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- Title
Comparing Lung Cancer Screening Strategies in a Nationally Representative US Population Using Transportability Methods for the National Lung Cancer Screening Trial.
- Authors
Robertson, Sarah E.; Joyce, Nina R.; Steingrimsson, Jon A.; Stuart, Elizabeth A.; Aberle, Denise R.; Gatsonis, Constantine A.; Dahabreh, Issa J.
- Abstract
Key Points: Question: What is the comparative effectiveness of low-dose computed tomography (CT) vs chest radiography screening strategies evaluated in the National Lung Screening Trial (NLST) in a nationally representative target population of US adults who meet the NLST eligibility criteria? Findings: In this comparative effectiveness study, transportability analysis was used to reweight NLST data to resemble a nationally representative target population. Estimates of the comparative effectiveness of low-dose CT screening compared with chest radiography on lung cancer–specific and all-cause mortality in the target population of 5.7 million adults were similar to estimates from unweighted NLST analyses, but differences in baseline characteristics between the NLST and the target population resulted in increased uncertainty. Meaning: These results suggest that low-dose CT screening resulted in improved outcomes compared with chest radiography in a nationally representative population NLST-eligible individuals, indicating that the trial findings are transportable to this target population. This comparative effectiveness study conducts a transportability analysis of the National Lung Screening Trial to compare effectiveness of low-dose computed tomography and chest radiography screening for US adults. Importance: The National Lung Screening Trial (NLST) found that screening for lung cancer with low-dose computed tomography (CT) reduced lung cancer–specific and all-cause mortality compared with chest radiography. It is uncertain whether these results apply to a nationally representative target population. Objective: To extend inferences about the effects of lung cancer screening strategies from the NLST to a nationally representative target population of NLST-eligible US adults. Design, Setting, and Participants: This comparative effectiveness study included NLST data from US adults at 33 participating centers enrolled between August 2002 and April 2004 with follow-up through 2009 along with National Health Interview Survey (NHIS) cross-sectional household interview survey data from 2010. Eligible participants were adults aged 55 to 74 years, and were current or former smokers with at least 30 pack-years of smoking (former smokers were required to have quit within the last 15 years). Transportability analyses combined baseline covariate, treatment, and outcome data from the NLST with covariate data from the NHIS and reweighted the trial data to the target population. Data were analyzed from March 2020 to May 2023. Interventions: Low-dose CT or chest radiography screening with a screening assessment at baseline, then yearly for 2 more years. Main Outcomes and Measures: For the outcomes of lung-cancer specific and all-cause death, mortality rates, rate differences, and ratios were calculated at a median (25th percentile and 75th percentile) follow-up of 5.5 (5.2-5.9) years for lung cancer–specific mortality and 6.5 (6.1-6.9) years for all-cause mortality. Results: The transportability analysis included 51 274 NLST participants and 685 NHIS participants representing the target population (of approximately 5 700 000 individuals after survey-weighting). Compared with the target population, NLST participants were younger (median [25th percentile and 75th percentile] age, 60 [57 to 65] years vs 63 [58 to 67] years), had fewer comorbidities (eg, heart disease, 6551 of 51 274 [12.8%] vs 1 025 951 of 5 739 532 [17.9%]), and were more educated (bachelor's degree or higher, 16 349 of 51 274 [31.9%] vs 859 812 of 5 739 532 [15.0%]). In the target population, for lung cancer–specific mortality, the estimated relative rate reduction was 18% (95% CI, 1% to 33%) and the estimated absolute rate reduction with low-dose CT vs chest radiography was 71 deaths per 100 000 person-years (95% CI, 4 to 138 deaths per 100 000 person-years); for all-cause mortality the estimated relative rate reduction was 6% (95% CI, −2% to 12%). In the NLST, for lung cancer–specific mortality, the estimated relative rate reduction was 21% (95% CI, 9% to 32%) and the estimated absolute rate reduction was 67 deaths per 100 000 person-years (95% CI, 27 to 106 deaths per 100 000 person-years); for all-cause mortality, the estimated relative rate reduction was 7% (95% CI, 0% to 12%). Conclusions and Relevance: Estimates of the comparative effectiveness of low-dose CT screening compared with chest radiography in a nationally representative target population were similar to those from unweighted NLST analyses, particularly on the relative scale. Increased uncertainty around effect estimates for the target population reflects large differences in the observed characteristics of trial participants and the target population.
- Subjects
UNITED States; CAUSES of death; CHEST X rays; CONFIDENCE intervals; CROSS-sectional method; EX-smokers; AGE distribution; LUNG tumors; EARLY detection of cancer; INTERVIEWING; HEALTH status indicators; COMPARATIVE studies; SURVEYS; QUESTIONNAIRES; DESCRIPTIVE statistics; RESEARCH funding; COMPUTED tomography; DATA analysis software; LONGITUDINAL method; COMORBIDITY; EDUCATIONAL attainment
- Publication
JAMA Network Open, 2024, Vol 7, Issue 1, pe2346295
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2023.46295