Department of Epidemiology, University of Michigan, Ann Arbor.
Department of Biomedical Data Sciences, Stanford University, Stanford, California.
JAMA. 2021 Mar 9;325(10):988-997. doi: 10.1001/jama.2021.1077.
The US Preventive Services Task Force (USPSTF) is updating its 2013 lung cancer screening guidelines, which recommend annual screening for adults aged 55 through 80 years who have a smoking history of at least 30 pack-years and currently smoke or have quit within the past 15 years.
To inform the USPSTF guidelines by estimating the benefits and harms associated with various low-dose computed tomography (LDCT) screening strategies.
DESIGN, SETTING, AND PARTICIPANTS: Comparative simulation modeling with 4 lung cancer natural history models for individuals from the 1950 and 1960 US birth cohorts who were followed up from aged 45 through 90 years.
Screening with varying starting ages, stopping ages, and screening frequency. Eligibility criteria based on age, cumulative pack-years, and years since quitting smoking (risk factor-based) or on age and individual lung cancer risk estimation using risk prediction models with varying eligibility thresholds (risk model-based). A total of 1092 LDCT screening strategies were modeled. Full uptake and adherence were assumed for all scenarios.
Estimated lung cancer deaths averted and life-years gained (benefits) compared with no screening. Estimated lifetime number of LDCT screenings, false-positive results, biopsies, overdiagnosed cases, and radiation-related lung cancer deaths (harms).
Efficient screening programs estimated to yield the most benefits for a given number of screenings were identified. Most of the efficient risk factor-based strategies started screening at aged 50 or 55 years and stopped at aged 80 years. The 2013 USPSTF-recommended criteria were not among the efficient strategies for the 1960 US birth cohort. Annual strategies with a minimum criterion of 20 pack-years of smoking were efficient and, compared with the 2013 USPSTF-recommended criteria, were estimated to increase screening eligibility (20.6%-23.6% vs 14.1% of the population ever eligible), lung cancer deaths averted (469-558 per 100 000 vs 381 per 100 000), and life-years gained (6018-7596 per 100 000 vs 4882 per 100 000). However, these strategies were estimated to result in more false-positive test results (1.9-2.5 per person screened vs 1.9 per person screened with the USPSTF strategy), overdiagnosed lung cancer cases (83-94 per 100 000 vs 69 per 100 000), and radiation-related lung cancer deaths (29.0-42.5 per 100 000 vs 20.6 per 100 000). Risk model-based vs risk factor-based strategies were estimated to be associated with more benefits and fewer radiation-related deaths but more overdiagnosed cases.
Microsimulation modeling studies suggested that LDCT screening for lung cancer compared with no screening may increase lung cancer deaths averted and life-years gained when optimally targeted and implemented. Screening individuals at aged 50 or 55 years through aged 80 years with 20 pack-years or more of smoking exposure was estimated to result in more benefits than the 2013 USPSTF-recommended criteria and less disparity in screening eligibility by sex and race/ethnicity.
美国预防服务工作组（USPSTF）正在更新其 2013 年肺癌筛查指南，该指南建议对年龄在 55 岁至 80 岁之间、吸烟史至少 30 包年、目前仍吸烟或在过去 15 年内戒烟的成年人进行年度筛查。
通过估计各种低剂量计算机断层扫描（LDCT）筛查策略的获益和危害，为 USPSTF 指南提供信息。
设计、地点和参与者：使用 4 种针对 1950 年和 1960 年美国出生队列人群的肺癌自然史模型，对年龄从 45 岁到 90 岁的个体进行比较模拟建模。
采用不同的起始年龄、停止年龄和筛查频率进行筛查。基于年龄、累计包年数和戒烟年限（基于风险因素）或基于年龄和个体肺癌风险估计（使用不同风险阈值的风险预测模型）的资格标准。共模拟了 1092 种 LDCT 筛查策略。假设所有情况下都能充分接受和坚持筛查。
与不筛查相比，估计可避免的肺癌死亡人数和获得的生命年数（获益）。估计终生接受 LDCT 筛查次数、假阳性结果、活检、过度诊断病例和与辐射相关的肺癌死亡人数（危害）。
确定了最有效的风险因素为基础的筛查策略，这些策略预计能在给定的筛查次数内产生最大的获益。大多数有效的筛查策略起始于 50 岁或 55 岁，停止于 80 岁。2013 年 USPSTF 推荐的标准并不是针对 1960 年美国出生队列的有效策略。20 包年吸烟史的年度筛查策略是有效的，与 2013 年 USPSTF 推荐的标准相比，预计将增加筛查的可及性（20.6%-23.6%的人群符合条件，而不是 14.1%），可避免的肺癌死亡人数（10 万人中有 469-558 人，而不是 381 人），以及获得的生命年数（10 万人中有 6018-7596 人，而不是 4882 人）。然而，这些策略预计会导致更多的假阳性检测结果（每人筛查 1.9-2.5 次，而 USPSTF 策略为每人筛查 1.9 次），过度诊断的肺癌病例（每 10 万人中有 83-94 例，而不是每 10 万人中有 69 例），以及与辐射相关的肺癌死亡人数（每 10 万人中有 29.0-42.5 例，而不是每 10 万人中有 20.6 例）。基于风险模型的策略与基于风险因素的策略相比，预计会带来更多的获益和更少的与辐射相关的死亡，但会有更多的过度诊断病例。
微观模拟研究表明，与不筛查相比，LDCT 筛查肺癌可能会增加肺癌死亡人数的减少和生命年数的增加，前提是优化目标和实施。对吸烟暴露至少 20 包年、年龄在 50 岁或 55 岁至 80 岁之间的个体进行筛查，预计会带来比 2013 年 USPSTF 推荐标准更多的获益，而且在性别和种族/族裔方面的筛查可及性差距也会更小。
