Patient Population Under Consideration

This recommendation applies to adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years.

Assessment of Risk

Smoking and older age are the 2 most important risk factors for lung cancer.3-5 The risk of lung cancer in persons who smoke increases with cumulative quantity and duration of smoking and with age but decreases with increasing time since quitting for persons who formerly smoked.3 The USPSTF considers adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years to be at high risk and recommends screening for lung cancer with annual LDCT in this population.

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African American/Black (Black) men have a higher incidence of lung cancer than White men, and Black women have a lower incidence than White women.1 These differences are likely related to differences in smoking exposure (ie, prevalence of smoking) and related exposure to carcinogens in cigarettes.7,8 The differences may also be related to other social risk factors.

Other risk factors for lung cancer include environmental exposures, prior radiation therapy, other (noncancer) lung diseases, and family history. Lower level of education is also associated with a higher risk of lung cancer.7 The USPSTF recommends using age and smoking history to determine screening eligibility rather than more elaborate risk prediction models because there is insufficient evidence to assess whether risk prediction model-based screening would improve outcomes relative to using the risk factors of age and smoking history for broad implementation in primary care.

Screening Tests

Low-dose computed tomography has high sensitivity and reasonable specificity for the detection of lung cancer, with demonstrated benefit in screening persons at high risk.9-11 Other potential screening modalities that are not recommended because they have not been found to be beneficial include sputum cytology, chest radiography, and measurement of biomarker levels.12,13

Screening Intervals

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The 2 lung cancer screening trials that showed a benefit of lung cancer screening used different screening intervals. The National Lung Screening Trial (NLST) screened annually for 3 years.10 The Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) trial screened at intervals of 1 year, then 2 years, then 2.5 years.11 Modeling studies from the Cancer Intervention and Surveillance Modeling Network (CISNET)14,15 suggest that annual screening for lung cancer leads to greater benefit than does biennial screening. Based on the available evidence and these models, the USPSTF recommends annual screening.

Treatment and Interventions

Lung cancer can be treated with surgery, chemotherapy, radiation therapy, targeted therapies, immunotherapy, or combinations of these treatments.16 Surgical resection is generally considered the current treatment of choice for patients with stage I or II non-small cell lung cancer (NSCLC).17

Implementation of Lung Cancer Screening

Available data indicate that uptake of lung cancer screening is low. One recent study using data for 10 states found that 14.4% of persons eligible for lung cancer screening (based on 2013 USPSTF criteria) had been screened in the prior 12 months.18 Increasing lung cancer screening discussions and offering screening to eligible persons who express a preference for it is a key step to realizing the potential benefit of lung cancer screening.

Screening Eligibility, Screening Intervals, and Starting and Stopping Ages

As noted above, the USPSTF recommends annual screening for lung cancer with LDCT in adults aged 50 to 80 years who have at least a 20 pack-year smoking history. Screening should be discontinued once a person has not smoked for 15 years.

The NLST9 and the NELSON trial11 enrolled generally healthy persons, so those study findings may not accurately reflect the balance of benefits and harms in persons with comorbid conditions. The USPSTF recommends discontinuing screening if a person develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Smoking Cessation Counseling

All persons enrolled in a screening program who are current smokers should receive smoking cessation interventions. To be consistent with the USPSTF recommendation on counseling and interventions to prevent tobacco use and tobacco-caused disease,19 persons referred for lung cancer screening through primary care should receive these interventions concurrent with referral. Because many persons may enter screening through pathways besides referral from primary care, the USPSTF encourages incorporating such interventions into all screening programs.

Shared Decision-Making

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Shared decision-making is important when clinicians and patients discuss screening for lung cancer. The benefit of screening varies with risk because persons at higher risk are more likely to benefit. Screening does not prevent most lung cancer deaths; thus, smoking cessation remains essential. Lung cancer screening has the potential to cause harm, including false-positive results and incidental findings that can lead to subsequent testing and treatment, including the anxiety of living with a lung lesion that may be cancer. Overdiagnosis of lung cancer and the risks of radiation exposure are harms, although their exact magnitude is uncertain. The decision to undertake screening should involve a thorough discussion of the potential benefits, limitations, and harms of screening.

Standardization of LDCT Screening and Follow-up of Abnormal Findings

The randomized clinical trials (RCTs) that provide evidence for the benefit of screening for lung cancer with LDCT were primarily conducted in academic centers with expertise in the performance and interpretation of LDCT and the management of lung lesions seen on LDCT. Clinical settings that have similar experience and expertise are more likely to duplicate the beneficial results found in trials.

In an effort to minimize the uncertainty and variation about the evaluation and management of lung nodules and to standardize the reporting of LDCT screening results, the American College of Radiology developed the Lung Imaging Reporting and Data System (Lung-RADS) classification system and endorses its use in lung cancer screening.20 Lung-RADS provides guidance to clinicians on which findings are suspicious for cancer and the suggested management of lung nodules detected on LDCT. Data suggest that the use of Lung-RADS may decrease the rate of false-positive results in lung cancer screening.21

Additional Tools and Resources

The Centers for Disease Control and Prevention has several websites with many resources to help patients stop smoking:

• “How to Quit” resources (https://www.cdc.gov/quit)
• Smoking Cessation: Fast Facts (https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/smoking-cessation-fast-facts/)
• Tips From Former Smokers (https://www.cdc.gov/tobacco/campaign/tips/)

The National Cancer Institute has developed resources to help patients stop smoking (https://www.smokefree.gov). It has also developed patient and clinician guides on screening for lung cancer:

• Lung Cancer Screening (PDQ)-Patient Version (https://www.cancer.gov/types/lung/patient/lung-screening-pdq)
• Lung Cancer Screening (PDQ)-Health Professional Version (https://www.cancer.gov/types/lung/hp/lung-screening-pdq)

Other Related USPSTF Recommendations

Prevention of initiation of smoking and smoking cessation for those who smoke are the most important interventions to prevent lung cancer. The USPSTF has made recommendations on interventions to prevent the initiation of tobacco use in children and adolescents22 and on the use of pharmacotherapy and counseling for tobacco cessation.19

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