[ Original Research COPD ]

Identification of COPD Patients at High Risk

for Lung Cancer Mortality Using the
COPD-LUCSS-DLCO
Juan P. de-Torres, MD; Jose M. Marín, MD; Ciro Casanova, MD; Victor Pinto-Plata, MD; Miguel Divo, MD;
Claudia Cote, MDy; Bartolome R. Celli, MD; and Javier J. Zulueta, MD

BACKGROUND: The COPD-Lung Cancer Screening Score (COPD-LUCSS) is a tool designed to

help identify patients with COPD with the highest risk of developing lung cancer (LC). The
COPD-LUCSS includes the determination of radiological emphysema, a potential limitation
for its implementation in clinical practice. The diffusing capacity for carbon monoxide (DLCO)
is a surrogate marker of emphysema and correlates well with CT-determined emphysema.
To explore the use of the COPD-LUCSS using the DLCO instead of radiological
OBJECTIVE:
emphysema, as a tool to identify patients with COPD at higher risk of LC death.
METHODS: The Body Mass Index, Airflow Obstruction, Dyspnea, Exercise Performance in-
ternational cohort database was analyzed. By logistic regression analysis, we confirmed that
the other parameters included in the COPD-LUCSS (age > 60, pack-years > 60, BMI < 25)
were independently associated with LC death. We selected the best cutoff value for DLCO
that independently predicted LC death. We then integrated the new COPD-LUCSS-DLCO
assigning points to each parameter according to its hazard ratio value in the Cox regres-
sion model. The score ranges from 0 to 8 points.
RESULTS: By regression analysis, age > 60, BMI <25 kg/m2, pack-year history > 60, and
DLCO < 60% were independently associated with LC diagnosis. Two COPD-LUCSS-DLCO
risk categories were identified: low risk (scores 0-3) and high risk (scores 3.5-8). In com-
parison to patients at low risk, risk of death from LC increased 2.4-fold (95% CI, 2.0-2.7) in
the high-risk category.
CONCLUSIONS: The COPD-LUCSS using DLCO instead of CT-determined emphysema is a
useful tool to identify patients with COPD at risk of LC death and may help in its imple-
mentation in clinical practice. CHEST 2016; 149(4):936-942

KEY WORDS: chronic obstructive pulmonary disease; DLCO; lung cancer; screening

ABBREVIATIONS: ATS = American Thoracic Society; AUC = area
under the curve; BODE = Body Mass Index, Airflow Obstruction,
Dyspnea, Exercise Performance database; DLCO = diffusing capacity
for carbon monoxide; ERS = European Respiratory Society;
GOLD = Global Initiative for COPD; HR = hazard ratio; LC =
lung cancer; LDCT = low-dose CT; LUCSS = Lung Cancer
Screening Score
AFFILIATIONS: From the Pulmonary Department (Drs de-Torres and
Zulueta), Clínica Universidad de Navarra, Pamplona, Spain; Pulmo-
nary Department (Dr Marín), Hospital Universitario Miguel Servet,
Instituto Aragones Ciencias Salud and CIBER Enfermedades Respira-
torias, Zaragoza, Spain; Pulmonary Department (Dr Casanova), Hos-
pital Ntra Sra de Candelaria, Tenerife, Spain; Respiratory Research
Unit (Dr Casanova), Hospital Ntra Sra de Candelaria, Tenerife, Spain;
Pulmonary and Critical Care Department (Dr Cote), Bay Pines VA
Medical Healthcare System, Bay Pines, FL; and Pulmonary Department
(Drs Pinto-Plata, Divo, and Celli), Brigham and Women’s Hospital,
Harvard Medical School Boston, MA.
y
Deceased.
FUNDING SUPPORT: This work was supported (in part) by a grant
(RD12/0036/0062) from Red Temática de Investigación Cooperativa
en Cáncer, Instituto de Salud Carlos III, Spanish Ministry of Econ-
omy and Competitiveness & European Regional Development Fund
“Una manera de hacer Europa,” Spanish Ministry of Health FIS
Projects: PI04/2404, PI07/0792, PI10/01652, PI11/01626 and PI15/
02157 from Spanish Ministry of Science and Innovation (project
ADE 10/00028).

936 Original Research [ 149#4 CHEST APRIL 2016 ]

Lung cancer (LC) is one of the most frequent causes
of death in patients with COPD,1 and strategies to
identify patients at high risk of developing LC are
urgently needed. The National Lung Screening Trial
demonstrated that performing a low-dose CT (LDCT)
scan of the chest in a selected sample of active or former
smokers decreases LC mortality by at least 20%.2 This
has led the US Preventive Services Task Force and
several professional organizations to recommend
screening for higher risk individuals.3-6
Because of their high risk, patients with COPD
may be good targets for LC screening programs.7
The recently developed COPD-Lung Cancer Screening
Score (LUCSS) has been tested and validated in
two different populations of patients with COPD
participating in LC screening programs in the United
States and Spain.8 The score ranges from 0 to 10
points and includes four parameters: age > 60 years
Methods
Patients with COPD participating in this study were part of the Body
Mass Index, Airflow Obstruction, Dyspnea, Exercise Performance
(BODE) international cohort that was recruited and followed
between January 1997 and December 2013.13 For the purpose of the
present study, the outcomes of LC diagnosis and death were
specifically targeted in an effort to provide novel information on the
important interaction between COPD and LC. All patients were
prospectively recruited in pulmonary clinics in one hospital in the
United States (Bay Pines VA Medical Healthcare System, Bay Pines,
FL) and three in Spain (Hospital Miguel Servet, Zaragoza; Clinica
Universidad de Navarra, Pamplona; and Hospital Nuestra Sra de La
Candelaria, Tenerife). All patients regularly seen in the pulmonary
clinics were invited to participate in the study regardless of disease
severity.
COPD was defined by a history of smoking at least 10 pack-years and
an FEV1/FVC ratio of less than 0.70 after 400 mg of inhaled albuterol.14
Patients were excluded if they had a history of asthma, bronchiectasis,
tuberculosis, or other confounding diseases such as severe congestive
heart failure (stage III-IV New York Heart Association), obliterative
bronchiolitis, or diffuse panbronchiolitis. At entry time, none of the
patients had symptoms (hemoptysis, cough, recent weight loss, or
chest pain) or chest radiograph findings suggestive of LC. All COPD
participants were clinically stable (free of exacerbation for at least
8 weeks) and were receiving standard medical treatment according
to the American Thoracic Society/European Respiratory Society
(ATS/ERS) guidelines.14
The human-research review board at each institution approved the
study, and all patients signed an informed consent (Comité de Etica
CORRESPONDENCE TO: Juan P. de-Torres, MD, Pulmonary Depart-
ment, Clinica Universidad de Navarra, Avenida Pio XII 36, Pamplona,
Spain 31008; e-mail: jupa65@hotmail.com
Copyright Ó 2016 American College of Chest Physicians. Published by
Elsevier Inc. All rights reserved.
DOI: http://dx.doi.org/10.1378/chest.15-1868
journal.publications.chestnet.org
(3 points), pack-year history > 60 (2 points), BMI
< 25 kg/m2 (1 point), and the presence of radiological
emphysema (4 points). The need for visual assessment
of the presence or absence of radiological emphysema
could potentially limit the implementation of this
score because it requires a chest CT. However, the
diffusing capacity for carbon monoxide (DLCO),
which is widely available in most pulmonary medicine
services, has been shown to correlate with the degree
of emphysema9-12 and could be used as a surrogate
marker.
The aim of this study is to validate the use of the COPD-
LUCSS-DLCO (using the DLCO instead of radiological
emphysema) as a tool to identify patients with the
highest risk of dying from LC in a large and well-
characterized population of patients with COPD. Using
DLCO instead of CT-determined emphysema may help
to introduce LUCSS into clinical practice.
de la Investigación, Universidad de Navarra Institutional Review
Board No.: 043/2006).
Clinical and Physiological Parameters Measurements
Trained personnel obtained the following information at the time of
recruitment: age, sex, and body mass index (BMI), calculated as the
weight in kilograms divided by height in square meters. A specific
questionnaire was used to determine smoking status (current or
former) and smoking history (age at initiation and discontinuation
as well as intensity). From this information we calculated the total
smoking exposure and expressed it as pack-years.
Pulmonary function tests (spirometry, lung volumes, and diffusing
capacity) were performed following ATS/ERS guidelines14 on all
patients at study entry, and those values were used in the present
study. Patients were classified using the grades of airway limitation
proposed by the new Global Initiative for COPD (GOLD) strategy.15
The inspiratory capacity was measured as previously described. The
DLCO was determined by the single breath technique following the
ATS/ERS guidelines.16 We used the following formula to adjust for
hemoglobin levels: DLCO predicted corrected ¼ DLCO predicted 
[1.7  Hgb/(age-sex-factor þ Hgb)],17 where Hgb indicates
hemoglobin.
The presence of comorbidities was evaluated using the Charlson
comorbidity index.18
LC Diagnosis and Histological Type
The time between enrollment and either diagnosis of or death from LC
was expressed in months.
Cause of Death
The cause of death was investigated in all of the patients, as previously
published in the BODE study protocol.13 Patients were evaluated after
enrollment and seen every 6 months for at least 10 years or until death.
The patient and family were contacted if the patient failed to return for
appointments. Death from any cause was recorded. The investigators
at each site determined the cause of death after reviewing the
medical record and death certificate.
937
Statistical Analysis
Quantitative data with a normal distribution were expressed using the
mean and the SD. Quantitative data with non-normal distribution were
described with the median and the interquartile range. Qualitative data
were described using relative frequencies. We first confirmed by Cox
regression analysis that three of the previously selected variables
included in the COPD-LUCSS (age > 60 years, pack-years > 60,
BMI < 25 kg/m2) were also independently associated with LC death
in this cohort.
To determine the threshold of the categorical variables to be included
in the score, we first divided each continuous variable in quartiles or
quintiles. We then visually compared their Kaplan-Meier curves and
selected the best cutoff values of each predictive variable (data not
shown). We selected age > 60 years, pack-years > 60, and BMI
< 25. To determine the best cutoff value for DLCO, we used similar
methodology choosing the following thresholds: DLCO > 80%,
79% to 60%, 59% to 40%, 39% to 20%, and < 20%. The use of the
Results
A total of 2,256 patients were included in this study:
1,367 from Spain (900 from Zaragoza, 202 from
Pamplona, and 265 from Tenerife), and 889 from
Florida. The clinical and physiological characteristics
of these patients are described in Table 1.
The cohort consisted primarily of men older than age
60 years; 30% were active smokers, one-third had a
BMI < 25, and more than 40% had a greater than
60 pack-year history of tobacco smoking. They were
followed for a median of 5 years. The different degrees of
airway obstruction were well-represented, with a greater
proportion of GOLD grades 2 and 3. There was a wide
range of DLCO values.
Table 2 shows the independent association between
the proposed parameters of the COPD-LUCSS and LC
death. In the Cox regression analysis, an age > 60 years,
a tobacco consumption history > 60 pack-year history,
and a BMI <25 kg/m2 were all significantly associated
with LC death.
Kaplan-Meier survival curves (e-Figure 1) show the
probability of LC death for each DLCO category:
> 80%, 79% to 60%, 59% to 40%, 39% to 20%, and
<20%. Visual inspection shows an inflection at a
threshold value of DLCO of 60%. We selected this
cutoff value to categorize DLCO because it was also
significantly and independently associated with LC
death in a Cox regression analysis (Table 2).
Table 2 shows the multivariable analysis of the four
components of the COPD-LUCSS-DLCO used to
determine the relative weight of each parameter in
the final score. The relative weight of each predictor
was calculated using the ratio of the log (hazard ratio)
938 Original Research
predictors as continuous variables showed that the model has a
similar statistical performance before and after categorization.
To build the COPD-LUCSS-DLCO, we determined the relative
weight of each predictor in the score. We assigned each predictor
a value based on the ratio between its log hazard ratios and the
lowest one obtained in the Cox analysis. The final COPD-LUCSS-
DLCO is obtained by adding the value of each predictor. The
COPD-LUCSS-DLCO risk categories were selected after visual
inspection of the LC risk profile. Using the low-risk category as a
reference, Cox regression was used to explore the association
between COPD-LUCSS-DLCO categories and the probability of LC
diagnosis.
A receiver operating characteristic analysis determined the new
COPD-LUCSS-DLCO discriminative capacity for LC death in each
spirometric GOLD stage. Significance for all tests was established at
a two-tailed P value # .05. Calculations were made with SPSS
version, 20.0 Inc. (IBM).
(log HR) of each variable in relation to the log HR
of the variable with the lowest value (in this case,
pack-years > 60) obtained in the Cox analysis. Thus,
log HR BMI < 25/log HR pack-years > 60 ¼ 1.33
(rounded to 1.5 for its clinical application), log HR
pack-years > 60/log HR pack-years > 60 ¼ 1, log HR
age > 60 years/log HR pack-years > 60 ¼ 2.42
(rounded to 2.5 for its clinical application), and log
HR DLCO < 60%/log HR pack-years > 60 ¼ 2.86
(rounded to 3 for its clinical application). Table 3
shows the final value of the COPD-LUCSS, obtained
from adding the value of each predictor (range, 0 to
8 points).
Then, two COPD-LUCSS-DLCO risk categories were
selected after visual inspection of the LC risk profile of
each point of the COPD-LUCSS-DLCO (e-Figure 2).
Visually, groups 0 to 3 and 3.5 to 8 appear to be
clustered, showing a gap between scores 3 and 3.5.
Based on the grouping of the Kaplan-Meier curves
of each score, two categories were selected: high risk
(scores between 3.5 and 8 points) and low risk (scores
between 0 and 3 points). Using the low-risk category
as the reference, a Cox regression analysis was done to
explore the association between COPD-LUCSS-DLCO
categories and the probability of LC death (Table 4).
In comparison with patients in the lowest risk
category, patients in the high-risk category have a
2.4-fold greater risk of dying from LC. Figure 1 shows
Kaplan-Meier survival curves with the probability
of LC death for the low- and high-risk categories
(log rank P value < .001).
Patients in the high-risk LC group had a higher
Charlson score (mean, 5; SD, 1) than those in the
low-risk group (median, 4; SD, 1), P value < .001.
[ 149#4 CHEST APRIL 2016 ]
TABLE 1 ] Baseline Characteristics of Patients With TABLE 3 ] COPD-LUCSS
COPD in This Study
COPD-LUCSS-DLCO Point Assignment
Clinical and Physiological Characteristics n ¼ 2,255
Components
Age, y (SD) 65 (9) BMI < 25 1.5 points
Age > 60 y (%) 64 Pack-y history > 60 1 point
Sex (male %/female %) (92/8) Age > 60 y 2.5 points
BMI in kg/m2 (SD) 27 (5) DLCO < 60% 3 points
BMI < 25 (%) 29 Total 8 points
Pack-years (SD) 58 (40) Categories
Pack-years > 60 (%) 42 Low risk: 0-3 points
Charlson score (SD) 4 (1) High risk: 3.5-8 points
Current smoking (%) 30
See Table 1 legend for expansion of abbreviations.
Follow-up time, mo (IQR) 61 (30-90)
FEV1, % (SD) 55 (21) Receiver operating characteristic analysis showed that
FVC, % (SD) 86 (21) the discriminative capacity of the COPD-LUCSS-DLCO
GOLD grades of airway limitation 14, 42, 31, 13 is discriminative for patients in GOLD grades 1 (area
(%) for grades 1, 2, 3, 4
under the curve [AUC], 0.61), GOLD 2 (AUC, 0.57),
IC/TLC < 0.25 (%) 25
and GOLD 3 (AUC, 0.60), but not for patients in GOLD
DLCO (SD) 67 (24)
4 (AUC, 0.41). e-Figure 3 shows LC probability for each
DLCO < 60% predicted 14% GOLD grade of airway obstruction.
Patients with cancer, No. (%) 197 (8.7)
By GOLD grades 1, 2, 3, 4 (%) 11, 9.3, 8.2, 4.6 Discussion
LC deaths/1,000 person-y The original COPD-LUCSS was designed to help identify
Entire cohort 16.7/1,000 patients with COPD with the highest risk of dying from
COPD-LUCSS low-risk group 13.3/1,000 LC, who in turn may benefit most from LC screening.
COPD-LUCSS high-risk group 21.0/1,000 It was initially tested and validated in two cohorts of
patients with COPD that were part of two LC screening
Values with normal distribution are shown with their mean (SD); values
studies in the United States and in Spain.8 The score is
with non-normal distribution with their median (IQR); and categorical
variables with percentages. DLCO ¼ diffusing capacity for carbon mon- composed of four parameters: age > 60 years (3 points),
oxide; GOLD ¼ Global Initiative for COPD; IC ¼ inspiratory capacity; pack-year history > 60 (2 points), BMI < 25 kg/m2
IQR ¼ interquartile range; LC ¼ lung cancer; LUCSS ¼ Lung Cancer
Screening Score; TLC ¼ total lung capacity.
(1 point), and the presence of radiological emphysema
(4 points). The aim of this study was 2 fold. First, we
wanted to test the score substituting DLCO for
radiological emphysema because we believe the former is
TABLE 2 ] Univariate and Multivariate Cox Analysis more widely available for clinicians managing patients
Exploring the Independent Association of
with COPD. Second, we intended to validate the LUCSS
the Studied Variables With LC Death
in a different population of patients with COPD: the
Studied Variables P Value HR 95% CI
BODE cohort. The main finding of the study is that after
Univariate Cox Analysis substituting DLCO for CT-determined emphysema, the
Age > 60 vs < 60, y .001 1.9 1.6-2.3 COPD-LUCSS is still capable of identifying patients
BMI < 25 vs > 25 .026 1.6 1.4-1.8 with COPD with a greater risk of dying from LC. In
Pack-y > 60 vs < 60 .001 1.4 1.3-1.7 addition, the score was validated in a large COPD cohort
DLCO < 60% vs > 60% .001 2.7 2.3-3.1 that is not part of a screening trial, as were the original
Multivariate Cox Analysis two cohorts with which the score was developed.
Age: > 60 vs < 60, y .005 1.9 1.6-2.2
BMI < 25 vs > 25 .015 1.4 1.2-1.7
TABLE 4 ] Cox Regression Analysis Comparing Each
COPD-LUCSS-DLCO LC Category Risk
Pack-y > 60 vs < 60 .001 1.3 1.1-1.5
Risk Category P Value HR 95% CI
DLCO < 60% vs > 60% .001 2.2 1.7-2.5
Low- vs high-risk category .001 2.4 2.0-2.7
HR ¼ hazard ratio. See Table 1 legend for expansion of other
abbreviations. See Table 1 and 2 legends for expansion of abbreviations.

journal.publications.chestnet.org 939

0.3
Probability of lung cancer death
0.2 Log Rank P < .001
0.1
0.0
0 12 24 36 48 60
Follow-up months
Figure 1 – Kaplan-Meier curves of COPD-Lung Cancer Screening Score-
diffusing capacity for carbon monoxide high- and low-risk categories
probability of lung cancer death.
Because of its known relationship, we reasoned that the
DLCO could replace CT-determined emphysema.9-12
We identified a cutoff value of DLCO < 60% that was
independently associated with a higher risk of dying
from LC in this cohort. Interestingly, in a previous study
with the same cohort,19 a higher cutoff value of DLCO
(< 80%) was one of the most important parameters
predicting LC deaths. In that previous study, we
arbitrarily selected an abnormal DLCO value (< 80%) to
explore the potential impact of the diffusing capacity on
LC death. In the present study, we selected the best
cutoff value of DLCO (that turned out to be < 60%),
providing evidence that, similar to CT-detected
emphysema, DLCO is also associated with LC death. It is
well-known that DLCO is associated with the severity of
CT-detected emphysema.9-12 Based on this information,
we suggest that the initial risk assessment of patients
with COPD consider whether these patients should be
included or not in an LC screening program that could
be done before performing a low-dose LDCT of the
chest. This might have important cost implications.
The interest in identifying patients at high risk for LC
has increased after the publication of the National Lung
Screening Trial results showed that screening with
LDCT reduces LC mortality.2 Patients with COPD are
potentially good candidates for screening because of
their known increased risk of LC.20,21 And preliminary
data suggest that LC screening of patients with COPD
has the potential to decrease mortality.7
Although the parameters included in the score have
the same cutoff values of the original COPD-LUCSS
940 Original Research
score, the relative weight of each variable in the score
has changed as follows: BMI < 25 from 1 to 1.5; pack-
year history > 60 from 2 to 1; age > 60 years from 3 to
2.5; and emphysema, now DLCO < 60%, from 4 to 3.
This could be partially explained by the fact that the
High risk
original COPD-LUCSS was developed and validated
in an LC screening population with a younger mean
age (61 vs 65 years) and a higher proportion (98%)
of GOLD grades 1 and 2 than in the present cohort
Low risk (56%).8
Interestingly, the discriminative capacity of the score is
not the same for the different GOLD grades of airway
72 84 limitation. It is acceptable for GOLD grades 1, 2, and
3, but it is not discriminative for GOLD 4. The
discriminative capacity of the COPD-LUCSS-DLCO
decreases from an AUC of 0.69 when calculated with
CT-detected emphysema, as was done in the original
study,8 in which patients had mostly GOLD grades
1 and 2, to 0.57 to 0.61 when a DLCO < 60% was
used as was done in the present study. In other words,
although DLCO appears to be a good surrogate marker
of emphysema,9-12,22 the presence of emphysema on a
CT scan appears to be a more powerful tool for the
assessment of LC risk. In view of these results, the
new COPD-LUCSS using DLCO should not be used
to calculate LC risk in patients with COPD in GOLD
grade 4. However, as we have shown in previous studies,
the cause of death in advanced COPD (FEV1 < 30%)
is usually not LC, but end-stage respiratory failure or
infection.19 Furthermore, a report23 demonstrated that
severe and very severe airway obstructions (GOLD
grades 3 and 4) are independently associated with
shorter survival in patients with LC; thus, those with
grade 4 obstruction should not be included in LC
screening programs. In addition, because of patients’
high risk of dying from competing causes of death, using
an LC risk calculation to decide whether to initiate LC
screening is probably not indicated in those with very
low DLCO because we already know that their outcomes
from lung resection are poor.24
The identification of patients with COPD at high risk
of dying from LC may be important when prioritizing
the best candidates to be included in LC screening
programs. As has been demonstrated, patients with
COPD in GOLD grades of airway limitation 1 and 2
have a 2 to 3 fold higher risk of developing LC.20,21
Within this group, patients with low diffusing capacity
resulting from emphysema or interstitial changes are the
ones that should be carefully evaluated because they
could be included in LC screening as a result of their
[ 149#4 CHEST APRIL 2016 ]
high risk of complications or death during a putative
surgical resection.23,24
Interestingly, patients in the high-risk group have more
comorbidities as measured by the Charlson score. This
suggests that patients that are at increased risk of
developing LC also suffer from other comorbidities,
prompting the need for them to be more closely
monitored for potential medical complications.
The results of this study could be misinterpreted to
indicate that screening for LC should only be limited to
patients with COPD with the highest risk. It is known
from several publications that even those in the lower
risk category have a greater incidence density of LC than
do matched smokers without the disease (13.3/1,000
patient-years vs 3/100 patient-years, respectively).20,21
Thus, even low-risk patients with COPD have a higher
risk for LC than so-called healthy smokers. In our
opinion, the data we present here and in previous
publications suggest that the degree of risk of LC might
have an effect on the frequency of screening intervals,
although this will have to be analyzed prospectively.
The present study has several limitations. Firstly, the
findings are restricted to the type of patients with COPD
here represented (ie, male patients with COPD in GOLD
grades 1-3 seen in pulmonary clinics at tertiary care
hospitals). Whether COPD-LUCSS-DLCO also
identifies higher risk patients in the primary care setting
journal.publications.chestnet.org
will need to be confirmed, although intuitively it is likely
that it does. Second, although the discriminative capacity
of the COPD-LUCSS-DLCO is only acceptable and
suitable to be used in spirometric GOLD grades 1, 2,
and 3, it allows the identification of patients with COPD
at higher risk in the of airway obstruction range in
which LC is more common.19 Third, a low DLCO could
be due to other frequent comorbidities associated with
COPD, such as interstitial lung disease or pulmonary
hypertension,25 and this could also explain why a
radiological marker of emphysema is a better predictor
of LC than a low DLCO. Fourth, although recruitment
was offered equally to men and women, more than
90% of the study participants were male. Thus, findings
in this study cannot be extrapolated to women with
COPD. Last, we acknowledge that risk is not perceived
as a “binary variable” and therefore variables such as age,
BMI, pack-year history, and especially DLCO should be
used as continuous variables. Our main goal was to
construct an easy-to-use risk score that we believe could
help in daily clinical practice, and so we used binary
variables that simplify calculation.
In summary, the COPD-LUCSS-DLCO, now including
DLCO < 60% instead of the presence of CT-detected
emphysema, allows the identification of patients with
COPD at high risk of death from LC. A prospective
study in an LC screening population is now needed to
confirm these findings.
941
Acknowledgments
Author contributions: J. P. d.-T., J. M. M., C.
Casanova, V. P.-P., M. D., C. Cote, B. R. C.,
and J. J. Z. undertook conception and design,
analysis and interpretation, and drafting the
manuscript for important intellectual
content.
Financial/nonfinancial disclosures: The
authors have reported to CHEST the
following: J. P. d. T. received consultancy
fees for participating in the Takeda
Pharmaceuticals International GmbH,
Menarini, and Novartis AG Advisory Boards;
he also received fees for speaking activities
for GlaxoSmithKline plc, AstraZeneca,
Chiesi, Menarini, Novartis AG, Merck,
Sharp & Dohme Corporation, and Takeda
Pharmaceuticals International GmbH and
consultancy fees for participating in the
Takeda Pharmaceuticals International
GmbH and Novartis AG Advisory Boards.
C. Casanova has participated in speaking
activities, industry advisory committees and
other activities related to industry sources by
Almirall S.A., AstraZeneca, GlaxoSmithKline
plc, Menarini, and Novartis AG. J. J. Z. is a
shareholder of VisionGate, Inc and a nonpaid
member of the Medical Advisory Board.
None declared (J. M. M., V. P.-P., M. D.,
C. Cote, and B. R. C.).
Role of sponsors: The sponsor had no role in
the design of the study, the collection and
analysis of the data, or the preparation of the
manuscript.
Additional information: The e-Figures can
be found in the Supplemental Materials
section of the online article.
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[ 149#4 CHEST APRIL 2016 ]