Perceptions of Incidental Findings on Lung Cancer Screening Exams: A National Survey of Primary Care Clinicians and Radiologists

RATIONALE: Unlike other common cancer screenings, annual lung cancer screening often identifies a spectrum of incidental findings unrelated to lung cancer. While these findings could be actionable, how to best communicate and manage them can be a challenge, often falling upon primary care clinicians. OBJECTIVES: Evaluate primary care clinician and radiologist approaches to and preferences for reporting commonly identified incidental findings on lung cancer screening. METHODS: In this cross-sectional study, we conducted an electronic survey of primary care clinicians and radiologists practicing in the Veterans Health Administration, which was distributed from August to September 2025. Clinicians' professional data and clinical practice details were captured. Three clinical vignettes reflecting common cardiopulmonary incidental findings (coronary artery calcifications, pulmonary emphysema, and pulmonary fibrosis) were used to identify management approaches and preferences for communicating incidental findings. Additional questions were posed to explore opinions on how artificial intelligence could be used to assist in reporting and management. RESULTS: The survey was completed by 560 primary care clinicians and 55 radiologists. Both groups of clinicians preferred incidental findings be communicated through the radiology report rather than direct communication (95%) with the majority of primary care clinicians preferring incidental findings be included in both the impressions and findings sections of the report. The American College of Radiology Quick Reference Guide for Incidental Findings indicates that only new or previously undocumented incidental findings be reported, however primary care clinicians preferred incidental findings be communicated on both baseline and follow-up screening exams (68% in coronary artery calcification, 68% in emphysema, and 75% in pulmonary fibrosis). The majority of radiologists indicated that they report these incidental findings, but some indicated that they do not use the S-modifier for certain disease states. Using artificial intelligence to review the medical record to indicate which incidental findings had previously been diagnosed was favored by 76% of primary care clinicians and 82% of radiologist respondents. CONCLUSIONS: As lung cancer screening uptake continues to increase, incidental findings will continue to pose a reporting and management dilemma. This study provides insight into primary care clinician and radiologist views and provides important data to guide future research.