Personalizing lung cancer screening recommendations for heterogeneous populations: a microsimulation study.

Abstract

There is little guidance on how to personalize recommendations for lung cancer screening that accounts for the variation in expected net benefit from screening. We sought to explore the individual and population implications of identifying net benefit thresholds where lung cancer screening could be encouraged, discouraged, or offered as an option through neutral shared decision making due to screening being highly preference sensitive. With a simulated US population of 40- to 80-year-old individuals who had ever smoked, we used microsimulation to estimate individualized quality-adjusted life-years saved with lung cancer screening. We then identified 2 net benefit thresholds for lung cancer screening that account for a range of patient preferences and scientific uncertainties and compared this approach with the current United States Preventive Services Task Force (USPSTF) guidelines. Our simulated population included 59 million people. In total, 15 million were USPSTF eligible; of those, 53% (8 million) maintained net benefit, even after accounting for unfavorable preferences about screening. Of the USPSTF population, 3% (450 000) are considered low net benefit (routinely discourage) and 47% (7 million) are in an intermediate gray area, where net benefit depends on patient preferences about lung cancer screening (offer-neutral shared decision making). Among adults who had ever smoked, 2.5 million are high net benefit but excluded by current USPSTF criteria; 20.5 million US adults who had ever smoked are intermediate net benefit but currently excluded by USPSTF criteria. We estimate that half of the USPSTF lung cancer screening-eligible population is in a high-net-benefit group where lung cancer screening could be routinely encouraged. Current lung cancer screening eligibility criteria likely exclude many ever-smokers who are high net benefit and many more with intermediate net benefit.