Development and Validation of Risk Models to Select Ever-Smokers for CT Lung Cancer Screening.
Development and Validation of Risk Models to Select Ever-Smokers for CT Lung Cancer Screening.
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DOI：
10.1001/jama.2016.6255
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发表时间：
2016-06-07
期刊：
影响因子：
--
通讯作者：
Chaturvedi AK
中科院分区：
文献类型：
--
作者：
Katki HA;Kovalchik SA;Berg CD;Cheung LC;Chaturvedi AK
美国预防服务工作组(USPSTF)建议对55-80岁、吸烟至少30包且戒烟不超过15年的吸烟者进行计算机断层扫描(CT)肺癌筛查。然而，使用个性化的肺癌风险计算来选择吸烟者进行筛查可能比USPSTF目前的建议更有效和高效。基于风险的CT肺部筛查策略与USPSTF建议的模型化结果的比较。使用前列腺癌、肺癌、结直肠癌和卵巢癌筛查试验(PLCO；1993-2009)对照组中曾经吸烟者的数据，在没有CT筛查的情况下建立肺癌发病率和死亡的经验风险模型。协变量包括年龄、教育程度、性别、种族、吸烟强度/持续时间/戒烟年限、体重指数、肺癌家族史和自我报告的肺气肿。在PLCO和国家肺部筛查试验(NLST；2002-2009)的胸部放射科小组中的模型验证，以及在美国代表性样本--国家健康访谈调查(NHIS；1997-2001)中对死亡模型的额外验证。将模型应用于美国50-80岁的吸烟者(NHIS 2010-2012)，以评估CT肺部筛查基于风险的选择的结果，假设对所有吸烟者的筛查产生NLST中观察到的肺癌检测和死亡的百分比变化。每年一次的CT肺部筛查，为期3年。模型有效性：校正(模型预测病例数除以观察病例数(估计/观测))和判别(曲线下面积(AUC))。模拟筛查结果：估计可避免筛查的肺癌死亡人数、估计筛查效果(筛查所需的数目(NNS)以防止1例肺癌死亡)。肺癌发病率和死亡风险模型在PLCO和NLST中得到了很好的校准。肺癌死亡模型对50-80岁的美国吸烟者有很好的校正和区分能力(NHIS 1997-2001：估计/观察=0.94，95%CI=0.84-1.05；AUC=0.78，95%CI=0.76-0.80)。根据USPSTF的建议，模型估计有900万美国烟民有资格进行肺癌筛查，5年内46,488人(95%CI=43,924-49,053)的肺癌死亡估计为筛查可避免的(估计NNS=194，95%CI=187-201)。相比之下，基于风险的选择筛查同样数量的吸烟者(900万)，具有最高的5年肺癌风险(≥1.9%)，估计可避免20%以上的死亡(55,717人；95%CI=53,033-58,400)，并估计可将估计的NNS减少17%(NNS=162，95%CI=157-166)。在年龄在50-80岁的美国吸烟人群中，与基于USPSTF建议的模型相比，应用基于风险的肺癌CT筛查模型估计与在5年内预防更多肺癌死亡有关，同时防止1例肺癌死亡的NNS较低。
The US Preventive Services Task Force (USPSTF) recommends computed-tomography (CT) lung-cancer screening for ever-smokers ages 55-80 years who smoked at least 30 pack-years with no more than 15 years since quitting. However, selecting ever-smokers for screening using individualized lung-cancer risk calculations may be more effective and efficient than current USPSTF recommendations. Comparison of modeled outcomes from risk-based CT lung-screening strategies versus USPSTF recommendations. Empirical risk models for lung-cancer incidence and death in the absence of CT screening using data on ever-smokers from the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO; 1993-2009) control group. Covariates included age, education, sex, race, smoking intensity/duration/quit-years, Body Mass Index, family history of lung-cancer, and self-reported emphysema. Model validation in the chest radiography groups of the PLCO and the National Lung Screening Trial (NLST; 2002-2009), with additional validation of the death model in the National Health Interview Survey (NHIS; 1997-2001), a representative sample of the US. Models applied to US ever-smokers ages 50-80 (NHIS 2010-2012) to estimate outcomes of risk-based selection for CT lung-screening, assuming screening for all ever-smokers yields the percent changes in lung-cancer detection and death observed in the NLST. Annual CT lung-screening for 3 years. Model validity: calibration (number of model-predicted cases divided by number of observed cases (Estimated/Observed)) and discrimination (Area-Under-Curve (AUC)). Modeled screening outcomes: estimated number of screen-avertable lung-cancer deaths, estimated screening effectiveness (number needed to screen (NNS) to prevent 1 lung-cancer death). Lung-cancer incidence and death risk models were well-calibrated in PLCO and NLST. The lung-cancer death model calibrated and discriminated well for US ever-smokers ages 50-80 (NHIS 1997-2001: Estimated/Observed=0.94, 95%CI=0.84-1.05; AUC=0.78, 95%CI=0.76-0.80). Under USPSTF recommendations, the models estimated 9.0 million US ever-smokers would qualify for lung-cancer screening and 46,488 (95%CI=43,924-49,053) lung-cancer deaths were estimated as screen-avertable over 5 years (estimated NNS=194, 95%CI=187-201). In contrast, risk-based selection screening the same number of ever-smokers (9.0 million) at highest 5-year lung-cancer risk (≥1.9%), was estimated to avert 20% more deaths (55,717; 95%CI=53,033-58,400) and was estimated to reduce the estimated NNS by 17% (NNS=162, 95%CI=157-166). Among a cohort of US ever-smokers age 50-80 years, application of a risk-based model for CT screening for lung cancer compared with a model based on USPSTF recommendations was estimated to be associated with a greater number of lung-cancer deaths prevented over 5 years along with a lower NNS to prevent 1 lung-cancer death.