Bridging the lung cancer screening eligibility gap: evaluation of guideline applicability in asymptomatic patients

Early-onset (50 years with heavy smoking histories. We applied the US Preventive Services Task Force (USPSTF) 2021 screening criteria as the primary definition of high-risk individuals eligible for lung cancer screening and assessed the potential optimization of these criteria using real-world lung cancer data in China. In this nationwide, multicenter, hospital-based observational study, we enrolled asymptomatic patients with surgically resected primary lung cancer across 26 tertiary hospitals from January 1, 2014 to December 31, 2021. Screening eligibility was classified using USPSTF 2021 criteria (aged 50−80 years, ≥20 pack-year smoking history, and ≤15 quit-years for former smokers). Temporal trends in eligibility, screening utilization, and mortality risks were assessed through joinpoint regression and Cox proportional hazards models. A total of 106,266 asymptomatic patients with lung cancer were enrolled. Among the 102,555 patients with complete age and smoking information, only 8.8% (8985/102,555) met the USPSTF 2021 eligibility criteria. The eligibility proportion declined sharply from 21.6% (350/1617) in 2014 to 6.1% (1737/28,582) in 2021, with the annual percentage change being −17.4% 95% confidence interval (CI) −19.1 to −15.9. Patients with screening utilization, irrespective of eligibility status, demonstrated a higher proportion of stage Ia diagnoses compared with those who were not screened. Screening- ineligible group exhibited 40% lower mortality risk overall adjusted hazard ratio ( HR )=0.60, 95% CI 0.55−0.66, with consistent survival advantages across stage I (adjusted HR =0.63, 95% CI 0.54−0.74) and stage III (adjusted HR =0.76, 95% CI 0.64−0.90) subgroups. Rigid age- and smoking-based criteria overlook substantial at-risk populations in China. Implementing individualized risk stratification is essential to advance equitable lung cancer screening.