Estimating long-term effectiveness of lung cancer screening in the Mayo CT screening study

Abstract

Purpose: To use individual-level data provided from the single-arm study of helical computed tomographic (CT) screening at the Mayo Clinic (Rochester, Minn) to estimate the long-term effectiveness of screening in Mayo study participants and to compare estimates from an existing lung cancer simulation model with estimates from a different modeling approach that used the same data.

Materials and methods: The study was approved by institutional review boards and was HIPAA compliant. Deidentified individual-level data from participants (1520 current or former smokers aged 50-85 years) in the Mayo Clinic helical CT screening study were used to populate the Lung Cancer Policy Model, a comprehensive microsimulation model of lung cancer development, screening findings, treatment results, and long-term outcomes. The model predicted diagnosed cases of lung cancer and deaths per simulated study arm (five annual screening examinations vs no screening). Main outcome measures were predicted changes in lung cancer-specific and all-cause mortality as functions of follow-up time after simulated enrollment and randomization.

Results: At 6-year follow-up, the screening arm had an estimated 37% relative increase in lung cancer detection, compared with the control arm. At 15-year follow-up, five annual screening examinations yielded a 9% relative increase in lung cancer detection. The relative reduction in cumulative lung cancer-specific mortality from five annual screening examinations was 28% at 6-year follow-up (15% at 15 years). The relative reduction in cumulative all-cause mortality from five annual screening examinations was 4% at 6-year follow-up (2% at 15 years).

Conclusion: Screening may reduce lung cancer-specific mortality but may offer a smaller reduction in overall mortality because of increased competing mortality risks associated with smoking.

Figure 1:

Base-case incidence. Model-predicted incident (first) lung cancers per 1000 participants at risk are shown as a function of years since simulated randomization, in screening arm versus control arm. Baseline screening (year 0) yields a high number of NSCLCs; after five screening examinations, the incidence rate in the screening arm decreases below that of the control arm. Table 1 provides further details about baseline screening.

Figure 2:

Base-case stage shift. Model-predicted lung cancer cases (per 1000 participants) detected in the first 5 years after simulated randomization, stratified according to trial arm. Compared with nonscreening cohort, screening yields a higher number of NSCLCs, a greater proportion of which are stage I. Also predicted is a stage shift from stage IV NSCLC to earlier stages. No comparable increase in cases of SCLCs was predicted, and the distribution of limited stage (LS) versus extensive stage (ES) was not substantially changed with screening.