USPSTF Continues to Recommend Against COPD Screening in Asymptomatic Adults

After a reaffirmation deliberation process, the US Preventive Services Task Force (USPSTF) reaffirmed its decision from 2016 that screening asymptomatic adults for chronic obstructive pulmonary disease (COPD) had no net benefit.¹

This recommendation is applied to all adults who do not recognize or report respiratory symptoms. Patients with chronic cough, sputum production, difficulty breathing, or wheezing do not fall under this recommendation.

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

The evidence update found that externally validated questionnaires that assessed risk factors, symptoms, or both had high sensitivity but poor specificity in detecting COPD (sensitivity: 67% to 90%; specificity: 25% to 73%). The USPSTF also did not find any new studies that directly assessed the effects of screening for COPD in asymptomatic adults on morbidity, mortality, or quality of life.

The USPSTF reviewed 3 trials that had newly published analyses that evaluated pharmacologic treatment in patients with mild to moderate COPD and varying levels of symptoms. The 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 of people with or at risk for cardiovascular disease demonstrated in adults with symptomatic moderate COPD that LABAs, ICS, or LABAs and ICS reduced the annual rate of exacerbations and hospitalizations for exacerbations compared with placebo at a median of 1.8 years of follow-up. Exacerbation rates had been low at baseline.

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

Subgroup analysis of minimal lysymptomatic patients with moderate COPD in the UPLIFT trial demonstrated that LAMAs were associated with a reduction in the proportion of patients with exacerbations compared with placebo (48% vs 54%, respectively; RR, 0.64; 95% CI, 0.47-0.89). No studies demonstrated that they reduced cardiovascular morbidity, mortality, or all-cause mortality. Evidence demonstrated that pharmacotherapy may reduce exacerbations in adults with symptomatic moderate COPD, which may not be generalizable for the asymptomatic population.

The USPSTF also assessed 13 new trials that evaluated nonpharmacologic interventions that are used in the management of mild to moderate COPD or in patients with COPD who are minimally symptomatic. Investigators observed no consistent benefit across the range of outcomes (eg, exacerbations, quality of life, difficulty breathing, exercise or physical performance measures).

The USPSTF last reviewed data from 6 treatment trials and 2 observational studies that reported on pharmacologic or nonpharmacologic treatment harms in patients with mild to moderate COPD. None of the trials found significant harms but were limited by small population.

There was 1 study that found an increased risk of a serious cardiovascular event following LABA or LAMA initiation (odds ratio [OR], 1.50; 95% CI, 1.35-1.67); the association of cardiovascular risk with LABAs or LAMAs was absent or reduced with use of inhaled therapy. A second study found that ICS may increase risk of developing diabetes (HR, 1.32; 95% CI, 1.06-1.64). Serious harms from treatment trials were not consistently reported, but the large observational studies suggested possible harms for LAMA or LABA initiation or use of ICS, which is 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 on the potential benefits of COPD screening.² In particular, they noted that the symptoms of COPD can go unrecognized or chalked up to age, obesity, or effects from smoking, so sensitive questionnaires may be effective for identifying symptoms not reported by patients.

“Even though available data may not support screening asymptomatic adults for COPD, there is substantial rationale for further investigation of strategies to enhance earlier detection of this condition,” they concluded.

References

1. US Preventive Services Task Force. Screening for chronic obstructive pulmonary disease US preventive services task force reaffirmation recommendation statement. JAMA. 2022;327(18):1806-1811. doi:10.1001/jama.2022.5692
2. Bhatt SP, O’Connor GT. Screening for chronic obstructive pulmonary disease challenges and opportunities. JAMA. 2022;327(18):1768-1770. doi:10.1001/jama.2022.3823