Presentation (CTI)

OBJECTIVES: Lung cancer is the leading cause of cancer-related deaths worldwide. Based on findings from the National Lung Screening Trial (NLST), the U.S. Preventive Services Task Force recommends annual screening for high-risk individuals. However, self-selection may reduce the effectiveness of screening in lowering mortality rates. This paper examines how self-selection into lung cancer screening affects mortality outcomes and healthcare costs, and evaluates screening policies when screening decisions are endogenously determined.
METHODS: This study develops a dynamic discrete-choice model that jointly models participation in the National Lung Screening Trial (NLST) and lung cancer screening decisions. The model incorporates beliefs about lung cancer risk, survival, and the costs and benefits of screening, including uncertainty from false-positive and false-negative test results. Model parameters are estimated using data from the NLST and the 2015 National Health Interview Survey (NHIS), together with Surveillance, Epidemiology, and End Results (SEER) data from 2000 to 2019. The framework is used to study screening behavior, health outcomes, healthcare costs, and counterfactual policies.
RESULTS: The results show that individuals with lower lung cancer risk are more likely to undergo screening, driven by unobserved preferences for proactive health investment that are correlated over time. Among NLST participants, screened individuals experience lower mortality rates. In contrast, in the general population, individuals who choose to screen have higher mortality rates, reflecting self-selection. Counterfactual analysis shows that survival benefits from universal screening are limited, making full uptake unlikely. However, targeting underrepresented groups reduces mortality by 27% at minimal cost. Overall, annual lung cancer screening remains the most effective strategy for reducing deaths.
CONCLUSIONS: Self-selection plays an important role in the effects of lung cancer screening. While universal screening provides limited survival benefits, targeted screening policies can achieve meaningful reductions in mortality at low cost. Accounting for endogenous screening decisions is important for effective policy design.