Effect of emphysema on lung cancer risk in smokers: a computed tomography-based assessment

Abstract

The contribution of emphysema to lung cancer risk has been recognized, but the effect size needs to be further defined. In this study, 565 primary lung cancer cases were enrolled though a prospective lung cancer cohort at Mayo Clinic, and 450 controls were smokers participating in a lung cancer screening study in the same institution using spiral computed tomography (CT). Cases and controls were frequency matched on age, gender, race, smoking status, and residential region. CT imaging using standard protocol at the time of lung cancer diagnosis (case) or during the study (control) was assessed for emphysema by visual scoring CT analysis as a percentage of lung tissue destroyed. The clinical definition of emphysema was the diagnosis recorded in the medical documentation. Using multiple logistic regression models, emphysema (≥ 5% on CT) was found to be associated with a 3.8-fold increased lung cancer risk in Caucasians, with higher risk in subgroups of younger (<65 years old, OR = 4.64), heavy smokers (≥ 40 pack-years, OR = 4.46), and small-cell lung cancer (OR = 5.62). When using >0% or ≥ 10% emphysema on CT, lung cancer risk was 2.79-fold or 3.33-fold higher than controls. Compared with CT evaluation (using criterion ≥ 5%), the sensitivity, specificity, positive and negative predictive values, and the accuracy of the clinical diagnosis for emphysema in controls were 19%, 98%, 73%, 84%, and 83%, respectively. These results imply that an accurate evaluation of emphysema could help reliably identify individuals at greater risk of lung cancer among smokers.

Figure 1

The existence of emphysema in subjects by different CT criteria. A, in cases by CT criterion >0%. B, in cases by CT criterion ≥5%. C, in cases by CT criterion ≥10%. D, in controls by CT criterion >0%. E, in controls by CT criterion ≥5%. F, in controls (CT criterion ≥10%). Abbreviation: dx, diagnosis.

Figure 1

The existence of emphysema in subjects by different CT criteria. A, in cases by CT criterion >0%. B, in cases by CT criterion ≥5%. C, in cases by CT criterion ≥10%. D, in controls by CT criterion >0%. E, in controls by CT criterion ≥5%. F, in controls (CT criterion ≥10%). Abbreviation: dx, diagnosis.

Figure 1

The existence of emphysema in subjects by different CT criteria. A, in cases by CT criterion >0%. B, in cases by CT criterion ≥5%. C, in cases by CT criterion ≥10%. D, in controls by CT criterion >0%. E, in controls by CT criterion ≥5%. F, in controls (CT criterion ≥10%). Abbreviation: dx, diagnosis.

Figure 2

Diagnostic performance of clinical assessment for emphysema compared to CT diagnosis (by three different criteria, respectively). A, in cases. B, in controls.

Figure 3

Stratified multivariable logistic regression analyses: effects of emphysema on lung cancer risk in Caucasians by age, pack-years, cell type, and stage.