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Millions More with Smoking History are Recommended for Lung-Cancer Screening in New Guidance

Despite improved lung cancer treatments, only a fraction of eligible Americans get screened.

minute read

Written by Mark Harden on November 3, 2023

The American Cancer Society (ACS) this week called for millions more people who formerly smoked to be screened for lung cancer than it previously recommended. But while a University of Colorado Cancer Center member calls the news “exciting,” she said the overarching challenge is to get more people already eligible to be screened.

Nina Thomas, MD, assistant professor of pulmonary and critical care medicine at the CU School of Medicine and director of the lung nodule and lung cancer screening program, says that even with advances in lung cancer treatment, early detection is vital. Yet most people who should be screened aren't for a variety of reasons.

Previous ACS guidance advised that people with a history of smoking get a low-dose CT scan only if they quit more recently than 15 years ago. The ACS' updated screening guidelines – published Nov. 1 in CA: A Cancer Journal for Clinicians and on the society's website – say that how long ago someone quit should not be a factor in screening eligibility.

The society also said people who smoked 20 pack-years or more should be screened, rather than the higher threshold of 30 pack-years it previously recommended. (Pack-years are calculated by multiplying average packs smoked per day by total number of years smoked. For example, 10 pack-years is an average of one pack of cigarettes per day for 10 years.)

The ACS also expanded its advised age range for screening to ages 50 to 80 from the previous 55-74 age range.

Thomas walks us through the new ACS guidance and the need for screening generally in an interview.

Q&A Header

What are your thoughts on the new ACS guidelines for lung cancer screenings?

They partially reflect the update that we saw with the 2021 guidelines from (the U.S. Preventive Services Task Force, or USPSTF), because screening now starts at younger ages – at age 50 – and a lower pack-year smoking history at 20 pack-years. But the one major difference is that ACS is removing the years-since-quitting criteria. That’s based on modeling data that showed that even after 15 years of quitting smoking, people still had some risk to develop lung cancer, and would probably benefit from cancer screening.

Lowering the age and smoking history criteria were based on new data surrounding patients who were under-represented in the original screening trials – Black, Asian, and Hispanic populations. They are at higher risk to develop lung cancer. And women and Black people are more likely to be diagnosed with lung cancer at younger ages and with a lower pack-year smoking history.

The hard part is that only about 5% to 6% of people who qualify for lung cancer screening actually get screened, and in Colorado it’s 3%-4%. So while these changes in guidelines improve who could be eligible for screening, if we don’t actually improve the implementation of screening, it’s hard to have a clear impact on who’s actually getting screened, diagnosed with lung cancer, and treated.

So what should happen next?

You would hope that the USPSTF and (the Centers for Medicare & Medicaid Services, or CMS) look at this data and eventually update their criteria as well, because that's going to be the difference for insurance companies covering lung cancer screening. Insurance companies follow CMS guidelines, which usually follow USPSTF guidelines, when it comes to lung cancer, screening and coverage.

But there are still lots of barriers besides insurance that we still have to work with to improve that screening rate. That includes improving on the health-care side, getting more primary-care physicians who have the closest contact with these patients to recognize who qualifies for lung cancer screening and get them screened. There are also community efforts that need to be done to educate people and their communities on the benefits and process. Then, it's getting them in the door. People may need to take off work, get child care and may not even have access to care and lung cancer screening centers. So how do we incentivize it and help patients get those screenings on a regular basis?

So what happens when someone gets screened for lung cancer?

It's pretty painless. It involves a low-dose CT, so it's just like a CT scan any other way, but with lower radiation exposure. It's about a 10-15 minute scan where you lie on a table, you put your hands above your head, you take a deep breath and you travel through the scanner.

What's more important is making sure we follow up on the results and findings. The most common thing that we find is lung nodules, or spots on the lung. There are criteria on how we manage those nodules. Actually, the majority of the nodules we find are not cancerous. So usually it takes following up on these nodules with additional CTs, or being referred to a pulmonologist to evaluate whether you need follow-up tests, like biopsies, to evaluate for cancer.

What would you say to someone who’s reluctant to get screened?

There's a lot of fear and stigma around lung cancer screening. But the treatment of lung cancer has drastically changed over the last 15 to 20 years. So whereas 20 years ago, people thought lung cancer was more of a death sentence, it's a much more manageable disease now. The benefit of lung cancer screening is, we're trying to diagnose people at earlier stages when they probably don't have any symptoms yet. The earlier the stage, the more manageable and curable the cancer can be often with treatments like surgery or radiation.

The stigma of smoking is another part of it. A lot of patients don't want to talk about their smoking past or their current smoking. But our role as physicians is not to scold or wag our fingers at these patients. Our role is to collaborate with them in a non-judgmental way and support them to help them quit, but also to get them eligible screening.

What’s the current state of lung cancer as a health threat?

It's still the leading cause of cancer-related deaths in the U.S. and world. It's the second-most-common cancer in the U.S., and lung cancer deaths in the U.S. outrank breast, colon, and prostate cancer deaths combined. So it's still a major problem, but we're seeing with improving lung cancer screening and early detection, advancements with technology and treatment that is becoming a much more manageable disease than it was 20 years ago.

Information on Lung Cancer Screenings

• From our clinical partners at UCHealth: Visit uchealth.org/treatments-procedures/lung-cancer-screening-program/ or call 720-848-9264.

• From GO2 for Lung Cancer: Visit go2.org/ or call 1-800-298-2436.

Information on how to quit smoking visit: uchealth.org/services/respiratory-lung-care/smoking-cessation/

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Nina Thomas, MD