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Risk-based lung cancer screening may save more lives than current USPSTF guidelines

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1. Risk-based lung cancer screening may save more lives than current USPSTF guidelines
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2067
URLs go live when the embargo lifts

Lung cancer screening based on individual risk has the potential to save more lives than current recommendations by the U.S. Preventive Services Task Force (USPSTF). The findings are published in Annals of Internal Medicine.

The USPSTF recommends annual lung cancer screening with low-dose computed tomography (CT) for persons aged 55 to 80 years who currently smoke or quit within the past 15 years and have at least a 30-pack-year history of cigarette smoking. These criteria may miss smokers at high risk for lung cancer who would have been selected for CT screening by individual risk calculators that more specifically account for demographic, clinical, and smoking characteristics.

Researchers from the National Cancer Institute used data from the National Health Interview Survey to compare USPSTF eligibility criteria with individualized, risk-based eligibility and estimate the effect of eligibility on lung cancer deaths preventable by screening since 2005. They found that using the Lung Cancer Risk Assessment Tool would draw in high-risk moderate smokers with a history of 20 to 29 pack-years who are currently ineligible for screening using USPSTF criteria. This approach could have prevented over 5,000 more deaths in 2015 than using the USPSTF screening criteria. Because of the U.S. population changes related to smoking between 2010 and 2015, adhering to the USPSTF criteria led to fewer ever-smokers being eligible for CT screening and fewer lung cancer deaths being averted by screening.

Media contacts: For an embargoed PDF, please contact Angela Collom. For an interview with Li C. Cheung, PhD, please contact the NCI Press Office at [email protected] or 240-760-6600.

2. Risk-based CT screening may reduce deaths from lung cancer, but is less efficient in terms of cost and quality of life-years gained
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1401
Editorial: http://annals.org/aim/article/doi/10.7326/M17-3316
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Compared to National Lung Screening Trial criteria, targeting screening those at highest risk from lung cancer mortality using a risk prediction tool may improve efficiency in terms of greater reduction in mortality from lung cancer in the short term per person screened. However, such a targeted approach does not offer substantial gains in terms of life-years saved, quality-adjusted life-years (QALYs), and cost-effectiveness. The findings are published in Annals of Internal Medicine.

Most current lung cancers screening guidelines, including those from the U.S. Preventive Services Task Force (USPSTF), use screening criteria based on findings from the National Lung Screening Trial. Therefore, screening is recommended for persons between the ages of 55 and 74 years with a smoking history of at least 30 pack-years and former smokers who had no more than 15 years of smoking abstinence. However, targeting low-dose computed tomography (LDCT) for lung cancer screening to persons at highest risk for lung cancer mortality has been suggested as a way to improve screening efficiency.

Researchers from Tufts Medical Center compared the cost-effectiveness of a risk-targeted screening strategy to that of using National Lung Screening trial (NLST) criteria by estimating the quality-adjusted life-years (QALYs) gained relative to the cost of screening with each of these strategies. While high risk patients were more likely to have lung cancer detected, and targeted screening was more likely to avert lung cancer death over the seven years of the trial, those at higher risk were also older, had greater smoking exposure, and were more likely to have a preexisting diagnosis of chronic obstructive pulmonary disease. These patients have a shorter life expectancy and a lower quality of life; this means that preventing a death in a higher-risk individual translates to fewer QALYs than preventing a death in someone at a lower risk. Moreover, LDCT screening high risk patients is also more costly because it leads to more invasive testing. Thus, applying such a risk model to target screening is unlikely to lead to substantial improvement in the cost-effectiveness of LDCT screening in terms of QALYs gained compared to the NLST criteria.

The authors of a related editorial from Memorial Sloan Kettering Cancer Center write that lung cancer is still one of the most deadly types of cancer in the U.S. and LDCT screening offers a potentially effective means to improve on that fact. Although risk-based identification of persons who should be offered screening is empirically superior to using the current cutoffs, the more pressing concern is why people, regardless of how their eligibility is defined, are not receiving the test.

Media contacts: For an embargoed PDF, please contact Angela Collom. For an interview with David Kent, MD, MS, please contact Jeremy Lechan at [email protected] or Rhonda Mann at [email protected]

3. Increased scrutiny may result in overdiagnosis of cancer and overestimation of risk factors
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2792
URLs go live when the embargo lifts

The act of observation can affect the apparent incidence of cancer, as well as the apparent risk factors for the disease. An ideas and opinions piece from H. Gilbert Welch, MD, MPH, of The Dartmouth Institute for Health Policy and Clinical Practice and Otis Brawley, MD, FACP, of the American Cancer Society, is published in Annals of Internal Medicine.

The authors point to prostate cancer as an example of scrutiny-dependent cancer. When physicians look harder for it, more cases become apparent; when they look less hard, fewer cases become apparent. Indolent prostate cancer is common, which means increased detection is likely to be overdiagnosis.

Indolent thyroid cancer, melanoma, and breast cancer are also scrutiny-dependent cancers, according to the authors; and the degree of scrutiny can also affect the assessment of risk factors. For example, The more scrutiny, the more likely that biologically indolent (low grade) cases of breast cancer are found. Relative to cancer found by women themselves, cases found by mammography, ultrasound, or MRI are more likely to be indolent. As physicians look harder, they find not only more cases of cancer, but those that are less important, or more likely to grow slowly.

This same scrutiny affects assessment of risk factors. Recent data shows that women in the highest quintile of neighborhood socioeconomic status had twice the rate of breast cancer diagnosis as women in the lowest quintile. High socioeconomic status is not likely a true independent risk factor for breast cancer. Instead, women in these neighbrohoods are more connected to health care and more likely to undergo not just mammography, but ultrasound and MRI, as well.

The authors conclude that risk factor epidemiology must shift from diagnosis to "harder" outcomes more related to the disease process. As cancer diagnosis becomes increasingly sensitive to scrutiny, those investigating the risk for cancer should focus on risk factors for death from cancer, and not just the cancer diagnosis.

Media contacts: For an embargoed PDF, please contact Angela Collom. For an interview with H. Gilbert Welch MD, MPH please contact him directly at [email protected] For an interview with Otis W. Brawley, MD, please contact Miriam Falco at [email protected]

4. Broader statin use more likely to prevent cardiovascular events
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0681
Editorial: http://annals.org/aim/article/doi/10.7326/M17-2917
URLs go live when the embargo lifts

Guidelines recommending that more persons use statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) should prevent more events than guidelines recommending use by fewer persons. The findings are published in Annals of Internal Medicine.

Researchers from Copenhagen University Hospital compared the utility of five guidelines published since 2013 for the primary prevention of ASCVD. Despite being founded on the same evidence, the five guidelines have substantial differences, including in the recommended prediction model for ASCVD and in the risk threshold and low-density lipoprotein cholesterol (LDL-C) cut point for assignment of statin use.

Researchers conducted an observational study of actual ASCVD events during 10 years followed by a modeling study to estimate the effectiveness of different guidelines in a contemporary cohort of 45,750 persons aged 40 to 75 years who did not use statins and did not have ASCVD at baseline between 2003 and 2009.

The study found that the percentage of participants eligible for statins was 44 percent by the Canadian Cardiovascular Society (CCS) guideline, 42 percent by the American College of Cardiology/American Heart Association (ACC/AHA), 40 percent by the National Institute for Health and Care Excellence (NICE), 31 percent by the U.S. Preventive Services Task Force (USPSTF), and 15 percent by ESC/EAS. The estimated percentage of ASCVD events that could have been prevented by using statins for 10 years was 34 percent for CCS, 34 percent for ACC/AHA, 32 percent for NICE, 27 percent for USPSTF, and 13 percent for the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS).

Guidelines from the ACC/AHA, CCS, or NICE should be followed rather than those from the USPSTF and ESC/EAS, the researchers concluded.

Media contacts: For an embargoed PDF, please contact Angela Collom. The author, Borge Gronne Nordestgaard, MD, DMSc, can be contacted directly at [email protected]

Also new in this issue:
Use of Immune Checkpoint Inhibitors in the Treatment of Patients with Cancer and Preexisting Autoimmune Disease
Noha Abdel-Wahab, MD, PhD; Mohsin Shah, MD; Maria A. Lopez-Olivo, MD, PhD; and Maria E. Suarez-Almazor, MD, PhD
Review
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2073
Editorial: http://annals.org/aim/article/doi/10.7326/M17-3079

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