Actionable Incidental Findings at Baseline Lung Cancer Screening: Identifying Opportunities in a Universal Healthcare System

Purpose: To determine the prevalence of actionable incidental findings (AIFs) in a high-risk lung cancer screening cohort within a universal healthcare setting and identify potential opportunities in system-level quality improvement for AIF detection and management. Methods: This retrospective cohort study identified all individuals that presented for a baseline lung cancer screening exam between August 2019 and September 2025. Structured computed tomography (CT) report text was extracted and included an affirmation of whether an AIF was present, a description of the AIF, and a management recommendation. AIF type and prevalence were compared to guideline literature to identify areas of lower-than-expected reporting. Comparisons were performed using t -tests or chi-square tests. Results: There were 3169 unique individuals with eligible CT reports (37.2% female, 64.0 ± 5.2 years of age) with 424 AIFs identified in 370 (11.7%) individuals. AIFs were associated with higher body mass index, active smoking, Lung-RADS score, and less common with a personal history of cancer ( P < .05). Moderate or severe coronary artery calcification (n = 106, 3.3%), thyroid lesions (n = 43, 1.4%), and interstitial lung abnormalities (n = 41, 1.3%) were most common. Bone mineral density (0%), vertebral fractures (0.1%), and indeterminate adrenal lesions (0.1%) were infrequently reported despite guidelines suggesting clinical relevance. Management recommendations were generally aligned with provincial program-specific guidance. Conclusion: AIFs were common, but prevalence was relatively low for several key, potentially significant findings. Standardized reporting of AIFs and program-specific guidance is required considering the downstream costs associated with systematic identification of these AIFs.