JAMA Netw Open. 2025 Jun 2;8(6):e2517149. doi: 10.1001/jamanetworkopen.2025.17149.
ABSTRACT
IMPORTANCE: Many individuals with lung cancer are not eligible for lung cancer screening (LCS). Race-based and sex-based differences in smoking patterns reduce the effectiveness of LCS criteria.
OBJECTIVE: To assess the value of expanding LCS criteria beyond US Preventive Services Task Force (USPSTF) 2021 guidelines by relaxing cigarette smoking exposure criteria.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included individuals enrolled in an incidental pulmonary nodule (IPN) program with non-screening-detected, potentially malignant pulmonary nodules, or enrolled in a LCS program from 2015 to 2023. Participants were treated in a community-based health care system serving more than 125 counties in Mississippi, Tennessee, Arkansas, Kentucky, Missouri, and Alabama. Data were examined from October 1, 2024, to May 29, 2025.
EXPOSURES: LCS eligibility criteria included USPSTF 2021, Potter criteria (20-year smoking history), and American Cancer Society criteria ([ACS] 20 pack-years, no quit duration), and expansions to 10 years or 10 pack-years.
MAIN OUTCOMES AND MEASURES: The main outcomes were proportions of individuals eligible for LCS and diagnosis of lung cancer. Characteristics between groups were compared using the χ2 test for categorical variables and the Wilcoxon-Mann-Whitney test for continuous variables.
RESULTS: In this study, 43 521 individuals were evaluated, including 13 770 (32%) from LCS and 29 751 (68%) from IPN programs. Of the 29751 individuals in IPN programs, 3840 (13%) were eligible for LCS by USPSTF 2021 criteria, 4905 (16%) by IPN-Potter criteria, 5263 (18%) by IPN-ACS criteria, and 6307 (21%) by IPN-Potter-ACS criteria. There were 1103 additional individuals eligible by IPN-Potter criteria (606 female [55%] and 382 Black [35%]), 1423 by IPN-ACS criteria (628 female [44%]; 237 Black [17%]), and 2467 by IPN-Potter-ACS criteria (1200 female [49%]; 615 Black [25%]). There were significant differences in the number of additional eligible individuals who were female (55% vs 48%; P < .001) and Black (35% vs 22%; P < .001) between the IPN-Potter and USPSTF 2021 criteria. Lung cancer was diagnosed in 504 of 13 770 of LCS enrollees (4%) and 1714 of 29 751 of IPN enrollees (6%), including 872 of 4905 (18%) eligible by IPN-Potter criteria, 955 of 5263 (18%) by IPN-ACS criteria, and 1051 of 6307 (17%) by IPN-Potter-ACS criteria. The additional eligible individuals with lung cancer in IPN programs who were female included 70 of 128 (55%) by IPN-Potter criteria, 89 of 208 (43%) by IPN-ACS criteria, and 143 of 304 (47%) by IPN-Potter-ACS criteria, with statistically significant differences between the IPN-Potter criteria and USPSTF 2021 criteria (55% vs 48%; P < .001). The additional eligible individuals who were Black included 50 of 128 (39%) by IPN-Potter criteria, 32 of 208 (15%) by IPN-ACS criteria, and 73 of 304 (24%) by IPN-Potter-ACS criteria, with statistically significant differences between IPN-Potter criteria and IPN-USPSTF 2021 criteria (39% vs 22%; P < .001). When LCS criteria were expanded to individuals older than 50 years who had smoked for 10 years or 10 pack-years, 7993 of 29 751 individuals (27%) from IPN programs would have been eligible. Among these, 1251 of 7993 (16%) were diagnosed with lung cancer.
CONCLUSIONS AND RELEVANCE: In this cohort study, changing smoking criteria from 20 pack-years to a 20-year smoking history was associated with improved access to LCS while maintaining diagnostic efficiency. Expansion to individuals with a 10-year or 10 pack-years smoking history should be explored.
PMID:40553471 | DOI:10.1001/jamanetworkopen.2025.17149
