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Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits.

ABSTRACT: Harms and benefits of cancer screening depend on age and comorbid conditions, but reliable estimates are lacking.To estimate the harms and benefits of cancer screening by age and comorbid conditions to inform decisions about screening cessation.Collaborative modeling with 7 cancer simulation models and common data on average and comorbid condition level-specific life expectancy.U.S. population.U.S. cohorts aged 66 to 90 years in 2010 with average health or 1 of 4 comorbid condition levels: none, mild, moderate, or severe.Mammography, prostate-specific antigen testing, or fecal immunochemical testing.Lifetime cancer deaths prevented and life-years gained (benefits); false-positive test results and overdiagnosed cancer cases (harms). For each comorbid condition level, the age at which harms and benefits of screening were similar to that for persons with average health having screening at age 74 years.Screening 1000 women with average life expectancy at age 74 years for breast cancer resulted in 79 to 96 (range across models) false-positive results, 0.5 to 0.8 overdiagnosed cancer cases, and 0.7 to 0.9 prevented cancer deaths. Although absolute numbers of harms and benefits differed across cancer sites, the ages at which to cease screening were consistent across models and cancer sites. For persons with no, mild, moderate, and severe comorbid conditions, screening until ages 76, 74, 72, and 66 years, respectively, resulted in harms and benefits similar to average-health persons.Comorbid conditions influenced only life expectancy.Comorbid conditions are an important determinant of harms and benefits of screening. Estimates of screening benefits and harms by comorbid condition can inform discussions between providers and patients about personalizing screening cessation decisions.National Cancer Institute and Centers for Disease Control and Prevention.

SUBMITTER: Lansdorp-Vogelaar I

PROVIDER: S-EPMC4160041 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits.

Lansdorp-Vogelaar Iris I Gulati Roman R Mariotto Angela B AB Schechter Clyde B CB de Carvalho Tiago M TM Knudsen Amy B AB van Ravesteyn Nicolien T NT Heijnsdijk Eveline A M EA Pabiniak Chester C van Ballegooijen Marjolein M Rutter Carolyn M CM Kuntz Karen M KM Feuer Eric J EJ Etzioni Ruth R de Koning Harry J HJ Zauber Ann G AG Mandelblatt Jeanne S JS

Annals of internal medicine 20140701 2

<h4>Background</h4>Harms and benefits of cancer screening depend on age and comorbid conditions, but reliable estimates are lacking.<h4>Objective</h4>To estimate the harms and benefits of cancer screening by age and comorbid conditions to inform decisions about screening cessation.<h4>Design</h4>Collaborative modeling with 7 cancer simulation models and common data on average and comorbid condition level-specific life expectancy.<h4>Setting</h4>U.S. population.<h4>Patients</h4>U.S. cohorts aged ...[more]

PMID: 25023249

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Project description:The U.S. Preventive Services Task Force recently concluded that the harms of existing prostate-specific antigen (PSA) screening strategies outweigh the benefits.To evaluate comparative effectiveness of alternative PSA screening strategies.Microsimulation model of prostate cancer incidence and mortality quantifying harms and lives saved for alternative PSA screening strategies.National and trial data on PSA growth, screening and biopsy patterns, incidence, treatment distributions, treatment efficacy, and mortality.A contemporary cohort of U.S. men.Lifetime.Societal.35 screening strategies that vary by start and stop ages, screening intervals, and thresholds for biopsy referral.PSA tests, false-positive test results, cancer detected, overdiagnoses, prostate cancer deaths, lives saved, and months of life saved.Without screening, the risk for prostate cancer death is 2.86%. A reference strategy that screens men aged 50 to 74 years annually with a PSA threshold for biopsy referral of 4 µg/L reduces the risk for prostate cancer death to 2.15%, with risk for overdiagnosis of 3.3%. A strategy that uses higher PSA thresholds for biopsy referral in older men achieves a similar risk for prostate cancer death (2.23%) but reduces the risk for overdiagnosis to 2.3%. A strategy that screens biennially with longer screening intervals for men with low PSA levels achieves similar risks for prostate cancer death (2.27%) and overdiagnosis (2.4%), but reduces total tests by 59% and false-positive results by 50%.Varying incidence inputs or reducing the survival improvement due to screening did not change conclusions.The model is a simplification of the natural history of prostate cancer, and improvement in survival due to screening is uncertain.Compared with standard screening, PSA screening strategies that use higher thresholds for biopsy referral for older men and that screen men with low PSA levels less frequently can reduce harms while preserving lives.National Cancer Institute and Centers for Disease Control and Prevention.

Project description:Context and objectiveStandards for clinical practice guidelines require explicit statements regarding how values and preferences influence recommendations. However, no cancer screening guideline has addressed the key question of what magnitude of benefit people require to undergo screening, given its harms and burdens. This article describes the development of a new method for guideline developers to address this key question in the absence of high-quality evidence from published literature.Summary of methodThe new method was developed and applied in the context of a recent BMJ Rapid Recommendation clinical practice guideline for colorectal cancer (CRC) screening. First, we presented the guideline panel with harms and burdens (derived from a systematic review) associated with the CRC screening tests under consideration. Second, each panel member completed surveys documenting their views of expected benefits on CRC incidence and mortality that people would require to accept the harms and burdens of screening. Third, the panel discussed results of the surveys and agreed on thresholds for benefits at which the majority of people would choose screening. During these three steps, the panel had no access to the actual benefits of the screening tests. In step four, the panel was presented with screening test benefits derived from a systematic review of clinical trials and microsimulation modelling. The thresholds derived through steps one to three were applied to these benefits, and directly informed the panel's recommendations.ConclusionWe present the development and application of a new, four-step method enabling incorporation of explicit and transparent judgements of values and preferences in a screening guideline. Guideline panels should establish their view regarding the magnitude of required benefit, given burdens and harms, before they review screening benefits and make their recommendations accordingly. Making informed screening decisions requires transparency in values and preferences judgements that our new method greatly facilitates.

Project description:Lung cancer is the leading cause of cancer death. Most patients are diagnosed with advanced disease, resulting in a very low 5-year survival. Screening may reduce the risk of death from lung cancer.To conduct a systematic review of the evidence regarding the benefits and harms of lung cancer screening using low-dose computed tomography (LDCT). A multisociety collaborative initiative (involving the American Cancer Society, American College of Chest Physicians, American Society of Clinical Oncology, and National Comprehensive Cancer Network) was undertaken to create the foundation for development of an evidence-based clinical guideline.MEDLINE (Ovid: January 1996 to April 2012), EMBASE (Ovid: January 1996 to April 2012), and the Cochrane Library (April 2012).Of 591 citations identified and reviewed, 8 randomized trials and 13 cohort studies of LDCT screening met criteria for inclusion. Primary outcomes were lung cancer mortality and all-cause mortality, and secondary outcomes included nodule detection, invasive procedures, follow-up tests, and smoking cessation.Critical appraisal using predefined criteria was conducted on individual studies and the overall body of evidence. Differences in data extracted by reviewers were adjudicated by consensus.Three randomized studies provided evidence on the effect of LDCT screening on lung cancer mortality, of which the National Lung Screening Trial was the most informative, demonstrating that among 53,454 participants enrolled, screening resulted in significantly fewer lung cancer deaths (356 vs 443 deaths; lung cancer?specific mortality, 274 vs 309 events per 100,000 person-years for LDCT and control groups, respectively; relative risk, 0.80; 95% CI, 0.73-0.93; absolute risk reduction, 0.33%; P = .004). The other 2 smaller studies showed no such benefit. In terms of potential harms of LDCT screening, across all trials and cohorts, approximately 20% of individuals in each round of screening had positive results requiring some degree of follow-up, while approximately 1% had lung cancer. There was marked heterogeneity in this finding and in the frequency of follow-up investigations, biopsies, and percentage of surgical procedures performed in patients with benign lesions. Major complications in those with benign conditions were rare.Low-dose computed tomography screening may benefit individuals at an increased risk for lung cancer, but uncertainty exists about the potential harms of screening and the generalizability of results.

Project description:Timing of initiation of screening for breast cancer is controversial in the United States.To determine the threshold relative risk (RR) at which the harm-benefit ratio of screening women aged 40 to 49 years equals that of biennial screening for women aged 50 to 74 years.Comparative modeling study.Surveillance, Epidemiology, and End Results program, Breast Cancer Surveillance Consortium, and medical literature.A contemporary cohort of women eligible for routine screening.Lifetime.Societal.Mammography screening starting at age 40 versus 50 years with different screening methods (film, digital) and screening intervals (annual, biennial).life-years gained, breast cancer deaths averted; harms: false-positive mammography findings; harm-benefit ratios: false-positive findings/life-years gained, false-positive findings/deaths averted.Screening average-risk women aged 50 to 74 years biennially yields the same false-positive findings/life-years gained as biennial screening with digital mammography starting at age 40 years for women with a 2-fold increased risk above average (median threshold RR, 1.9 [range across models, 1.5 to 4.4]). The threshold RRs are higher for annual screening with digital mammography (median, 4.3 [range, 3.3 to 10]) and when false-positive findings/deaths averted is used as an outcome measure instead of false-positive findings/life-years gained. The harm-benefit ratio for film mammography is more favorable than for digital mammography because film has a lower false-positive rate.The threshold RRs changed slightly when a more comprehensive measure of harm was used and were relatively insensitive to lower adherence assumptions.Risk was assumed to influence onset of disease without influencing screening performance.Women aged 40 to 49 years with a 2-fold increased risk have similar harm-benefit ratios for biennial screening mammography as average-risk women aged 50 to 74 years. Threshold RRs required for favorable harm-benefit ratios vary by screening method, interval, and outcome measure.National Cancer Institute.

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Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits.

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Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits.

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