Evolving standards. Lung cancer screening (LCS) using low-dose CT (LDCT) has expanded significantly across the United States since the original 2015 policy statement from the American College of Chest Physicians and American Thoracic Society. Research advances and real-world clinical experience have reshaped how programs identify eligible patients, detect nodules, and deliver high-quality screening.
Purpose of the update. A multidisciplinary panel of pulmonologists, thoracic surgeons, radiologists, and health services researchers reviewed a decade of evidence and refined the original 9 essential components down to 8 updated components that every LCS program should implement to maximize benefit and minimize harm.
Persistent gaps remain. Despite progress, LCS uptake in the United States is only 18-20% of eligible individuals - far below the 72-76% rates seen for breast, cervical, and colorectal cancer screening. Ensuring equitable access, high adherence, and high-quality program delivery remain central challenges for the field.
Expanding eligibility criteria. Multiple major organizations have updated their LCS eligibility guidelines since 2015. The US Preventive Services Task Force (USPSTF) expanded criteria in 2021 to include individuals aged 50-80 with 20 or more pack-years of smoking who currently smoke or quit within the past 15 years - a broader net than before.
Further expansions under consideration. The American Cancer Society (2023) removed the quit-year requirement entirely, based on data showing persistently elevated lung cancer risk beyond 15 years after cessation. The National Comprehensive Cancer Network additionally removed the upper age limit and encourages risk calculator use alongside age and smoking history.
Risk-based versus criteria-based selection. Individual risk prediction tools, such as the PLCOm2012 model, can detect 20% more lung cancers compared to older USPSTF criteria at a 1.7% six-year risk threshold, and may reduce racial and ethnic disparities in who qualifies for screening.
Practical and payer considerations. Insurance coverage largely follows USPSTF 2021 criteria, with both Medicare and many private insurers covering annual LDCT for qualifying individuals. Those who meet expanded ACS, CHEST, or NCCN criteria may not always have coverage, creating real-world access barriers.
Future directions. Molecular biomarkers and multicancer early detection blood tests are being studied as potential tools to supplement or refine eligibility criteria, but they require further validation before entering routine clinical use.
Uptake is critically low. Only 18-20% of eligible Americans receive lung cancer screening, compared to over 70% for breast and colorectal cancer screening. Uptake varies substantially by race, geography, insurance type, and number of coexisting health conditions.
Adherence is equally problematic. Annual screening adherence in real-world settings is only 20-40%, far below the 95% adherence rates seen in clinical trials. Modeling studies suggest that at a 46% adherence rate, the mortality reduction from LCS is cut in half compared to trial conditions.
Who is most at risk for non-adherence. Factors associated with lower adherence include belonging to a racial minority group, current smoking status, and lower income. Higher educational attainment and centralized screening programs are associated with better adherence.
Strategies to improve participation. Effective approaches include leveraging electronic health records to identify and track eligible patients, engaging primary care providers as champions, enhancing community outreach, using patient navigators, and incorporating telemedicine into the screening workflow.
What shared decision-making involves. Effective shared decision-making (SDM) for LCS includes confirming eligibility, discussing both benefits and potential harms of screening, using structured decision aids, exploring individual patient values, and addressing tobacco use. This process helps patients make informed, value-aligned choices about screening participation.
Variability in SDM quality. How SDM is delivered varies widely - by clinician type, in-person versus telemedicine settings, and use of standardized aids. Studies show that non-White race and lower educational attainment are associated with lower LCS knowledge and greater decisional conflict, highlighting the need for culturally tailored approaches.
Tobacco treatment is essential. LCS is most effective and most cost-effective when paired with successful smoking cessation. Medicare requires tobacco treatment as part of a comprehensive SDM visit. Despite this, clinical trials of smoking cessation interventions integrated into LCS visits have shown mixed results, with no consistent benefit from more intensive approaches over usual care.
Tools and resources. Decision aids and clinician-facing tools such as the Decision Precision tool, the shouldiscreen.com patient portal, and the Saved By The Scan campaign provide support for both providers and patients to facilitate high-quality SDM in diverse clinical settings.
Radiation dose standards. LDCT imaging should be performed using a technique that yields a dose index volume of 3 mGy or less for standard-sized patients - roughly equivalent to 10 chest X-rays. Technical parameters including gantry rotation time, milliamperes, and peak kilovoltage should be specified in a standardized protocol to minimize patient exposure while maintaining image quality.
Expertise matters. Institutions where only radiologists and medical physicists with specialized expertise develop LDCT protocols have significantly lower radiation doses. One multicenter analysis found a 44% higher mean radiation dose index at institutions that allowed any radiologist to set protocols, compared to those with expert-only oversight.
Cumulative radiation from downstream imaging. Screening-detected nodules often trigger follow-up imaging, adding to lifetime radiation exposure. Guideline-concordant management of these findings - avoiding unnecessary repeat scans - is an important strategy for reducing radiation-related harms.
National benchmarking. Facilities can submit equipment and dose data to the American College of Radiology (ACR) Dose Index Registry and Lung Cancer Screening Registry to compare their performance against regional and national standards and identify opportunities for improvement.
The Lung-RADS classification system. The ACR Lung CT Screening Reporting and Data System (Lung-RADS) remains the gold standard for reporting and guiding follow-up of nodules found on screening LDCT. The updated version 2022 classifies nodules based on size, appearance (attenuation), location, and growth rate.
Cancer risk scales with category. Analyses of over one million screened individuals confirm that cancer detection rates rise sharply with Lung-RADS category - from 0.4% for category 3 nodules to 11-13% for category 4B and nearly 20% for category 4X findings, validating the system's clinical usefulness.
Refined classifications in 2022 update. Lung-RADS 2022 adds new categories for juxtapleural nodules, atypical pulmonary cysts, airway nodules, and suspected inflammatory or infectious findings. These refinements may reduce unnecessary short-interval follow-up scans and false-positive results that lead to unneeded procedures.
AI as an emerging tool. Artificial intelligence-based imaging tools are being studied to assist radiologists in detecting and characterizing lung nodules more efficiently, with the potential to expand screening capacity as programs grow and maintain interpretation accuracy.
Most nodules are low risk. In a real-world analysis of over one million screened individuals, 83% had Lung-RADS category 1 or 2 findings (likely benign), 10% had category 3 (low risk requiring 6-month follow-up), and only 7% had category 4 findings requiring more intensive evaluation.
Stepped management for higher-risk nodules. For Lung-RADS categories 4A, 4B, and 4X, clinicians must weigh options including surveillance CT, PET-CT, tissue sampling, or subspecialty referral. Lung-RADS 2022 also introduces stepped-down management for stable or shrinking nodules, allowing less intensive follow-up over time.
Multidisciplinary decision-making. Higher-risk nodules benefit from review at a lung nodule conference or tumor board, where pulmonologists, radiologists, thoracic surgeons, and oncologists can collectively determine the best management strategy taking into account individual lung cancer risk, procedure risks, and patient preferences.
Advances in bronchoscopy and biopsy. Technical innovations including robotic-assisted bronchoscopy and electromagnetic navigation have improved the ability to biopsy small peripheral lung nodules. These tools facilitate early and accurate diagnosis - increasingly important given the role of neoadjuvant immunotherapy for locally advanced disease.
Future integration of AI and biomarkers. Radiomic algorithms combined with clinical and molecular data may eventually help predict the likelihood of clinically active lung cancer in screen-detected nodules, potentially streamlining complex management decisions and reducing unnecessary invasive procedures.
Common additional findings. LDCT scans frequently reveal incidental findings unrelated to lung nodules. In the National Lung Screening Trial, 33.8% of participants had a significant nonnodule finding. The most common include emphysema (found in 43% of NLST participants) and coronary artery calcifications (found in 62% of ACR Lung Cancer Screening Registry participants).
Clinical significance of incidental findings. These findings carry their own clinical weight. Screen-detected coronary artery calcifications can predict cardiovascular mortality, and LDCT-detected emphysema is linked to higher lung cancer incidence and mortality. The 2024 GOLD guidelines recommend spirometry when CT findings suggest COPD.
The challenge of inconsistent reporting. Use of the ACR's 'S modifier' to flag significant nonnodule findings is highly variable across and within institutions, and even across scans from the same patient. This inconsistency can lead to clinically relevant conditions being missed or inadequately followed up.
Programmatic workflows are needed. LCS programs should establish standardized workflows for communicating and evaluating nonnodule findings, including clear assignment of responsibility between the LCS program and the patient's primary care or ordering clinician.
Key quality indicators. The National Lung Cancer Roundtable identified six consensus LCS quality indicators: screening an appropriate target population, offering tobacco treatment, adhering to recommended LDCT follow-up, and achieving timely diagnosis for high-risk category 4 nodules. Additional metrics may include cancer detection rates and rates of nonmalignant surgical resection.
Electronic health record challenges. Despite their potential to store and harmonize large volumes of patient data, electronic health records fall short in enabling reliable LCS-specific quality monitoring. Problems include incomplete smoking history documentation, inconsistent use of screening billing codes, and difficulty tracking expected versus actual follow-up timelines.
Tracking software and registries. Specialized tracking software can automate patient reminders and facilitate data submission to national registries such as the ACR Lung Cancer Screening Registry. However, many such systems operate outside the primary EHR and require ongoing staff resources to maintain.
Upcoming accountability measures. New Healthcare Effectiveness Data and Information Set (HEDIS) measures focused on tobacco use documentation and LCS uptake will create added pressure on health systems to improve data capture and quality monitoring. An International Association for the Study of Lung Cancer statement on quality metrics is anticipated in 2025.
Eight essential components. The updated 2025 framework identifies 8 structural components that every LCS program should implement: defining the target population, improving uptake and adherence, delivering effective shared decision-making including tobacco treatment, performing LDCT according to dose standards, systematically reporting nodules using Lung-RADS, managing screen-detected nodules guideline-concordantly, evaluating nonnodule findings, and monitoring quality metrics.
Health equity as a core principle. Ensuring equitable access across race, geography, income, and insurance status must be an explicit goal of every LCS program. Disparities in who gets screened and who adheres to screening are among the most consequential challenges preventing lung cancer screening from achieving its full potential to save lives.
Looking ahead. Molecular biomarkers, artificial intelligence tools for imaging interpretation, and advances in implementation science are expected to drive further progress over the next decade. Critically evaluating new evidence before integrating it into practice - and scaling programs with equity and quality as guiding principles - will determine how many lives lung cancer screening ultimately saves.