In 2016, the American company in charge of prevention strategies, l’US preventive services task force (USPSTF), had already issued recommendations against systematic screening for chronic obstructive pulmonary disease (COPD) in asymptomatic subjects. In a context of increasing incidence and the arrival on the market of new treatments, the USPSTF has endeavored to revise these recommendations, in the light of clinical studies published on this subject over the past six years (1). As a result, she persists and signs. Screening of asymptomatic subjects, even those who may be considered at risk, is strictly prohibited. Among the reasons mentioned, beyond the lack of exploratory studies on the possible benefit of such screening, it is above all the limited benefit/risk ratio of treatment in asymptomatic patients that is put forward, followed by the benefit-cost ratio, probably very limited, even downright negative, associated with such screening.
An update associated with the analysis of six intervention trials plus two observational studies
For the update of its recommendations, the USPSTF analyzed new studies published since 2015. None of them had explored the possible benefit of a screening strategy for asymptomatic at-risk subjects. A total of eight studies were selected. These are three clinical studies involving more than 20,000 patients, dedicated to pharmacological interventions; three much smaller studies (3,600 patients), looking at non-pharmacological interventions; two large observational cohort studies, bringing together nearly 244,000 patients (2).
An excess of events by treating too early
What does this new data bring? Nothing really new, according to the USPSTF: “The results of the pharmacological intervention clinical studies confirm the previous data. They confirm the recommendations of the USPSTF on the use of bronchodilators, associated or not with corticosteroids, which can reduce exacerbations, when tiotropium cannot improve the quality of life of patients suffering from moderate COPD. On the other hand, we still have no conclusive data on the possible benefit of non-pharmacological management, whatever it is and for what type of COPD we are addressing. As for the two large cohort studies in a target population, they highlight an excess occurrence of major cardiovascular events in naïve COPD patients treated with antimuscarinic or long-acting antibeta-agonists, and an excess occurrence of diabetes in COPD patients on inhaled corticosteroids”, summarizes the USPSTF (2). Observations in real life which, it will be admitted, do not encourage the treatment of asymptomatic subjects.
A benefit limited to exacerbations… of symptomatic subjects
The benefit of pharmacological interventions remains very largely limited to subjects suffering from moderate COPD. In these patients, there may be a benefit in terms of exacerbations. But, even in those who are frankly symptomatic, the benefit is to be tempered by the side effects, cardiovascular and metabolic. The benefit, in terms of mortality, remains to be demonstrated.
In addition, non-pharmacological interventions have still not demonstrated their benefit in clinical practice, either in mild to moderate COPD or in very mildly symptomatic COPD.
(1) Screening for chronic obstructive pulmonary disease: reaffirmation recommendation statement. Jama 2022; 327:1806-11
(2) E M.Webber et al. Screening for chronic obstructive pulmonary disease updated evidence report and systematic review for the USPSTF. JAMA 2022; 327:1812-16