# Lung screening eligibility by risk score, not pack-years, including high-risk never-smokers

Source: https://onco.cc/ideas/idea-prev-lung-screening-risk-model-eligibility/  
OnCo record `idea-prev-lung-screening-risk-model-eligibility` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Pack-year rules miss people who get lung cancer without heavy smoking, including East Asian women who never smoked, as Taiwan's TALENT study showed. Eligibility by a validated risk model with a set threshold, plus a never-smoker arm where family history matters, would find more cancers per scan.

## Summary

PLCOm2012 risk-based selection is more efficient than USPSTF criteria; Taiwan's TALENT study found high detection in never-smoking women with family history. Propose eligibility by a validated risk model with a threshold (e.g. 1.5% six-year risk) plus a never-smoker arm for populations with high never-smoker incidence.

## Fields

- Kind: Idea
- Last checked: 2026-09-08
- Hypothesis: Risk-model eligibility increases cancers detected per 1,000 scans by at least 30%, and never-smoker criteria in East Asian populations achieve detection rates comparable to smoker screening.
- Rationale: Screening efficiency scales with baseline risk; never-smoker EGFR-mutant lung cancer in East Asian women is a distinct epidemic not captured by tobacco criteria.
- Proposed test: Pragmatic comparison within a national programme (England's Targeted Lung Health Check) and a never-smoker RCT in Taiwan, China, or Korea with mortality follow-up.
- Maturity: being-tested-at-scale
- Actor: policy

## Sources

- Bottleneck evidence (The hardest cancers are found late): Crosby et al., Early detection of cancer (Science 2022): https://doi.org/10.1126/science.aay9040

## Connected records

- roadmaps: [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](https://onco.cc/roadmaps/lung-cancer-evidence-roadmap/)
- ideas: [Decide who is screened for lung cancer by individual risk, not by pack-years](https://onco.cc/ideas/idea-lung-screening-eligibility-by-risk-not-pack-years/)
- cancers: [Non-small-cell lung cancer](https://onco.cc/cancers/nsclc/)
- fronts: [Early Detection & Screening](https://onco.cc/fronts/early-detection/)
- technologies: [CT (computed tomography)](https://onco.cc/technologies/ct/)
- targets: [EGFR](https://onco.cc/targets/egfr/)
- bottlenecks: [The hardest cancers are found late](https://onco.cc/bottlenecks/b-early-detection/), [Trials do not represent the people who get cancer](https://onco.cc/bottlenecks/b-trial-diversity/)
- key papers: [Early detection of cancer](https://onco.cc/key-papers/paper-crosby-science/), [Evaluation of USPSTF Lung Cancer Screening Guidelines Among African American Adult Smokers](https://onco.cc/key-papers/paper-aldrich-uspstf-screening-african-american-smokers-jama-oncol-2019/), [NELSON: volume-based CT screening reduces lung cancer deaths with fewer false alarms](https://onco.cc/key-papers/paper-nelson-nejm-2020/), [NLST: yearly low-dose CT scans cut lung cancer deaths in heavy smokers](https://onco.cc/key-papers/paper-nlst-nejm-2011/), [Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement](https://onco.cc/key-papers/paper-uspstf-lung-cancer-screening-jama-2021/)

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