ASCO CONFERENCE COVERAGE

Retrospective VA Cohort Study Links Smoking Duration Criteria to Fewer Missed Lung Cancer Diagnoses

Edited by:
Anthony Calabro, MA

Key Highlights

  • The retrospective cohort study included 960,770 Veterans aged 50 to 80 years.
  • Tobacco smoking duration criteria identified 59.4% of the cohort as screening eligible, compared with 45.6% under 2021 USPSTF pack-year criteria.
  • The proportion of missed lung cancer diagnoses was 7.5% with smoking duration criteria vs 17.1% with 2021 pack-year criteria.
  • Eligibility was higher with smoking duration criteria than with pack-year criteria among Black individuals and women.

Tobacco smoking duration may identify more patients eligible for lung cancer screening and reduce the proportion of missed lung cancer diagnoses compared with tobacco pack-year criteria, according to results from a national Veterans Health Administration cohort study presented at the 2026 American Society of Clinical Oncology Annual Meeting in Chicago, IL.

Researchers conducted a retrospective cohort study of Veterans aged 50 to 80 years in the Veterans Health Administration. The primary exposure was smoking history quantified as tobacco pack-years and tobacco smoking duration; the primary outcome was 5-year lung cancer incidence from 2021 to 2025. The study compared risk-adjusted 5-year lung cancer incidence based on 2013 USPSTF guidelines, 2021 USPSTF guidelines, proposed tobacco smoking duration criteria of at least 20 years, and never-smoking. Investigators also estimated the theoretical number of missed lung cancer diagnoses, defined as the proportion of lung cancers diagnosed in screening-ineligible individuals, and performed subgroup analyses by race and sex.

Study Findings

The cohort included 960,770 Veterans, of whom 340,312 were current smokers, 304,589 were former smokers, and 315,869 had never smoked. Median age was 64.9 years. Most participants were male (91.2%) and White (70.6%).

Overall, 341,061 participants, or 35.5%, qualified for screening under 2013 tobacco pack-year criteria; 437,803, or 45.6%, qualified under 2021 tobacco pack-year criteria; and 571,087, or 59.4%, qualified under tobacco smoking duration criteria. Among those who met smoking duration criteria, 127,604 individuals did not meet 2021 pack-year criteria, suggesting that smoking duration criteria would increase the eligible screening population by 28.8%. Five-year lung cancer incidence was 0.95% overall, 1.87% among those meeting 2013 pack-year criteria, 1.73% among those meeting 2021 pack-year criteria, 1.48% among those meeting smoking duration criteria, and 0.13% among never-smokers.

The proportion of missed lung cancer diagnoses was 30.3% under 2013 pack-year criteria, 17.1% under 2021 pack-year criteria, and 7.5% under smoking duration criteria. Among Black current or former smokers, eligibility was 34.7% under 2013 pack-year criteria, 54.0% under 2021 pack-year criteria, and 83.7% under smoking duration criteria. Among female current or former smokers, eligibility was 38.5%, 55.1%, and 83.7%, respectively.

Clinical Implications

According to the study authors, smoking duration performed at least as well as tobacco pack-years in predicting lung cancer risk and substantially expanded screening eligibility with fewer missed cancers. The authors also stated that tobacco smoking duration criteria were associated with improved equity.

The abstract did not include a formal limitations section. The study population consisted of Veterans and was predominantly male and White, as described in the abstract.

Expert Commentary

“These findings support revisiting national lung cancer screening guidelines to prioritize smoking duration over pack-years,” the researchers concluded.

Reference
Heiden B, Eaton DB Jr, Puri V, et al. Redefining lung cancer screening eligibility: smoking duration vs pack-years in a national VA cohort of nearly 1 million patients. Presented at: 2026 American Society of Clinical Oncology Annual Meeting; abstract 8004.