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  3. Association of computed tomography screening with lung cancer stage shift and survival in the United States: quasi-experimental study
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Research

Association of computed tomography screening with lung cancer stage shift and survival in the United States: quasi-experimental study

BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-069008 (Published 30 March 2022) Cite this as: BMJ 2022;376:e069008

Editorial

Screening high risk populations for lung cancer
  1. Alexandra L Potter, research assistant1,
  2. Allison L Rosenstein, research assistant1,
  3. Mathew V Kiang, assistant professor of epidemiology and population health2,
  4. Shivani A Shah, medical student1,
  5. Henning A Gaissert, associate professor of surgery1,
  6. David C Chang, director of healthcare research and policy development, associate professor of surgery34,
  7. Florian J Fintelmann, assistant professor of radiology5,
  8. Chi-Fu Jeffrey Yang, assistant professor of surgery1 6
  1. 1Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
  2. 2Department of Epidemiology and Population Health, Stanford, CA, USA
  3. 3Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
  4. 4Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
  5. 5Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
  6. 6Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
  1. Correspondence to: C F J Yang cjyang{at}mgh.harvard.edu (or @ChiFuJeffYang on Twitter)
  • Accepted 15 February 2022

Abstract

Objective To determine the effect of the introduction of low dose computed tomography screening in 2013 on lung cancer stage shift, survival, and disparities in the stage of lung cancer diagnosed in the United States.

Design Quasi-experimental study using Joinpoint modeling, multivariable ordinal logistic regression, and multivariable Cox proportional hazards modeling.

Setting US National Cancer Database and Surveillance Epidemiology End Results program database.

Participants Patients aged 45-80 years diagnosed as having non-small cell lung cancer (NSCLC) between 1 January 2010 and 31 December 2018.

Main outcome measures Annual per cent change in percentage of stage I NSCLC diagnosed among patients aged 45-54 (ineligible for screening) and 55-80 (potentially eligible for screening), median all cause survival, and incidence of NSCLC; multivariable adjusted odds ratios for year-to-year changes in likelihood of having earlier stages of disease at diagnosis and multivariable adjusted hazard ratios for changes in hazard of death before versus after introduction of screening.

Results The percentage of stage I NSCLC diagnosed among patients aged 55-80 did not significantly increase from 2010 to 2013 (from 27.8% to 29.4%) and then increased at 3.9% (95% confidence interval 3.0% to 4.8%) per year from 2014 to 2018 (from 30.2% to 35.5%). In multivariable adjusted analysis, the increase in the odds per year of a patient having one lung cancer stage lower at diagnosis during the time period from 2014 to 2018 was 6.2% (multivariable adjusted odds ratio 1.062, 95% confidence interval 1.048 to 1.077; P<0.001) higher than the increase in the odds per year from 2010 to 2013. Similarly, the median all cause survival of patients aged 55-80 did not significantly increase from 2010 to 2013 (from 15.8 to 18.1 months), and then increased at 11.9% (8.9% to 15.0%) per year from 2014 to 2018 (from 19.7 to 28.2 months). In multivariable adjusted analysis, the hazard of death decreased significantly faster after 2014 compared with before 2014 (P<0.001). By 2018, stage I NSCLC was the predominant diagnosis among non-Hispanic white people and people living in the highest income or best educated regions. Non-white people and those living in lower income or less educated regions remained more likely to have stage IV disease at diagnosis. Increases in the detection of early stage disease in the US from 2014 to 2018 led to an estimated 10 100 averted deaths.

Conclusions A recent stage shift toward stage I NSCLC coincides with improved survival and the introduction of lung cancer screening. Non-white patients and those living in areas of greater deprivation had lower rates of stage I disease identified, highlighting the need for efforts to increase access to screening in the US.

Footnotes

  • Contributors: ALP, ALR, MVK, SAS, HAG, DCC, FJF, and CJY conceived and designed the study, acquired data, interpreted the results, drafted the manuscript, and reviewed or revised the manuscript for important intellectual content. ALP, ALR, and CJY acquired data and did the statistical analyses. All authors interpreted the results and contributed to the drafting and review of the manuscript. All authors approved the final draft. CJY is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: None.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; ALP, ALR, and CJY have leadership roles in the American Lung Cancer Screening Initiative.

  • The senior author (the manuscript’s guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: We plan to distribute the work to primary care providers, other clinicians, and lung cancer advocacy groups. In addition, we plan to disseminate the results through social media and as a plain language summary on the American Lung Cancer Screening Initiative website (www.alcsi.org).

  • Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Data used in this study included the National Cancer Database 2018 non-small cell lung cancer file and Surveillance Epidemiology End Results Program database. Data from the National Cancer Database are available through the American College of Surgeons to institutions participating in the National Cancer Database. Data from the Surveillance Epidemiology End Results program database are available at https://seer.cancer.gov/seerstat/download/. Code used for the analyses in this study is available on reasonable request to the corresponding author.

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This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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