Experts Call for Expanded Lung Cancer Screening Eligibility Criteria

The variety of lung cancer screening guidelines and the increased adoption of technological advances such as machine learning and minimally invasive surgical techniques provide a robust yet incomplete picture of lung cancer risk, experts say. Multidisciplinary collaboration and continued research into lung cancer risk factors are essential for expanding the use of effective screening and treatment strategies to benefit a greater number of patients.

“Mortality is significantly improved with early detection because of…surgical techniques,” Kim L. Sandler, MD, said in an interview with OncLive^®. “It is essential that we find these cancers early because we know they are occurring. We are going to continue to work to get that message out there, improve screening uptake, and expand recommendations.”

Sandler is director of the Vanderbilt Lung Screening Program, vice chair of faculty development for the Department of Radiology, and a professor of radiology and radiological sciences at Vanderbilt University Medical Center in Nashville, Tennessee.

What are some of the most common lung cancer screening recommendations, and how do they translate to clinical practice?

Several sets of screening eligibility criteria are staples across different institutions. For instance, the United States Preventive Services Task Force recommends annual low-dose CT lung cancer screening for people aged 50 to 80 years with a 20-pack-year smoking history who currently smoke or who have smoked within the past 15 years.¹ These guidelines further state that screening should be discontinued once a person has quit smoking for 15 years or develops a health issue that substantially limits their life expectancy or their ability or willingness to undergo curative lung surgery. Alternatively, the American Cancer Society recommends continued screening beyond the 15-year time point for quitting smoking.² Furthermore, the PLCOm2012 risk prediction model accounts for characteristics beyond age and smoking history, such as family history of lung cancer, personal history of other malignancies, education level, and race.³

However, Sandler noted that patients’ individual insurance coverage ultimately determines many screening decisions.

“We like to have those conversations individually with patients and also with their referring providers to make sure they have all that data,” she said. “But we want to always make sure the patients know what exams are covered by insurance.”

How are lung cancer screening advances increasingly accounting for individual patient characteristics?

Beyond conventional guidance, Sandler said, "There are factors that increase a person’s likelihood of having lung cancer, so if a patient wants to be screened and has a risk factor or a risk that’s outside of smoking, we have those conversations.”

She reported that current lung cancer screening recommendations do not account for certain familial syndromes that are linked with increased risk for lung cancer, nor do they acknowledge the increased risk of lung cancer in young women, as well as in patients with a history of breast cancer.

“A lot of us in the lung cancer screening [field] feel strongly that the eligibility recommendations should be expanded, so we’re working to do that by gathering data from several different sites across the country and around the world, where we’re seeing increased incidence of lung cancer, particularly outside of tobacco use,” she reported.

What does lung cancer risk prediction look like for patients presenting with lung nodules?

When a lung nodule is found in a patient through imaging or incidentally, several tools exist to help estimate the likelihood of the lesion being cancerous.

“Even when we think [a nodule] is suspicious, it’s much more likely that we recommend additional imaging than a patient go directly to tissue sampling,” Sandler explained. “In radiology, we work in probabilities. What is the probability of this finding being malignant? When we see nodules that are suspicious, [meaning] there’s a greater than 5%, 10%, or 15% chance that that nodule represents cancer, that’s when we like to get our [surgical] colleagues…and our interventional pulmonary medicine colleagues on board and have discussions around whether we think this nodule is worth following with short-term surveillance or proceeding to biopsy.”

Eric L. Grogan, MD, MPH, FACS, emphasized in an interview with OncLive that in his practice, the presence of high-risk lesions often necessitates the use of the Vanderbilt TREAT 2.0 algorithm, which he and Sandler find to be a useful tool for determining the likelihood of malignancy in a nodule and a patient’s chances of developing lung cancer over the next several years.

Grogan is a professor of thoracic surgery, vice chair for research, and chief of thoracic surgery at the Veterans Affairs Medical Center at Vanderbilt Health.

A patient with a Vanderbilt-classified very high-risk lesion may require additional biopsies, surgery, or PET imaging, Grogan explained. Conversely, he noted that a patient with a Vanderbilt-classified very low-risk lesion might not need more than interval follow-ups every few months.

“It’s a tool that allows a [physician] with a positive finding on imaging to determine the next steps from there, based on the likelihood that it’s cancer,” he said. “That’s what we have to do when we find a lesion on lung cancer screening. The clinician is then required to estimate the likelihood that this is cancer, because that will determine the next steps.”

How might lung cancer testing developments help refine surgical decision-making and reduce the rates of unnecessary invasive procedures in patients with intermediate pulmonary nodules?

When patients present with intermediate peripheral nodules on imaging, the next steps for evaluating the potential for disease range from surgery to less-invasive techniques. However, the experts cautioned that deciding between these approaches requires consideration of the nodule’s characteristics, as well as familiarity with the latest technological advances in this area.

Sandler explained that more centrally located nodules can often be easily accessed via bronchoscopy, whereas CT-guided biopsy is often preferred for peripheral nodules. Regardless of which approach an oncologist seeks to take, however, collaboration with an interventional pulmonologist is key, she said.

“What’s happened over the past several years is that the incorporation of imaging with the bronchoscopy has made navigational bronchoscopy even more effective, and nodules that we used to think could not be accessed through the airways now can be accessed relatively easily by our pulmonary colleagues,” she emphasized. “At Vanderbilt, in particular, we’ve seen a shift more to these bronchoscopic interventions, because the technology has advanced in a way that makes those procedures more accurate and more likely to find a diagnosis.”

Grogan added that in patients with lesions that are difficult to locate through bronchoscopy, dyes or other localization tools may be added to the area of the lesion to make it easier to find and biopsy during surgery. He also noted that emerging research with blood-based biomarkers may help further stratify patients into risk categories when they are found to have intermediate-risk nodules.

“[Using] a nodule predictor [such as] a calculator to [shift] the people in that intermediate likelihood of cancer [category into] high-risk vs low-risk categories will allow you to either follow them or become more aggressive with your approach and proceed with biopsies,” Grogan said. “This field is rapidly evolving, so there’s a lot of work being done by a lot of different groups and parties to add blood-based biomarkers into this to help us improve the calculators.”

However, he also highlighted the role of combining diagnostic and therapeutic procedures into the same surgery, or even foregoing biopsy in favor of immediate surgical resection in certain patients. For instance, he explained that if a calculator or blood test reveals that the nodule has an approximately 80% to 90% of being cancer, even in the event of a negative bronchoscopic biopsy, surgery is often still recommended.

“One of the advantages of surgery is that you know when you leave the operating room whether [the patient has] cancer,” he stated. “If they have cancer, then you can do the therapeutic operation for the lung cancer component of the procedure. Sometimes we take those patients straight to the operating room, remove the lesion in its entirety so we can get a definitive diagnostic procedure, and then do the lung cancer operation at the same setting. Most of the time, we can do this minimally invasively.”

Grogan highlighted the benefits of minimally invasive surgical techniques in this setting, which aim to minimize patient pain and shorten their recovery time. He noted that although preferred methods may vary by institution, video- and robotic-assisted approaches produce relatively equivalent outcomes. He said that procedures such as sublobar resections have had equivalent oncologic outcomes compared with lobar resection in patients with cancers that are found early in the disease course and are smaller than 2 cm.⁴

However, Grogan cautioned that “sometimes the lesions are in locations where [sublobar resection] cannot occur, and so you don’t want to sacrifice the cancer operation for a less-invasive approach and not do the right thing for the patient.”

What might the future of lung cancer screening look like?

Overall, the experts emphasized the importance of not only adhering to established lung cancer screening guidelines but also conducting further research to identify additional risk factors that updated guidelines should incorporate, thereby enabling more individuals at risk for developing this disease to be counseled and screened. 

“We all need to be looking for excuses to scan more people and use our clinical judgment, which we’re all trained to do as clinicians, for considering who’s going to be slightly at an increased risk who otherwise wouldn’t qualify by the guidelines, and look for reasons to expand lung cancer screening,” Grogan concluded.

References

1. US Preventive Services Task Force; Krist AH, Davidson KW, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117
2. Wolf AMD, Oeffinger KC, Shih TYC, et al. Screening for lung cancer: 2023 guideline update from the American Cancer Society. CA Cancer J Clin. 2024;74(1):50-81. doi:10.3322/caac.21811
3. Vogel-Claussen J, Bollmann BA, May K, et al. Effectiveness of NELSON versus PLCOm2012 lung cancer screening eligibility criteria in Germany (HANSE): a prospective cohort study. Lancet Oncol. 2025;26(12):1541-1551. doi:10.1016/S1470-2045(25)00490-5
4. Altorki N, Wang X, Kozono D, et al. Lobar or sublobar resection for peripheral stage IA non-small-cell lung cancer. N Engl J Med. 2023;388(6):489-498. doi:10.1056/NEJMoa2212083