Lung cancer screening based on gains in life expectancy could maximize benefits

Risk-based and life-gained-based strategies provide substantially greater life extension and death prevention than screening based on current recommendations from the U.S. Preventive Services Task Force, a study found.

Selecting candidates for lung cancer screening based on gains in life expectancy could maximize the benefits and minimize the harms of screening programs in the United States, a modeling study found.

The study assessed whether a screening program based on years of life gained may have a better balance of benefits and harms than current guidelines from the U.S. Preventive Services Task Force (USPSTF) that recommend CT screening for patients ages 55 to 80 years who have smoked within the past 15 years and have 30 or more pack-years of exposure.

Researchers from the National Cancer Institute used data from 130,964 National Health Interview Survey participants to develop and validate an individualized prediction model for overall mortality and for gains in individual life expectancy after three rounds of CT screening in patients ages 40 to 84 years who had ever smoked versus no screening. Findings from the modeling study were published Oct. 22 by Annals of Internal Medicine.

Both risk-based and life-gained-based strategies provided substantially greater life extension and death prevention than current USPSTF recommendations, the study found. Compared with risk-based selection, life-gained-based selection resulted in the greatest gains in life expectancy and identified a population of moderately high-risk smokers who would also greatly benefit from screening but would otherwise be missed by risk-based or USPSTF recommendations. Life-gained-based selection would increase the total life expectancy from CT screening (633,400 vs. 607,800 years) but prevent fewer lung cancer deaths (52,600 vs. 55,000) compared with risk-based selection.

A life-gained-based screening approach should also consider the number of prevented deaths, the balance of benefits and harms, program efficiency, and costs, the authors said. “In contrast to risk-based selection, life-gained-based selection circumvents the need for ages at initiation and cessation of screening because it naturally excludes persons with neither high enough disease risk to benefit from screening nor long enough life expectancy to gain life-years from screening, regardless of age,” they wrote. “It also explicitly identifies persons with fewer comorbidities, better performance status, and favorable benefit-harm ratios. Thus, under such a framework, guidelines need only specify a minimum gain in life expectancy relative to harms to recommend persons for screening.”

An editorial noted that the effectiveness of risk-based screening will depend on how health systems incorporate the concept into electronic health records and communicate such screenings in a patient-centered model.

“However, concerns about risk model-based recommendations not being ‘evidence-based’ should not be a barrier,” the editorial stated. “These models can greatly improve our ability to estimate benefit for individual patients and can substantially improve the effectiveness, safety, and patient-centeredness of lung cancer screening programs. Screening guidelines should strongly consider a transition to newer methods that are likely to deliver better care.”