Identifying older adults who benefit from lung cancer screening

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PROJECT SUMMARY/ABSTRACT Lung cancer is primarily a disease of aging. Lung cancer is the number one cause of cancer death in the United States, with 127,000 deaths annually. Lung cancer screening (LCS) can prevent lung cancer death among older adults ages 50-80 without advanced comorbidities. Screening must balance the risk of immediate harms against the potential to prevent death years in the future. There is a fundamental knowledge gap in how to identify older adults who are “healthy enough” for LCS, among the 14.5 million who are currently eligible. My long-term goal is to maximize the benefit of LCS for older adults by providing them individualized estimates of net benefit from LCS based on health status, and become an expert on preventive health interventions for older adults. The objective of the proposed project is to examine the association between health and use of LCS and then measure risks of immediate harms after LCS by health status. I will define health in various ways and identify a metric of health that best predicts harms of LCS. The central hypothesis of this proposal is that LCS is common among those in the poor health, which undermines its benefit and increases the risk of harm (e.g., complications of invasive procedures after abnormal lung scans). I will leverage national data from Veterans Health Affairs (VHA), which has pioneered a tool to systematically assess LCS eligibility via detailed smoking history. I will test my central hypothesis in the following specific aims. Aim 1: Determine the associations between use of LCS and pre-screening health as measured by three health metrics – (1) life expectancy, (2) life years gained by screening, and (3) advanced chronic obstructive pulmonary disease. Aim 2: Determine the rates of complications from diagnostic procedures prompted by LCS across pre-screening health status measured with the same three health metrics, using advanced quantitative methods (i.e., joint modeling) to account for the interrelated nature of procedure choice and complication risk. This project is methodologically innovative because I will (1) apply a novel, validated algorithm to exclude diagnostic imaging to provide unbiased estimates of LCS use and harms, (2) apply joint modeling to identify older adults at higher risk of adverse screening outcomes, and (3) utilize detailed smoking and health data in the VHA which is not available elsewhere and has been a persistent barrier to prior work. This project is conceptually innovative because I will use health metrics uniquely relevant to LCS. The proposed project is significant in that it will provide a rich understanding of how LCS is currently used across categories defined by health and advance our knowledge by identifying those most likely to benefit from LCS. This knowledge could guide older adults and their clinicians towards informed, individualized screening decisions that prioritize LCS among competing health needs. This project directly responds to the National Institute on Aging’s priorities to meet the needs of older adults with multiple comorbidities and to optimize their health by personalizing decision-making based on their unique health status.