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When the American Cancer Society updated its lung cancer

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screening guideline, it made it some important changes.

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Their initial guideline mirrored that of the U-S-P-S-T-F

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with 55 to 74 years being the age criteria and 30 pack years

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or more being the smoking criteria for those

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who currently smoke or quit in the last 15 years.

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However, important evidence indicates that the risk

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of lung cancer remains high beyond 15 years after quitting

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and increases with age.

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The updated guideline

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that recommends annual lung cancer screening

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with low dose CT and asymptomatic individuals who smoke

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or use to smoke age 50 to 80 years of age with a 20

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or more pack year history of smoking.

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Note, they have removed the year since quit Criterion.

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The American Cancer Society's guideline published in the

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journal cancer was accompanied

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by five additional supporting articles,

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and these are open access on the journal cancers website.

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They look at lung cancer diagnosis

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and mortality beyond the 15 years since quit in individuals

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with the 20 or more pack year history of cancer

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as a systematic review

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and increasing the lung cancer screening eligibility.

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Related to that, these companion papers together

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with the guideline are important in removing this

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eligibility criterion in the systematic review

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of lung cancer and looking at years since quit.

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They revisited all of the evidence.

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We have the clear message

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that smoking cessation is beneficial

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for reducing lung cancer related outcomes,

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and the surgeon's general report compared lung cancer

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outcomes with individuals

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who never smoked as the reference group.

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And the results were equally clear.

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The rates of incidents

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of mortality remain elevated from lung cancer among those

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who used to smoke at all points in their life compared

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with those who never smoked beyond 15 years since quitting.

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If we look at individuals

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who formally smoked when they hit the 15 years since quit

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criteria, they can continue to be screened for 15 years,

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but as they become older,

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their lung cancer risk remains high.

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They should therefore still be eligible

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for lung cancer screening.

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Under the current U-S-P-S-T-F guidelines on Medicare

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coverage decision, these individuals lose their eligibility

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and insurance coverage

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for lung cancer screening at the very time

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where their lung cancer risk continues to increase.

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For decades, we've confused a relative decline in lung

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cancer risk as an absent decline, misleading individuals

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who used to smoke and ourselves.

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People with a 20 pack year history who used to smoke,

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have enduring and rising risk as they age

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and should not be excluded from starting

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or continuing screening.

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If all individuals were able to follow this guideline,

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21% more lives would be saved and 19% more live years gained

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because of including them in eligibility for screening,

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it would increase the number of people eligible

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for lung cancer screening to

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19.2 million people increasing from 32% of persons

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who ever smoked to 43%.

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And most of this increase in eligible individuals does not

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represent an expansion into a new risk group.

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It represents retaining individuals in the lung cancer

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screening pool who would

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otherwise age out once they hit the year since 15.

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Quick criteria. This is currently not included in the

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U-S-P-S-D-F recommendation

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or the CMS national coverage decision.

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Many organizations are lobbying to both

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of those organizations to update their guideline

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and take this information to effect.

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Until that happens, it limits insurance coverage.

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Private payer copays would not be waived

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and patients would not be eligible under the U-S-P-S-T-F

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linkage to coverage and they wouldn't be eligible under

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Medicare coverage decision either.

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This is an important issue to pay attention to the future

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to see if these patients will be included more broadly in

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future recommendations.