Screening for Lung Cancer, Overdiagnosis, and Healthcare Utilization: A Nationwide Population-Based Study

So Yeon Kim; Gerard A Silvestri; Yeon Wook Kim; Roger Y Kim; Sang-Won Um; Yunjoo Im; Jung Hye Hwang; Seung Ho Choi; Jung Seop Eom; Kang Mo Gu; Yong-Soo Kwon; Shin Yup Lee; Hyun Woo Lee; Dong Won Park; Yeonjeong Heo; Seung Hun Jang; Kwang Yong Choi; Yeol Kim; Young Sik Park

doi:10.1016/j.jtho.2024.12.006

Screening for Lung Cancer, Overdiagnosis, and Healthcare Utilization: A Nationwide Population-Based Study

J Thorac Oncol. 2024 Dec 9:S1556-0864(24)02503-6. doi: 10.1016/j.jtho.2024.12.006. Online ahead of print.

Authors

So Yeon Kim¹, Gerard A Silvestri², Yeon Wook Kim³, Roger Y Kim⁴, Sang-Won Um⁵, Yunjoo Im⁵, Jung Hye Hwang⁶, Seung Ho Choi⁷, Jung Seop Eom⁸, Kang Mo Gu⁹, Yong-Soo Kwon¹⁰, Shin Yup Lee¹¹, Hyun Woo Lee¹², Dong Won Park¹³, Yeonjeong Heo¹⁴, Seung Hun Jang¹⁵, Kwang Yong Choi¹⁵, Yeol Kim¹⁶, Young Sik Park¹⁷

Affiliations

¹ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
² Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, United States.
³ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
⁴ Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
⁵ Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
⁶ Center for Health Promotion, Samsung Medical Center, Seoul, South Korea.
⁷ Department of Internal Medicine, Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, South Korea.
⁸ Department of Internal Medicine, Pusan National University School of Medicine, Busan, South Korea.
⁹ Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea.
¹⁰ Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea.
¹¹ Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, South Korea.
¹² Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea.
¹³ Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea.
¹⁴ Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon, South Korea.
¹⁵ Department of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea.
¹⁶ Department of Cancer Control, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, South Korea.
¹⁷ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea. Electronic address: mdyspark@snu.ac.kr.

PMID: 39662732
DOI: 10.1016/j.jtho.2024.12.006

Abstract

Introduction: Guideline-discordant low-dose computed tomography (LDCT) screening may cause lung cancer (LC) overdiagnosis, but its extent and consequences are unclear. This study aimed to investigate the prevalence of self-initiated, non-reimbursed LDCT screening in a predominantly non-smoking population and its impact on LC epidemiology and healthcare utilization.

Methods: This nationwide cohort study analyzed data from Korea's National Health Information Database (NHID) and eleven academic hospital screening centers (1999-2022). The overall analysis encompassed the entire Korean population. For non-reimbursed LDCT screening prevalence, which NHID does not capture, a separate analysis was conducted on a cohort of 1.7 million adults to extrapolate nationwide rates. Outcomes included trends in self-initiated, non-reimbursed LDCT screening, LC incidence, mortality, stage and age at diagnosis, 5-year survival, and LC-related healthcare utilization, including surgeries and biopsies. Joinpoint regression assessed trend changes.

Results: Self-initiated, non-reimbursed LDCT screening during health check-ups increased from 29% to 60% in men and 7% to 46% in women, despite only 2.4% of men and 0.04% of women qualifying for risk-based screening. In women, localized-stage LC incidence nearly doubled (age-standardized incidence rate [ASIR], from 7.6 to 13.7 per 100,000), while distant-stage incidence decreased (ASIR, from 16.1 to 15.0 per 100,000). LC mortality declined (age-standardized mortality rate, from 23.3 to 19.8 per 100,000), while 5-year survival rates improved significantly. LC diagnoses in women shifted towards earlier stages and younger ages. Lung surgeries for both malignant and benign lesions, frequently lacking nonsurgical biopsies, increased sharply in women.

Conclusions: Widespread guideline-discordant LDCT screening correlates with LC overdiagnosis and increased healthcare utilization, particularly in women. Randomized controlled trials are needed to assess the risks and benefits of screening in low-risk populations to determine its efficacy and consequences.

Keywords: healthcare utilization; lung cancer screening; overdiagnosis.