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National Lung Screening Trial Findings by Age: Medicare-Eligible Versus Under-65 PopulationNational Lung Screening Trial Findings by Age

Paul F. Pinsky, PhD; David S. Gierada, MD; William Hocking, MD; Edward F. Patz Jr., MD; and Barnett S. Kramer, MD, MPH
[+] Article, Author, and Disclosure Information

From the National Cancer Institute, Bethesda, Maryland; Washington University School of Medicine, St. Louis, Missouri; Marshfield Clinic, Marshfield, Wisconsin; and Duke University School of Medicine, Durham, North Carolina.

Grant Support: By the National Institutes of Health (U01-CA-80098, U01-CA-79778, N01-CN-25522, N01-CN-25511, N01-CN-25512, N01-CN-25513, N01-CN-25514, N01-CN-25515, N01-CN-25516, N01-CN-25518, N01-CN-25524, N01-CN-75022, N01-CN-25476, and N02-CN-63300).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1484.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Pinsky (e-mail, pp4f@nih.gov). Data set: Available upon request at https://biometry.nci.nih.gov/cdas.

Requests for Single Reprints: Paul F. Pinsky, PhD, National Cancer Institute, 9609 Medical Center Drive, Room 5E108, Bethesda, MD 20892.

Current Author Addresses: Drs. Pinsky and Kramer: National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD 20892.

Dr. Gierada: Washington University School of Medicine, 510 South Kingshighway Boulevard, St. Louis, MO 63110.

Dr. Hocking: Marshfield Clinic Research Foundation, 1000 North Oak Avenue, Marshfield, WI 54449.

Dr. Patz: Duke University School of Medicine, 1515B Hosp North, Durham, NC 27710.

Author Contributions: Conception and design: P.F. Pinsky, D.S. Gierada, E.F. Patz.

Analysis and interpretation of the data: P.F. Pinsky, D.S. Gierada, W. Hocking, E.F. Patz, B.S. Kramer.

Drafting of the article: P.F. Pinsky, W. Hocking, E.F. Patz.

Critical revision of the article for important intellectual content: P.F. Pinsky, D.S. Gierada, W. Hocking, E.F. Patz, B.S. Kramer.

Final approval of the article: P.F. Pinsky, D.S. Gierada, W. Hocking, E.F. Patz, B.S. Kramer.

Provision of study materials or patients: W. Hocking.

Statistical expertise: P.F. Pinsky.

Obtaining of funding: W. Hocking.

Collection and assembly of data: D.S. Gierada, W. Hocking.


Ann Intern Med. 2014;161(9):627-633. doi:10.7326/M14-1484
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Background: The NLST (National Lung Screening Trial) showed reduced lung cancer mortality in high-risk participants (smoking history of ≥30 pack-years) aged 55 to 74 years who were randomly assigned to screening with low-dose computed tomography (LDCT) versus those assigned to chest radiography. An advisory panel recently expressed reservations about Medicare coverage of LDCT screening because of concerns about performance in the Medicare-aged population, which accounted for only 25% of the NLST participants.

Objective: To examine the results of the NLST LDCT group by age (Medicare-eligible vs. <65 years).

Design: Secondary analysis of a group from a randomized trial (NCT00047385).

Setting: 33 U.S. screening centers.

Patients: 19 612 participants aged 55 to 64 years (under-65 cohort) and 7110 participants aged 65 to 74 years (65+ cohort) at randomization.

Intervention: 3 annual rounds of LDCT screening.

Measurements: Demographics, smoking and medical history, screening examination adherence and results, diagnostic follow-up procedures and complications, lung cancer diagnoses, treatment, survival, and mortality.

Results: The aggregate false-positive rate was higher in the 65+ cohort than in the under-65 cohort (27.7% vs. 22.0%; P < 0.001). Invasive diagnostic procedures after false-positive screening results were modestly more frequent in the older cohort (3.3% vs. 2.7%; P = 0.039). Complications from invasive procedures were low in both groups (9.8% in the under-65 cohort vs. 8.5% in the 65+ cohort). Prevalence and positive predictive value (PPV) were higher in the 65+ cohort (PPV, 4.9% vs. 3.0%). Resection rates for screen-detected cancer were similar (75.6% in the under-65 cohort vs. 73.2% in the 65+ cohort). Five-year all-cause survival was lower in the 65+ cohort (55.1% vs. 64.1%; P = 0.018).

Limitation: The oldest screened patient was aged 76 years.

Conclusion: NLST participants aged 65 years or older had a higher rate of false-positive screening results than those younger than 65 years but a higher cancer prevalence and PPV. Screen-detected cancer was treated similarly in the groups.

Primary Funding Source: National Institutes of Health.

Figures

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Figure.

All-cause survival among patients with screen-detected cancer, by age group.

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