Evaluation of the Lung Cancer Risks at Which to Screen Ever- and Never-Smokers: Screening Rules Applied to the PLCO and NLST Cohorts
Evaluation of the Lung Cancer Risks at Which to Screen Ever- and Never-Smokers: Screening Rules Applied to the PLCO and NLST Cohorts
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DOI：
10.1371/journal.pmed.1001764
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发表时间：
2014-12-01
期刊：
影响因子：
15.8
通讯作者：
Berg, Christine D.
中科院分区：
文献类型：
--
作者：
Tammemaegi, Martin C.;Church, Timothy R.;Berg, Christine D.
背景：肺癌的风险，个人应筛选与计算机断层扫描（CT）肺癌尚未决定。这项研究的目的是确定一个风险阈值，选择个人进行筛查，比较其效率与美国预防服务工作组（USPSTF）的标准，以确定筛选，并确定是否从不吸烟者应进行筛选。肺癌的风险比较吸烟者之间的年龄55-64岁和>= 65-80岁。方法和结果：应用PLCOm 2012模型，一个基于6年肺癌发病率的模型，我们确定了国家肺筛查试验的风险阈值，（NLST，n = 53，CT组肺癌死亡率始终低于胸部X线（CXR）组。我们评估了干预组（CXR）的USPSTF和PLCOm 2012风险标准吸烟者（n = 37，327）的前列腺癌、肺癌、结直肠癌和卵巢癌筛查试验（PLCO）。评估了筛选的吸烟者人数，以及识别肺癌的敏感性、特异性和阳性预测值（PPV）。一种改良模型（PLCOall 2014）评价了从不吸烟者的风险。在PLCOm 2012风险>= 0.0151（风险的第65百分位数）时，NLST CT组的死亡率始终低于CXR组的死亡率。在第65至100百分位风险组中，预防一例肺癌死亡所需的筛查人数为255人。（95% CI 143至1，184），第30至<65百分位风险组为963（95%CI 291至-754）;由于没有肺癌死亡病例，无法估计<30百分位风险组中需要筛查的人数。当应用于PLCO干预组吸烟者时，与USPSTF标准相比，PLCOm 2012风险>= 0.0151阈值选择的筛查个体减少8.8%（p < 0.001），但识别出的肺癌增加了12.4%（敏感性80.1% [95% CI 76.8%-83.0%]对比71.2% [95% CI 67.6%-74.6%]，p < 0.001），有更少的假阳性（特异性66.2% [95% CI 65.7%-66.7%]对比62.7% [95% CI 62.2%-63.1%]，p < 0.001），PPV较高（4.2% [95% CI 3.9%-4.6%] vs 3.4% [95% CI 3.1%-3.7%]，p < 0.001）。总体而言，根据USPSTF标准筛选的个体中有26%的风险低于PLCOm 2012风险> 0.0151的阈值。在戒烟时间> 15年的PLCO前吸烟者中，8.5%的PLCOm 2012风险>= 0.0151。65，711名PLCO从不吸烟者的PLCOm 2012风险均不大于0.0151。年龄≥ 65-80岁的PLCO吸烟者患肺癌的风险显著高于55-64岁的吸烟者。结论：USPSTF标准CT筛查包括一些低风险的个人和排除一些高风险的个人。使用PLCOm 2012风险>= 0.0151标准可以提高筛查效率。目前，不吸烟者不应接受筛查。年龄>= 65-80岁的吸烟者是一个高危人群，他们可能会从筛查中受益。
Background: Lung cancer risks at which individuals should be screened with computed tomography (CT) for lung cancer are undecided. This study's objectives are to identify a risk threshold for selecting individuals for screening, to compare its efficiency with the U.S. Preventive Services Task Force (USPSTF) criteria for identifying screenees, and to determine whether never-smokers should be screened. Lung cancer risks are compared between smokers aged 55-64 and >= 65-80 y.Methods and Findings: Applying the PLCOm2012 model, a model based on 6-y lung cancer incidence, we identified the risk threshold above which National Lung Screening Trial (NLST, n = 53,452) CT arm lung cancer mortality rates were consistently lower than rates in the chest X-ray (CXR) arm. We evaluated the USPSTF and PLCOm2012 risk criteria in intervention arm (CXR) smokers (n = 37,327) of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO). The numbers of smokers selected for screening, and the sensitivities, specificities, and positive predictive values (PPVs) for identifying lung cancers were assessed. A modified model (PLCOall2014) evaluated risks in never-smokers. At PLCOm2012 risk >= 0.0151, the 65th percentile of risk, the NLST CT arm mortality rates are consistently below the CXR arm's rates. The number needed to screen to prevent one lung cancer death in the 65th to 100th percentile risk group is 255 (95% CI 143 to 1,184), and in the 30th to < 65th percentile risk group is 963 (95% CI 291 to -754); the number needed to screen could not be estimated in the < 30th percentile risk group because of absence of lung cancer deaths. When applied to PLCO intervention arm smokers, compared to the USPSTF criteria, the PLCOm2012 risk >= 0.0151 threshold selected 8.8% fewer individuals for screening (p < 0.001) but identified 12.4% more lung cancers (sensitivity 80.1% [95% CI 76.8%-83.0%] versus 71.2% [95% CI 67.6%-74.6%], p < 0.001), had fewer false-positives (specificity 66.2% [95% CI 65.7%-66.7%] versus 62.7% [95% CI 62.2%-63.1%], p < 0.001), and had higher PPV (4.2% [95% CI 3.9%-4.6%] versus 3.4% [95% CI 3.1%-3.7%], p < 0.001). In total, 26% of individuals selected for screening based on USPSTF criteria had risks below the threshold PLCOm2012 risk > 0.0151. Of PLCO former smokers with quit time > 15 y, 8.5% had PLCOm2012 risk >= 0.0151. None of 65,711 PLCO never-smokers had PLCOm2012 risk >= 0.0151. Risks and lung cancers were significantly greater in PLCO smokers aged >= 65-80 y than in those aged 55-64 y. This study omitted cost-effectiveness analysis.Conclusions: The USPSTF criteria for CT screening include some low-risk individuals and exclude some high-risk individuals. Use of the PLCOm2012 risk >= 0.0151 criterion can improve screening efficiency. Currently, never-smokers should not be screened. Smokers aged >= 65-80 y are a high-risk group who may benefit from screening.