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About one lung cancer in five happens to someone who never smoked, and they are outside every screening programme in the world. The genomes show it is a different disease that grows more slowly, which is exactly the kind of cancer a screening test could catch.
Sherlock-Lung sequenced 232 lung cancers in never smokers and found three subtypes defined by copy-number structure, none carrying a tobacco mutational signature. The dominant piano subtype has a low mutational burden, long telomeres and slow growth, with driver progenitor cells datable to many years before diagnosis. Hill and Swanton then showed that oncogenic EGFR and KRAS mutations are present in 18 and 53 percent of histologically normal lung tissue, and proposed that fine particulate matter promotes rather than initiates the cancer.
Together these say that never-smoker lung cancer has a long pre-clinical phase and an identifiable molecular starting point, which are the two properties that make screening work. Nobody screens for it, because eligibility everywhere is written in pack-years. 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.
It reframes air quality as cancer policy rather than respiratory policy, and it explains the shape of lung cancer in never-smokers: the mutations are common and mostly silent, and what differs is whether something inflames the tissue enough to let one of them grow.
Lung cancer in never-smokers is not smokers' lung cancer with the smoking removed; it is a different set of diseases with a different clock. The slow-growing piano subtype in particular is the argument that a screening test aimed at never-smokers would need to look for something other than what low-dose computed tomography was built to find.
The document that defines who is offered a scan in the United States, and therefore the document any argument about the screening eligibility gap has to engage with. Eligibility is still defined by pack-years and years since quitting rather than by an individual risk estimate.
Shares Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement, Early detection roadmap: organ screening → blood tests for many cancers, Low-dose CT lung screening, 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 and the tag lung-evidence.
Shares Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement, Low-dose CT lung screening, 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, Trials do not represent the people who get cancer and the tag lung-evidence.
Shares Cancer prevention roadmap: tobacco control and vaccines → biomarker-guided chemoprevention → interception in carriers, 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, Prevention we already have is not deployed, The hardest cancers are found late and the tag lung-evidence.
Shares Early detection roadmap: organ screening → blood tests for many cancers, Low-dose CT lung screening, 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, The hardest cancers are found late and the tag lung-evidence.
Shares Genomic and evolutionary classification of lung cancer in never smokers, Lung adenocarcinoma promotion by air pollutants, 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, Whole-exome & whole-genome sequencing and the tag lung-evidence.
Shares Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement, 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, The hardest cancers are found late, Liquid biopsy (ctDNA) and the tag lung-evidence.
Shares Adenocarcinoma of the lung, 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, Trials do not represent the people who get cancer, EGFR-mutated non-small-cell lung cancer and the tag lung-evidence.
Shares Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement, 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, Trials do not represent the people who get cancer, Lung cancer (all types) and the tag lung-evidence.