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• W2997806505 abstract "In 2016, the US Preventive Services Task Force (USPSTF) “did not find evidence that screening for COPD in asymptomatic persons improves health-related quality of life, morbidity, or mortality.”1US Preventive Services Task Force (USPSTF)Screening for chronic obstructive pulmonary disease: US Preventive Services Task Force recommendation statement.JAMA. 2016; 315: 1372-1377Crossref PubMed Scopus (146) Google Scholar The Task Force also concluded that early detection of COPD does not alter the course of disease or improve patient outcomes.1US Preventive Services Task Force (USPSTF)Screening for chronic obstructive pulmonary disease: US Preventive Services Task Force recommendation statement.JAMA. 2016; 315: 1372-1377Crossref PubMed Scopus (146) Google Scholar The thought process underlying this decision could be summarized as follows: the only known intervention shown to change the natural history of COPD is smoking cessation; there is no evidence that knowledge of a COPD diagnosis increases the likelihood of smoking cessation; every smoker should stop smoking; thus there is no rationale to screen for COPD (particularly in a person who has no symptoms). The way this recommendation is written, neither spirometry nor other screening tools, such as questionnaires, provide a net benefit in asymptomatic persons. The recommendations against screening for COPD are not limited to those of the USPSTF. In the 2011 consensus statement of the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society the first recommendation is that spirometry results be obtained to diagnose airflow obstruction in patients with respiratory symptoms, but that spirometry should not be used to screen for airflow obstruction in individuals without respiratory symptoms (grade: strong recommendation, moderate-quality evidence).2Qaseem A. Wilt T.J. Weinberger S.E. et al.Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society.Ann Intern Med. 2011; 155: 179-191Crossref PubMed Scopus (818) Google Scholar Likewise, the American Academy of Family Physicians stresses that screening for COPD in asymptomatic patients who are at increased risk is not recommended.3Gentry S. Gentry B. Chronic obstructive pulmonary disease: diagnosis and management.Am Fam Physician. 2017; 95: 433-441PubMed Google Scholar The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document notes that “there are no data to indicate that screening spirometry is effective in directing management decisions or in improving COPD outcomes in patients who are identified before the development of significant symptoms.”4Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) Scientific CommitteeGlobal Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report.https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdfDate accessed: August 1, 2019Google Scholar The answer to the question addressed by this editorial, “Can Screening for COPD Improve Outcomes?” is, at the present time, “No,” in agreement with the recommendation from the USPSTF and others. We address here the several different components to this issue, including the rationale for screening for disease, defining COPD, and how one ascertains outcomes in COPD and their improvement. What is the rationale for screening for disease? Wilson and Jungner5Wilson J.M. Jungner Y.G. Principles and Practice of Screening for Disease. Public Health Papers No. 34. World Health Organization, Geneva1968https://apps.who.int/iris/bitstream/handle/10665/37650/WHO_PHP_34.pdf?sequence=17&isAllowed=yDate accessed: August 1, 2019Google Scholar described the necessary components of a screening program in a classic World Health Organization report in 1968. Table 1 lists these components, along with our assessment of how these criteria may be applied in the screening, diagnosis, and treatment of COPD.Table 1Components Applied in the Screening, Diagnosis, and Treatment of COPDWilson and Jungner5Wilson J.M. Jungner Y.G. Principles and Practice of Screening for Disease. Public Health Papers No. 34. World Health Organization, Geneva1968https://apps.who.int/iris/bitstream/handle/10665/37650/WHO_PHP_34.pdf?sequence=17&isAllowed=yDate accessed: August 1, 2019Google Scholar Classic Screening CriteriaApplication in COPD1. The condition sought should be an important health problem+ + + +2. There should be an accepted treatment for patients with recognized disease+ + +3. Facilities for diagnosis and treatment should be available+ + +4. There should be a recognizable latent or early symptomatic stage+5. There should be a suitable test or examination+ +6. The test should be acceptable to the population+ +7. The natural history of the condition, including development from latent to declared disease, should be adequately understood+8. There should be an agreed policy on whom to treat as patients+9. The cost of case-finding (including diagnosis and treatment of patients with COPD) should be economically balanced in relation to possible expenditure on medical care as a whole+ +10. Case-finding should be a continuing process and not a “once and for all” project+ + Open table in a new tab Some of the questions and challenges represented in Table 1 revolve around the question of defining COPD. While COPD is characterized and diagnosed by the physiologic parameter of airflow obstruction,6Celli B.R. MacNee W. ATS/ERS Task ForceStandards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.Eur Respir J. 2004; 23: 932-946Crossref PubMed Scopus (3522) Google Scholar the causes of this physiologic abnormality can arise from a number of different processes, including those involving large airways, small airways, alveoli, and the pulmonary vasculature.7Rennard S.I. COPD heterogeneity: what this will mean in practice.Respir Care. 2011; 56: 1181-1187Crossref PubMed Scopus (12) Google Scholar In addition, by the time physiologic impairment is present (Fig 1), disease is well established and often advanced, with limited opportunity for disease modification.8Decramer M. Cooper C.B. Treatment of COPD: the sooner the better?.Thorax. 2010; 65: 837-841Crossref PubMed Scopus (78) Google Scholar Returning to Table 1, some of the gaps and uncertainties are apparent. The progression of COPD from early or latent disease to established disease is not well defined. Many patients with mild impairment do not progress to more severe impairment,9Putcha N. Drummond M.B. Connett J.E. et al.Chronic productive cough is associated with death in smokers with early COPD.COPD. 2014; 11: 451-458Crossref PubMed Scopus (21) Google Scholar and there is a growing body of evidence that other abnormalities, such as radiographic or physiologic ones, might occur early in the course of disease development.10Mannino D.M. Make B.J. Is it time to move beyond the “O” in early COPD?.Eur Respir J. 2015; 46: 1535-1537Crossref PubMed Scopus (9) Google Scholar Even if early disease were defined and established, there is no known treatment that has been shown to be effective or capable of modifying disease progression among those with early disease. The use of spirometry as the primary way of defining disease is a particular problem. The spirometer was invented by Dr John Hutchinson in the 1840s, and its basic structure is still used today.11Petty T.L. John Hutchinson’s mysterious machine revisited.Chest. 2002; 121: 219S-223SAbstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The spirometer, however, is a flawed screening and diagnostic tool, especially if one is looking for latent or early disease. Campaigns for primary care physicians to use spirometry in their offices have generally failed.12National Lung Health Education Program (NLHEP)Strategies in preserving lung health and preventing COPD and associated diseases.Chest. 1998; 113: 123S-163SPubMed Google Scholar Most primary care physicians do not have a spirometer; those who do rarely use them, and many of the spirometric procedures performed in primary care do not meet American Thoracic Society quality guidelines.13Lusuardi M. De Benedetto F. Paggiaro P. et al.A randomized controlled trial on office spirometry in asthma and COPD in standard general practice: data from spirometry in asthma and COPD: a comparative evaluation Italian study.Chest. 2006; 129: 844-852Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 14Leuppi J.D. Miedinger D. Chhajed P.N. et al.Quality of spirometry in primary care for case finding of airway obstruction in smokers.Respiration. 2010; 79: 469-474Crossref PubMed Scopus (48) Google Scholar Furthermore, postbronchodilator spirometry is almost never performed in primary care, and considering the millions at potential risk for COPD, the cost of just prebronchodilator spirometry would be extreme. While other means of determining early COPD are potentially available, such as CT imaging or measurement of diffusion capacity,10Mannino D.M. Make B.J. Is it time to move beyond the “O” in early COPD?.Eur Respir J. 2015; 46: 1535-1537Crossref PubMed Scopus (9) Google Scholar these are neither practical nor of low enough cost for use in primary care or as a screening tool. The final component of the question to be addressed is whether screening (and resulting interventions coming from that screening) would improve outcomes. Ideally, an intervention would keep a disease from becoming established, or if the disease was established, keep it in its milder stages. A number of different outcomes have been used in COPD clinical trials and population studies, with the most common ones being lung function decline, exacerbations of disease, symptoms, quality of life measures, and mortality. Of these, the metric thought to best represent disease modification is lung function decline, which is plagued by the same issues noted previously in discussing spirometry. Decreasing mortality is also a type of disease modification, but to date only smoking cessation,15Anthonisen N.R. Skeans M.A. Wise R.A. et al.The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial.Ann Intern Med. 2005; 142: 233-239Crossref PubMed Scopus (1050) Google Scholar domiciliary oxygen16Nocturnal Oxygen Therapy Trial GroupContinuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial.Ann Intern Med. 1980; 93: 391-398Crossref PubMed Scopus (2111) Google Scholar (for hypoxemic patients), and lung volume reduction surgery (in selected patients)17Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1668) Google Scholar have been shown to demonstrate this benefit. Of these interventions, only smoking cessation would apply across the entire continuum of patients with COPD. Returning to the question concerning whether COPD screening would improve outcomes: while the answer is currently “No,” our hope is that with advances in knowledge we can change this narrative. We have a roadmap for this from the world of cardiovascular medicine, where great advances have been made in the early detection of precursors of cardiovascular disease, which respond to treatment. People with risk factors for cardiovascular disease, and who have evidence of elevated low-density lipoprotein (LDL) cholesterol, can be treated with statins to decrease their risk of developing disease before they have had their first myocardial infarction.18Chou R. Dana T. Blazina I. Daeges M. Jeanne T.L. Statins for prevention of cardiovascular disease in adults: evidence report and systematic review for the US Preventive Services Task Force.JAMA. 2016; 316: 2008-2024Crossref PubMed Scopus (361) Google Scholar What the respiratory health world needs is a similar biomarker of very early disease that would be responsive to early and acceptable intervention. This biomarker, or set of biomarkers, should be easy to detect and interpret, and usable in the primary care setting. In addition, new therapies and interventions that would interrupt disease in its earliest phases, before lung function is lost and symptoms become established, are critically needed. Another critical need, returning to the rationale as to why screening for COPD is not currently recommended (other than to urge every smoker to stop smoking), is for better treatment of tobacco and nicotine addiction. Despite the advancement in knowledge gained from the initial Surgeon General’s Report in 1964,19US Surgeon General’s Advisory Committee on Smoking and HealthSmoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service. Public Health Service Publication No. 1103. US Department of Health, Education, and Welfare, Public Health Service, Washington, DC1964http://purl.access.gpo.gov/GPO/LPS107851Date accessed: August 1, 2019Google Scholar a large proportion of the population in the United States and the world continues to smoke cigarettes and other tobacco products.20Wang T.W. Asman K. Gentzke A.S. et al.Tobacco product use among adults—United States, 2017.MMWR Morb Mortal Wkly Rep. 2018; 67: 1225-1232Crossref PubMed Scopus (462) Google Scholar In addition, a new generation of products is being marketed to the next generation of users, with no demonstration that these products are less harmful than cigarettes. While therapies, both pharmacologic and nonpharmacologic, exist for tobacco addiction their success is limited. To conclude, screening for COPD, which as currently defined represents disease that is well advanced and not amenable to disease-modifying interventions, does not appear to be the best use of resources. Identifying and targeting changes in the lungs before they become established seems to be the best potential way of actually modifying the natural history of COPD. /cms/asset/8146096b-5ea3-470c-ab31-76c4dde044b6/mmc1.mp3Loading ... Download .mp3 (17.31 MB) Help with .mp3 files Audio POINT: Can Screening for COPD Improve Outcomes? YesCHESTVol. 157Issue 1PreviewCOPD is a common but often underrecognized and underdiagnosed condition, especially in primary care settings in the United States.1 Despite being the fourth leading cause of death in the United States, both diagnosed and undiagnosed COPD are a major cause of morbidity, mortality, disability, hospitalizations, and health-care expenditures.2 The slow decline in lung function and compensatory activity limitation often results in failure of symptom reporting to clinicians, with patients attributing symptoms to aging, obesity, poor conditioning, or “smoker’s cough.” Primary care physicians also fail to query regarding chronic respiratory symptoms or note recurrent respiratory events as significant, leaving these patients to appear to be “asymptomatic.” Full-Text PDF Rebuttal From Drs Yawn and MartinezCHESTVol. 157Issue 1PreviewWe read with great interest Drs Mannino and Thomashow’s discussion of COPD screening for asymptomatic individuals1 and agree it provides limited ability to identify, prevent, or treat COPD before symptoms appear. Indeed, smoking cessation and prevention remain key to disease prevention and progression. Full-Text PDF Rebuttal From Drs Mannino and ThomashowCHESTVol. 157Issue 1PreviewIn their argument supporting the idea that screening for COPD can improve outcomes, Drs Yawn and Martinez1 argue that “COPD screening must develop better, more symptom-based tools and appropriate follow-up support.” We certainly agree with that conclusion and hope that CAPTURE (COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk) will lead to earlier diagnosis and earlier therapy.2 However, even if the ongoing study attempting to validate the utility of this tool in primary care confirms earlier results without disrupting practice patterns,3 the patients identified will be symptomatic but will not have received a diagnosis. Full-Text PDF" @default.
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