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NCCN Flash Updates: NCCN Guidelines Updated for Lung Cancer Screening

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™) for Lung Cancer Screening. These NCCN Guidelines® are currently available as Version 1.2023.

Link directly to the Updates section of the NCCN Guidelines: Lung Cancer Screening


  • Link revised throughout: See appropriate NCCN Guidelines for Non-Small Cell Lung Cancer.


  • Risk Assessment:
    • First bullet revised: Cigarette smoking history.
    • Seventh bullet revised: Cigarette smoking exposure (second-hand smoke).
    • New bullet added: Risk calculator to enhance determination of risk status.
  • Risk status:
    • High risk:
      • First bullet revised: Age ≥50 y (category 1).
      • Second bullet revised: ≥20 pack-year history of smoking cigarettes (category 1).
    • Low risk, second bullet revised: ≥20 pack-year history of smoking cigarettes.


  • Footnotes revised:
    • Footnote a: It is recommended that institutions performing lung cancer screening use a multidisciplinary approach that includes the specialties of thoracic radiology, pulmonary medicine, and thoracic surgery. Some institutions also include medical oncology, radiation oncology, and/or pathology.
    • Footnote b: Lung cancer screening with LDCT is appropriate to consider for high-risk patients at high risk for cancer who are potential candidates for definitive treatment. Chest x-ray is not recommended for lung cancer screening.
    • Footnote d: . . . Cigarette Ssmoking history should document both extent of exposure in pack-years (number of packs smoked every day multiplied by the number of years) and the amount of time since smoking cessation in former individuals who previously smokedrs. See also the NCCN Guidelines for Smoking Cessation.
    • Footnote e: Documented sustained and substantially elevated radon exposure, which substantially increases the risk for lung cancer in patients who also have a history of heavy smoking. Many state websites have information more specific to local areas, including areas of known elevated radon.
    • Footnote f: Agents that are identified specifically as carcinogens targeting the lungs include: arsenic, asbestos, beryllium, cadmium, chromium, coal smoke, diesel fumes, nickel, silica, soot, and uranium.
    • Footnote i: NCCN encourages providers to consider using risk calculators, if possible, because additional candidates at high risk for cancer may be identified for lung screening. to the degree they are able to. Through the use of risk calculators, consideration of additional groups may be identified. See Tammemagi lung cancer risk calculator. Sands J, et al. J Thorac Oncol 2021:16:37-53.
  • Footnotes revised:
    • Footnote j: Shared decision-making aids may assist in determining if screening should be performed. Examples of decision-making aids can be found at: http://www.shouldiscreen.com/benefits-and-harms-screeningUse of risk models may identify patients with a lower risk or higher risk within the current recommendations.
    • Footnote n: All screening and follow-up chest CT scans should be use performed at low dose (100–120 kVp and ≤40–60 mAs) set to yield a CT dose index volume (CTDIvol) threshold of 3 mGy or less for a patient of average size, unless evaluating mediastinal abnormalities or lymph nodes, where standard-dose CT with IV contrast might be appropriate (see LCS-A). Parameters should be adjusted for patients of smaller or larger size. There should be a systematic process for appropriate follow-up. ACR-STR Practice Parameter for the Performance and Reporting of Lung Cancer Screening Thoracic Computed Tomography (CT). (Also pages LCS-2A, LCS-3A, LCS-4A, LCS-5 through 7A, LCS-8A, LCS-9A, and LCS-10A)


  • Screening Findings, bottom of page:
    • First option revised: No lung nodule(s) on LDCT or Benign appearance (eg, perifissural nodules, benign patterns of calcification, fat-containing nodules).
    • Second option revised: Findings requiring follow-up for diseases other than lung cancer Other radiographic abnormality (eg, suspicious for other cancers, COPD other potential malignancy, emphysema, interstitial lung disease [ILD], moderate to severe coronary artery calcification [CAD], and aortic aneurysm)


  • Footnotes revised:
    • Footnote o: The NCCN Guidelines for Lung Cancer Screening are harmonized with Lung-RADS with rounding of mean measurement to the nearest whole number (mm). https://www.acr.org/-/media/ACR/Files/RADS/Lung-RADS/LungRADSAssessmentCategoriesv1-1.pdf. (Also pages LCS-3A, LCS-4A, LCS-5, LCS-7A, LCS-8A, LCS-9A, and LCS-10A).
    • Footnote r: A nodule is a rounded opacity, measuring up to 3 cm in diameter. A solid nodule has a homogeneous soft-tissue attenuation, a ground-glass nonsolid nodule (also known as a nonsolid ground-glass nodule) has hazy increased attenuation that does not obliterate bronchial and vascular margins, and a part-solid nodule has elements of both solid and ground-glass nonsolid nodules. Nodules should be evaluated and measured on CT using lung windows. The size of all nodules is underestimated when viewed on soft-tissue windows, and some nodules may not even be visible, particularly ground-glass nonsolid nodules and small nodules. Bankier AA, et al. Radiology 2017;285:584-600. (Also pages LCS-3A, LCS-4A, LCS-5 through 7A, LCS-8A, LCS-9A, LCS-10A, and LCS-11)
  • New footnote s added: Ideally, the annual LDCT is performed 12 months from the initial or interval scan. (Also pages LCS-3A, LCS-4A, LCS-5 through 7A, LCS-8A, LCS-9A, and LCS-10A).


  • Follow-Up of Screening Findings: following ≥15 mm, first option revised: Chest CT ± contrast and/or PET/CT and/or tissue sampling.


  • Footnote z revised: In many cases, p Patients with a strong clinical suspicion of stage I or II lung cancer (based on risk factors and radiologic appearance) do not require a biopsy before surgery. A biopsy adds time, cost, and procedural risk and is frequently unnecessary may not be needed for treatment decisions. A preoperative biopsy may be preferred by the surgeon and/or patient prior to surgery. A preoperative biopsy may be appropriate if a non-lung cancer diagnosis is strongly suspected, which can be diagnosed by bronchoscopy, percutaneous core biopsy, or fine-needle aspiration (FNA), or if an intraoperative diagnosis appears difficult or very risky. When a preoperative tissue diagnosis has not been obtained, an intraoperative procedure diagnosis (ie, wedge resection or needle biopsy) should be performed to confirm a cancer diagnosis is necessary before proceeding with lobectomy, bilobectomy, or pneumonectomy. See Principles of Diagnostic Evaluation in the NCCN Guidelines for Non-Small Lung Cancer.
  • New footnotes added:
    • Footnote aa: If nonsurgical therapy is contemplated without tissue confirmation, multidisciplinary evaluation that at least includes interventional radiology, thoracic surgery, and interventional pulmonology is required to determine the safest and most efficient approach for biopsy, or to provide consensus that a biopsy is too risky or difficult and that the patient can proceed with therapy without tissue confirmation. IJsseldijk MA, et al. J Thorac Oncol 2019;14:583-595. (Also pages LCS-4A, LCS-7A, LCS-8A, LCS-9A, and LCS-10A)
    • Footnote bb: Stereotactic ablative body radiotherapy (SABR) is also an appropriate option for patients with high surgical risk. This should include a multidisciplinary evaluation, including at least thoracic surgery and radiation oncology. (Also page LCS-4A, LCS-7A, LCS-8A, LCS-9A, and LCS-10A)


  • New footnote cc added: All part-solid nodules ≥6 mm should be identified and solid areas should be measured.


  • Footnote ee revised: Lung-RADS 1.1 has increased the size of a nonsolid nodule that can continue with annual screening to <30 mm, rather than <20 mm as recommended in the previous version. The NCCN Guidelines Panel has not harmonized this portion of the Lung-RADS update, as the panel members feel that baseline or new nonsolid nodules ≥20 mm should have an earlier evaluation at 6 months. Hammer MM, et al. Radiology 2021;300:586-593. (Also page LCS-10A)


  • Footnote t added: Nodules should be measured on lung windows and reported as the average diameter rounded to the nearest whole number; for round nodules only a single diameter measurement is necessary. Mean diameter is the mean of the longest diameter of the nodule and its perpendicular diameter. (Also LCS-8A, LCS-9A, and LCS-10A)

LCS-A 1 of 2

  • Nodule Parameters, following Density, description revised: Solid, ground glass nonsolid (also known as ground glass) or mixed (mixed, otherwise referred to as part solid) part solid (also known as mixed).


  • Risks, first bullet revised: Futile detection of small aggressive tumors or indolent disease.
  • Footnote removed: Ru Zhao Y, et al. Cancer Imaging 2011;11 Spec No A:S79-S84.
  • New footnote added: Sands J, et al. J Thorac Oncol 2021;16:37-53.

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patientguidelines.

Free NCCN Guidelines apps for iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps.

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