One such approach, developed by Li Cheung, PhD, a staff scientist in the division of cancer epidemiology and genetics at the National Cancer Institute, and colleagues aims to maximize benefits and minimize harms by recommending screening for ever-smokers who have both a high risk of lung cancer and a long life expectancy. Their findings, published in The Annals of Internal Medicine, focused on “individual life-years gained” in determining who best to screen for the disease.1 It is a significant departure from the US Preventive Services Task Force (USPSTF) recommendations for screening, which are currently under review. USPSTF guidelines call for annual low-dose computed tomography (CT) screening in adults aged 55 to 80 years who currently smoke or have quit within the past 15 years and have ≥30 pack-years of exposure. Typically, Dr. Cheung explains, the benefits of cancer screening are assessed at the population level. For example, researchers might ask if an entire population is screened, approximately how many lives would be saved? As a secondary consideration, they might also take into account how many life-years that population as a whole would gain. “Our approach is a new way of thinking,” he says. “The focus is on years of life gained from an individual perspective, which better defines the benefits of screening.” This may also help to address experts' concerns about the population-wide screening program—namely, that while it can reduce mortality by detecting cancer at earlier stages, it only modestly extends life expectancy and can also lead to additional costs, unnecessary follow-up, and patient anxiety. Some researchers have developed risk prediction models that select individuals for CT screening based on who is at the highest risk of developing or dying of lung cancer. However, according to Dr. Cheung, the drawback to those models is that they tend to select individuals who are at higher risk of death for a variety of reasons. Indeed, mathematical modeling studies suggest that screening individuals who are at high risk for lung cancer primarily because of older age or multiple smoking-related comorbidities does not always provide a net benefit in terms of life-years gained, he says. For that reason, he and his colleagues decided to develop and validate a life-gained screening model that could provide an answer for individual patients and their physicians regarding whether they should undergo screening and, if so, when to start and stop. Furthermore, because a life-gained model tends to select more young people with fewer comorbidities than risk-based selection, there is less likelihood of harm to those individuals in terms of additional tests and procedures performed, he adds. “What we have tried to develop for clinicians is another tool that they can use in their discussions to make the screening decision,” Dr. Cheung says. “Patients can ask, ‘If I do this, how much longer would it help me live?’” Using data from the National Health Interview Survey, the investigators created an individualized prediction model for overall mortality and gains to individual life expectancy for ever-smokers aged 40 to 84 years who underwent 3 rounds of CT screening. Researchers included data from 131,000 participants representing approximately 60 million ever-smokers in the United States from 1997 to 2015. Results demonstrated that both risk-based and life-gained strategies provided substantially greater years of life gained and mortality reduction than current USPSTF screening recommendations. Furthermore, in comparing the risk-based selection strategy with the life-gained selection approach for ever-smokers, the life-gained selection model led to the greatest gains in life expectancy. It also identified a population of moderately high-risk, but younger and healthier, smokers who would benefit from screening and otherwise would be excluded by both risk-based and USPSTF screening recommendations. In explaining why risk-based or USPSTF screening recommendations may not benefit some patients, Dr. Cheung gives the example of a high-risk individual who is discovered to have a potential lung cancer but is too frail or unhealthy to undergo follow-up procedures. “Despite detecting a potential lung cancer, the benefits of screening for that individual would not outweigh the harms,” he says, adding that neither the risk-based strategy nor USPSTF recommendations would impact the years of life gained in this case. In an accompanying editorial,2 University of Michigan professors Tanner Caverly, MD, MPH, an assistant professor of learning health sciences and internal medicine, and Rafael Meza, PhD, an associate professor in the department of epidemiology, praised the added accuracy of both risk-based and life-gained approaches. They also pointed to the need for future studies that evaluate the acceptability of including race and socioeconomic status when calculating both lung cancer risk and life expectancy. Ashley Prosper, MD, assistant clinical professor of radiology at the University of California at Los Angeles and co-director of its lung cancer screening program, agrees that the USPSTF recommendations need to be improved. However, she favors a risk-based screening approach over the life-gained model. Dr. Prosper notes that in the study, the risk-based model comprised 79% former smokers and approximately 21% current smokers, whereas the life-gained model was essentially the opposite: it included 77% current smokers and 23% former smokers. “I find that particularly interesting because we know that the smoking rate is declining in the United States, and if this trend continues, I think we have to be cautious about excluding former smokers who are at risk for lung cancer,” Dr. Prosper says. “When we think about revising the selection criteria, we really want to be as inclusive as possible.” With regard to ethnicity, Dr. Prosper says, those selected solely by the life-gained model included fewer numbers of African American and Hispanic individuals (11% and 3%) compared with the risk-based model (13% and 6%, respectively). She points out that African American men in particular are 37% more likely than white men to develop lung cancer, although their overall exposure to cigarette smoke is lower, according to the American Lung Association. “We want to be really careful not to potentiate health care disparities, particularly when we know that African Americans have the highest morbidity and mortality problems in lung cancer,” Dr. Prosper says. “Some of the strengths of the risk-based model are that you're able to capture more former smokers and older patients at risk and improve inclusion of both blacks and Hispanics.” However, Dr. Cheung says, when also considering the 6.73 million adults selected by both strategies, the percentages of minorities are essentially the same, with African American, Hispanic, and Asian individuals at 13.1%, 3.3%, and 1.4%, respectively, in the risk-based model versus 12.7%, 2.7%, and 1.4% in the life-gained model. Moreover, he adds, both approaches include more African Americans than the current USPSTF guidelines (7.7%). “The life-gained–based approach also remedies racial and ethnic health disparities, while choosing people who are more likely to benefit from screening,” he says.