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prev.lung-cancer-screening.v1

Lung cancer screening (LDCT, adult)

general_internal_medicinechronicadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Eligibility gate (the prior selector): asymptomatic adult age 50-80, ≥20 pack-yr smoking history, currently smoking OR quit <15 yr, with sufficient life expectancy AND willingness/ability for curative-intent lung surgery. Below any threshold the false-positive cascade + overdiagnosis harm exceeds expected mortality benefit → STOP-screening. Excludes symptomatic patients (diagnosis, not screening) and prior-lung-cancer survivorship surveillance (USPSTF 2021 Grade B PMID 33687470)

Inputs
5
Actions
0
Advance rule
Set
Advance when

Asymptomatic, USPSTF-eligible (or PLCOm2012-expanded), adequate life expectancy + curative-surgery candidacy confirmed

Patient inputs (12)

LDCT eligibility window is age 50-80; age also raises the pre-test prevalence prior (USPSTF 2021 PMID 33687470)

≥20 pack-yr is the USPSTF categorical threshold and the dominant PLCOm2012 input — sets the lung-cancer prior (USPSTF 2021; Tammemägi NEJM 2013 PMID 23425165)

Current smoker or quit <15 yr = eligible; quit ≥15 yr = STOP (prevalence decays below the benefit threshold) (USPSTF 2021 PMID 33687470)

Screening benefit requires sufficient life expectancy AND willingness/ability for curative lung surgery; below that lead-time + overdiagnosis harm exceeds benefit → STOP (USPSTF 2021)

USPSTF 2021 explicitly conditions screening on willingness + ability to undergo curative-intent lung surgery — otherwise a positive screen cannot change management

Hemoptysis, unexplained weight loss, or a known mass means this is DIAGNOSIS not screening — exit to onc.lung-cancer.core.v1 (USPSTF 2021 — screening is for the asymptomatic)

Prior LDCT date + Lung-RADS category set the next interval and the conditional post-test prior (annual vs 6-mo vs 3-mo) (ACR Lung-RADS v2022)

COPD/emphysema raises the lung-cancer prior (a PLCOm2012 predictor) and is itself an actionable LDCT incidental finding (Tammemägi NEJM 2013 PMID 23425165)

First-degree relative with lung cancer is a PLCOm2012 predictor that raises the pre-test prevalence (Tammemägi NEJM 2013 PMID 23425165)

Radon/asbestos/silica/diesel exposure raises the lung-cancer prior; informs shared decision and may justify PLCOm2012-based expansion (ACCP)

Pregnancy defers LDCT (ionizing radiation) unless a compelling clinical indication — special-population branch (defer to postpartum)

Prior-lung-cancer survivors follow survivorship surveillance, NOT average-risk screening — different prior + protocol (NCCN survivorship)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninglung_rads_4b_4x_or_growing_nodule_route_to_diagnosis — ACR Lung-RADS v2022
    Lung-RADS 4B/4X (PPV >15%; clinical-practice malignancy 36-77%) OR a new/growing nodule on interval LDCT — screening has converted to diagnosis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelung_rads_category_drives_ppv_appropriate_followup — ACR Lung-RADS v2022
    Lung-RADS v2022 category = the likelihood ratio applied to the prior: 3 (PPV ~1-2%) → 6-mo LDCT; 4A (PPV 5-15%) → 3-mo LDCT or PET/CT; 4B/4X (PPV >15%) → tissue/PET/multidisciplinary — post-test probability now high enough that the harm of NOT working up exceeds the harm of the diagnostic cascade
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_patient_is_diagnosis_not_screening — USPSTF 2021
    Hemoptysis, unexplained weight loss, or a known/suspected mass — the pre-test probability is already diagnostic; LDCT screening criteria do not apply
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateplco_m2012_crosses_eligibility_threshold_expand_screening — Tammemägi NEJM 2013
    PLCOm2012 6-yr risk ≥1.3-1.7% in a patient who misses the USPSTF categorical rule — the calculated prior crosses the eligibility/action threshold (sens 83.0% vs USPSTF 71.1% at matched spec, 41.3% fewer cancers missed)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefalse_positive_cascade_and_overdiagnosis_harm — NLST
    A positive LDCT in this prior context is far more likely false-positive (NLST: 24.2% positive rate, 96.4% benign over 3 rounds — mostly granulomas / intrapulmonary nodes) or an incidental finding than true cancer; overdiagnosis (indolent screen-detected cancer) is the other harm — the denominator the Lung-RADS PPV is weighed against
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpretest_prevalence_below_testing_threshold_do_not_screen — USPSTF 2021
    Age <50 or >80, <20 pack-yr (and PLCOm2012 <1.3-1.7%), quit ≥15 yr, limited life expectancy, OR unwilling/unable for curative lung surgery — pre-test prevalence × harm of the false-positive cascade (NLST 96.4% benign) + overdiagnosis exceeds expected mortality benefit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildstop_screening_quit_interval_or_life_expectancy_or_surgical_candidacy — USPSTF 2021
    Patient has not smoked for ≥15 yr, OR develops a health problem substantially limiting life expectancy, OR is unwilling/unable to undergo curative lung surgery — the deprescribing-equivalent
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RISK_STRATIFICATIONoptionalDrives screening
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Recommended regimen

Lung — annual LDCT + integrated smoking cessation (USPSTF 2021 Grade B PMID 33687470; NLST PMID 21714641; NELSON PMID 31995683)
axis: screening_modality_lung_ldct
Selected axis "Lung — annual LDCT + integrated smoking cessation (USPSTF 2021 Grade B PMID 33687470; NLST PMID 21714641; NELSON PMID 31995683)" by default fallback (first axis)
  • low_dose_chest_ct_annual
    first line
    imaging_screen
    LDCT annually, age 50-80, ≥20 pack-yr, current or quit <15 yr • imaging • annual
    triggers: uspstf_categorical_eligible
    NLST (Aberle NEJM 2011 PMID 21714641): 20.0% lung-ca mortality RR + 6.7% all-cause RR vs CXR; 24.2% positive rate; 96.4% of positives false-positive over 3 rounds; NNS ~320 (NCI). Initial-round sens 93.8% / spec 73.4% (Church NEJM 2013 PMID 23697514). NELSON (de Koning NEJM 2020 PMID 31995683): cumulative lung-ca death RR 0.76 men / 0.67 women at 10 yr, 2.1% referral rate with volumetric Lung-RADS.
  • plco_m2012_risk_model_eligibility
    add on
    risk_model
    PLCOm2012 6-yr risk ≥1.3-1.7% threshold • n/a • at eligibility assessment
    triggers: categorical_miss_but_risk_model_eligible, borderline_pack_year_or_quit_interval
    Expands LDCT to higher-yield candidates missed by the categorical rule: PLCOm2012 sens 83.0% vs USPSTF 71.1% at matched spec (62.9% vs 62.7%), 41.3% fewer cancers missed (Tammemägi NEJM 2013 PMID 23425165; Ten Haaf PLoS Med 2017 PMID 28376113).
  • lung_rads_v2022_ppv_followup
    add on
    structured_reporting
    Lung-RADS v2022 category → PPV → action • n/a • each LDCT
    triggers: screen_positive_lung_rads_3_or_higher
    Category IS the likelihood ratio: 1/2 (<1%) annual; 3 (~1-2%) 6-mo LDCT; 4A (5-15%) 3-mo LDCT or PET; 4B/4X (>15%) tissue/PET/MDD (ACR Lung-RADS v2022).
  • varenicline
    first line
    nicotinic_partial_agonist
    0.5 mg PO daily ×3 d → 0.5 mg BID ×4 d → 1 mg BID • PO • BID × 12 wk (extend to 24 wk)
    triggers: active_smoker_in_lung_screening_program
    Most effective monotherapy; LDCT mortality benefit is conditional on cessation — cessation alone is 3-5x the benefit of early detection in the NLST cohort (USPSTF 2021). RxCUI 591622 RxNav-verified 2026-05-16 (tty=IN).
    rxcui 591622
  • bupropion
    second line
    aminoketone_antidepressant
    150 mg PO daily ×3 d → 150 mg BID, start 1-2 wk before quit date • PO • BID × 7-12 wk
    triggers: varenicline_intolerant_or_declined, concurrent_depression
    Second-line cessation pharmacotherapy; may combine with NRT (USPSTF 2021). RxCUI 42347 RxNav-verified 2026-05-16 (tty=IN).
    rxcui 42347
  • nicotine
    add on
    nicotine_replacement_therapy
    Patch 21 mg/24 h (>10 cig/d) + short-acting gum/lozenge PRN • transdermal • daily patch + PRN short-acting
    triggers: active_smoker_combination_therapy, pharmacotherapy_contraindication_to_orals
    Combination NRT (long-acting patch + short-acting) ≈ varenicline efficacy; integrate at every screen (USPSTF 2021). RxCUI 7407 RxNav-verified 2026-05-16 (tty=IN).
    rxcui 7407

outpatient playbook — drug actions (2)

  1. 1. varenicline (first-line cessation)
    rxcui 591622
    0.5 mg→1 mg • PO • titrate to BID × 12 wk
    trigger: Active smoker in lung-screening program (USPSTF 2021)
    LDCT benefit conditional on cessation — integrate at every screen; cessation 3-5x benefit of early detection in NLST cohort
  2. 2. bupropion or combination NRT (second-line/add-on cessation)
    rxcui 42347
    150 mg BID (bupropion) or 21 mg patch + PRN (NRT, RxCUI 7407) • PO / transdermal • per cessation protocol
    trigger: Varenicline intolerant/declined or combination therapy (USPSTF 2021)
    Second-line / combination cessation pharmacotherapy; RxCUIs RxNav-verified 2026-05-16

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Routine preventive/wellness visit — adult 50-80 with smoking history; assess LDCT eligibility (USPSTF 2021 Grade B PMID 33687470); Overdue or never-screened eligible smoker identified at any encounter — close the screening gap (USPSTF 2021); PLCOm2012 6-yr risk ≥1.3-1.7% — risk-model-based eligibility expands beyond the USPSTF pack-year rule (Tammemägi NEJM 2013 PMID 23425165).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Lung cancer screening (LDCT, adult)** (prev.lung-cancer-screening.v1).
Phenotype framing: True-positive (early-stage lung cancer, stage-shift 158 vs 70 stage I in NLST) vs false-positive cascade (benign granuloma, intrapulmonary lymph node — 96.4% of positives in NLST) vs incidental findings (emphysema, coronary calcium, adrenal/thyroid nodule, fibrotic ILD). The false-positive cascade + overdiagnosis are encoded as harm DATA, not prose (NLST PMID 21714641; Gould AJRCCM 2015 PMID 26214244)
Scope: Eligibility gate (the prior selector): asymptomatic adult age 50-80, ≥20 pack-yr smoking history, currently smoking OR quit <15 yr, with sufficient life expectancy AND willingness/ability for curative-intent lung surgery. Below any threshold the false-positive cascade + overdiagnosis harm exceeds expected mortality benefit → STOP-screening. Excludes symptomatic patients (diagnosis, not screening) and prior-lung-cancer survivorship surveillance (USPSTF 2021 Grade B PMID 33687470)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Lung — annual LDCT + integrated smoking cessation (USPSTF 2021 Grade B PMID 33687470; NLST PMID 21714641; NELSON PMID 31995683)**.
1. low_dose_chest_ct_annual LDCT annually, age 50-80, ≥20 pack-yr, current or quit <15 yr imaging annual (imaging_screen, first line) — NLST (Aberle NEJM 2011 PMID 21714641): 20.0% lung-ca mortality RR + 6.7% all-cause RR vs CXR; 24.2% positive rate; 96.4% of positives false-positive over 3 rounds; NNS ~320 (NCI). Initial-round sens 93.8% / spec 73.4% (Church NEJM 2013 PMID 23697514). NELSON (de Koning NEJM 2020 PMID 31995683): cumulative lung-ca death RR 0.76 men / 0.67 women at 10 yr, 2.1% referral rate with volumetric Lung-RADS.
2. plco_m2012_risk_model_eligibility PLCOm2012 6-yr risk ≥1.3-1.7% threshold n/a at eligibility assessment (risk_model, add on) — Expands LDCT to higher-yield candidates missed by the categorical rule: PLCOm2012 sens 83.0% vs USPSTF 71.1% at matched spec (62.9% vs 62.7%), 41.3% fewer cancers missed (Tammemägi NEJM 2013 PMID 23425165; Ten Haaf PLoS Med 2017 PMID 28376113).
3. lung_rads_v2022_ppv_followup Lung-RADS v2022 category → PPV → action n/a each LDCT (structured_reporting, add on) — Category IS the likelihood ratio: 1/2 (<1%) annual; 3 (~1-2%) 6-mo LDCT; 4A (5-15%) 3-mo LDCT or PET; 4B/4X (>15%) tissue/PET/MDD (ACR Lung-RADS v2022).
4. varenicline 0.5 mg PO daily ×3 d → 0.5 mg BID ×4 d → 1 mg BID PO BID × 12 wk (extend to 24 wk) (nicotinic_partial_agonist, first line) — Most effective monotherapy; LDCT mortality benefit is conditional on cessation — cessation alone is 3-5x the benefit of early detection in the NLST cohort (USPSTF 2021). RxCUI 591622 RxNav-verified 2026-05-16 (tty=IN).
5. bupropion 150 mg PO daily ×3 d → 150 mg BID, start 1-2 wk before quit date PO BID × 7-12 wk (aminoketone_antidepressant, second line) — Second-line cessation pharmacotherapy; may combine with NRT (USPSTF 2021). RxCUI 42347 RxNav-verified 2026-05-16 (tty=IN).
6. nicotine Patch 21 mg/24 h (>10 cig/d) + short-acting gum/lozenge PRN transdermal daily patch + PRN short-acting (nicotine_replacement_therapy, add on) — Combination NRT (long-acting patch + short-acting) ≈ varenicline efficacy; integrate at every screen (USPSTF 2021). RxCUI 7407 RxNav-verified 2026-05-16 (tty=IN).

Setting playbook (outpatient) — Set the smoking-burden pre-test prior (USPSTF categorical vs PLCOm2012), confirm life-expectancy + curative-surgery candidacy, order annual LDCT, apply Lung-RADS v2022 PPV reasoning to positives, integrate smoking cessation, document shared decision + tobacco counseling + harms, schedule recall, and apply STOP-screening logic when harm exceeds benefit (USPSTF 2021 PMID 33687470)
7. varenicline (first-line cessation) 0.5 mg→1 mg PO titrate to BID × 12 wk — Active smoker in lung-screening program (USPSTF 2021) (LDCT benefit conditional on cessation — integrate at every screen; cessation 3-5x benefit of early detection in NLST cohort)
8. bupropion or combination NRT (second-line/add-on cessation) 150 mg BID (bupropion) or 21 mg patch + PRN (NRT, RxCUI 7407) PO / transdermal per cessation protocol — Varenicline intolerant/declined or combination therapy (USPSTF 2021) (Second-line / combination cessation pharmacotherapy; RxCUIs RxNav-verified 2026-05-16)

Non-pharmacologic actions:
- Order annual LDCT if USPSTF-eligible or PLCOm2012-expanded — document 96.4% false-positive, NNS ~320, and overdiagnosis (USPSTF 2021; NLST PMID 21714641)
- Apply Lung-RADS v2022: 1/2 → annual; 3 → 6-mo LDCT; 4A → 3-mo LDCT or PET; 4B/4X → tissue/PET/MDD (ACR Lung-RADS v2022)
- Document shared decision-making AND tobacco cessation counseling (CMS LDCT coverage requirement)
- Manage incidental findings (emphysema, coronary calcium, adrenal/thyroid nodule, fibrotic ILD) per modality-specific guidance
- Patient education: test sensitivity/specificity, Lung-RADS PPV, false-positive cascade, NNS, overdiagnosis, value of stopping when harm dominates (USPSTF 2021)

AVOID / contraindication checks:
- No_ldct_if_not_willing_or_able_for_curative_lung_surgery (USPSTF 2021 PMID 33687470 — a positive screen cannot change management)
- No_ldct_if_life_expectancy_substantially_limited (USPSTF 2021 — lead time + overdiagnosis harm exceeds benefit)
- Stop_ldct_once_quit_ge_15yr (USPSTF 2021 — prevalence decays below the benefit threshold)
- No_screening_lt_age_50_or_gt_age_80 (USPSTF 2021 — outside the Grade B window)
- No_screening_lt_20_pack_years_unless_plco_m2012_eligible (USPSTF 2021; Tammemägi NEJM 2013 PMID 23425165)
- Symptomatic_patient_is_diagnosis_not_screening_route_onc_lung_cancer (USPSTF 2021)
- Shared_decision_AND_tobacco_counseling_required_document_false_positive_96pct_NNS_320_and_overdiagnosis (USPSTF 2021; NLST PMID 21714641; CMS coverage)
- Special_pop:pregnancy_defer_ldct_unless_compelling_indication (ionizing radiation — defer to postpartum)
- Special_pop:prior_lung_cancer_survivor_use_survivorship_surveillance_not_screening (NCCN survivorship)
- Varenicline_dose_adjust_eGFR_lt_30_and_neuropsychiatric_monitoring (label)
- Bupropion_contraindicated_seizure_disorder_or_eating_disorder_or_MAOI (label)

Monitoring

Regimen monitoring:
- annual ldct while eligible age 50 to 80 (USPSTF 2021)
- lung rads v2022 structured reporting PPV by category drives nodule recall (ACR Lung-RADS v2022)
- recheck quit interval and life expectancy and curative surgery candidacy each visit (USPSTF 2021)
- cessation pharmacotherapy offered and adherence tracked at every screen (USPSTF 2021 — benefit conditional on cessation)
- stop screening review each visit (USPSTF 2021 — quit ≥15 yr / limited life expectancy / non-surgical-candidate)

Setting (outpatient) monitoring:
- Annual LDCT 50-80 while eligible (USPSTF 2021)
- Lung-RADS-driven nodule recall (6-mo category 3, 3-mo category 4A) (ACR Lung-RADS v2022)
- Re-check quit interval + life expectancy + curative-surgery candidacy each visit (USPSTF 2021)
- Cessation pharmacotherapy adherence + abstinence tracked at every screen (USPSTF 2021)

Follow-up plan: STOP-screening logic (the deprescribing-equivalent): discontinue when the patient has not smoked for ≥15 yr, OR develops a health problem substantially limiting life expectancy, OR is unwilling/unable to undergo curative lung surgery (USPSTF 2021). Patient education on the false-positive rate (NLST 96.4% of positives benign over 3 rounds), the NNS (~320 to prevent 1 lung-cancer death), overdiagnosis, and the value of NOT screening when harm dominates (USPSTF 2021 PMID 33687470; NLST PMID 21714641)
- Close-out criterion: Stop-screening decision OR continued-annual-interval education delivered and documented

Monitoring phase: Interval + recall: annual LDCT while eligible age 50-80 (USPSTF 2021); Lung-RADS-driven nodule recall (6-mo for category 3, 3-mo for 4A); re-check quit interval and life-expectancy/curative-surgery candidacy at each visit (the prior and the benefit horizon are time-dependent) (USPSTF 2021 PMID 33687470; ACR Lung-RADS v2022)

Disposition

Current setting: outpatient — Set the smoking-burden pre-test prior (USPSTF categorical vs PLCOm2012), confirm life-expectancy + curative-surgery candidacy, order annual LDCT, apply Lung-RADS v2022 PPV reasoning to positives, integrate smoking cessation, document shared decision + tobacco counseling + harms, schedule recall, and apply STOP-screening logic when harm exceeds benefit (USPSTF 2021 PMID 33687470)

Disposition criteria:
- Continue annual LDCT if Lung-RADS 1/2 and still eligible (USPSTF 2021)
- Refer to diagnostic pathway for Lung-RADS 4B/4X / growing nodule (ACR Lung-RADS v2022)
- STOP screening when quit ≥15 yr, life expectancy substantially limited, or non-surgical-candidate — the deprescribing-equivalent (USPSTF 2021)

Escalation triggers (move to higher acuity):
- Lung-RADS 4B/4X or new/growing nodule → pulmonology/thoracic surgery/oncology; route onc.lung-cancer.core.v1 (ACR Lung-RADS v2022)
- Incidental fibrotic-ILD/UIP pattern → route pulm.idiopathic_pulmonary_fibrosis.v1 (do not over-call as Lung-RADS nodule)
- Red-flag symptoms (hemoptysis/weight loss/mass) → diagnostic pathway onc.lung-cancer.core.v1 (this is diagnosis, not screening)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Lung-RADS 4B/4X (PPV >15%; clinical-practice malignancy 36-77%) OR a new/growing nodule on interval LDCT — screening has converted to diagnosis
- [SEVERE] Lung-RADS v2022 category = the likelihood ratio applied to the prior: 3 (PPV ~1-2%) → 6-mo LDCT; 4A (PPV 5-15%) → 3-mo LDCT or PET/CT; 4B/4X (PPV >15%) → tissue/PET/multidisciplinary — post-test probability now high enough that the harm of NOT working up exceeds the harm of the diagnostic cascade
- [SEVERE] Hemoptysis, unexplained weight loss, or a known/suspected mass — the pre-test probability is already diagnostic; LDCT screening criteria do not apply

Citations

- USPSTF 2021 Lung Cancer Screening Recommendation Statement (JAMA 2021;325:962-970, Grade B) + ACR Lung-RADS v2022 + PLCOm2012 risk-model eligibility (Tammemägi NEJM 2013); USPSTF 2021 re-verified CURRENT 2026-05-16 (not superseded 2021→2026) [PMID:33687470](https://pubmed.ncbi.nlm.nih.gov/33687470/)
- Cited evidence (PMID 21714641) [PMID:21714641](https://pubmed.ncbi.nlm.nih.gov/21714641/)
- Cited evidence (PMID 23697514) [PMID:23697514](https://pubmed.ncbi.nlm.nih.gov/23697514/)
- Cited evidence (PMID 31995683) [PMID:31995683](https://pubmed.ncbi.nlm.nih.gov/31995683/)
- Cited evidence (PMID 23425165) [PMID:23425165](https://pubmed.ncbi.nlm.nih.gov/23425165/)

Last reconciled with current guidelines: 2026-05-16.
References
  • USPSTF 2021 Lung Cancer Screening Recommendation Statement (JAMA 2021;325:962-970, Grade B) + ACR Lung-RADS v2022 + PLCOm2012 risk-model eligibility (Tammemägi NEJM 2013); USPSTF 2021 re-verified CURRENT 2026-05-16 (not superseded 2021→2026) — PMID:33687470
  • Cited evidence (PMID 21714641) — PMID:21714641
  • Cited evidence (PMID 23697514) — PMID:23697514
  • Cited evidence (PMID 31995683) — PMID:31995683
  • Cited evidence (PMID 23425165) — PMID:23425165