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Alternative criteria for lung cancer screening identified high-benefit groups who were not covered by U.S. Preventive Services Task Force (USPSTF) criteria, according to results based on model projections.

These alternative criteria -- people who smoked any amount each year for at least 40 years and people ages 60 to 80 years with at least 40 pack-years of smoking -- compared with the USPSTF criteria had higher sensitivity (91% vs 78%, P<0.001) and specificity (86% vs 84%, P<0.001) for identifying high-benefit people, reported Lauren E. Kearney, MD, of Boston University, and colleagues.

The number of people selected for lung cancer screening using the alternative criteria would be similar to the number using USPSTF criteria (those with a smoking duration of ≥40 years but <20 pack-years and a quit history of >15 years), the authors noted in the .

Furthermore, the alternative criteria would lead to "better support of the ethical principle of 'equal management for equal risk,' and substantially reduce racial disparities," Kearney and colleagues wrote.

The alternative criteria provided greater numerical gains in sensitivity than the USPSTF criteria for Black (83% vs 56%, P<0.001), Hispanic (95% vs 73%, P=0.086), and Asian (94% vs 68%, P=0.171) adults, with similar specificity, though this was only significant for Black adults.

For this study, Kearney and team accessed responses from smoking adults ages 40 to 80 from 1997 to 2018 in the annual National Health Interview Survey. They defined three cohorts -- odd-numbered years from 1997 to 2014 for the training set, even-numbered years for the test set, and all years from 2015 to 2018 for the evaluation set.

"High-benefit" was defined as gaining an average of at least 16.2 days of life from three annual screenings, with life-years gained from lung cancer screening estimated using the life-years gained from screening computed tomography (LYFS-CT) model. They used fast-and-frugal tree algorithms to develop alternative lung cancer screening criteria, and used the training set to model outcomes of at least 16.2 days of life gained with lung cancer screening.

The training set included 71,978 respondents, the test set included 69,395, and the evaluation set included 31,975.

Kearney and colleagues observed that the substantial increase in sensitivity with the alternative criteria versus the USPSTF criteria could partially be explained by the fact that they identified smoking duration as an important variable. They noted that pack-years of tobacco use was an inclusion criterion in both the NELSON trial and , and subsequently this criterion has been included in lung cancer screening criteria to sum up cumulative tobacco exposure.

However, "duration of tobacco use seems to be a more considerable risk factor than intensity of tobacco use," the authors wrote. "Our analysis is consistent with these findings and shows that a major limitation of current eligibility criteria is the disproportionate exclusion of people with a long duration of low-intensity tobacco use who do not meet the criterion of at least 20 pack-years."

They also pointed out that a limitation of using pack-years is the challenge of getting accurate pack-year history. The alternative criteria -- one of which is simply based on years of smoking -- allows clinicians to identify patients "who would derive high benefit from lung cancer screening without having to assess average pack-per-day smoking intensity or calculate pack-years," they wrote.

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