Lung Cancer Screening Guidelines in the US Miss Roughly Two-Thirds of Cases, New Study Finds

Only 35% of patients with lung cancer met US Preventive Services Task Force (USPSTF) screening criteria in a cohort study of 997 patients, while a proposed age-based screening approach would detect 94% of cancers and prove substantially more cost-effective than current breast and colorectal cancer screening programs.

The findings, from a team at Northwestern University Feinberg School of Medicine and published in JAMA Network Open, revealed that the 65% of individuals who did not meet USPSTF criteria included disproportionate numbers of women (61% vs 52%), Asian adults (10% vs 4%), and never-smokers (38% of the the group not meeting guideline criteria). This excluded population also demonstrated better overall survival than guideline-eligible patients (median 9.5 vs 4.4 years; HR 0.67, 95% CI 0.55-0.82, P <.001).

"Policy revisions should expand eligibility, address non-tobacco risks, and mitigate implementation barriers to ensure equitable early detection," Ankit Bharat, MD, Chief of Thoracic Surgery in the Department of Surgery, Harold L. and Margaret N. Method Professor of Surgery, and colleagues wrote.

Screening Gaps and Disparities

Current USPSTF criteria, published in 2021, recommend annual screening for adults aged 50 to 80 years with at least 20 pack-years of smoking history who currently smoke or quit within 15 years. However, lung cancer increasingly affects individuals outside these parameters. Never-smokers represented 25% of all participants with lung cancer in the study, while others were excluded due to age (4%), fewer than 20 pack-years (7%), or quitting more than 15 years prior despite heavy smoking (13%).

For the study, Bharat et al analyzed consecutive individuals diagnosed with lung cancer from 2018 to 2023 at Northwestern Medicine, with follow-up through 2024. They stratified participants by USPSTF eligibility and compared clinical characteristics, survival outcomes, and modeled various expanded screening scenarios. Among the 997 participants, (median age 67 years, 58% women), 68% identified as White, 16% as Black, 8% as Asian, and 4% as Hispanic.

Histologic patterns differed significantly between groups, the authors found. Adenocarcinoma predominated in non-guideline participants (72% vs 55%), while squamous cell carcinoma (21% vs 11%) and small cell lung cancer (13% vs 4%) were more common in those who were guideline-eligible. Despite similar rates of stage IV disease, non-guideline participants had more stage I diagnoses (28% vs 21%).

Age-Based Screening Models

Bharat and colleagues modeled several expanded screening approaches. Extending the age range to 40 to 85 years, lowering the smoking threshold to 10 pack-years, and eliminating the 15-year cessation limit would increase detection to 62% of cases. A universal age-based screening program (ages 40-85 years), however, would capture 94% of lung cancers, they wrote.

When they applied economic modeling they found that universal age-based screening would cost $101,000 per life saved (95% CI $82,000-$120,000), substantially less than breast cancer screening ($890,000, 95% CI $700,000-$1,100,000) and colorectal screening ($920,000, 95% CI $700,000-$1,200,000). At a 30% stage I detection rate, such a program would prevent 26,124 deaths annually (95% CI 20,000-32,248 deaths).

The superior cost-effectiveness reflects the dramatic difference in treatment costs by stage, the researchers explained.

• Stage IV treatment with modern immunotherapy or targeted therapy costs $380,000 to $520,000 compared with $53,000 to $67,000 for stage I treatment.
• Age-based screening achieving 30% stage I detection would save $24.76 billion annually in treatment costs alone, far exceeding the $2.6 billion screening program cost.

The team reported that radiation exposure posed minimal risk, with 108 to 284 lung cancer deaths prevented for every radiation-induced cancer death. Low-dose CT also provides additional benefits beyond lung cancer detection, identifying coronary artery calcification in 39% of participants, emphysema in 24%, and other actionable findings that contribute to all-cause mortality reduction.

Implementation Challenges

While the potential benefits are attractive, Bharat et al stress that current US lung cancer screening participation remains below 15% of eligible individuals, contrasting with 67% to 69% participation rates for breast and colorectal cancer screening.2 The researchers noted that breast and colorectal screening increased participation after transitioning from risk-based to age-based guidelines.1

Only 13% of guideline-eligible individuals in this cohort underwent low-dose CT screening, though those who did showed earlier-stage diagnoses and improved survival compared withthe non-screened guideline group. Among the 45 participants who did undergo screening, approximately 25% of initial scans identified nodules requiring follow-up, though contemporary protocols ensure more than 92% are managed with imaging alone.1

Among the study's limitations the authors acknowledged the single-institution design, which may limit generalizability. The assumed 70% participation rate for expanded screening exceeds current rates, though sensitivity analyses demonstrated consistent benefits across all participation levels.1

Quoting the US screening participation rate of less than 15%, the investigators also pointed out that "unlike risk-based lung cancer screening focused exclusively on tobacco smoking, universal breast and colorectal cancer programs have simplified access and increased participation."2 They suggest that risk-specific guidelines "may deter participation by implying lifestyle blame or creating eligibility confusion, compounded by stigma."3

The authors concluded that age-based screening could substantially improve detection, demonstrate superior cost-effectiveness compared with existing cancer screening programs, and address current inequities in lung cancer screening access. "Simplifying eligibility criteria could improve participation, although clinician education remains essential," they concluded.

References

1. Yang HC, Chang A, Visa M, et al. Age-base screening for lung cancer surveillance in the US. JAMA Netw Open. 2025;8(11):e2546222. doi:10.1001/jamanetworkopen.2025.46222
2. Anderson LM, Adeney KL, Shinn C, Safranek S, Buckner-Brown J, Krause LK. Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations. Cochrane Database Syst Rev. 2015;2015(6):CD009905. doi:10.1002/14651858.CD009905.pub2
3. Chambers SK, Dunn J, Occhipinti S, et al. A systematic review of the impact of stigma and nihilism on lung cancer outcomes. BMC Cancer. 2012;12:184. doi:10.1186/1471-2407-12-184