Lung Cancer Screening: A Missed Opportunity for Early Detection

Kim Sandler, MD

Photo courtesy of American College of Physicians

At the American College of Physicians Internal Medicine Meeting 2025, Kim L. Sandler, MD, a cardiothoracic radiologist and director of the Vanderbilt Lung Screening Program (VLSP) at Vanderbilt University Medical Center in Nashville, TN, delivered an informative presentation on lung cancer screening, emphasizing its underutilization and the significant survival benefit of early detection. Speaking to a room of internists and primary care physicians, Dr Sandler outlined current screening guidelines, real-world challenges in implementation, and the essential role of shared decision-making in lung cancer screening.

Why Screen?

“Lung cancer kills more women than breast and ovarian cancer combined,” Dr Sandler opened, underscoring the lethal nature of the disease and the missed opportunities for early detection. Lung cancer remains a leading cause of cancer-related mortality in the US, despite the availability of validated screening tools such as low-dose computed tomography (LDCT) for high-risk individuals.

The VLSP has diagnosed 128 lung cancers to date, the majority (65%) of which were stage I or II at diagnosis—a testament to the power of early detection through screening. Dr Sandler also highlighted findings from 3 clinical trials evaluating the effectiveness of lung cancer screening in reducing mortality rates:

1. National Lung Screening Trial (NLST): Found a 20% reduction in lung cancer mortality through LDCT screening compared with annual chest radiography.¹
2. Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial: Showed a 60% reduction in lung cancer mortality through screening in women and a 26% decrease among men.²
3. Multicentric Italian Lung Detection (MILD) study: Demonstrated that prolonged LDCT screening was associated with a 39% reduction in lung cancer mortality among approximately 4000 current and former smokers of 20 pack-years.³

Evolving Guidelines: USPSTF and Beyond

Dr Sandler reviewed the evolution of the US Preventive Services Task Force (USPSTF) recommendations:

• 2013 USPSTF Guidelines: Screening was recommended for adults aged 55 to 80 years with a 30 pack-year smoking history, including current smokers and those who had quit within 15 years.
• 2021 Update: The age threshold was lowered to 50 years, and the smoking history requirement reduced to 20 pack-years.⁴ These changes effectively doubled the number of individuals eligible for screening—from 104 000 to 167 000 at Vanderbilt University Medical Center (VUMC) alone.

Other guidelines, including those from the American Cancer Society (2023), National Comprehensive Cancer Network (2022), American College of Radiology (2022), and the Centers for Medicare & Medicaid Services, largely align with the 2021 USPSTF criteria: age 50 to 80 years, a 20+ pack-year smoking history, and cessation within the past 15 years.

The Role of Shared Decision-Making

Dr. Sandler emphasized the critical importance of a Shared Decision-Making Visit (SDMV) in the screening process. This visit should involve:

• Determining eligibility
• Reviewing decision aids
• Counseling on the risks and benefits of annual LDCT
• Discussing comorbidities that may impact the value of screening
• Addressing the implications of potential follow-up imaging, biopsy, or treatment
• Offering smoking cessation resources

Screening in the Real World

Despite clear recommendations and demonstrable benefit, only about 13–15% of eligible individuals in Tennessee, home of the VLSP, are currently enrolled in a lung cancer screening program. This low uptake reflects a combination of systemic, provider, and patient-level barriers. Among these are lack of awareness, logistical challenges, and clinician uncertainty about eligibility or program availability.

The VLSP has attempted to address some of these challenges with coordinated outreach and navigator support. The results are promising. Of the 83 cancers diagnosed on baseline LDCT exam in the VLSP, 59 were stage I, and 12 were stage II. Among 45 cancers diagnosed with follow-up scans, 30 were stage I.

Final Takeaways

Dr Sandler closed with 3 concise but crucial messages:

1. Lung cancer screening saves lives by detecting disease at earlier, more treatable stages.
2. Eligibility criteria are broadening, increasing the number of patients who could benefit from screening.
3. Uptake remains low, and internal medicine providers play a vital role in improving access and adherence.

References

1. National Lung Screening Trial Research Team; Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. doi:10.1056/NEJMoa1102873
2. de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513. doi: 10.1056/NEJMoa1911793
3. Pastorino U, Sverzellati N, Sestini S, et al. Ten-year results of the Multicentric Italian Lung Detection trial demonstrate the safety and efficacy of biennial lung cancer screening. Eur J Cancer. 2019;118:142-148. doi:10.1016/j.ejca.2019.06.009
4. Jennings S. USPSTF: New Lung Cancer Screening Recommendations Will Double Number of Eligible Patients. Patient Care Online. July 14, 2020. https://www.patientcareonline.com/view/uspstf-new-lung-cancer-screening-recommendations-will-double-number-of-eligible-patients