Developing Risk-Based Screening Guidelines: Translational Epidemiology in Action

Abstract

The proliferation ofdisease riskcalculatorshasnot ledtoa proliferationofriskbased screening guidelines. The focus of risk-based screening guidelines is connecting risk stratification under natural history of disease (without intervention) and “benefi ts tratification”: whether the risk stratification actually distinguishes people who have high benefit vs. low benefit from a screening intervention. To link risk stratification to benefit stratification, we propose the principle of “equal management of people at equal risk of disease” .W hen applicable, this principle leads to simplified and consistent management of peoplewithdifferentriskfactorsortestresultsleadingtothesamediseaserisk, people who might also have a similar benefit/harm profile. We describe two examples of our approach. First, we demonstrate how the “equal management of equal risks” principle was applied to thoroughly integrate HPV testing into the new risk-based cervical cancer screening guidelines, the first thoroughly risk-based cancer screening guidelines. Second, we revisit our proposal to use risk of lung cancerdeathforestimatingbenefit stratification to better target CT lung cancerscreening.We showhow we calculatedbenefitstratificationfor CT lung screening, and also the analogous “harm stratification” and “efficiency stratification”. We critically examine the limits of the “equal management of equal risks” principle. Our approach of calculating benefit stratification and applying “equal management of equal risks” might be a template for translational epidemiology studies that help pave the way for risk-based medicine.