Advancing Lung Cancer Screening and Managing Nodules

Ben Wandtke, MD, MS, Vice Chair of the ACR Commission on Quality and Safety and Chair of the Recommendations Follow-up Improvement Collaborative within the ACR Learning Network, was a guest columnist for Alan H. Matsumoto, MD, MA, FACR, in this "From the Chair of the Board of Chancellors" column.

This is part two of this month’s Board of Chancellors column on early detection through screening. Check out what Debra L. Monticciolo, MD, FACR, Chair, Screening Leadership Group and Communications, ACR Commission on Breast Imaging, has to say in part one that focuses on breast cancer.

Lung cancer remains the leading cause of cancer death in the U.S., claiming more lives than breast, colorectal and prostate cancers combined each year. In 2025, an estimated 235,000 new cases will be diagnosed, with more than 125,000 deaths expected. While incidence rates have declined somewhat over the past two decades — largely due to reduced smoking rates — lung cancer’s population health impact remains profound. Survival rates lag far behind those of other major cancers with the overall five-year survival rate is just 25%, compared to 90% for breast cancer and 65% for colorectal cancer. This disparity underscores the urgent need for improved early detection.

Low-dose CT (LDCT) screening has been proven to reduce lung cancer mortality by detecting disease at earlier, more treatable stages. Current USPSTF guidelines recommend annual LDCT for adults ages 50–80 with a 20 pack-year smoking history who currently smoke or have quit within the past 15 years. Despite strong evidence and insurance coverage, screening uptake in the U.S. remains low — only about 16% of eligible individuals were screened in 2024. While volumes have grown modestly in recent years, barriers persist such as limited awareness among patients and providers, the stigma associated with smoking and logistical challenges in rural areas.

A significant and often underappreciated challenge in early lung cancer detection is the management of incidental pulmonary nodules (IPNs). Pulmonary nodules are quite common, with about 1.6 million identified by radiologists each year in the U.S. While most are benign, a subset represents early lung cancer, including cancers in patients who do not meet LDCT screening eligibility. In fact, roughly 25% of lung cancers occur in individuals who have never smoked, and more than half of lung cancers are diagnosed outside formal screening programs. These statistics highlight a gap in current screening criteria and a major opportunity to improve outcomes.

The College has recently taken a leading role in addressing this challenge through the development of the Early Lung Cancer Detection Registry (ELCDR). Building on the infrastructure of the Lung Cancer Screening Registry, starting this month the ELCDR will collect real-world data on incidentally detected pulmonary nodules and their follow-up. Participating sites can benchmark performance, track adherence to evidence-based management guidelines and identify areas for improvement. By participating in the Registry, the goal is to provide feedback on improving/maintaining quality of an IPN program at a site, using submitted data on appropriate recommendations for follow-up and whether that follow-up was completed. This should support positive/improved patient outcomes. The Registry’s goals are twofold:

1. Promoting consistent and accurate use of guideline-based actionable follow-up recommendations.
2. Improving patient care by ensuring timely, appropriate follow-up for incidental nodules — thereby increasing the likelihood of detecting cancers at an early stage.

The public health potential is enormous. By systematically addressing incidental findings, radiology can advance the promotion of early lung cancer detection for patients who do not meet LDCT screening eligibility criteria. Given the high prevalence of nodules and the substantial proportion of lung cancers diagnosed outside screening programs, optimizing incidental nodule management may one day be as impactful as LDCT screening programs. Just as mammography quality registries have driven measurable improvements in breast cancer outcomes, a robust national dataset for lung nodules could accelerate advances in early lung cancer detection.

ACR is now attacking lung cancer with a dual approach — expanding participation in proven LDCT screening programs and systematically capturing and managing incidental findings. As the ACR’s ELCDR continues to grow, it will not only enhance the quality of nodule management but also help inform more inclusive and effective screening strategies for the future.

Early detection saves lives. For lung cancer — where time is often the most critical factor — our ability to find and act on the disease before symptoms arise remains our most powerful tool. While participation in the IPN registry component of the ELCDR by the more than 2,500 organizations actively participating in ACR Lung Screening Registry is optional, by committing to both proactive screening and vigilant follow-up of incidental nodules, radiologists can play a leading role in changing the trajectory of this disease.