LUNG cancer screening may miss aggressive disease while exposing some low-risk individuals to unnecessary repeat scans.
A narrative review has highlighted a clinical paradox in current screening practice, in which overscreening and underscreening occur simultaneously. The authors suggest that fixed eligibility criteria and screening intervals may not reflect the biological diversity of lung cancer.
Lung Cancer Screening May Not Match Tumor Biology
Low-dose computed tomography has reduced lung cancer mortality among high-risk populations. However, current programs remain largely centered on age and smoking history, potentially excluding younger people, never-smokers, and others who develop lung cancer outside traditional eligibility criteria.
The review identified marked differences between screening outcomes in Western and East Asian populations. Western trials have predominantly enrolled people with substantial smoking histories and solid lung nodules. East Asian programs have detected higher proportions of early-stage disease, frequently involving ground-glass nodules among younger never-smokers.
These findings reflect the different evolutionary trajectories of lung cancer. Some tumors metastasize early or progress rapidly between screening rounds, leaving a narrow window for curative treatment. Conversely, some ground-glass nodules may progress over 10 to 20 years, creating opportunities for less intensive surveillance.
Overscreening and Underscreening Coexist
Overscreening may involve annual scans in low-risk individuals with negative baseline results or frequent follow-up of indolent nodules. This can increase radiation exposure, unnecessary procedures, financial costs, and benign lung resections without demonstrating proportional clinical benefit.
Underscreening presents a different challenge. Many high-risk individuals do not receive recommended screening, while smoking-focused criteria may overlook cancers among never-smokers and younger populations. Aggressive interval cancers can also develop between scheduled scans or be missed during image interpretation, allowing the curative window to close.
Could Risk Adapted Screening Improve Detection?
The authors explored a hypothesis-generating “low-age, low-frequency” strategy. This approach would offer earlier baseline screening to a broader population while extending intervals for low-risk individuals with negative initial scans or slow-growing lesions.
Artificial intelligence, radiomics, molecular biomarkers, family history, and environmental exposure data could eventually help distinguish rapidly progressing tumors from indolent disease. However, the proposed model is not intended to replace established annual screening for high-risk smokers.
The authors emphasized that prospective trials are needed before broader eligibility criteria or personalized screening intervals can be adopted in clinical practice.
Reference
Cao H et al. Over- and underscreening for lung cancer. Transl Lung Cancer Res. 2026;15(6):185.
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