ROC curves for low-dose CT in the National Lung Screening Trial

The National Lung Screening Trial (NLST) reported a 20% reduction in lung cancer specific mortality using low-dose chest CT (LDCT) compared with chest radiograph (CXR) screening. The high number of false positive screens with LDCT (around 25%) raises concerns. NLST radiologists reported LDCT screens as either positive or not positive, based primarily on the presence of a 4+ mm non-calcified lung nodule (NCN). They did not explicitly record a propensity score for lung cancer. However, by using maximum NCN size, or alternatively, radiologists' recommendations for diagnostic follow-up categorized hierarchically, surrogate propensity scores (PSSZ and PSFR) were created. These scores were then used to compute ROC curves, which determine possible operating points of sensitivity versus false positive rate (1-Specificity). The area under the ROC curve (AUC) was 0.934 and 0.928 for PSFR and PSSZ, respectively; the former was significantly greater than the latter. With the NLST definition of a positive screen, sensitivity and specificity of LDCT was 93.1% and 76.5%, respectively. With cutoffs based on PSFR, a specificity of 92.4% could be achieved while only lowering sensitivity to 86.9%. Radiologists using LDCT have good predictive ability; the optimal operating point for sensitivity and specificity remains to be determined.