Age-Based Screening for Lung Cancer Surveillance in the US

Lung cancer is increasingly diagnosed in never-smokers, suggesting that the current US Preventive Services Task Force (USPSTF) screening criteria using low-dose computed tomography exclude many at-risk individuals, thus raising concerns about their effectiveness and equity.

To evaluate the proportion, clinical characteristics, and survival of patients with lung cancer who meet or are excluded from USPSTF criteria and to use institutional and published data to model expanded criteria and evaluate age-based screening.

Patients with lung cancer diagnosed from 2018 to 2023 at an academic center were analyzed, with follow-up through 2024. Patients were stratified by 2021 USPSTF eligibility (age 50-80 years, ≥20 pack-years, and current or quit <15 years). Expanded scenarios were modeled and benchmarked against breast and colorectal screening.

Diagnosis of lung cancer.

The primary outcome was the proportion of patients meeting USPSTF criteria. Secondary outcomes included survival, clinical characteristics, and modeled impact of expanded screening scenarios on detection, cost-effectiveness, and risks. Group comparisons were performed using Pearson χ2 or Fisher exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Cox proportional hazards models were used to calculate hazard ratios (HRs) with 95% CIs.

Among 997 patients (median [IQR] age, 67 [18-99] years; 577 [58.0%] women), only 350 (35.1%) met USPSTF criteria. The nonguideline group included more women (396 of 647 patients [61.0%] vs 181 of 350 patients [52.0%]), Asian patients (62 of 647 patients [9.6%] vs 13 of 350 patients [3.7%]), and never-smokers (247 of 647 patients [38.0%]); had more adenocarcinoma diagnoses (469 of 647 patients [72.0%] vs 192 of 350 patients [55.0%]); and had better overall survival (median [IQR], 9.5 [6.6-12.3] vs 4.4 [3.7-6.0] years; HR, 0.67; 95% CI, 0.55-0.82; P < .001) than the guideline group. Never-smokers (247 of 997 patients [24.8%]), those who quit longer than 15 years (134 of 997 patients [13.0%]), those with less than 20 pack-years (65 of 997 patients [6.5%]), and those aged outside the 50 to 80 year range (41 of 997 patients [4.1%]) were excluded. Expanding criteria to age 40 to 85 years, 10 or more pack-years, and no cessation limit increased detection to 62.1% (619 of 997 patients). A modeled age-based screening (40-85 years) captured 93.9% of cases (936 of 997 patients) and prevented 26 124 deaths annually (95% CI, 20 000-32 248 deaths annually) at $101 000 per life saved (95% CI, $82 000-$120 000), compared with $890 000 (95% CI, $700 000-$1 100 000) for breast cancer and $920 000 (95% CI, $700 000-$1 200 000) for colorectal cancer screening. Sensitivity analysis confirmed robust findings across all parameter ranges, with 98.7% probability of superior cost-effectiveness.

Current USPSTF guidelines exclude two-thirds of patients, disproportionately women and never-smokers. Age-based screening substantially improved detection, demonstrated 6-fold superior cost-effectiveness compared with existing programs, and addressed inequities.