Development and Cost Analysis of a Lung Nodule Management Strategy Combining Artificial Intelligence and Lung-RADS for Baseline Lung Cancer Screening

Objectives: To develop a lung nodule management strategy combining the Lung CT Screening Reporting and Data System (LungRADS) with an artificial intelligence (AI) malignancy risk score and determine its impact on follow-up investigations and associated costs in a baseline lung cancer screening population. Materials and Methods: Secondary analysis was undertaken of a data set consisting of AI malignancy risk scores and Lung-RADS classifications from six radiologists for 192 baseline low-dose CT studies. Low-dose CT studies were weighted to model a representative cohort of 3,197 baseline screening patients. An AI risk score threshold was defined to match average sensitivity of six radiologists applying Lung-RADS. Cases initially Lung-RADS category 1 or 2 with a high AI risk score were upgraded to category 3, and cases initially category 3 or higher with a low AI risk score were downgraded to category 2. Follow-up investigations resulting from Lung-RADS and the AI informed management strategy were determined. Investigation costs were based on the 2019 US Medicare Physician Fee Schedule. Results: The AI-informed management strategy achieved sensitivity and specificity of 91% and 96%, respectively. Average sensitivity and specificity of six radiologists using Lung-RADS only was 91% and 66%, respectively. Using the AI-informed management strategy, 41 (0.2%) category 1 or 2 classifications were upgraded to category 3, and 5,750 (30%) category 3 or higher classifications were downgraded to category 2. Minimum net cost savings using the AI-informed management strategy was estimated to be $72 per patient screened. Conclusion: Using an AI risk score combined with Lung-RADS at baseline lung cancer screening may result in fewer follow-up investigations and substantial cost savings.