Association of Computed Tomographic Screening Promotion With Lung Cancer Overdiagnosis Among Asian Women

Abstract

Importance: As smoking continues to decline in many developed countries, the proportion of lung cancers in nonsmokers will rise. This shift may create substantial pressure to further expand lung cancer screening to lower-risk groups.

Objective: To determine the association of lung cancer incidence with the promotion of screening in a largely nonsmoking population.

Design, setting, and participants: This population-based ecological cohort study of stage-specific lung cancer incidence used the Taiwan Cancer Registry to identify women diagnosed with lung cancer from January 1, 2004, to December 31, 2018. Smoking prevalence among Taiwanese women has been less than 5% since 1980. Data were analyzed from February 13, 2020, to November 10, 2021.

Exposures: Low-dose computed tomography (LDCT) screening for lung cancer, initiated during the early 2000s.

Main outcomes and measures: Change in stage-specific lung cancer incidence. An effective cancer screening program will not only increase the incidence of early-stage cancer but also decrease the incidence of cancer presenting at a late stage.

Results: A total of 57 898 women were diagnosed with lung cancer in a population of approximately 12 million Taiwanese women. After the introduction of LDCT screening, the incidence of early-stage (stages 0-I) lung cancer in women increased more than 6-fold, from 2.3 to 14.4 per 100 000 population (absolute difference, 12.1 [95% CI, 11.3-12.8]) from 2004 to 2018. There was no change, however, in the incidence of late-stage (stages II-IV) lung cancer, from 18.7 to 19.3 per 100 000 (absolute difference, 0.6 [95% CI, -0.5 to 1.7]). Because the additional 12.1 per 100 000 early-stage cancers were not accompanied by a concomitant decline in late-stage cancers, virtually all the additional cancers detected represent overdiagnosis. Despite stable mortality, 5-year survival more than doubled from 2004 to 2013, from 18% to 40%, which is arguably the highest lung cancer survival rate in the world.

Conclusions and relevance: This population-based ecological cohort study found that low-dose computed tomographic screening of mostly nonsmoking Asian women was associated with considerable lung cancer overdiagnosis. Five-year survival is biased by the increased LDCT detection of indolent early-stage lung cancers. Unless randomized trials can demonstrate some value to low-risk groups, LDCT screening should remain targeted only to heavy smokers.

Figure 1.. Taiwanese Lung Cancer Screening Promotions Featuring Young Women

LDCT indicates low-dose computed tomography. A, Reprinted with permission from Mr Suwannaphoom and copyright holder. B, Reprinted with permission from the InfoTimes. C, Reprinted with permission from Ms Yao and copyright holder. D, Reprinted with permission from Department of Medical Imaging and Intervention Chang Gueng Memorial Hospital, Taiwan.

Figure 2.. Self-reported Smoking Prevalence Among Taiwanese Adults by Sex, 1980-2018

Data are from the Adult Smoking Behaviors Survey 2018, Health Promotion Administration, Taiwan. Adult indicates 18 years or older. Before 1997, a smoker was defined as smoking on average 3 or more cigarettes per day; after 1997, a smoker was defined as smoking every day or smoking sometimes in the last 30 days.

Figure 3.. Lung Cancer Incidence and Mortality in Taiwanese Women, 1998-2018

From the Taiwan National Cancer Registry and the Ministry of Health and Welfare, Taiwan.

Figure 4.. Stage-Specific Lung Cancer Incidence and Mortality in Taiwanese Women, 2004-2018

Early stage indicates stages 0 to I; late stage, stages II to IV. Absolute rates are age adjusted to the 2000 world standard population; in rates relative to 2004, 1 denotes no change. Gray shading indicates lung cancer 5-year survival for all women diagnosed with lung cancer in 2004 and 2013, the most recent year with 5 years of follow-up.

Figure 5.. 5-Year Survival Trends for Women With Lung Cancer in High-Income Countries, 2000-2013

Data are from the Cancer Survival in High-Income Countries (SURVMARK-2) project of the International Agency for Research on Cancer. The project calculates 5-year relative survival among women aged 15 to 99 years. We used matching age criteria to obtain data from Taiwan and the US.