Abstract Rationale Current lung cancer screening criteria worldwide rely primarily on age and cumulative smoking exposure. Whether adjusting these thresholds alone can meaningfully enhance detection of clinically significant lung cancer remains unclear. Methods We analyzed a nationally representative cohort of incident lung cancer cases in South Korea (2014-2019). Screening eligibility was assessed under existing criteria, and demographic, clinical, and outcome characteristics were compared between eligible and ineligible patients. Alternative age and pack-year thresholds were evaluated using sensitivity, specificity, and number-needed-to-screen (NNS), and benchmarked against USPSTF 2021, NLST, and PLCOm2012 models. Results Only 24.4% of patients met current eligibility criteria, with marked sex disparities (34.6% of men vs. 2.1% of women). Among those deemed ineligible, 98.5% nonetheless had clinically significant, potentially treatable cancer. Modifying thresholds expanded eligibility to 58.0%, but no age-pack-year combination achieved both high sensitivity and acceptable specificity. The most efficient smoking-based criterion—age 50-80 with ≥20 pack-years—yielded 88% sensitivity and 60% specificity with an NNS comparable to PLCOm2012, yet still failed to identify nearly half of all cases, particularly among women, individuals who have never smoked, and older adults. Conclusion Refining age and smoking cutoffs improves screening reach but does not overcome the inherent limitations of a smoking-based framework. Even optimized thresholds miss a substantial proportion of clinically important cancers. Meaningful advances in early detection will require risk-prediction strategies that incorporate additional determinants beyond age and smoking history. This abstract is funded by: None
Kim et al. (Fri,) studied this question.
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