Dennis Schmidt started smoking as a teenager, when that was so unexceptional that his Catholic high school designated outdoor “senior smoking quarters,” where students in their final year could take cigarette breaks. He smoked a pack of menthols daily for nearly 40 years.
As a registered nurse at the University of Cincinnati Medical Center and a former Air Force medic, he knew this was a bad idea. “I made a couple of attempts to quit and they failed miserably,” said Mr. Schmidt, now 74.
Not until 2007 was he able to stop, using a newly approved prescription drug that reduced cigarette cravings. “I put them down and never went back,” he said.
Despite his years as a health care professional, Mr. Schmidt was unaware that lung cancer screening had become available for current and past smokers. The influential U.S. Preventive Services Task Force, an independent expert panel, recommended it in 2013.
Besides, he said, “I thought I was in the clear after all these years of not smoking.”
But in 2021, his primary care doctor, running down a list of questions at his annual Medicare wellness visit, asked whether he’d be willing to undergo a CT scan to detect lung cancer, and he agreed. A few days later, the results popped up on his patient portal: adenocarcinoma.
“It was stunning to read those words,” Mr. Schmidt recalled. “I knew what that was: cancer.”
Even with sharp declines in smoking, lung cancer remains the leading cause of cancer deaths in the United States, with 125,000 deaths estimated for this year, far exceeding fatal cases of colon, breast or prostate cancer.
Yet in 2024, of the patients eligible for lung cancer screening, only about a quarter — or even less, depending on which data researchers analyzed — were up-to-date on the recommended annual scans.
“Abysmally low, especially because of how deadly lung cancer is,” said Dr. Chi-Fu Jeffrey Yang, a thoracic surgeon at Mass General Brigham and the senior author of a recent JAMA editorial about the screening rates.
Patients over 65 were more likely than younger people to be up-to-date. Still, only about a third were screened regularly, a far lower proportion than received other cancer screenings. Mr. Schmidt, for instance, had dutifully undergone colonoscopies and prostate cancer tests for years.
Data from national registries shows that older adults face sharply higher lung cancer risks. “Age is a risk factor for cancer generally,” said Priti Bandi, an epidemiologist at the American Cancer Society. But seniors may also accumulate more years as smokers. About a fifth of lung cancer cases arise in people who never smoked, but smoking remains the most common cause, “even if the exposure happened much earlier in your life,” Dr. Bandi said.
Screening has been shown to save lives. In 2011, a landmark clinical trial demonstrated that annual screening with low-dose CT scans reduced lung cancer deaths by 20 percent compared with the chest X-rays used previously. That prompted the initial task force recommendation.
More recent European trials have found far greater reductions. In 2019, Italian researchers reported that after 10 years, patients with six years of screening had a 39 percent decrease in lung cancer deaths compared with those who weren’t screened.
Why, then, does screening remain so underused? “Lung cancer screening is so easy, a two-minute scan,” Dr. Yang said. “You don’t even have to put on a gown.”
One explanation: Determining eligibility gets complicated. The task force, in a 2021 revision, recommended screening for those a) 50 to 80 years old with b) a “20 pack-year” smoking history who c) currently smoke or stopped within the past 15 years.
Both patients and doctors struggle with these criteria. Pack-year? It refers to how heavily someone smoked over time. Smoking a pack a day for 20 years creates a 20 pack-year history; so does smoking half a pack daily for 40 years.
Calculating that number is time-consuming and “challenging,” said Dr. Teva Brender, a hospitalist at the San Francisco V.A. Medical Center and a co-author of an article in JAMA Internal Medicine about lung cancer screening. “You might smoke a pack a day, then cut back to half a pack for two years, then stop. Then start again.”
The stigma attached to smoking probably also plays a role, sometimes making patients reluctant to disclose tobacco use. “Some people blame patients with lung cancer: ‘You did this to yourself because you smoked,’” Dr. Yang said. Screening rates also vary by state and insurance status.
Yet advances in treating lung cancer, including minimally invasive and robotic surgical procedures and increasingly effective drug therapies, mean that a diagnosis is “no longer a death sentence,” Dr. Bandi said. “The survival rate has improved dramatically.”
About 80 percent of patients diagnosed in the earliest stages of the disease survive for five years or more, although survival drops sharply for more advanced cancers. And screening increases the odds of finding cancer early.
Frustrated that a potentially lifesaving tool remains so underused, some doctors and organizations are calling for changes in the Preventive Services Task Force recommendations, which lead to coverage by Medicare (Medicaid coverage varies by state) and many private insurers. “The screening guidelines are too restrictive,” Dr. Yang said.
The American Cancer Society and the National Comprehensive Cancer Network have both removed the 15-year requirement from their guidelines, which would make patients eligible for screening no matter how long ago they stopped smoking.
“We were disqualifying people from screening at a time when their risk was still rising,” said Robert Smith, a screening expert at the society. He and his colleagues have urged the task force to also drop the 15-year stipulation, submitting data to back their claim.
The cancer network went further, dropping both the 15-year and pack-years stipulations, and advocating screening for anyone who smoked for 20 years.
The task force, under fire from Health and Human Services Secretary Robert F. Kennedy Jr., hasn’t responded to the American Cancer Society’s analysis. Nor did it respond to a reporter’s emails asking whether it planned to revise its lung cancer screening recommendations.
Expanding eligibility so that more people can undergo screening could have downsides, too. Some scans will reveal abnormalities that don’t turn out to be lung cancer, but require additional scans (or, rarely, biopsies) and cause considerable anxiety. Even with low-dose scans, repeated screenings also involve some radiation exposure.
Moreover, a recent study showed that among older adults diagnosed with metastatic lung cancer, less than half undergo treatment. “If the public health goal is to reduce deaths from lung cancer through screening, it only works if you treat the people it identifies,” said Dr. Steven Woloshin, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice.
For Mr. Schmidt, though, screening and treatment worked as intended. The mass found by his 2021 screening, diagnosed as Stage 1 lung cancer, led to robotic surgery at the University of Cincinnati Cancer Center to remove the upper lobe of his right lung.
Surveillance scans followed every six months, then annually — until a 2025 scan revealed a small nodule in his lower lobe, another Stage 1 cancer. Surgery removed that nodule, too. Mr. Schmidt now takes a targeted anticancer drug daily, a three-year regimen, while continuing regular scans.
“It did what it was supposed to do,” Mr. Schmidt said of his screening. “I feel blessed.” He tends his extensive gardens in Bright, Ind., and flies kites and goes camping with his grandchildren. He still works several shifts a month as a fire department paramedic.
Experts cautioned, however, that lung cancer screening and treatment cannot substitute for the benefits of stopping smoking — or never having started. “The risk is lower the longer you are away from cigarettes,” Dr. Woloshin said. “But it doesn’t go to zero.”
The New Old Age is produced through a partnership with KFF Health News.
