Lung cancer screening with low-dose computed tomography—where do we go from here?

In the 13 years following the publication of the National Lung Screening Trial (NLST) demonstrating a 20% reduction in lung cancer death for smokers screened with low-dose computed tomography (1), we have made great progress toward mitigating lung cancer death through early detection.However, much work remains to be done.A 2013 recommendation from the US Preventative Services Task Force (USPSTF) endorsed lung cancer screening for individuals aged 55-80 years with a 30-pack-year smoking history, currently smoking, or within 15 years of cessation (2), mandating coverage by private insurers.A year later, the Centers for Medicare and Medicaid Services announced a national coverage decision for beneficiaries aged 55-77 years, with smoking requirements mirroring the USPSTF (3).Despite compelling data on lung cancer mortality reduction in clinical trials (1,4), and insurance coverage, lung cancer screening suffers from poor uptake.An early assessment of lung cancer screening in the United States comparing use in 2010 (before the NLST's publication) with 2015, following recommendations from the USPSTF and Centers for Medicare and Medicaid Services, saw a small increase from 3.3% to 3.9% participation among eligible individuals (5).Nearly 10 years later, rates of lung cancer screening use have marginally improved.The American Lung Association estimated that in 2022 only 4.5% of eligible Americans had been screened (6).When assessing the rate of lung cancer screening uptake, one must remember that the denominator, eligible smokers, has changed with time.Initial lung cancer screening eligibility recommendations were based largely on data from clinical trials.Reports from real-world clinical screening programs indicated that these guidelines were insufficiently inclusive.The Southern Community Cohort Study revealed that among those diagnosed with lung cancer, African Americans were much less likely (32%) to have met lung cancer screening eligibility than White study participants (56%) and were more likely to develop lung cancer at ages younger than 55 years and with less than 30 pack-years smoked (7).In light of this study and others, the USPSTF provided an updated 2021 recommendation including persons aged 50-80 years with at least a 20-pack-year smoking history (8), nearly doubling the number of Americans eligible for lung cancer screening and increasing access for women and non-Hispanic Black, Hispanic, and American Indian and Alaska Native persons