Absolute lung cancer risk increases among individuals with >15 quit-years: Analyses to inform the update of the American Cancer Society lung cancer screening guidelines

Assessing Lung Cancer Screening Eligibility of Patients With Lung Cancer in the Boston Lung Cancer Study: An Analysis of 7186 Lung Cancer Cases

BACKGROUND

This study sought to evaluate the proportion of patients with lung cancer who would have qualified for lung cancer screening under different eligibility criteria in the Boston Lung Cancer Study (BLCS).

METHODS

BLCS participants with a diagnosis of lung cancer from 1992 to 2024 were identified for analysis. The study evaluated the proportion of patients who would have qualified for screening under the 2021 US Preventive Services Task Force (USPSTF) (age 50-80 years, ≥20-pack-years, <15 quit-years), 20-year duration (age 50-80 years, ≥20-year smoking duration, <15 quit-years), American Cancer Society (age 50-80 years, ≥20-pack-years), National Comprehensive Cancer Network (NCCN) category A (age ≥50 years, ≥20-pack-years), and NCCN category AB (age ≥50 years, ≥20-pack-years or ≥20-year smoking duration) guidelines. The study also evaluated the proportion of patients with a smoking history who were ineligible for screening under the aforementioned guidelines and who had a PLCOm2012 risk score ≥1.0% (referred to as the "PLCOm2012 1.0% risk threshold"). The PLCOm2012 model is a lung cancer risk prediction model developed using data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.

RESULTS

Of 7186 patients meeting inclusion criteria, 33.4% currently smoked, 52.1% formerly smoked, and 14.5% had never smoked. Among these patients, 46.1% met the USPSTF guideline, 48.9% met the 20-year duration guideline, 61.0% met the American Cancer Society guideline, 66.1% met the NCCN category A guideline, and 71.7% met the NCCN category AB guideline. Although the PLCOm2012 1.0% risk threshold identified 52.2% of patients with a smoking history who were ineligible for screening under the USPSTF guideline, the PLCOm2012 1.0% risk threshold excluded the majority of patients with <20 pack-years.

CONCLUSIONS

In this analysis of 7186 patients with lung cancer, only 46.1% would have met the USPSTF guideline. Including a smoking duration criterion and removing the 15-years-since-quitting criterion from the USPSTF guideline would increase the proportion of patients eligible for screening.

Estimating the Burden of False Positives and Implementation Costs From Adding Multiple Single Cancer Tests or a Single Multi-Cancer Test to Standard-Of-Care Screening

BACKGROUND

Blood-based tests present a promising strategy to enhance cancer screening through two distinct approaches. In the traditional paradigm of "one test for one cancer", single-cancer early detection (SCED) tests a feature high true positive rate (TPR) for individual cancers, but high false-positive rate (FPR). Whereas multi-cancer early detection (MCED) tests simultaneously target multiple cancers with one low FPR, offering a new "one test for multiple cancers" approach. However, comparing these two approaches is inherently non-intuitive. We developed a framework for evaluating and comparing the efficiency and downstream costs of these two blood-based screening approaches at the general population level.

METHODS

We developed two hypothetical screening systems to evaluate the performance efficiency of each blood-based screening approach. The "SCED-10" system featured 10 hypothetical SCED tests, each targeting one cancer type; the "MCED-10" system included a single hypothetical MCED test targeting the same 10 cancer types. We estimated the number of cancers detected, cumulative false positives, and associated costs of obligated testing for positive results for each system over 1 year when added to existing USPSTF-recommended cancer screening for 100,000 US adults aged 50-79.

RESULTS

Compared with MCED-10, SCED-10 detected 1.4× more cancers (412 vs. 298), but had 188× more diagnostic investigations in cancer-free people (93,289 vs. 497), lower efficiency (positive predictive value: 0.44% vs. 38%; number needed to screen: 2062 vs. 334), 3.4× the cost ($329 M vs. $98 M), and 150× higher cumulative burden of false positives per annual round of screening (18 vs. 0.12).

CONCLUSIONS

A screening system for average-risk individuals using multiple SCED tests has a higher rate of false positives and associated costs compared with a single MCED test. A set of SCED tests with the same sensitivity as standard-of-care screening detects only modestly more cancers than an MCED test limited to the same set of cancers.

Estimated proportion of cancer deaths not addressed by current cancer screening efforts in the United States

BackgroundIt is unclear what proportion of the population cancer burden is covered by current implementation of USPSTF A/B screening recommendations.ObjectiveWe estimated the proportion of all US cancer deaths caused by cancer types not covered by screening recommendations or cancer types covered but unaddressed by current implementation.MethodsWe used 2018-2019 National Center for Health Statistics mortality data, Surveillance, Epidemiology, and End Results registries incidence-based mortality data, and published estimates of screening eligibility and receipt.ResultsOf approximately 600,000 annual cancer deaths in the US, 31.4% were from screenable cancer types, including colorectal, female breast, cervical, and smoking-associated lung cancers. Further accounting for the low receipt of lung cancer screening reduced the proportion to 17.4%; accounting for receipt of other screening reduced it to 12.8%. Thus, we estimated that current implementation of recommended screening may not address as much as 87.2% of cancer deaths-including 30.4% from individually uncommon cancer types unlikely ever to be covered by dedicated screening.ConclusionsThe large proportion of cancer deaths unaddressed by current screening represents a major opportunity for improved implementation of current approaches, as well as new multi-cancer screening technologies.

The American Cancer Society National Lung Cancer Roundtable strategic plan: Provider engagement and outreach

The American Cancer Society National Lung Cancer Roundtable strategic plan for provider engagement and outreach addresses barriers to the uptake of lung cancer screening, including lack of provider awareness and guideline knowledge about screening, concerns about potential harms from false-positive examinations, lack of time to implement workflows within busy primary care practices, insufficient infrastructure and administrative support to manage a screening program and patient follow-up, and implicit bias based on sex, race/ethnicity, social class, and smoking status. Strategies to facilitate screening include educational programming, clinical reminder systems within the electronic medical record, decision support aids, and tools to track nodules that can be implemented across a diversity of practices and health care organizational structures. PLAIN LANGUAGE SUMMARY: The American Cancer Society National Lung Cancer Roundtable strategic plan to reduce deaths from lung cancer includes strategies designed to support health care professionals, to better understand lung cancer screening, and to support adults who are eligible for lung cancer screening by providing counseling, referral, and follow-up.

The Development and Performance of Alternative Criteria for Lung Cancer Screening

BACKGROUND

The recommendation for lung cancer screening (LCS) developed by the U.S. Preventive Services Task Force (USPSTF) may exclude some high-benefit people.

OBJECTIVE

To determine whether alternative criteria can identify these high-benefit people.

DESIGN

Model-based projections.

SETTING

United States.

PARTICIPANTS

People from the 1997-2014 National Health Interview Survey (NHIS) to develop alternative criteria using fast-and-frugal tree algorithms and from the 2014-2018 NHIS and the 2022 Behavioral Risk Factor Surveillance System for comparisons of USPSTF criteria versus alternative criteria.

MEASUREMENTS

Life-years gained from LCS were estimated using the life-years gained from screening computed tomography (LYFS-CT) model. "High-benefit" was defined as gaining an average of at least 16.2 days of life from 3 annual screenings, which reflects high lung cancer risk and substantial life gains if lung cancer is detected by screening.

RESULTS

The final alternative criteria were 1) people who smoked any amount each year for at least 40 years, or 2) people aged 60 to 80 years with at least 40 pack-years of smoking. The USPSTF and alternative criteria selected similar numbers of people for LCS. Compared with the USPSTF criteria, the alternative criteria had higher sensitivity (91% vs. 78%; P < 0.001) and specificity (86% vs. 84%; P < 0.001) for identifying high-benefit people. For racial and ethnic minorities, the alternative criteria provided greater gains in sensitivity than the USPSTF criteria (Black: 83% vs. 56% [P < 0.001]; Hispanic: 95% vs. 73% [P = 0.086]; Asian: 94% vs. 68% [P = 0.171]) at similar specificity. The alternative criteria identify high-risk, high-benefit groups excluded by the USPSTF criteria (those with a smoking duration of ≥40 years but <20 pack-years and a quit history of >15 years), many of whom are members of racial and ethnic minorities.

LIMITATION

The results were based on model projections.

CONCLUSION

These results suggest that simple alternative LCS criteria can identify substantially more high-benefit people, especially in some racial and ethnic groups.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs Lung Precision Oncology Program.

Disparities across the continuum of lung cancer care: a review of recent literature

PURPOSE OF REVIEW

Lung cancer remains the leading cause of cancer mortality worldwide. Health disparities have long been noted in lung cancer incidence and survival and persist across the continuum of care. Understanding the gaps in care that arise from disparities in lung cancer risk, screening, treatment, and survivorship are essential to guiding efforts to achieve equitable care.

RECENT FINDINGS

Recent literature continues to show that Black people, women, and people who experience socioeconomic disadvantage or live in rural areas experience disparities throughout the spectrum of lung cancer care. Contributing factors include structural racism, lower education level and health literacy, insurance type, healthcare facility accessibility, inhaled carcinogen exposure, and unmet social needs. Promising strategies to improve lung cancer care equity include policy to reduce exposure to tobacco smoke and harmful pollutants, more inclusive lung cancer screening eligibility criteria, improved access and patient navigation in lung cancer screening, diagnosis and treatment, more deliberate offering of appropriate surgical and medical treatments, and improved availability of survivorship and palliative care.

SUMMARY

Given ongoing disparities in lung cancer care, research to determine best practices for narrowing these gaps and to guide policy change are an essential focus of future lung cancer research.

Updated American Cancer Society lung cancer screening guidelines: The new guidelines offer expanded criteria recommended for lung cancer screening based on age, smoking status, and smoking history

This news section offers Cancer readers timely information on events, public policy analysis, topical issues, and personalities. In this issue, updated American Cancer Society lung cancer screening guidelines focus on expanded criteria based on age, smoking status, and smoking history. In addition, one new study finds that telehealth visits for cancer care grew continuously from 2020 to 2021 without any duplicative care, and another study interviewed both patients with cancer and physicians to better understand their needs and challenges when receiving or returning unanticipated secondary findings on tumor genomic tests.

Screening for lung cancer: 2023 guideline update from the American Cancer Society

Lung cancer is the leading cause of mortality and person-years of life lost from cancer among US men and women. Early detection has been shown to be associated with reduced lung cancer mortality. Our objective was to update the American Cancer Society (ACS) 2013 lung cancer screening (LCS) guideline for adults at high risk for lung cancer. The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer due to a history of smoking. The ACS Guideline Development Group (GDG) utilized a systematic review of the LCS literature commissioned for the US Preventive Services Task Force 2021 LCS recommendation update; a second systematic review of lung cancer risk associated with years since quitting smoking (YSQ); literature published since 2021; two Cancer Intervention and Surveillance Modeling Network-validated lung cancer models to assess the benefits and harms of screening; an epidemiologic and modeling analysis examining the effect of YSQ and aging on lung cancer risk; and an updated analysis of benefit-to-radiation-risk ratios from LCS and follow-up examinations. The GDG also examined disease burden data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. The GDG judged that the overall evidence was moderate and sufficient to support a strong recommendation for screening individuals who meet the eligibility criteria. LCS in men and women aged 50-80 years is associated with a reduction in lung cancer deaths across a range of study designs, and inferential evidence supports LCS for men and women older than 80 years who are in good health. The ACS recommends annual LCS with low-dose computed tomography for asymptomatic individuals aged 50-80 years who currently smoke or formerly smoked and have a ≥20 pack-year smoking history (strong recommendation, moderate quality of evidence). Before the decision is made to initiate LCS, individuals should engage in a shared decision-making discussion with a qualified health professional. For individuals who formerly smoked, the number of YSQ is not an eligibility criterion to begin or to stop screening. Individuals who currently smoke should receive counseling to quit and be connected to cessation resources. Individuals with comorbid conditions that substantially limit life expectancy should not be screened. These recommendations should be considered by health care providers and adults at high risk for lung cancer in discussions about LCS. If fully implemented, these recommendations have a high likelihood of significantly reducing death and suffering from lung cancer in the United States.

Assessing the impact of increasing lung screening eligibility by relaxing the maximum years-since-quit threshold: A simulation modeling study

BACKGROUND

In 2021, the US Preventive Services Task Force expanded its lung screening recommendation to include persons aged 50-80 years who had ever smoked and had at least 20 pack-years of exposure and less than 15 years since quitting (YSQ). However, studies have suggested that screening persons who formerly smoked with longer YSQ could be beneficial.

METHODS

The authors used two validated lung cancer models to assess the benefits and harms of screening using various YSQ thresholds (10, 15, 20, 25, 30, and no YSQ) and the age at which screening was stopped. The impact of enforcing the YSQ criterion only at entry, but not at exit, also was evaluated. Outcomes included the number of screens, the percentage ever screened, screening benefits (lung cancer deaths averted, life-years gained), and harms (false-positive tests, overdiagnosed cases, radiation-induced lung cancer deaths). Sensitivity analyses were conducted to evaluate the effect of restricting screening to those who had at least 5 years of life expectancy.

RESULTS

As the YSQ criterion was relaxed, the number of screens and the benefits and harms of screening increased. Raising the age at which to stop screening age resulted in additional benefits but with more overdiagnosis, as expected, because screening among those older than 80 years increased. Limiting screening to those who had at least 5 years of life expectancy would maintain most of the benefits while considerably reducing the harms.

CONCLUSIONS

Expanding screening to persons who formerly smoked and have greater than 15 YSQ would result in considerable increases in deaths averted and life-years gained. Although additional harms would occur, these could be moderated by ensuring that screening is restricted to only those with reasonable life expectancy.