cigna to pay.