Young Robert P, Ward Ralph C, Scott Raewyn J, Silvestri Gerard A
Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; and.
Medical University of South Carolina, Charleston, South Carolina.
Ann Am Thorac Soc. 2025 Sep;22(9):1409-1418. doi: 10.1513/AnnalsATS.202411-1235OC.
Current eligibility criteria for lung cancer (LC) screening are derived from randomized controlled trials and largely based on age and smoking history. However, the individualized benefits of screening are highly variable and may be affected by the presence of coexisting comorbid disease, including diabetes mellitus (DM). This study examines differences in screening outcomes for those with or without DM. This was a secondary analysis of 53,452 high-risk subjects from the National Lung Screening Trial and compared outcomes after screening with computed tomography (CT) or chest radiography according to DM status. Models of LC mortality were derived after adjustment, and LC rate ratios (per 1,000 person-years), including 95% confidence intervals (95% CIs), were examined according to screening arm and DM status. Compared with those without DM, subjects with DM ( = 5,174; 9.7%) had twofold greater baseline prevalence of cardiovascular comorbidity ( < 0.0001), twofold greater non-LC mortality ( < 0.0001), and greater LC lethality ( = 0.02), with more later-stage lung cancer ( = 0.04). We found comparable stage shift and surgical rates favoring the CT arm in both DM and non-DM subgroups, but LC mortality was higher in the CT arm for subjects with DM (2.2% vs. 2.1%), whereas for subjects without DM, it was lower (1.6% vs. 2.0%). However, the unadjusted value for the interaction between DM status and screening arm was not significant ( = 0.28). In a competing-risk proportional hazards model for LC mortality adjusted for relevant risk factors, the non-DM group had a significant estimated screening benefit (hazard ratio, 0.82; 95% CI, 0.72, 0.94; = 0.003), whereas the DM group did not (hazard ratio, 1.03; 95% CI, 0.71, 1.50; = 0.88). However, the interaction between DM status and screening arm was again not significant ( = 0.27), indicating no overall screening difference according to DM status. Those reporting DM experienced more advanced LC, greater LC lethality, and greater non-LC mortality, whereas the benefits of CT-based screening remain unclear. Limitations from underpowering, lack of DM severity data, and older treatment approaches may have contributed to inconclusive results, and larger studies are warranted to better examine the effects of comorbid DM on current LC screening outcomes.
目前肺癌（LC）筛查的资格标准源自随机对照试验，主要基于年龄和吸烟史。然而，筛查的个体获益差异很大，可能会受到并存的合并症影响，包括糖尿病（DM）。本研究探讨了患有或未患有DM的人群在筛查结果上的差异。这是对来自国家肺癌筛查试验的53452名高危受试者的二次分析，根据DM状态比较了计算机断层扫描（CT）或胸部X线摄影筛查后的结果。调整后得出LC死亡率模型，并根据筛查组和DM状态检查LC发病率比（每1000人年），包括95%置信区间（95%CI）。与未患DM的人群相比，患有DM的受试者（n = 5174；9.7%）心血管合并症的基线患病率高出两倍（P < 0.0001），非LC死亡率高出两倍（P < 0.0001），且LC致死率更高（P = 0.02），晚期肺癌更多（P = 0.04）。我们发现在DM和非DM亚组中，CT组在分期转移和手术率方面具有相似优势，但患有DM的受试者中CT组的LC死亡率更高（2.2%对2.1%），而未患DM的受试者中CT组的LC死亡率更低（1.6%对2.0%）。然而，DM状态与筛查组之间交互作用的未调整P值不显著（P = 0.28）。在针对LC死亡率的竞争风险比例风险模型中，对相关风险因素进行调整后，非DM组有显著的筛查获益估计值（风险比，0.82；95%CI，0.72，0.94；P = 0.003），而DM组没有（风险比，1.03；95%CI，0.71，1.50；P = 0.88）。然而，DM状态与筛查组之间的交互作用再次不显著（P = 0.27），表明根据DM状态总体筛查无差异。报告患有DM的人群经历了更晚期的LC、更高的LC致死率和更高的非LC死亡率，而基于CT筛查的获益仍不明确。样本量不足、缺乏DM严重程度数据以及治疗方法较陈旧等局限性可能导致了结果不明确，需要更大规模的研究来更好地探讨合并DM对当前LC筛查结果的影响。
