Life-Gained–Based Versus Risk-Based Selection of Smokers for Lung Cancer Screening

Although risk-based selection of ever-smokers for screening could prevent more lung cancer deaths than screening according to the U.S. Preventive Services Task Force (USPSTF) guidelines, it preferentially selects older ever-smokers with shorter life expectancies due to comorbidities.To compare selection of ever-smokers for screening based on gains in life expectancy versus lung cancer risk.Cohort analyses and model-based projections.U.S. population of ever-smokers aged 40 to 84 years.130 964 National Health Interview Survey participants, representing about 60 million U.S. ever-smokers during 1997 to 2015.Annual computed tomography (CT) screening for 3 years versus no screening.Estimated number of lung cancer deaths averted and life-years gained after development of a mortality model.Using the calibrated and validated mortality model in U.S. ever-smokers aged 40 to 84 years and selecting 8.3 million ever-smokers to match the number selected by the USPSTF criteria in 2013 to 2015, the analysis estimated that life-gained-based selection would increase the total life expectancy from CT screening (633 400 vs. 607 800 years) but prevent fewer lung cancer deaths (52 600 vs. 55 000) compared with risk-based selection. The 1.56 million persons selected by the life-gained-based strategy but not the risk-based strategy were younger (mean age, 59 vs. 75 years) and had fewer comorbidities (mean, 0.75 vs. 3.7).Estimates are model-based and assume implementation of lung cancer screening with short-term effectiveness similar to that from trials.Life-gained-based selection could maximize the benefits of lung cancer screening in the U.S. population by including ever-smokers who have both high lung cancer risk and long life expectancy.Intramural Research Program of the National Cancer Institute, National Institutes of Health.