{"entity":{"id":"idea-lung-screening-eligibility-by-risk-not-pack-years","kind":"idea","name":"Decide who is screened for lung cancer by individual risk, not by pack-years","aka":[],"tldr":"The rules that decide who gets a lung scan count cigarettes. A risk model that also uses age, sex, family history, deprivation and lung disease would find more cancers in the same number of scans, and would stop excluding people who smoke less but are more likely to get the disease.","summary":"Eligibility for low-dose computed tomography screening is defined in the United States by age 50 to 80 with a 20 pack-year history and quitting within 15 years, and elsewhere by variations on the same two numbers. Aldrich showed what that costs: in a southern United States cohort 31 percent of white smokers were eligible against 17 percent of Black smokers, who develop lung cancer at lower cumulative exposure. Risk prediction models have been shown to select a higher-yield population than pack-year thresholds at the same screening volume, and the 2021 task force update considered them and did not adopt them.\n\nThe idea is to make risk-model eligibility the default, prospectively evaluated against threshold eligibility on cancers detected per thousand screened, stage distribution and the equity of who is invited, rather than on eligibility counts. UK and NHS specifics (Targeted Lung Health Check coverage and uptake, NICE positions and Cancer Drugs Fund status, molecular testing turnaround, thoracic surgery and radiotherapy capacity, audit indicators and trial access) are on the UK and NHS page for lung cancer and are not restated here.","asOf":"2026-09-25","links":[],"tags":["lung-evidence"],"related":["idea-prev-lung-screening-risk-model-eligibility","idea-prev-screening-default-appointments","early-detection-roadmap","lung-cancer-evidence-roadmap"],"cancers":["lung-cancer","nsclc"],"sections":["early-detection","prevention"],"technologies":["low-dose-ct-screening"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":[],"trials":[],"people":[],"bottlenecks":["b-early-detection","b-trial-diversity","b-global-access","b-prevention-adoption"],"keyPapers":["paper-aldrich-uspstf-screening-african-american-smokers-jama-oncol-2019","paper-uspstf-lung-cancer-screening-jama-2021","paper-nlst-nejm-2011","paper-nelson-nejm-2020"],"journals":[],"dependsOn":[],"notes":[],"hypothesis":"Replacing pack-year eligibility with an individual risk model detects more stage I and II lung cancers per thousand scans and narrows the gap in eligibility between the most and least deprived populations, without increasing the false-positive rate per cancer found.","rationale":"Pack-years are a single crude proxy for a risk that depends on age, duration and intensity of smoking, years since quitting, sex, chronic obstructive pulmonary disease, family history, occupational and particulate exposure and deprivation. A threshold on one variable cannot be calibrated across populations that differ on the others, and Aldrich's 31 against 17 percent is the measured consequence. Risk models also give a natural route to including never-smokers with other risk factors, who are currently excluded by construction.","test":"A pragmatic randomised comparison inside an existing screening programme: invitation by threshold eligibility against invitation by a validated risk model at matched screening capacity, with cancers detected by stage, interval cancers, false-positive rate per cancer found and eligibility by deprivation quintile and ethnicity as co-primary outcomes. Three years to first readout on detection, ten to mortality.","maturity":"early-clinical","actor":"policy","cost":"medium","horizonYears":5},"route":"/ideas/idea-lung-screening-eligibility-by-risk-not-pack-years/","neighbours":{"idea":[{"id":"idea-prev-lung-screening-risk-model-eligibility","kind":"idea","name":"Lung screening eligibility by risk score, not pack-years, including high-risk never-smokers","route":"/ideas/idea-prev-lung-screening-risk-model-eligibility/"},{"id":"idea-prev-screening-default-appointments","kind":"idea","name":"Send screening invitations with a pre-booked time, not a request to call","route":"/ideas/idea-prev-screening-default-appointments/"}],"roadmap":[{"id":"early-detection-roadmap","kind":"roadmap","name":"Early detection roadmap: organ screening → blood tests for many cancers","route":"/roadmaps/early-detection-roadmap/"},{"id":"lung-cancer-evidence-roadmap","kind":"roadmap","name":"Lung cancer roadmap: from Doll and Hill and the naming of tobacco, through the cytotoxic plateau, computed tomography screening, EGFR and ALK, immunotherapy by PD-L1, the perioperative trials and PACIFIC, to DLL3 in small-cell disease and a 2032 registry watch","route":"/roadmaps/lung-cancer-evidence-roadmap/"}],"cancer":[{"id":"lung-cancer","kind":"cancer","name":"Lung cancer (all types)","route":"/cancers/lung-cancer/"},{"id":"nsclc","kind":"cancer","name":"Non-small-cell lung cancer","route":"/cancers/nsclc/"}],"section":[{"id":"early-detection","kind":"section","name":"Early Detection & Screening","route":"/fronts/early-detection/"},{"id":"prevention","kind":"section","name":"Prevention & Risk","route":"/fronts/prevention/"}],"technology":[{"id":"low-dose-ct-screening","kind":"technology","name":"Low-dose CT lung screening","route":"/technologies/low-dose-ct-screening/"}],"bottleneck":[{"id":"b-global-access","kind":"bottleneck","name":"Most of the world has almost no cancer care","route":"/bottlenecks/b-global-access/"},{"id":"b-prevention-adoption","kind":"bottleneck","name":"Prevention we already have is not deployed","route":"/bottlenecks/b-prevention-adoption/"},{"id":"b-early-detection","kind":"bottleneck","name":"The hardest cancers are found late","route":"/bottlenecks/b-early-detection/"},{"id":"b-trial-diversity","kind":"bottleneck","name":"Trials do not represent the people who get cancer","route":"/bottlenecks/b-trial-diversity/"}],"paper":[{"id":"paper-aldrich-uspstf-screening-african-american-smokers-jama-oncol-2019","kind":"paper","name":"Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers","route":"/key-papers/paper-aldrich-uspstf-screening-african-american-smokers-jama-oncol-2019/"},{"id":"paper-nelson-nejm-2020","kind":"paper","name":"NELSON: volume-based CT screening reduces lung cancer deaths with fewer false alarms","route":"/key-papers/paper-nelson-nejm-2020/"},{"id":"paper-nlst-nejm-2011","kind":"paper","name":"NLST: yearly low-dose CT scans cut lung cancer deaths in heavy smokers","route":"/key-papers/paper-nlst-nejm-2011/"},{"id":"paper-uspstf-lung-cancer-screening-jama-2021","kind":"paper","name":"Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement","route":"/key-papers/paper-uspstf-lung-cancer-screening-jama-2021/"}]}}