Comparative performance of lung cancer risk models to define lung screening eligibility in the United Kingdom

Hilary A Robbins,Ruth C Travis,Philip A J Crosbie,Karine Alcala,David R Baldwin,Matthew Callister,Rebecca Landy,Anthony J Swerdlow,Nick Wareham,Mattias Johansson,Minouk J Schoemaker

doi:10.1038/s41416-021-01278-0

Abstract

BackgroundThe National Health Service England (NHS) classifies individuals as eligible for lung cancer screening using two risk prediction models, PLCOm2012 and Liverpool Lung Project-v2 (LLPv2). However, no study has compared the performance of lung cancer risk models in the UK.MethodsWe analysed current and former smokers aged 40–80 years in the UK Biobank (N = 217,199), EPIC-UK (N = 30,813), and Generations Study (N = 25,777). We quantified model calibration (ratio of expected to observed cases, E/O) and discrimination (AUC).ResultsRisk discrimination in UK Biobank was best for the Lung Cancer Death Risk Assessment Tool (LCDRAT, AUC = 0.82, 95% CI = 0.81–0.84), followed by the LCRAT (AUC = 0.81, 95% CI = 0.79–0.82) and the Bach model (AUC = 0.80, 95% CI = 0.79–0.81). Results were similar in EPIC-UK and the Generations Study. All models overestimated risk in all cohorts, with E/O in UK Biobank ranging from 1.20 for LLPv3 (95% CI = 1.14–1.27) to 2.16 for LLPv2 (95% CI = 2.05–2.28). Overestimation increased with area-level socioeconomic status. In the combined cohorts, USPSTF 2013 criteria classified 50.7% of future cases as screening eligible. The LCDRAT and LCRAT identified 60.9%, followed by PLCOm2012 (58.3%), Bach (58.0%), LLPv3 (56.6%), and LLPv2 (53.7%).ConclusionIn UK cohorts, the ability of risk prediction models to classify future lung cancer cases as eligible for screening was best for LCDRAT/LCRAT, very good for PLCOm2012, and lowest for LLPv2. Our results highlight the importance of validating prediction tools in specific countries.

Highlights

The National Health Service England (NHS) classifies individuals as eligible for lung cancer screening using two risk prediction models, PLCOm2012 and Liverpool Lung Project-v2 (LLPv2)
In European Prospective Investigation into Cancer and Nutrition (EPIC)-UK, 156 lung cancers and 100 lung cancer deaths occurred over 5 years among 30,813 participants, and in the Generations Study, 53 lung cancers and 26 lung cancer deaths occurred over 5 years among 25,777 participants
Calibration estimates for all risk models were >1 in all cohorts, indicating that the models predicted more lung cancer cases than were observed over the time period specified by the model (Fig. 1)

Summary

Introduction

The National Health Service England (NHS) classifies individuals as eligible for lung cancer screening using two risk prediction models, PLCOm2012 and Liverpool Lung Project-v2 (LLPv2). RESULTS: Risk discrimination in UK Biobank was best for the Lung Cancer Death Risk Assessment Tool (LCDRAT, AUC = 0.82, 95% CI = 0.81–0.84), followed by the LCRAT (AUC = 0.81, 95% CI = 0.79–0.82) and the Bach model (AUC = 0.80, 95% CI = 0.79–0.81). CONCLUSION: In UK cohorts, the ability of risk prediction models to classify future lung cancer cases as eligible for screening was best for LCDRAT/LCRAT, very good for PLCOm2012, and lowest for LLPv2. Compared with the implementation of lung screening in the USA, the UK has often been more successful in terms of overall uptake and engagement of populations with low socioeconomic status (SES),[6,9,10] and lung cancer detection rates have often exceeded those in the NLST.[3,6,11,12] Building on this success, the National

Methods

Results

Conclusion