Don’t Smoke? Here’s Why You Still Need to Be Screened for Lung Cancer

Updated: Dec. 19, 2022

If you smoke or smoked within the past 15 years, you should get screened. But what about everyone else?

It might not be surprising that 80% of lung cancer deaths are due to smoking tobacco, according to Robert Smith, PhD, senior vice president of cancer screening at the American Cancer Society.

But according to Dan Raz, MD, co-director of City of Hope’s Lung Cancer Thoracic Oncology Program in Duarte, CA, not everyone who gets lung cancer is, or ever was, a smoker. “Anyone can get lung cancer,” Dr. Raz says, adding that as many as 20% of lung cancers happen in people who’ve never smoked or smoked fewer than 100 cigarettes over their lifetime.

People who currently smoke should definitely be screened. What about people who smoked but quit, and people who’ve never smoked? The recommendations have news for them, too.

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Lung-cancer screening recommendations

Currently, the U.S. Preventive Services Task Force recommends annual screening with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history or more and who currently smoke or have quit within the past 15 years. (A “pack year” is the average number of packs you smoked per day, times the number of years you’ve smoked.) American Cancer Society guidelines are the same.

Medicare and most insurance plans will only cover screening costs within the parameters of these recommendations. If you’ve never smoked or quit more than 15 years ago, screening won’t be covered.

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Previous recommendations

The current guidelines expand the age for people eligible for screening and reduced the number of pack years. This not only means that more tumors may be detected, but also reduces disparities as African American men, in particular have a higher risk of lung cancer mortality, says Jacob Sands, MD, a volunteer spokesperson for the American Lung Association and thoracic medical oncologist at Dana Farber Cancer Institute.

Reasons for the recommendations

The current lung cancer screening recommendations focus on people whoh smoke now or used to smoke because they’re at high risk, but also because this is where the bulk of the evidence lies.

The biggest studies were done on people aged 50 or 55 who had smoked heavily, not on those who had never smoked. It’s not that screening doesn’t help people who’ve never smoked or who quit more than 15 years ago. It’s just that we don’t know, says Dr. Raz. It’s also more difficult to quantify other risk factors, like radon, adds Dr. Smith.

Research is starting to look at whether screening would be worthwhile for nonsmokers, especially those with other risk factors such as family history. But the evidence isn’t available yet.

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Is screening effective?

Yes, remarkably so. Cancer is detected on 1% to 2% of the scans—from there, says Dr. Raz, “at least 80% of cancer detected on screening are diagnosed at Stage 1 and are curable with surgery or radiation.”

According to studies, screening can lower the risk of dying from lung cancer by 20%, says Dr. Sands. Also remarkable is the fact that screening reduced dying of any cause by 7%, which suggests the actual number of people saved is higher. “A lowering of all-cause mortality is a pretty amazing thing to demonstrate after three years of annuaul screening,” Dr. Sands adds.

To put that in perspective, consider the figures when someone is diagnosed without screening. People with tumors detected at an early stage have an average 61% five-year survival rate. Those not caught before they have spread only have a survival rate of 7%—that’s about 44% of all cases. Typically this latter category already has symptoms like fatigue, coughing and trouble breathing. “When people are diagnosed with symptoms, most don’t have curable lung cancer.”

According to the American Lung Association State of Lung Cancer annual report 2022, five-year survival rates for lung cancer are increasing, standing now at 25%, up from 18% in 2018 and 23.7% in 2021. Some of this is due to better screening and some to better treatment, especially in earlier stages, says Dr. Smith.

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How does screening work?

Screening for lung cancer is done with LDCT, which uses about one-sixth of a regular radiation scan, says Dr. Raz.

Carol Russell, a patient who was diagnosed with lung cancer with LDCT at City of Hope, says, “It doesn’t hurt, and it’s quick and easy.” Russell, whose cancer is considered cured and who has since quit, had smoked a pack a day for about 50 years. Her husband, who never smoked, did not get screened and died of lung cancer.

If doctors say anything unusual on the scan, they may refer you for a follow-up scan or another procedure. Otherwise, the next appointment is in 12 months. “It’s very uncommon to have to do any kind of invasive testing, like a needle biopsy,” says Dr. Raz.

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Screening risks

LDCTs are generally safe, but you could get a false positive. This would mean the test indicates you do have lung cancer when in fact you do not. There’s also a chance the screening will pick up a cancer that never would have turned into a problem. Both situations could lead to unnecessary tests and procedures. The scan could also miss a cancer.

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Who should get screened now

In an ideal world, screenings would be recommended for everyone or virtually everyone. But even with the current recommendations, only 5.8% of the eligible population have been screened. In some states, such as California, the rate of screening is as low as 1%, says the new American Cancer Society Report. “Lung cancer screening is severely underutilized,” says Dr. Raz.

Researchers are working on strategies to detect lung cancer in a wider population. Dr. Raz, for instance, is looking into liquid biopsies, which are essentially blood tests to detect lung cancer. Until that and other technologies are available, people who are eligible for screening should go ahead and get screened. “The people who are at highest risk are those who fall in the criteria and by and large they aren’t getting screening. To me that’s the low hanging fruit,” says Dr. Raz. “We have a strategy that we know works very effectively.

“Getting screened means you could find something when it can be cured,” says Dr. Raz. “I cure lung cancer all the time. It is something that is absolutely possible.” Got wo to find out your risk and whether you can benefit from screening.

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