Navigating the Lung Cancer Screening and Nodule Management Pathway

This interactive infographic—part of CHEST’s Bridging Specialties^®: Timely Access to Lung Cancer Screening program—outlines how clinicians can navigate lung cancer screening and nodule management.

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This program is produced in partnership with CHEST and is sponsored by Lilly USA, LLC.

The Lung Cancer Screening Gap | Navigating Current Guidelines | Shared Decision-Making | Nodule Ordering and Management

The Lung Cancer Screening Gap

Navigating Current Guidelines

Shared
Decision-Making

Nodule Ordering and Management

Urgency and burden: The lung cancer screening gap

124,990

annual deaths (as many as breast, colon, and prostate cancer combined)

#1

cancer killer in the United States

~ 1 in 5

eligible adults screened in 2024 (~ 18.2%), the lowest of all major cancers

63% vs 8%

five-year survival for stage I (localized) vs stage IV (distant)

≥ 20%

reduction in lung cancer mortality with low-dose CT (LDCT) scan vs chest X-ray

≥ 24%

reduction in lung cancer mortality at 10 years in men with LDCT scan

Takeaway: Increasing lung cancer screening saves lives.

Mapping the lung cancer burden, state by state

Explore lung cancer incidence, screening rates, smoking rates, five-year survival rates, and early diagnosis rates across the United States.

Navigating current guidelines

Guideline evolution—2013 to present

Lung cancer screening eligibility has progressively expanded to improve early detection and reduce disparities. These cards detail the screening criteria across various guidelines over time, which have evolved to expand eligibility to capture previously excluded high-risk patients who are younger and have smoked less.

Age 55-80 years
≥ 30 pack-years
Quit ≤ 15 years (if formerly smoked)

These recommendations maintained the quit-year limit from the 2013 guidelines.

Age 50-80 years
≥ 20 pack-years
Quit ≤ 15 years

These guidelines removed the 15-year quit requirement and are the most inclusive.

Age 50-80 years
≥ 20 pack-years

These guidelines do not have a quit-year requirement and also remove the upper age limit. These guidelines are favored by oncologists.

Age ≥ 50 years
Category A: ≥ 20 pack-years
Category B: ≥ 20-year smoking history (not pack-years)

a person writing on a tablet with medical icons

Applying current screening criteria

Age: ≥ 50 years (no upper limit in NCCN)
Smoking exposure: ≥ 20 pack-years (or risk-based criteria)
Smoking status: Currently or formerly smoked (no quit-year limit in some guidelines)
Additional risk factors: COPD, family history, occupational exposures

Clinical Implication: Use guideline-aligned tools to individualize eligibility and support consistent screening decisions.

High-risk populations

Shared decision-making

Shared decision-making (SDM) involves collaborative conversations between clinicians and patients to weigh the benefits vs harms of LDCT scan, guided by the patients’:

Values and personal preferences
Comorbidities and overall health status
Willingness to undergo further diagnosis or treatment if something is found
Understanding of false-positive rates and incidental findings

Why is SDM required?

The Centers for Medicare and Medicaid Services requires SDM before the first LDCT scan. Without documented SDM, Medicare will not cover the scan at $0 cost-sharing.

USPSTF Grade B + Affordable Care Act §2713: LDCT scan covered at no cost-sharing ONLY after documented SDM
Must be done once before the first screen; not required at each annual visit
Documentation required: SDM note must appear in the medical record alongside the LDCT scan order
Billing: CPT 71271, G0296 | ICD-10 Z87.891 + Z12.2 + F17.210

The five-step SDM framework

LDCT scan ordering and nodule management

Lung-RADS^® and the Fleischner guidelines both help guide follow-up for pulmonary nodules, but they're built for different situations. Here's how they compare.

More about Lung-RADS^® Classification » | More about Fleischner Guidelines Algorithm »

Lung-RADS^® Classification

Comparison

Fleischner Guidelines Algorithm

Lung-RADS^® Classification LDCT scan

Used for

Fleischner Guidelines Algorithm Incidental nodules (found on a CT scan done for another reason)

Lung-RADS^® Classification Asymptomatic, high-risk individuals

Patient type

Fleischner Guidelines Algorithm Any patient with an unexpected nodule

Lung-RADS^® Classification Screening programs

Setting

Fleischner Guidelines Algorithm Routine clinical practice

Lung-RADS^® Classification Categories 1–4

Structure

Fleischner Guidelines Algorithm Size and risk-based recommendations

Lung-RADS^® Classification Standardized follow-up intervals

Output

Fleischner Guidelines Algorithm Flexible follow-up based on risk

Lung-RADS^® Classification Early cancer detection

Goal

Fleischner Guidelines Algorithm Avoid overmanagement or undermanagement

Note: Patients with a history of another cancer are not included in Lung-RADS nor Fleischner criteria. For this group, surveillance should be guided by the individual cancer’s surveillance recommendations.

Lung-RADS classification

These classifications are for standardized nodule assessment and management.

Category	Risk	Findings	Management
0	N/A	Prior chest CT scan needed for comparison OR portion of lungs obscured	Additional imaging
1-2	< 1%	Negative/benign: No nodules or definitely benign calcifications; solid or subsolid nodules < 6 mm	Routine annual LDCT scan
3	1%-2%	Probably benign: Solid 6 to < 8 mm, part-solid < 6 mm solid component or ≥ 6 mm; pure ground-glass ≥ 30 mm	6-month LDCT scan
4A	5%-15%	Suspicious: Solid 8 to < 15 mm, part-solid ≥ 6 mm solid component 6 to < 8 mm, or growing < 1.5 mm	3-month LDCT ± PET/CT scans
4B/4X	> 15%	Very suspicious: Solid ≥ 15 mm, part-solid with solid component ≥ 8 mm, or growing ≥ 1.5 mm 4X = Additional highly suspicious imaging features	Diagnostic workup

Fleischner guidelines algorithm

Fleischner guidelines apply to incidental nodules only. They do not apply to patients enrolled in an active lung cancer screening program. Use Lung-RADS for all LDCT screening exams.

Solid Nodules

< 6 mm	6-8 mm	> 8 mm
Low risk: No routine follow-up High risk: Optional CT scan at 12 months	Low risk: CT scan at 6-12 months, then consider 18-24 months High risk: CT scan at 6-12 months, then 18-24 months	All risks: Consider CT scan at 3 months, PET/CT scan, or tissue sampling

Subsolid Nodules

< 6 mm	≥ 6 mm (Pure ground-glass)	≥ 6 mm (Part-solid)
No routine follow-up required for single nodule	CT scan at 6-12 months If persistent, CT scan every 2 years until 5 years	CT scan at 3-6 months If persistent and solid composition ≥ 6 mm, highly suspicious

References

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Centers for Medicare and Medicaid Services. Decision Memo for Screening for Lung Cancer with LDCT (CAG-00439N). CMS. 2015.
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