FROM JAMA

There is no apparent benefit to screening for chronic obstructive pulmonary disease in asymptomatic patients, a new recommendation from the U.S. Preventive Services Task Force (USPSTF) concludes.

The recommendation statement , which was published in the April 5 edition of JAMA, meets Grade D criteria, which the task force defines as having “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits.”

Led by Dr. Albert L. Siu of the Icahn School of Medicine at Mount Sinai, New York, the 16-member task force “found no studies that directly assessed the effects of screening for COPD [chronic obstructive pulmonary disease] in asymptomatic adults on morbidity, mortality, or health-related quality of life,” they wrote (JAMA. 2016 Apr; 315[13]:1372-7). “The USPSTF also found no studies that examined the effectiveness of screening on relevant immunization rates.” The five studies identified that assessed the effects of screening on smoking cessation “primarily examined the incremental value of adding spirometry testing to existing smoking cessation programs. One trial showed a statistically significant increase in smoking cessation rates between participants who received explanations of their spirometry results using ‘lung age’ and those who did not. The other four trials did not report any significant differences in smoking abstinence rates.”

The recommendations are based on a systematic review of evidence that was commissioned by the USPSTF and published in the same issue of JAMA. The reviewers set out to determine the accuracy of screening questionnaires and office-based screening pulmonary function testing and the efficacy and harms of treatment of screen-detected COPD. After reviewing 33 studies that met inclusion criteria, five experts led by Dr. Janelle M. Guirguis-Blake found “no direct evidence available to determine the benefits and harms of screening asymptomatic adults for COPD using questionnaires or office-based screening pulmonary function testing or to determine the benefits of treatment in screen-detected populations,” they wrote (JAMA. 2016 Apr; 315[13]:1378-93). “Indirect evidence suggests that the CDQ [COPD Diagnostic Questionnaire] has moderate overall performance for COPD detection. Among patients with mild to moderate COPD, the benefit of pharmacotherapy for reducing exacerbations was modest.”

The USPSTF last published an update on COPD in 2008. That report recommended against screening for COPD with spirometry in asymptomatic adults, a Grade D recommendation based on the conclusion that screening for COPD had no net benefit and large associated costs.

According to the current recommendations, an estimated 14% of U.S. adults aged 40-79 years have COPD, and it is the third leading cause of death in the U.S. Although postbronchodilator spirometry is required to make a definitive diagnosis, “prescreening questionnaires can elicit current symptoms and previous exposures to harmful particles or gases,” Dr. Siu and his fellow task force members wrote.

They acknowledged limitations of the recommendations, including the fact that many of the reviewed studies did not report results separately by current versus former smokers. “Future studies that stratify risk by smoking status could help identify different risk groups that may benefit from screening,” they wrote “In addition, trials are needed that assess the effects of screening among current and previous smokers in primary care on long-term health outcomes. Long-term trials of treatment of COPD in screen-detected patients are also needed. Better treatment options for COPD and long-term epidemiological studies of the natural history and heterogeneity of COPD progression could also help identify patients who are at greatest risk for clinical deterioration.”

The systematic review was funded by the Agency for Healthcare Research and Quality under a contract to support the USPSTF. The authors of the recommendation statement reported having no financial disclosures.

dbrunk@frontlinemedcom.com

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