Personalizing annual lung cancer screening for patients with chronic obstructive pulmonary disease: A decision analysis

Abstract

Background Lung cancer screening with annual chest CT is recommended for current and former smokers with ≥30+ pack-year smoking history. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of developing lung cancer and may benefit from screening at lower pack-year thresholds. Methods We used a previously validated simulation model to compare the health benefits of lung cancer screening in current and former smokers ages 55-80 with ≥30 pack-years to hypothetical programs using lower pack-year thresholds for individuals with COPD (≥20, ≥10, and ≥1 pack-years). Calibration targets for COPD prevalence and associated lung cancer risk were derived using the Framingham Offspring Study Limited Dataset. We performed sensitivity analyses to evaluate the stability of results across different rates of adherence to screening, increased competing mortality risk due to COPD, and increased surgical ineligibility in individuals with COPD. The primary outcome was projected life expectancy. Results Programs using lower pack-year thresholds for individuals with COPD yielded the highest life expectancy gains for a given number of screens. Highest life expectancy was achieved when lowering the pack-year threshold to ≥1 pack-year for individuals with COPD, which dominated all other screening strategies. These results were stable across different adherence rates to screening and increases in competing mortality risk for COPD and surgical ineligibility. Conclusion Current and former smokers with COPD may disproportionately benefit from lung cancer screening. A lower pack-year threshold for screening eligibility may benefit this high-risk patient population.

Reduced Expiratory Flow Rate among Heavy Smokers Increases Lung Cancer Risk. Results from the National Lung Screening Trial–American College of Radiology Imaging Network Cohort

“…Our results confirm that smokers with underlying airflow limitation are at greater risk of lung cancer, and this is associated with a two-to fourfold greater lung cancer incidence in screening studies (9,38). In a simulation study, Lowry and colleagues (39) examined the effect of competing causes of death in CT screening participants, and concluded that those with COPD may disproportionately benefit from lung cancer screening. However, some argue that screening patients with COPD may not necessarily translate into mortality benefit due to factors such as competing causes of premature death (40).…”

Emphysema affects the number and appearance of solitary pulmonary nodules identified in chest low-dose computed tomography: a study on high risk lung cancer screenees recruited in Silesian District

“…[16][17][18] As a result, some investigators suggested that the presence of COPD or emphysema should be considered an inclusion criterion for lung cancer screening. [17][18][19][20] In this study, we aimed to provide data to support a hypothesis that the coexistence of SPNs along with emphysema may be a susceptibility factor for SPN malignancy.…”

Use of Biomarkers in Chronic Obstructive Pulmonary Disease: Clinical Implications

“…Several cohort studies, including some lung cancer screening trials, have indicated that patients with COPD are 2-6 times more likely to develop lung cancer than those without COPD, a risk that persists even after controlling for smoking exposure [18][19][20][21] . Furthermore, lung cancer risk has been shown to be strongly dependent on the timing between COPD diagnosis and lung cancer detection, with a threefold greater risk in patients diagnosed with COPD in the previous six months as compared to those with a more than 10-year history of COPD 22 .…”

“…Concerns might exist on whether individuals with COPD and/or emphysema should be included in lung cancer screening programs, and if those diagnosed with lung cancer will eventually benefit from treatment, as this group of patients experience higher competing mortality risks, which could catalogue them as ineligible for surgical resections 18,46 . The impact of lung cancer screening has been assessed in patients with mild and moderate COPD by comparing a sample that underwent screening with a matched sample that did not.…”