When the Average Applies to No One: Personalized Decision Making About Potential Benefits of Lung Cancer Screening

Memorial Sloan-Kettering Cancer Center, New York, New York, United States
Annals of internal medicine (Impact Factor: 16.1). 08/2012; 157(8). DOI: 10.7326/0003-4819-157-8-201210160-00524
Source: PubMed
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    ABSTRACT: Background: Patients with chronic obstructive pulmonary disease (COPD) are at high-risk for lung cancer (LC) and represent a potential target to improve the diagnostic yield of screening programs. Objective: Develop a predictive score for LC risk for patients with COPD. Methods: The Pamplona-IELCAP LC screening study (P-IELCAP) and the Pittsburgh Lung Screening Study (PLuSS) databases were analyzed. Only patients with COPD on spirometry were included. By logistic regression we determined which factors were independently associated with LC in PLuSS and developed a COPD lung cancer screening score (COPD-LUCSS) to be validated in P-IELCAP. Results: By regression analysis, age>60, BMI<25 kg/m2, pack-years history>60, and emphysema presence were independently associated with LC diagnosis and integrated into the COPD-LUCSS that ranges from 0 to 10 points. Two COPD-LUCSS risk categories were proposed: low risk (scores 0-6) and high risk (scores 7-10). In comparison to low risk patients, in both cohorts LC risk increased 3.5 fold in the high-risk category. Conclusions: The COPD-LUCSS is a good predictor of lung cancer risk in COPD patients participating in LC screening programs. Validation in two different populations adds strengths to the findings.
    American Journal of Respiratory and Critical Care Medicine 12/2014; DOI:10.1164/rccm.201407-1210OC · 11.99 Impact Factor
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    ABSTRACT: Objective. To evaluate clinical characteristics and outcomes in incidentally detected lung cancer and in symptomatic lung cancer. Material and Methods. We designed a retrospective study including all patients undergoing pulmonary resection with a curative intention for NSCLC. They were classified into two groups according to the presence or absence of cancer-related symptoms at diagnosis in asymptomatic (ASX)-incidental diagnosis-or symptomatic. Results. Of the 593 patients, 320 (53.9%) were ASX. In 71.8% of these, diagnosis was made by chest X-ray. Patients in the ASX group were older (P = 0.007), had a higher prevalence of previous malignancy (P = 0.002), presented as a solitary nodule more frequently (P < 0.001), and were more likely to have earlier-stage disease and smaller cancers (P = 0.0001). A higher prevalence of incidental detection was observed in the last ten years (P = 0.008). Overall 5-year survival was higher for ASX (P = 0.001). Median survival times in pathological stages IIIB-IV were not significantly different. Conclusion. Incidental finding of NSCLC is not uncommon even among nonsmokers. It occurred frequently in smokers and in those with history of previous malignancy. Mortality of incidental diagnosis group was lower, but the better survival was related to the greater number of patients with earlier-stage disease.
    01/2015; 2015:287604. DOI:10.1155/2015/287604
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    ABSTRACT: Lung cancer risks at which individuals should be screened with computed tomography (CT) for lung cancer are undecided. This study's objectives are to identify a risk threshold for selecting individuals for screening, to compare its efficiency with the U.S. Preventive Services Task Force (USPSTF) criteria for identifying screenees, and to determine whether never-smokers should be screened. Lung cancer risks are compared between smokers aged 55-64 and ≥65-80 y. Applying the PLCOm2012 model, a model based on 6-y lung cancer incidence, we identified the risk threshold above which National Lung Screening Trial (NLST, n = 53,452) CT arm lung cancer mortality rates were consistently lower than rates in the chest X-ray (CXR) arm. We evaluated the USPSTF and PLCOm2012 risk criteria in intervention arm (CXR) smokers (n = 37,327) of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO). The numbers of smokers selected for screening, and the sensitivities, specificities, and positive predictive values (PPVs) for identifying lung cancers were assessed. A modified model (PLCOall2014) evaluated risks in never-smokers. At PLCOm2012 risk ≥0.0151, the 65th percentile of risk, the NLST CT arm mortality rates are consistently below the CXR arm's rates. The number needed to screen to prevent one lung cancer death in the 65th to 100th percentile risk group is 255 (95% CI 143 to 1,184), and in the 30th to <65th percentile risk group is 963 (95% CI 291 to -754); the number needed to screen could not be estimated in the <30th percentile risk group because of absence of lung cancer deaths. When applied to PLCO intervention arm smokers, compared to the USPSTF criteria, the PLCOm2012 risk ≥0.0151 threshold selected 8.8% fewer individuals for screening (p<0.001) but identified 12.4% more lung cancers (sensitivity 80.1% [95% CI 76.8%-83.0%] versus 71.2% [95% CI 67.6%-74.6%], p<0.001), had fewer false-positives (specificity 66.2% [95% CI 65.7%-66.7%] versus 62.7% [95% CI 62.2%-63.1%], p<0.001), and had higher PPV (4.2% [95% CI 3.9%-4.6%] versus 3.4% [95% CI 3.1%-3.7%], p<0.001). In total, 26% of individuals selected for screening based on USPSTF criteria had risks below the threshold PLCOm2012 risk ≥0.0151. Of PLCO former smokers with quit time >15 y, 8.5% had PLCOm2012 risk ≥0.0151. None of 65,711 PLCO never-smokers had PLCOm2012 risk ≥0.0151. Risks and lung cancers were significantly greater in PLCO smokers aged ≥65-80 y than in those aged 55-64 y. This study omitted cost-effectiveness analysis. The USPSTF criteria for CT screening include some low-risk individuals and exclude some high-risk individuals. Use of the PLCOm2012 risk ≥0.0151 criterion can improve screening efficiency. Currently, never-smokers should not be screened. Smokers aged ≥65-80 y are a high-risk group who may benefit from screening. Please see later in the article for the Editors' Summary.
    PLoS Medicine 12/2014; 11(12):e1001764. DOI:10.1371/journal.pmed.1001764 · 14.00 Impact Factor