Rates of Downstream Procedures and Complications Associated With Lung Cancer Screening in Routine Clinical Practice : A Retrospective Cohort Study

Abstract

Background: Lung cancer screening (LCS) using low-dose computed tomography (LDCT) reduces lung cancer mortality but can lead to downstream procedures, complications, and other potential harms. Estimates of these events outside NLST (National Lung Screening Trial) have been variable and lacked evaluation by screening result, which allows more direct comparison with trials.

Objective: To identify rates of downstream procedures and complications associated with LCS.

Design: Retrospective cohort study.

Setting: 5 U.S. health care systems.

Patients: Individuals who completed a baseline LDCT scan for LCS between 2014 and 2018.

Measurements: Outcomes included downstream imaging, invasive diagnostic procedures, and procedural complications. For each, absolute rates were calculated overall and stratified by screening result and by lung cancer detection, and positive and negative predictive values were calculated.

Results: Among the 9266 screened patients, 1472 (15.9%) had a baseline LDCT scan showing abnormalities, of whom 140 (9.5%) were diagnosed with lung cancer within 12 months (positive predictive value, 9.5% [95% CI, 8.0% to 11.0%]; negative predictive value, 99.8% [CI, 99.7% to 99.9%]; sensitivity, 92.7% [CI, 88.6% to 96.9%]; specificity, 84.4% [CI, 83.7% to 85.2%]). Absolute rates of downstream imaging and invasive procedures in screened patients were 31.9% and 2.8%, respectively. In patients undergoing invasive procedures after abnormal findings, complication rates were substantially higher than those in NLST (30.6% vs. 17.7% for any complication; 20.6% vs. 9.4% for major complications).

Limitation: Assessment of outcomes was retrospective and was based on procedural coding.

Conclusion: The results indicate substantially higher rates of downstream procedures and complications associated with LCS in practice than observed in NLST. Diagnostic management likely needs to be assessed and improved to ensure that screening benefits outweigh potential harms.

Primary funding source: National Cancer Institute and Gordon and Betty Moore Foundation.

Figure 1.

Rates of Invasive Procedures in Screened PROSPR Patients Compared to NLST Abbreviations: LDCT= Low-Dose Computed Tomography; NLST = National Lung Screening Trial; PROSPR = Population-based Research to Optimize the Screening Process.

Figure 2.

Rates of Complications after Subsequent Invasive Procedures in PROSPR Patients Compared to NLST Abbreviations; LDCT= Low-Dose Computed Tomography; NLST = National Lung Screening Trial; PROSPR = Population-based Research to Optimize the Screening Process.