USPSTF continues to recommend against COPD screening in asymptomatic adults

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The US Preventive Services Task Force (USPSTF), after a reconfirmation process, found there was no net benefit from screening asymptomatic adults for chronic obstructive pulmonary disease (COPD).

After a renewed deliberative process, the US Preventive Services Task Force (USPSTF) reiterated its 2016 decision that there was no net benefit from screening asymptomatic adults for chronic obstructive pulmonary disease (COPD).1

This recommendation applies to all adults who do not recognize or report respiratory symptoms. Patients with chronic cough, sputum production, difficulty breathing, or wheezing are not covered by this recommendation.

The reconfirmation advisory process included an evidence update commissioned by the USPSTF, which aimed to determine whether there was new and substantial evidence since the previous review that would be sufficient to change the recommendation. This update of the confirmatory evidence focused on key questions about the benefits and harms of COPD screening in asymptomatic adults.

The evidence update found that externally validated questionnaires that assessed risk factors, symptoms, or both had high sensitivity but low specificity in detecting COPD (sensitivity: 67% to 90%; specificity: 25% to 73%). The USPSTF also found no new studies that directly assessed the impact of screening for COPD in asymptomatic adults on morbidity, mortality, or quality of life.

The USPSTF reviewed 3 studies that included newly published analyzes evaluating pharmacological treatment in patients with mild to moderate COPD and varying degrees of symptom severity. Studies included treating patients with COPD with long-acting beta agonists (LABAs), long-acting muscarinic antagonists (LAMAs), inhaled corticosteroids (ICS), or combination therapy.

The SUMMIT randomized clinical trial in people with or at risk for cardiovascular disease showed that LABAs, ICS, or LABAs and ICS increased the annual rate of exacerbations and hospitalizations for exacerbations compared to placebo by a median in adults with symptomatic moderately severe COPD track reduced from 1.8 years. Exacerbation rates were low at baseline.

The percentage reduction in the annual rate of moderate to severe exacerbations was greater for LABA and ICS (29%; 95% CI, 22% – 35%) than for LABA (10%; 95% CI, 2% – 18%). ICS (12%; 95% CI, 4%-19%) alone.

The subgroup analysis of minimally symptomatic patients with moderately severe COPD in the UPLIFT study showed that LAMAs were associated with a reduction in the proportion of patients with exacerbations compared to placebo (48% vs. 54%; RR: 0.64; 95% CI : 0.47-0.89). No study showed that they reduced cardiovascular morbidity, mortality, or all-cause mortality. Pharmacotherapy has been shown to reduce exacerbations in adults with symptomatic moderate COPD that may not generalize to the asymptomatic population.

The USPSTF also evaluated 13 new studies that evaluated nonpharmacological interventions used in the management of mild to moderate COPD or in patients with COPD with minimal symptoms. The researchers observed no consistent benefit across the range of endpoints (e.g., exacerbations, quality of life, breathing difficulties, exercise, or physical capacity measures).

The USPSTF most recently reviewed data from 6 treatment studies and 2 observational studies that reported pharmacological or non-pharmacological treatment harms in patients with mild to moderate COPD. None of the studies found significant damage but were limited to a small population.

There was 1 study that found an increased risk of a major cardiovascular event after starting LABA or LAMA treatment (odds ratio [OR], 1.50; 95% CI, 1.35-1.67); the association of cardiovascular risk with LABAs or LAMAs was absent or reduced when using inhalation therapy. A second study found that ICS may increase the risk of developing diabetes (HR, 1.32; 95% CI, 1.06-1.64). Serious harms from treatment studies have not been consistently reported, but the large observational studies suggested possible harms from initiating LAMA or LABA or using ICS, consistent with the previous review supporting the USPSTF’s 2016 recommendation.

In an editorial accompanying the recommendation statement, Surya P. Bhatt, MD, MSPH, and George T. O’Connor, MD, MS, called the recommendation “reasonable” and underscored the task force’s call for additional research into the potential benefits of COPD screening.2 In particular, they noted that the symptoms of COPD may go undetected or be due to age, obesity, or effects of smoking, so sensitive questionnaires can be effective in identifying symptoms that go unreported by patients.

“Although available data may not support the screening of asymptomatic adults for COPD, there is significant rationale for further investigation of strategies to improve earlier detection of this condition,” they concluded.

references

  1. US Task Force on Preventive Services. Screening for chronic obstructive pulmonary disease US Working Group on Preventive Services recommendation statement for confirmation. JAMA. 2022;327(18):1806-1811. doi:10.1001/jama.2022.5692
  2. Bhatt SP, O’Connor GT. Challenges and opportunities in screening for chronic obstructive pulmonary disease. JAMA. 2022;327(18):1768-1770. doi:10.1001/jama.2022.3823

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