# Improving Lung Cancer Screening Selection: A Comparative Analysis of Risk Models and Traditional Criteria in a Western European General Population

## TL;DR

This study shows current lung cancer screening rules miss many cases, suggesting broader eligibility could improve early detection in Western Europe.

## Contribution

The study proposes revised eligibility criteria for lung cancer screening based on smoking history and age to better capture high-risk individuals.

## Key findings

- Current age/smoking criteria capture only 28.4–42.2% of lung cancer cases.
- Risk prediction models capture 18.4–38.9% of cases, missing a significant portion.
- Many lung cancer cases occur in ineligible groups, especially former smokers and younger individuals.

## Abstract

While much debate focuses on whether to implement lung cancer screening, a more fundamental question remains: who should be screened? Current selection criteria fail to optimally balance the trade-offs between resource allocation (cost, workforce capacity) and screening benefits (cancer detection, mortality reduction). Our findings emphasize the need to strongly improve selection criteria for lung cancer screening to maximize its benefit. To improve early cancer detection rates, we propose expanding current eligibility criteria to include: (1) individuals who currently smoke at younger ages and (2) individuals who formerly smoked with extended duration since smoking cessation.

Background/Objectives: The objective of this study is to evaluate the performance of the traditional age/smoking criteria and existing risk prediction models in selecting high-risk populations for lung cancer screening from a Western European general population. Methods: Baseline data from the Dutch population-based Lifelines cohort, collected between 2006 and 2013, were linked to the Dutch cancer registry to confirm lung cancer diagnoses. Five-year lung cancer risk was estimated based on traditional age/smoking criteria (NLST, NELSON, SPSTF-2021) and risk prediction models (LLPv2, PLCOm2012, Hoggart, Bach and Shanghai-LCM). For every strategy, the number of individuals eligible was determined, and total lung cancer cases in the eligible groups versus the ineligible groups were calculated. Results: Among 139,120 participants (aged ≥18 years), 218 (0.2%) developed lung cancer within five years. Age/smoking criteria identified 2161–6295 (1.6–4.5%) participants as eligible, comprising 62–92 (28.4–42.2%) lung cancer cases. Risk prediction models identified 2372–4315 (1.7–3.1%) participants as eligible, comprising 40–85 (18.4–38.9%) lung cancer cases. Among lung cancers in ineligible groups, 46.2–59.6% occurred in individuals who formerly smoked, and 28.7–39.3% occurred in individuals who currently smoke. Additionally, 41.2–70.0% of lung cancer cases in ineligible groups were in individuals younger than 50, and 44.3–72.3% in individuals who had quit smoking > 15 years prior to diagnosis. Conclusions: In a Western European population, current lung cancer screening selection criteria resulted in identifying only 18–42% of lung cancer cases. Cases in ineligible groups predominantly concern individuals who currently smoke and are below the threshold age and individuals who quit smoking > 15 years ago, highlighting the opportunity for more personalized risk-based screening strategies to increase lung cancer detection.