Expanding Screening Criteria by adding smoking history may Boost Detection of Lung Cancer and Reduce Disparities: JAMA

A new multi-state cohort study published in the Journal of American Medical Association revealed that expansion of lung cancer screening eligibility to include individuals with a 20-year smoking history, regardless of pack-years, led to a 28% increase in those recommended for screening and a 17% rise in lung cancer detection. The revised criteria particularly improved detection among women and Black individuals, addressing under detection and reducing disparities, while maintaining diagnostic efficacy.

This study assessed over 43,000 individuals between 2015 and 2023 who were either enrolled in a lung cancer screening program or referred for evaluation of potentially malignant incidental pulmonary nodules (IPNs). This research evaluated existing U.S. Preventive Services Task Force (USPSTF) 2021 guidelines alongside alternative or expanded eligibility criteria, like the Potter criteria (20-year smoking history regardless of pack-years), the American Cancer Society (ACS) criteria (20 pack-years, no quit-time restriction), and combinations thereof. Additional expansions to include individuals with just 10 years or 10 pack-years of smoking history were also examined.

Under USPSTF 2021 guidelines, only 13% of those with concerning pulmonary nodules in the IPN group were eligible for LCS. However, applying broader criteria substantially increased eligibility. The Potter criteria alone captured 16%, while ACS criteria reached 18%, and a combined Potter-ACS approach identified 21% as eligible.

Also, the Potter approach alone flagged 1,103 more individuals compared to USPSTF standards—55% of whom were women and 35% were Black. These proportions were significantly higher than those captured under USPSTF (48% women and 22% Black), which revealed the race- and sex-based disparities in current screening reach.

Lung cancer was diagnosed in 6% of IPN participants, when compared to 4% in those in formal LCS programs. Among individuals who became eligible under the expanded Potter-ACS model, 17–18% were diagnosed with lung cancer. Among these, women made up nearly half of new diagnoses, and Black individuals represented up to 39%, depending on the criteria used, this highlighted the diagnostic utility and equity potential of relaxed guidelines.

The study further found that if criteria were broadened to include anyone over 50 with a 10-year or 10 pack-year smoking history, 27% of the IPN cohort would qualify for screening. Among them, 16% were diagnosed with lung cancer, reinforcing the effectiveness of more inclusive thresholds.

Overall, this research concluded that shifting from a rigid 20 pack-year requirement to a more flexible 20-year smoking history could significantly improve screening access without diminishing the diagnostic return. These changes could enable earlier detection, especially for populations historically underserved by current LCS standards.

Reference:

Smeltzer, M. P., Liao, W., Goss, J., Qureshi, T., Johnson, S., Harris, A., Dortch, K., Fehnel, C., Ely, S., Ray, M., & Osarogiagbon, R. U. (2025). Reducing smoking requirements for lung screening to address health disparities in a community cohort. JAMA Network Open, 8(6), e2517149. https://doi.org/10.1001/jamanetworkopen.2025.17149