Search

PURPOSE To investigate whether postdiagnosis smoking cessation may affect the risk of death and disease progression in patients with renal cell carcinoma (RCC) who smoked at the time of diagnosis. METHODS Two hundred twelve patients with primary RCC were recruited between 2007 and 2016 from the Urological Department in N.N. Blokhin National Medical Research Center of Oncology, Moscow, Russia. Upon enrollment, a structured questionnaire was completed, and the patients were followed annually through 2020 to repeatedly assess their smoking status and disease progression. Survival probabilities and hazards for all-cause and cancer-specific mortality and disease progression were investigated using extended the Kaplan-Meier method, time-dependent Cox proportional hazards regression, and Fine-Gray competing-risk models. RESULTS Patients were followed for a median of 8.2 years. During this time, 110 cases of disease progression, 100 total deaths, and 77 cancer-specific deaths were recorded. Eighty-four patients (40%) quit smoking after diagnosis. The total person-years at risk for this analysis were 748.2 for continuing smoking and 611.2 for quitting smoking periods. At 5 years of follow-up, both overall survival (85% v 61%) and progression-free survival (80% v 57%) rates were higher during the quitting than continuing smoking periods (both P < .001). In the multivariable time-dependent models, quitting smoking was associated with lower risk of all-cause mortality (hazard ratio [HR], 0.51; 95% CI, 0.31 to 0.85), disease progression (HR, 0.45; 95% CI, 0.29 to 0.71), and cancer-specific mortality (HR, 0.54; 95% CI, 0.31 to 0.93). The beneficial effect of quitting smoking was evident across all subgroups, including light smokers versus moderate-heavy smokers and those with early-stage versus late-stage tumors. CONCLUSION Quitting smoking after RCC diagnosis may significantly improve survival and reduce the risk of disease progression and cancer mortality among patients who smoke.

The frequency of lung cancer detection in the Manchester Lung Health Checks (MLHCs), a community-based screening service, was higher than in the National Lung Screening Trial (NLST) over two screening rounds. We aimed to identify the potential reasons for this difference.We analyzed individual-level data from NLST and MLHCs, restricting to MLHCs participants who met NLST eligibility criteria. We calculated 'detection ratios' comparing the frequency of lung cancer detection in MLHCs vs NLST, first after excluding NLST participants ineligible by MLHC eligibility criteria (6-year lung cancer risk ≥ 1.51 %), and then after standardization to remove the influence of different distributions of baseline lung cancer risk.Among the 1,079 MLHCs participants who met NLST eligibility criteria, 4.7% were diagnosed with lung cancer over two screening rounds compared with 1.7% in NLST, giving an initial detection ratio of 2.6 (95%CI 2.2-3.0). This was reduced to 2.2 (95%CI 1.3-2.3) after imposing the MLHCs eligibility criterion on NLST, and further to 1.6 (95%CI 1.2-2.1) after removing the influence of different risk distributions. In stratified analyses, the standardized detection ratio was particularly elevated in individuals who were older, living in areas of high socioeconomic disadvantage, or had an FEV/FVC ratio less than 60.The 2.6-fold higher lung cancer detection in the community-based MLHCs vs NLST is partly explained by differences in eligibility criteria and baseline risk distributions. The residual 60% increase may relate to higher detection in certain risk groups, including older participants, those with more obstructive lung disease, and those living in areas of socioeconomic disadvantage.

Objectives We propose a risk-tailored approach for management of lung cancer screening results. This approach incorporates individual risk factors and low-dose computed tomography (LDCT) image features into calculations of immediate and next-screen (1-y) risks of lung cancer detection, which in turn can recommend short-interval imaging or 1-year or 2-year screening intervals. Methods We first extended the "LCRAT+CT" individualized risk calculator to predict lung cancer risk after either a negative or abnormal LDCT screen result. To develop the abnormal screen portion, we analyzed 18,129 abnormal LDCT results in the National Lung Screening Trial (NLST), including lung cancers detected immediately (n = 649) or at the next screen (n = 235). We estimated the potential impact of this approach among NLST participants with any screen result (negative or abnormal). Results Applying the draft National Health Service (NHS) England protocol for lung screening to NLST participants referred 76% of participants to a 2-year interval, but delayed diagnosis for 40% of detectable cancers. The Lung Cancer Risk Assessment Tool+Computed Tomography (LCRAT+CT) risk model, with a threshold of less than 0.95% cumulative lung cancer risk, would also refer 76% of participants to a 2-year interval, but would delay diagnosis for only 30% of cancers, a 25% reduction versus the NHS protocol. Alternatively, LCRAT+CT, with a threshold of less than 1.7% cumulative lung cancer risk, would also delay diagnosis for 40% of cancers, but would refer 85% of participants for a 2-year interval, a 38% further reduction in the number of required 1-year screens beyond the NHS protocol. Conclusions Using individualized risk models to determine management in lung cancer screening could substantially reduce the number of screens or increase early detection.

BackgroundWhile lung cancer low-dose computed tomography (LDCT) screening is being rolled out in many regions around the world, differentiation of indeterminate pulmonary nodules between malignant and benign remains to a challenge for screening programs. We conducted one of the first systematic investigations of circulating protein markers for their ability to assess the risk of malignancy for screen-detected pulmonary nodules.MethodsBased on four LDCT screening studies in the United States, Canada and Europe, we assayed 1078 unique protein markers in pre-diagnostic samples based on a nested case-control design with a total of 1253 participants. Protein markers were measured using proximity extension assays and the data were analyzed using multivariate logistic regression, random forest, and penalized regressions.ResultsWe identified 36 potentially informative markers differentiating malignant nodules from benign nodules. Pathway analysis revealed a tightly connected network based on the 36 protein-coding genes. We observed a differential mRNA expression profile of the corresponding 36 mRNAs between lung tumors and adjacent normal tissues using data from The Cancer Genomic Atlas. We prioritized a panel of 9 protein markers through 10-fold nested cross-validations. We observed that circulating protein markers can increase sensitivity to 0.80 for nodule malignancy compared to the Brock model (p-valueConclusionsCirculating protein markers can help to differentiate between malignant and benign pulmonary nodules. Validating these results in an independent CT-screening study will be required prior to clinical implementation.

Background: Lung cancer is the leading cause of cancer death worldwide. We explored the relationship between socioeconomic status and lung cancer incidence across world regions, using educational level as a proxy for socioeconomic status. Methods: We analyzed the harmonized database of the Lung Cancer Cohort Consortium (LC3). The current study included data from 18 prospective cohorts from 15 countries in the US, Europe, Asia, and Australia. Separately for participants who never or currently/formerly smoked, we estimated the association between educational level and incident lung cancer using Cox proportional hazards models. Information on education was harmonized using the International Standard Classification of Education and then modeled as an ordinal variable in 4 categories. Models were adjusted for age, sex, and for participants who currently/formerly smoked, smoking duration, cigarettes per day, and time since cessation. Results: Among 2.6 million participants from 15 countries, 62,645 developed lung cancer during follow-up (median follow-up = 12.6 years). Among current/former smokers, increased educational level was associated with decreased lung cancer incidence in most cohorts after adjustment for age, sex, and detailed smoking information, with HRs ranging from 0.77 (95%CI: 0.42-1.41) per 1-unit increase in educational level in the Iranian Golestan Cohort Study to 1.02 (95%CI: 0.95-1.09) in the Australian Melbourne Collaborative Cohort Study. When grouping by world region, the association between education and lung cancer incidence among currently/formerly smoking participants was similar for the US (HRpooled=0.88, 95%CI: 0.87-0.89), Europe (HRpooled=0.89, 95%CI: 0.88-0.91), and Asia (HRpooled=0.91, 95%CI: 0.86-0.96), but attenuated in the Australian cohort (HR=1.02, 95%CI: 0.95-1.09). Among never smokers, after adjustment for age and sex, there was no statistically significant association between educational level and lung cancer incidence (p-trend>0.05 in all cohorts), with the exception of the US Southern Community Cohort Study, which comprises primarily African-Americans and showed a HR of 0.75 (95%CI: 0.62-0.90). Conclusion: Among currently and formerly smoking individuals, higher educational level showed a strikingly consistent decreased risk of incident lung cancer across cohorts from 4 continents, after detailed adjustment for smoking. In contrast, among people who never smoked, there was no association between education and lung cancer incidence in any cohort, with the exception of the Southern Community Cohort Study. Further research is needed to clarify the mechanisms, either related or unrelated to smoking, that contribute to the association between education and lung cancer risk. Citation Format: Justina U. Onwuka, Hana Zahed, Xiaoshuang Feng, Karine Alcala, Mattias Johansson, Hilary A. Robbins, Lung Cancer Cohort Consortium. Socioeconomic status and lung cancer incidence: An analysis of data from 15 countries in the Lung Cancer Cohort Consortium [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1950.

We examined whether draft 2020 United States Preventive Services Task Force (USPSTF) lung cancer screening recommendations “partially ameliorate racial disparities in screening eligibility” compared with the 2013 guidelines, as claimed. Using data from the 2015 National Health Interview Survey, USPSTF-2020 increased eligibility by similar proportions for minorities (97.1%) and Whites (78.3%). Contrary to the intent of USPSTF-2020, the relative disparity (differences in percentages of model-estimated gainable life-years from National Lung Screening Trial–like screening by eligible Whites vs minorities) actually increased from USPSTF-2013 to USPSTF-2020 (African Americans: 48.3%–33.4% = 15.0% to 64.5%–48.5% = 16.0%; Asian Americans: 48.3%–35.6% = 12.7% to 64.5%–45.2% = 19.3%; Hispanic Americans: 48.3%–24.8% = 23.5% to 64.5%–37.0% = 27.5%). However, augmenting USPSTF-2020 with high-benefit individuals selected by the Life-Years From Screening with Computed Tomography (LYFS-CT) model nearly eliminated disparities for African Americans (76.8%–75.5% = 1.2%) and improved screening efficiency for Asian and Hispanic Americans, although disparities were reduced only slightly (Hispanic Americans) or unchanged (Asian Americans). The draft USPSTF-2020 guidelines increased the number of eligible minorities vs USPSTF-2013 but may inadvertently increase racial and ethnic disparities. LYFS-CT could reduce disparities in screening eligibility by identifying ineligible people with high predicted benefit regardless of race and ethnicity.

The Integrative Analysis of Lung Cancer Etiology and Risk (INTEGRAL) program is an NCI-funded initiative with an objective to develop tools to optimize lung cancer screening. Here, we describe the rationale and design for the Risk Biomarker and Nodule Malignancy projects within INTEGRAL. The overarching goal of these projects is to systematically investigate circulating protein markers to include on a panel for use (i) pre-LDCT, to identify people likely to benefit from screening, and (ii) post-LDCT, to differentiate benign versus malignant nodules. To identify informative proteins, the Risk Biomarker project measured 1,161 proteins in a nested-case control study within 2 prospective cohorts (n=252 lung cancer cases and 252 controls) and replicated associations for a subset of proteins in 4 cohorts (n=479 cases and 479 controls). Eligible participants had any history of smoking and cases were diagnosed within 3 years of blood draw. The Nodule Malignancy project measured 1,077 proteins among participants with a heavy smoking history within 4 LDCT screening studies (n=425 cases within 5 years of blood draw, 398 benign-nodule controls, and 430 nodule-free controls). The INTEGRAL panel will enable absolute quantification of 21 proteins. We will evaluate its lung cancer discriminative performance in the Risk Biomarker project using a case-cohort study including 14 cohorts (n=1,696 cases and 2,926 subcohort representatives), and in the Nodule Malignancy project within 5 LDCT screening studies (n=675 cases, 648 benign-nodule controls, and 680 nodule-free controls). Future progress to advance lung cancer early detection biomarkers will require carefully designed validation, translational, and comparative studies.

IntroductionLow-dose CT (LDCT) screening of high-risk smokers reduces lung cancer (LC) specific mortality. Determining screening eligibility using individualised risk may improve screening effectiveness and reduce harm. Here, we compare the performance of two risk prediction models (PLCOM2012 and Liverpool Lung Project model (LLPv2)) and National Lung Screening Trial (NLST) eligibility criteria in a community-based screening programme.MethodsEver-smokers aged 55–74, from deprived areas of Manchester, were invited to a Lung Health Check (LHC). Individuals at higher risk (PLCOM2012 score ≥1.51%) were offered annual LDCT screening over two rounds. LLPv2 score was calculated but not used for screening selection; ≥2.5% and ≥5% thresholds were used for analysis.ResultsPLCOM2012 ≥1.51% selected 56% (n=1429) of LHC attendees for screening. LLPv2 ≥2.5% also selected 56% (n=1430) whereas NLST (47%, n=1188) and LLPv2 ≥5% (33%, n=826) selected fewer. Over two screening rounds 62 individuals were diagnosed with LC; representing 87% (n=62/71) of 6-year incidence predicted by mean PLCOM2012 score (5.0%). 26% (n=16/62) of individuals with LC were not eligible for screening using LLPv2 ≥5%, 18% (n=11/62) with NLST criteria and 7% (n=5/62) with LLPv2 ≥2.5%. NLST eligible Manchester attendees had 2.5 times the LC detection rate than NLST participants after two annual screens (≈4.3% (n=51/1188) vs 1.7% (n=438/26 309); padjOR 2.50, 95% CI 1.11 to 5.64; p=0.028).ConclusionProspective comparisons of risk prediction tools are required to optimise screening selection in different settings. The PLCOM2012 model may underestimate risk in deprived UK populations; further research focused on model calibration is required.

INTRODUCTION: The risk of prostate cancer among persons living with HIV (PWH) is not well understood and may be obscured by different opportunities for detection. METHODS: We identified 123,472 (37,819 PWH and 85,653 comparators) men enrolled in the Veterans Aging Cohort Study, a prospective national cohort of PWH and demographically-matched, uninfected comparators in 2000–2015. We calculated rates of PSA testing by HIV status and fit multivariable Poisson models comparing the rates of PSA testing, prostate biopsy, and cancer incidence. RESULTS: The mean age at enrollment was 52 years. Rates of PSA testing were lower in PWH versus uninfected comparators (0.58 versus 0.63 tests per person-year, respectively). Adjusted rates of PSA screening and prostate biopsy were lower among PWH (incidence rate ratio [IRR] 0.87, 95% CI 0.75–0.84) and IRR 0.79 (0.74–0.83), respectively. The crude IRR for prostate cancer was lower in PWH versus controls (IRR 0.90, 95% CI 0.83–0.97). However, in a multivariable model adjusting for PSA testing, cancer incidence was similar by HIV status (IRR=0.93, 95% CI 0.86–1.01, p=0.08). Among patients who received a prostate biopsy, incidence of prostate cancer did not differ significantly by HIV status (IRR 1.06, 95% CI 0.98–1.15, p=0.15). Among incident cancers, there were significant differences in the distributions of Gleason Grade (p=0.05), but not cancer stage (p=0.14) by HIV status. CONCLUSIONS: When accounting for less PSA testing among PWH, the incidence of prostate cancer was similar by HIV status. These findings suggest that less screening contributed to lower observed incidence of prostate cancer in PWH.

Lengthening the annual low-dose computed tomography (CT) screening interval for individuals at lowest risk of lung cancer could reduce harms and improve efficiency. We analyzed 23 328 participants in the National Lung Screening Trial who had a negative CT screen (no ≥4-mm nodules) to develop an individualized model for lung cancer risk after a negative CT. The Lung Cancer Risk Assessment Tool + CT (LCRAT+CT) updates “prescreening risk” (calculated using traditional risk factors) with selected CT features. At the next annual screen following a negative CT, risk of cancer detection was reduced among the 70% of participants with neither CT-detected emphysema nor consolidation (median risk = 0.2%, interquartile range [IQR] = 0.1%–0.3%). However, risk increased for the 30% with CT emphysema (median risk = 0.5%, IQR = 0.3%–0.8%) and the 0.6% with consolidation (median = 1.6%, IQR = 1.0%–2.5%). As one example, a threshold of next-screen risk lower than 0.3% would lengthen the interval for 57.8% of screen-negatives, thus averting 49.8% of next-screen false-positives among screen-negatives but delaying diagnosis for 23.9% of cancers. Our results support that many, but not all, screen-negatives might reasonably lengthen their CT screening interval.

Background: Melanoma aetiology has been proposed to have two pathways, which are determined by naevi and type of sun exposure and related to the anatomical site where melanoma develops. Objectives: We examined associations with melanoma by anatomical site for a comprehensive set of risk factors including pigmentary and naevus phenotypes, ultraviolet radiation exposure and polygenic risk. Methods: We analysed harmonized data from 2617 people with incident first invasive melanoma and 975 healthy controls recruited through two population-based case–control studies in Australia and the UK. Questionnaire data were collected by interview using a single protocol, and pathway-specific polygenic risk scores were derived from DNA samples. We estimated adjusted odds ratios using unconditional logistic regression that compared melanoma cases at each anatomical site with all controls. Results: When cases were compared with control participants, there were stronger associations for many naevi vs. no naevi for melanomas on the trunk, and upper and lower limbs than on the head and neck (P-heterogeneity < 0·001). Very fair skin (vs. olive/brown skin) was more weakly related to melanoma on the trunk than to melanomas at other sites (P-heterogeneity = 0·04). There was no significant difference by anatomical site for polygenic risk. Increased weekday sun exposure was positively associated with melanoma on the head and neck but not on other sites. Conclusions: We found evidence of aetiological heterogeneity for melanoma, supporting the dual pathway hypothesis. These findings enhance understanding of risk factors for melanoma and can guide prevention and skin examination education and practices.

Low-dose CT (LDCT) screening of high-risk smokers reduces lung cancer (LC) specific mortality. Determining screening eligibility using individualised risk may improve screening effectiveness and reduce harm. Here, we compare the performance of two risk prediction models (PLCOEver-smokers aged 55-74, from deprived areas of Manchester, were invited to a Lung Health Check (LHC). Individuals at higher risk (PLCOPLCOProspective comparisons of risk prediction tools are required to optimise screening selection in different settings. The PLCO

Background: Some uses of “race correction” in clinical algorithms and prediction models unfairly reduce access to care, resulting in calls to remove racial/ethnic variables from all models and algorithms. However, for models that are based on unbiased, high-quality, and plentiful data, removing racial/ethnic variables may reduce prediction accuracy for minorities. We model racial/ethnic disparities in screening eligibility from augmenting USPSTF-2021 guidelines (ages 50-80, ≥20 pack-years, ≤15 quit-years) to also include individuals selected by an NCCN-recommended risk model that includes race (PLCOM2012) versus the same model with race/ethnicity removed (PLCOM2012_NoRace). Methods: We used previously published methodology to model the performance of lung cancer screening using 6915 ever-smokers ages 50-80 from the US-representative 2015 National Health Interview Survey (NHIS). Individuals were considered eligible for screening if they are eligible by USPSTF-2021 guidelines or by PLCOM2012 (“USPSTF+PLCOM2012”), versus being eligible by USPSTF-2021 or PLCOM2012_NoRace (“USPSTF+PLCOM2012_NoRace”). Both models used the NCCN-recommended ≥1.3% 6-year risk-threshold for eligibility. We evaluated model accuracy (average percent over/under-estimation) by race/ethnicity, estimated the proportion of life-years gainable achieved by each eligible cohort (LYG), and evaluated the LYG disparity (difference in LYG between whites and each minority). Results: USPSTF+PLCOM2012 and USPSTF+PLCOM2012_NoRace identified similar numbers of minorities as eligible for screening (~2.7 million). However, USPSTF+PLCOM2012_NoRace selected 125% more Hispanic-Americans and 31% less African-Americans. LYG disparities decreased using USPSTF+PLCOM2012_NoRace versus USPSTF+PLCOM2012 for Hispanic Americans (LYG: 33% to 29%). However, LYG disparities for African Americans increased (LYG: 16% to 18%). PLCOM2012 underestimated lung cancer risk by 49% for Hispanic-Americans, whereas PLCOM2012_NoRace performed well (4% overestimation). However, PLCOM2012underestimated risk in African-Americans by only 6%, PLCOM2012_NoRace underestimated risk in African-Americans by 36%. Conclusion: The model that was most accurate for a minority group was projected to reduce disparities the most for that group. Removing race from the PLCOM2012 model substantially underestimated risk for African-Americans and may increase disparities. Inexplicably, PLCOM2012 substantially underestimated risk in Hispanic-Americans despite including race/ethnicity, which was alleviated by removing race/ethnicity. Great care must be taken when removing racial/ethnic variables from models, because this will assign minorities risk estimates that may be largely, or entirely, based on the majority population. Citation Format: Corey D. Young, Li C. Cheung, Christine D. Berg, Patricia Rivera, Hilary A. Robbins, Anil K. Chaturvedi, Hormuzd A. Katki, Rebecca Landy. Potential effect on racial/ethnic disparities of removing racial/ethnic variables from risk models: The example of lung-cancer screening [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PR-13.

Background The incidence of HPV-related head and neck squamous cell carcinoma (HPV-HNSCC) is increasing. Oral samples are easy and non-invasive to collect, but the diagnostic accuracy of oral HPV detection methods for classifying HPV-positive HNSCC tumors has not been well explored. Methods In a systematic review, we identified eight studies of HNSCC patients meeting our eligibility criteria of having: (1) HPV detection in oral rinse or oral swab samples, (2) tumor HPV or p16 testing, (3) a publication date within the last 10 years (January 2007–May 2017, as laboratory methods change), and (4) at least 15 HNSCC cases. Data were abstracted from each study and a meta-analysis performed to calculate sensitivity and specificity. Results Eight articles meeting inclusion criteria were identified. Among people diagnosed with HNSCC, oral HPV detection has good specificity (92%, 95% CI = 82–97%) and moderate sensitivity (72%, 95% CI = 45–89%) for HPV-positive HNSCC tumor. Results were similar when restricted to studies with only oropharyngeal cancer cases, with oral rinse samples, or testing for HPV16 DNA (instead of any oncogenic HPV) in the oral samples. Discussion Among those who already have HNSCC, oral HPV detection has few false-positives but may miss one-half to one-quarter of HPV-related cases (false-negatives). Given these findings in cancer patients, the utility of oral rinses and swabs as screening tests for HPV-HNSCC among healthy populations is probably limited.

Background Human papillomavirus type 16 (HPV16)-E6 antibodies are detectable in peripheral blood before diagnosis in the majority of HPV16-driven oropharyngeal squamous cell carcinoma (OPSCC), but the timing of seroconversion is unknown. Patients and methods We formed the HPV Cancer Cohort Consortium which comprises nine population cohorts from Europe, North America and Australia. In total, 743 incident OPSCC cases and 5814 controls provided at least one pre-diagnostic blood sample, including 111 cases with multiple samples. Median time between first blood collection and OPSCC diagnosis was 11.4 years (IQR = 6–11 years, range = 0–40 years). Antibodies against HPV16-E6 were measured by multiplex serology (GST fusion protein based Luminex assay). Results HPV16-E6 seropositivity was present in 0.4% of controls (22/5814; 95% CI 0.2% to 0.6%) and 26.2% (195/743; 95% CI 23.1% to 29.6%) of OPSCC cases. HPV16-E6 seropositivity increased the odds of OPSCC 98.2-fold (95% CI 62.1–155.4) in whites and 17.2-fold (95% CI 1.7–170.5) in blacks. Seropositivity in cases was more frequent in recent calendar periods, ranging from 21.9% pre-1996 to 68.4% in 2005 onwards, in those with blood collection near diagnosis (lead time 30 years (N = 24), 20–30 years (N = 148), 10–20 years (N = 228), and

Background In the National Lung Screening Trial (NLST), screen-detected cancers that would not have been identified by the Lung Computed Tomographic Screening Reporting and Data System (Lung-RADS) nodule management guidelines were frequently ground-glass opacities (GGOs). Lung-RADS suggests that GGOs with diameter less than 20 mm return for annual screening, and GGOs greater than or equal to 20 mm receive 6-month follow-up. We examined whether this 20-mm threshold gives consistent management of GGOs compared with solid nodules. Methods First, we calculated diameter-specific malignancy probabilities for GGOs and solid nodules in the NLST. Using the solid-nodule malignancy risks as benchmarks, we suggested risk-based management categories for GGOs based on their probability of malignancy. Second, we compared lung-cancer mortality between GGOs and solid nodules in the same risk-based category. Results Using the Lung-RADS v1.0 classifications, malignancy probability is higher for GGOs than solid nodules within the same category. A risk-based classification of GGOs would assign annual screening for GGOs 4 to 5 mm (0.4% malignancy risk); 6-month follow-up for GGOs 6 to 7 mm (1.1%), 8 to 14 mm (3.0%), and 15 to 19 mm (5.2%); and 3-month follow-up for greater than or equal to 20 mm (10.9%). This reclassification would have assigned similarly fatal cancers to 3-month follow-up (hazard ratio = 2.0 for lung-cancer death in GGOs versus solid-nodule cancers, 95% confidence interval: 0.4–8.7), but for 6-month follow-up, mortality was lower in GGO cancers (hazard ratio = 0.18, 95% confidence interval: 0.05–0.67). Conclusions If Lung-RADS categories for GGOs were based on malignancy probability, then 6- to 19-mm GGOs would receive 6-month follow-up and greater than or equal to 20-mm GGOs would receive 3-month follow-up. Such risk-based management for GGOs could improve the sensitivity of Lung-RADS, especially for large GGO cancers. However, small GGO cancers were less aggressive than their solid-nodule counterparts.

Background: For the same age and smoking history as whites, minorities have substantially different lung-cancer risk. However, current US Preventive Services Task Force (USPSTF) lung-cancer screening recommendations make no allowance for race/ethnicity and may induce health disparities. Incorporating individualized prediction-models into USPSTF guidelines may reduce racial/ethnic disparities in lung-cancer screening eligibility. We examine whether expanding current USPSTF lung cancer screening eligibility to include ever-smokers whose risk (calculated by an individualized prediction model) exceeded a threshold would reduce racial/ethnic disparities induced by current USPSTF guidelines. Methods: We used the US- representative 2015 National Health Interview Survey to examine screening eligibility. We identified the thresholds for each of 5 models: lung-cancer risk (Bach, PLCOM2012 and LCRAT models), lung-cancer death risk (LCDRAT model), and life- years gained by attending screening (LYFS-CT model), which select the same number of ever-smokers aged 50-80yrs as USPSTF guidelines. We defined 5 cohorts of ever- smokers as eligible for screening if they were eligible by each screening model or USPSTF guidelines. Among each race/ethnicity, we calculated the number eligible for screening, proportion of preventable lung-cancer deaths prevented (LCD sensitivity), proportion of gainable life-years gained (LYG sensitivity) and screening effectiveness (the number needed to screen to prevent one lung-cancer death). Results: USPSTF criteria performed best for whites (20% eligible, preventing 55% of preventable lung- cancer deaths). Asian-Americans had the least effective screening (NNS=419), only 13% of African-Americans were eligible despite having the most effective screening (NNS=135), and Hispanic-Americans had the lowest percentages eligible (9%) and deaths preventable (30%). Augmenting USPSTF criteria with LCDRAT or LYFS-CT prediction-models nearly equalized the performance of screening for African- Americans with that of whites, doubling the number of African-Americans eligible and increasing the number of preventable deaths and life-years gained by nearly 80%, although at a 25% loss in effectiveness. Prediction-models improved all screening metrics for Asian-Americans and Hispanic-Americans. However models estimated risk more accurately for whites than minorities. Conclusions: Augmenting USPSTF criteria with the LCDRAT or LYFS-CT prediction-models nearly eliminated the white/African-American disparity. All screening metrics were substantially improved for Asian/Hispanic-Americans. Citation Format: Rebecca Landy, Corey D. Young, Martin Skarzynski, Li C. Cheung, Christine D. Berg, M. Patricia Rivera, Hilary A. Robbins, Anil K. Chaturvedi, Hormuzd A. Katki. Use of prediction models to reduce racial/ethnic disparities in eligibility for lung-cancer screening [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-247.

Lung cancer screening is receiving increasing attention worldwide, both in the medical community and the general public. Multiple randomised trials — including the US National Lung Screening Trial (NLST), the Multicentric Italian Lung Detection trial, and preliminary results from the Dutch-Belgian NELSON trial — have provided definitive evidence that low-dose CT screening can reduce lung cancer mortality. However, any screening programme is associated with both benefits and harms, and accurately communicating these to patients and the general public is a complex challenge. Given the complexity of the debate, it is difficult for primary care providers to understand and explain the benefits and harms of screening to their patients. Multiple graphical tools have been developed and published to aid this conversation, each based on the NLST, and other bespoke graphics have been used in pilot studies. However, some of the published graphics can be misleading, and all represent outcomes based on the NLST protocol, which is now nearly 20 years old. We engaged an international group of lung screening experts with the goal of assembling and providing accurate and balanced information on the benefits and harms of NLST-like low-dose CT screening. We compiled these results into an infographic, along with a full-page version with explanatory text. Our new infographic represents a contemporary interpretation of the findings of NLST using a modern protocol.

Solid organ transplant recipients, who are medically immunosuppressed to prevent graft rejection, have increased melanoma risk, but risk factors and outcomes are incompletely documented. We evaluated melanoma incidence among 139,991 non-Hispanic white transplants using linked US transplant-cancer registry data (1987–2010). We used standardized incidence ratios (SIRs) to compare incidence with the general population and incidence rate ratios (IRRs) from multivariable Poisson models to assess risk factors. Separately, we compared post-melanoma survival among transplant recipients (n=182) and non-recipients (n=131,358) using multivariable Cox models. Among transplant recipients, risk of invasive melanoma (n=519) was elevated (SIR=2.20, 95% CI 2.01–2.39), especially for regional stage tumors (SIR=4.11, 95% CI 3.27–5.09). Risk of localized tumors was stable over time after transplantation but higher with azathioprine maintenance therapy (IRR=1.35, 95% CI 1.03–1.77). Risk of regional/distant stage tumors peaked within 4 years following transplantation and increased with polyclonal antibody induction therapy (IRR=1.65, 95% CI 1.02–2.67). Melanoma-specific mortality was higher among transplant recipients than non-recipients (hazard ratio 2.98, 95% CI 2.26–3.93). Melanoma exhibits increased incidence and aggressive behavior under transplant-related immunosuppression. Some localized melanomas may result from azathioprine, which acts synergistically with UV radiation, whereas T-cell–depleting induction therapies may promote late-stage tumors. Our findings support sun safety practices and skin screening for transplant recipients.

ObjectiveWe suggested cervical cancer screening strategies for women living with HIV (WLHIV) by comparing their precancer risks to general population women, and then compared our suggestions with current Centers for Disease Control and Prevention (CDC) guidelines.DesignWe compared risks of biopsy-confirmed cervical high-grade squamous intraepithelial neoplasia or worse (bHSIL+), calculated among WLHIV in the Women's Interagency HIV Study, to 'risk benchmarks' for specific management strategies in the general population.MethodsWe applied parametric survival models among 2423 WLHIV with negative or atypical squamous cell of undetermined significance (ASC-US) cytology during 2000-2015. Separately, we synthesized published general population bHSIL+ risks to generate 3-year risk benchmarks for a 3-year return (after negative cytology, i.e. 'rescreening threshold'), a 6-12-month return (after ASC-US), and immediate colposcopy [after low-grade squamous intraepithelial lesion (LSIL)].ResultsAverage 3-year bHSIL+ risks among general population women ('risk benchmarks') were 0.69% for a 3-year return (after negative cytology), 8.8% for a 6-12-month return (after ASC-US), and 14.4% for colposcopy (after LSIL). Most CDC guidelines for WLHIV were supported by comparing risks in WLHIV to these benchmarks, including a 3-year return with CD4 greater than 500 cells/μl and after either three negative cytology tests or a negative cytology/oncogenic human papillomavirus cotest (all 3-year risks≤1.3%); a 1-year return after negative cytology with either positive oncogenic human papillomavirus cotest (1-year risk = 1.0%) or CD4 cell count less than 500 cells/μl (1-year risk = 1.1%); and a 6-12-month return after ASC-US (3-year risk = 8.2% if CD4 cell count at least 500 cells/μl; 10.4% if CD4 cell count = 350-499 cells/μl). Other suggestions differed modestly from current guidelines, including colposcopy (vs. 6-12 month return) for WLHIV with ASC-US and CD4 cell count less than 350 cells/μl (3-year risk = 16.4%) and a lengthened 2-year (vs. 1-year) interval after negative cytology with CD4 cell count at least 500 cells/μl (2-year risk = 0.98%).ConclusionsCurrent cervical cancer screening guidelines for WLHIV are largely appropriate. CD4 cell count may inform risk-tailored strategies.

The glutathione S-transferase (GST)-L1 multiplex serology assay has favorable properties for use in clinical trials and epidemiologic studies, including low cost, high throughput capacity, and low serum volume requirement. Therefore, we evaluated the GST-L1 assay as a measure of HPV16/18 vaccine immunogenicity. Our study population included 65 women selected from the Costa Rica Vaccine Trial who received the bivalent HPV16/18 virus-like particle (VLP) vaccine at the recommended 0/1/6-month schedule. We tested replicate serum samples from months 0/1/12 (i.e., after 0/1/3 doses) by GST-L1 and 3 other commonly used serology assays, VLP-ELISA, SEAP-NA, and cLIA. We calculated the percentage of women seropositive by GST-L1 by time point and HPV type (14 HPV types), and compared GST-L1 to other assays using Spearman rank correlation coefficients. After 1 vaccine dose, seropositivity by GST-L1 was 40% each for HPV16 and HPV18, increasing to 100% and 98%, respectively, after 3 doses. Seropositivity after 3 doses ranged from 32% to 69% for HPV types 31/33/45, for which partial vaccine efficacy is reported, though increases also occurred for types with no evidence for cross-protection (e.g., HPV77). GST-L1 correlated best after 3 doses with VLP-ELISA (HPV16 and HPV18 each ρ = 0.72) and SEAP-NA (HPV16 ρ = 0.65, HPV18 ρ = 0.71) (all P

Anecdotally, short lung transplant candidates suffer from long waiting times and higher rates of death on the waiting list compared with taller candidates.To examine the relationship between lung transplant candidate height and waiting list outcomes.We conducted a retrospective cohort study of 13,346 adults placed on the lung transplant waiting list in the United States between 2005 and 2011. Multivariable-adjusted competing risk survival models were used to examine associations between candidate height and outcomes of interest. The primary outcome was the time until lung transplantation censored at 1 year.The unadjusted rate of lung transplantation was 94.5 per 100 person-years among candidates of short stature (162 cm) and 202.0 per 100 person-years among candidates of average stature (170-176.5 cm). After controlling for potential confounders, short stature was associated with a 34% (95% confidence interval [CI], 29-39%) lower rate of transplantation compared with average stature. Short stature was also associated with a 62% (95% CI, 24-96%) higher rate of death or removal because of clinical deterioration and a 42% (95% CI, 10-85%) higher rate of respiratory failure while awaiting lung transplantation.Short stature is associated with a lower rate of lung transplantation and higher rates of death and respiratory failure while awaiting transplantation. Efforts to ameliorate this disparity could include earlier referral and listing of shorter candidates, surgical downsizing of substantially oversized allografts for shorter candidates, and/or changes to allocation policy that account for candidate height.

Racial disparities exist in cancer incidence and survival, some of which may be explained by differences in cancer risk factors, screening, and treatment (1–3). For example, in the United States, blacks have higher mortality than whites for most common cancers and cancer overall (3). Additionally, studies have reported younger ages at diagnosis for blacks compared with whites for several cancer types. For female breast cancer, blacks have been reported to be five to 10 years (4,5) or even over 20 years (6) younger on average at diagnosis. A younger age in blacks has also been reported for prostate (7), lung (8), colon (9), rectal (10), head and neck (11), uterine corpus (12), and various hematologic cancers (13,14). Changes in screening guidelines and other clinical practices, targeted specifically to blacks, have been suggested partially on the basis of these apparent age differences (5,6,9,15). Reports of a younger age at diagnosis in blacks are typically based on comparisons of the mean or median age calculated among observed cancer cases, without consideration of the underlying populations from which cancer cases arise. Some have noted that these case-only comparisons may be biased, because the underlying population age distributions are different for blacks and whites (7,9,14,16–18). In the United States, there are proportionally fewer blacks than whites in older age groups (eg, 19.5% of whites are age ≥60 years old compared with 12.4% of blacks [19]) and cancer risk is greatest at older ages. Therefore, cancer cases that occur in blacks are inherently more likely to arise among younger age groups. A similar bias has been noted in other populations with different age distributions (20,21). In this study, we sought to assess whether there are racial differences in the age at cancer diagnosis after appropriately accounting for differences in population age structure between US blacks and whites. We hypothesized that correction for population differences might demonstrate that reports of a younger age in blacks are overstated for many cancers, and also potentially reveal true age differences that have previously been obscured.

Merkel cell carcinoma (MCC) is an uncommon skin cancer of neuroendocrine differentiation. MCC behaves aggressively, and five-year relative survival is only 62% (1). Like other skin cancers, MCC largely affects light-skinned populations (2,3), especially those highly exposed to ultraviolet radiation (UVR) (4). Recently, a previously unknown virus, Merkel cell polyomavirus (MCV), was detected in most but not all MCC tumors tested (5). This discovery has revived interest in MCC epidemiology, especially regarding the role of impaired immunity in promoting viral carcinogenesis. However, details regarding the relevant type of immunosuppression are poorly understood. Immunosuppression is suspected as important to MCC causation, as risk is increased among persons with human immunodeficiency virus (HIV) (6,7), chronic lymphocytic leukemia, (3,8) and other hematologic malignancies (8). MCC risk is also elevated following solid organ transplantation (9–12), after which patients must be pharmacologically immunosuppressed to prevent graft rejection. Also, some immunosuppressant medications used in transplantation may have direct skin carcinogenic effects, including interacting with UVR to enhance DNA damage (13–18). These direct effects may relate to the very high risks of squamous cell skin cancers in transplant recipients (19). Prior studies of transplant-related MCC have included fewer than 50 case patients and have not provided information on how risk differs by age, timing of transplant, or specific immunosuppressive medications (9–12). In the present study, we evaluated the occurrence of MCC among solid organ transplant recipients in the Transplant Cancer Match (TCM) Study, a large, population-based cohort of US transplant recipients for which cancer ascertainment was conducted uniformly via linkage with cancer registries. We quantified MCC risk overall and according to recipient demographic characteristics, transplanted organ, UVR exposure based on place of residence, length of time since transplant, and type of immunosuppressive drugs received.

BACKGROUND: In the course of screening, individual risk of disease evolves based on screening results. We calculated how individual lung cancer risk changes based on screening CT findings using data from the National Lung Screening Trial (NLST), which conducted annual screening for 3 years. METHODS: We calculated lung cancer risks by combining CT findings with individual predicted 1-year “pre-screening risk.” Pre-screening risk r(x) was predicted in the absence of screening using a validated risk model (Katki et al., JAMA 2016) with covariates (x): age, education, sex, race, smoking intensity/duration/quit-years, body mass index, family history of lung cancer, and self-reported emphysema. We used log-binomial regression to calculate the risk of an “interval” lung cancer (within 1 year of a negative screen) or a “screen-detected” cancer detected at the next annual screen. For each, covariates included log-transformed 1-year pre-screening risk and CT findings including classification as negative or false-positive and other specific features. RESULTS: The median 1-year pre-screening risk at the first NLST screen was 0.32% (interquartile range 0.19-0.53%). Among CT-negatives, risk over the next year was substantially reduced as r(x)1.32 (median interval cancer risk 0.05%), but risk at the next screen reverted to pre-screening risk as r(x)1. Risk at the next screen was higher for those whose CT noted either emphysema (r(x)0.95, median risk 0.53%) or consolidation (r(x)0.76, median risk 1.6%). Among CT-false-positives, overall risk at the next screen increased as r(x)0.74 (median risk 1.5%). Risk was higher among those with nodule(s) that were larger, had spiculated margins (median risk 4.1%), were located in the upper lobes (median risk 1.4%), or grew during the most recent screening interval (median risk 7.9%), while nodules with smooth margins indicated lower risk (median risk 0.71%). Those with a smooth-margins nodule and no risk-increasing factors essentially reverted to their pre-screening risk at the next screen as r(x)1.01 (median risk 0.29%), as if they had screened negative. Overall, only the immediately prior screen result, and not earlier screens, predicted lung cancer risk (all p>0.2). Exponents were similar for each interval and at each screen (all p>0.07). CONCLUSIONS: CT-negatives experienced reduced lung cancer risk over the next year, but reverted to their pre-screening risk at the next screen. CT-false-positives experienced substantially increased lung cancer detection at the next annual screen, with most risks exceeding 1%. These risk increases were explained by specific CT features including nodule size, location, margins, and growth. Citation Format: Hilary A. Robbins, Christine D. Berg, Li C. Cheung, Anil K. Chaturvedi, Hormuzd A. Katki. Effect of screening CT results and features on lung cancer risk prediction within the National Lung Screening Trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5291. doi:10.1158/1538-7445.AM2017-5291

Background Several assays are used to measure type-specific serological responses to human papillomavirus (HPV), including the bead-based glutathione S-transferase (GST)-L1 multiplex serology assay and virus-like particle (VLP)-based ELISA. We evaluated the high-throughput GST-L1, which is increasingly used in epidemiologic research, as a measure of cumulative HPV infection and future immune protection among HPV-unvaccinated women. Methods We tested enrollment sera from participants in the control arm of the Costa Rica Vaccine Trial (n = 488) for HPV16 and HPV18 using GST-L1, VLP-ELISA, and two assays that measure neutralizing antibodies (cLIA and SEAP-NA). With statistical adjustment for sampling, we compared GST-L1 serostatus to established HPV seropositivity correlates and incident cervical HPV infection using odds ratios. We further compared GST-L1 to VLP-ELISA using pair-wise agreement statistics and by defining alternate assay cutoffs. Results Odds of HPV16 GST-L1 seropositivity increased with enrollment age (OR = 1.20 per year, 95%CI 1.03-1.40) and lifetime number of sexual partners (OR = 2.06 per partner, 95%CI 1.49-2.83), with similar results for HPV18. GST-L1 seropositivity did not indicate protection from incident infection over 4 years of follow-up (HPV16 adjusted OR = 1.72, 95%CI 0.95-3.13; HPV18 adjusted OR = 0.38, 95%CI 0.12-1.23). Seroprevalence by GST-L1 (HPV16 and HPV18, respectively) was 5.0% and 5.2%, compared to 19.4% and 23.8% by VLP-ELISA, giving positive agreement of 39.2% and 20.8%. Lowering GST-L1 seropositivity cutoffs improved GST-L1/VLP-ELISA positive agreement to 68.6% (HPV16) and 61.5% (HPV18). Conclusions Our data support GST-L1 as a marker of cumulative HPV infection, but not immune protection. At lower seropositivity cutoffs, GST-L1 better approximates VLP-ELISA.

OBJECTIVE HIV-infected people have elevated risk for some cancers. Changing incidence of these cancers over time may reflect changes in three factors: HIV population demographic structure (e.g. age distribution), general population (background) cancer rates, and HIV-associated relative risks. We assessed the contributions of these factors to time trends for 10 cancers during 1996-2010. DESIGN Population-based registry linkage study. METHODS We applied Poisson models to data from the U.S. HIV/AIDS Cancer Match Study to estimate annual percentage changes (APCs) in incidence rates of AIDS-defining cancers [ADCs: Kaposi sarcoma, non-Hodgkin lymphoma (NHL), and cervical cancer] and seven non-AIDS-defining cancers (NADCs). We evaluated HIV-infected cancer trends with and without adjustment for demographics, trends in background rates, and trends in standardized incidence ratios (SIRs, to capture relative risk). RESULTS Cancer rates among HIV-infected people rose over time for anal (APC 3.8%), liver (8.5%), and prostate (9.8%) cancers, but declined for Kaposi sarcoma (1996-2000: -29.3%; 2000-2010: -7.8%), NHL (1996-2003: -15.7%; 2003-2010: -5.5%), cervical cancer (-11.1%), Hodgkin lymphoma (-4.0%), and lung cancer (-2.8%). Breast and colorectal cancer incidence did not change over time. Based on comparison to adjusted models, changing demographics contributed to trends for Kaposi sarcoma and breast, colorectal, liver, lung, and prostate cancers (all P

Solid organ transplant recipients have increased colorectal cancer (CRC) risk. We assessed CRC risk among transplant recipients and identified factors contributing to this association. The US transplant registry was linked to 15 population-based cancer registries (1987-2010). We compared CRC risk in recipients to the general population by using standardized incidence ratios (SIRs) and identified CRC risk factors by using Poisson regression. Based on 790 cases of CRC among 224 098 transplant recipients, the recipients had elevated CRC risk (SIR 1.12, 95% confidence interval [CI] 1.04 to 1.20). The increase was driven by an excess of proximal colon cancer (SIR 1.69, 95% CI 1.53 to 1.87), while distal colon cancer was not increased (SIR 0.93, 95% CI 0.80 to 1.07), and rectal cancer was reduced (SIR 0.64, 95% CI 0.54 to 0.76). In multivariate analyses, CRC was increased markedly in lung recipients with cystic fibrosis (incidence rate ratio [IRR] 12.3, 95% CI 6.94 to 21.9, vs. kidney recipients). Liver recipients with primary sclerosing cholangitis and inflammatory bowel disease also had elevated CRC risk (IRR 5.32, 95% CI 3.73 to 7.58). Maintenance therapy with cyclosporine and azathioprine was associated with proximal colon cancer (IRR 1.53, 95% CI 1.05 to 2.23). Incidence was not elevated in a subgroup of kidney recipients treated with tacrolimus and mycophenolate mofetil, pointing to the relevance of the identified risk factors. Transplant recipients have increased proximal colon cancer risk, likely related to underlying medical conditions (cystic fibrosis and primary sclerosing cholangitis) and specific immunosuppressive regimens.

Background: Women living with HIV (WLHIV) have increased cervical cancer risk. Guidelines suggest screening WLHIV with negative cervical cytology annually, and managing WLHIV with ASC-US cytology by general population (GP) guidelines (1 year return if HPV testing unavailable). Methods: We used risk benchmarking to compare cervical precancer risk in WLHIV to the GP. For WLHIV ages 21-65 years in the Women's Interagency HIV Study (WIHS), we evaluated the first cytology result from 2000 or later. We used parametric survival models to calculate HSIL risks after negative or ASC-US cytology, overall and by CD4 cell count. Separately, we synthesized HSIL risk estimates among GP women in 13 published studies using mixed-effects models. We then benchmarked risks in WLHIV to the 3-year GP risks, which for negative cytology represent the threshold for re-screening. Results: Among 2,653 WLHIV, 1,982 (75%) had negative cytology and 377 (14%) had ASC-US cytology. Most WLHIV with negative (72%) and ASC-US (52%) cytology had CD4≥350 cells/μL. We observed 95 cases of HSIL (CIN2+; 44 were CIN3+ including 1 cancer) within 5 years of cytology. After negative cytology, 3-year GP risk “benchmarks” were 0.83% (CIN2+) and 0.60% (CIN3+). WLHIV with CD4≥350 met both benchmarks by 2 years (1.1% and 0.68% respectively), while WLHIV with CD4 Conclusions: For WLHIV with CD4≥350, these data suggest that the interval for re-screening after negative cervical cytology can be lengthened from 1 to 2 years, and that inclusion in GP guidelines for managing ASC-US cytology is appropriate. In contrast, WLHIV with CD4 Citation Format: Hilary A. Robbins, L. Stewart Massad, Christopher B. Pierce, Lisa Flowers, Teresa M. Darragh, Howard Minkoff, Lisa Rahangdale, Marla J. Keller, Joel Milam, Margaret Fischl, Sadeep Shrestha, Christine Colie, Howard Strickler, Gypsyamber D’Souza. Optimizing cervical cancer screening for HIV-infected women: A risk-based approach. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2580.