CHEST: The Face of Lung Cancer Has Changed, but Screening, Care Have Gaps

Pulmonologists may have an image of what a patient with lung cancer looks like: an older man with a long history of smoking.

But today, up to 20% of those diagnosed with lung cancer have never smoked,¹ with the median age at diagnosis trending below 70.² Screening, diagnostic, and treatment practices do not reflect the diversity of patients with the disease, speakers said Sunday at CHEST 2026, the annual meeting of the American College of Chest Physicians meeting in Phoenix, Arizona.

The session, “Lung Cancer Redefined: Disparities, New Demographics, and Paths to Equity,” featured Eric Singhi, MD, of The University of Texas MD Anderson Cancer Center; Stella Ogake, MBBCh, FCCP, of The Ohio State University Wexner Medical Center; and Brett Bade, MD, FCCP, of Mayo Clinic.

Screening Has a Blind Spot: Nonsmokers

Singhi opened with a case familiar from his clinic: a previously healthy 42-year-old woman who never smoked, with weeks of persistent cough and progressive shortness of breath that did not resolve after steroids and antibiotics from urgent care.

“The face of lung cancer is changing. You keep hearing this. I'm going to tell you that it has changed,” Singhi said. One in 5 patients diagnosed with lung cancer in the United States has never smoked, he noted, and risk factors beyond personal smoking history include secondhand smoke, occupational exposures, radon, family history, and germline variants.

Because the US Preventive Services Task Force (USPSTF) screening recommendation is anchored on age and smoking history,³ it misses people younger than 50, those who never smoked, and those with lower-intensity tobacco exposure. Singhi cited a Northwestern Medicine analysis published last year in JAMA Network Open, in which only 35% of patients diagnosed with lung cancer at the institution met current USPSTF criteria; an age-based approach covering ages 40 to 85, similar to breast and colorectal cancer screening, would have captured nearly 94% of cases.⁴

“Today's screening criteria defines who we screen, but it does not define who can get lung cancer,” he said.

Patients with young-onset disease—typically defined as younger than 50—are more often women and more likely to have adenocarcinoma; more than half present with stage IV disease. They are also more likely to have actionable alterations such as EGFR, ALK, and ROS1.

“Young age, again, should really increase—not decrease—your urgency for getting that biomarker testing done,” Singhi said.

He called on clinicians to look beyond genomics, using what he calls the “4 Cs” of young-onset lung cancer: career, caregiving, children, and connection, which includes fertility, intimacy, and relationships. “All of this is not describing the biology; it's describing the person that's sitting [with] you in clinic,” he said.

UT MD Anderson, which saw 646 new patients with young-onset lung cancer from 2023 to 2024, launched one of the nation's first programs dedicated to this population. Singhi is lead investigator of the YOLC-HOPE registry (Young Onset Lung Cancer: Health Outcomes and Patient Experience), which has enrolled more than 150 patients since October 2025 and tracks quality of life, financial toxicity, and supportive care needs alongside clinical and genomic outcomes.⁵

“Please don't let age close the differential,” he told the audience, noting that pulmonologists are often the first specialists these patients see.

Disparities That Compound Across the Continuum

In her talk, Ogake described disparities as additive across the continuum, from risk through survivorship. “Whenever you're thinking about the structural socioeconomic things that affect patients, they do not arise from the patient themselves. They arise from the environment in which they live,” she said.

Black and Native Hawaiian individuals who smoke develop lung cancer at higher rates than other groups, even if they have lower levels of cigarette consumption, a pattern that Ogake linked in part to targeted marketing of menthol cigarettes. Residents of low-income, rural, and persistent-poverty counties face higher smoking prevalence, weaker tobacco control, and greater exposure to air pollution.

The 2021 USPSTF update—which lowered the starting age for screening and reduced the pack-year threshold from 30 to 20—increased eligibility among Black, Hispanic, and female individuals.⁶ But patients who are uninsured, those without a primary care physician, and rural residents still lag behind other groups on screening, and the American Cancer Society's 2023 removal of the years-since-quitting criterion paradoxically widened the Black-White eligibility gap from 7 to 12 percentage points, Ogake said.

Gaps persist after diagnosis. Ogake cited data showing that only 27.9% of Black patients with non–small cell lung cancer (NSCLC) received molecular testing vs 40.4% of White patients, and that 61.8% of patients with metastatic NSCLC did not receive guideline-concordant biomarker testing.^7,8 Just 28.5% of Black patients vs 40.2% of White patients received an immune checkpoint inhibitor,⁹ and Black patients have consistently been less likely to be offered surgery.

"This is something that we can change as clinicians, because we are the ones who … do the testing," Ogake said. When patients received guideline-concordant care, she noted, survival was equal across racial and ethnic groups. "That's dependent on what we do, and not their income or their race or their ethnicity."

She pointed to the multisite ACCURE (Accountability for Cancer Care through Undoing Racism and Equity) intervention,¹⁰ which gave clinicians feedback on treatment rates by race, as evidence that the gap is modifiable.

Order the Scan—and Advocate

Bade focused on solutions, starting with data showing that patients who receive a low-dose CT order or screening referral at the visit are more likely to be screened. "It may be simplistic, but don't defer that ordering scan to somebody else. That should be our responsibility," he said.

Individualized risk prediction models such as PLCOm2012 perform well for Black and White patients, he said, but less reliably for Asian and Hispanic patients, who are underrepresented in the models. Centralized screening programs achieve higher adherence to follow-up than decentralized ones, and online outreach and patient navigation—including a Boston program for people experiencing homelessness—have increased screening participation.

Treatment remains a gap. In National Cancer Database data, about 62% of patients received guideline-concordant therapy and 1 in 5 received no treatment at all,¹¹ while Medicare data on older adults suggest more than half of patients with metastatic disease never receive systemic therapy; lack of an oncology referral and lack of biomarker testing were key risk factors.¹² Delays matter, too: in early-stage disease, surgery more than 8 weeks after diagnosis was associated with worse long-term survival.

Bade urged clinicians to dispel outdated ideas about treatment that patients may hold after a loved one's experience. “The message I think is there are treatments that are less toxic and more effective than there were 20 years ago,” he said. Even if patients ultimately decline therapy, “not making that referral, I think, is a big driver of these low rates of guideline-concordant care.”

He cited improved 2-year survival and early-stage diagnosis rates in Medicaid expansion states,¹³ and narrower racial gaps in surgery and survival within the Veterans Health Administration, as evidence that access to care improves outcomes. Gaps include inconsistent coverage for follow-up testing after a baseline screen, and Bade worries about the effects of the One Big Beautiful Bill Act's coverage reductions,. "What good is it if I can get somebody a baseline screening CT, but I can't get them biopsied?"

He pointed to New York's law eliminating cost sharing for lung cancer screening as a model of what works. Changes to Medicaid threaten to undo recent progress. “Insufficient access to care threatens the advances that we've made in the last 10, 20 years,” Bade said.

References

1. Lung cancer among people who have never smoked. CDC. May 12, 2026. Accessed October 19, 2026. https://www.cdc.gov/lung-cancer/nonsmokers/index.html

2. Sumiya R, Matsunaga T, Suzuki K. Lung cancer in young individuals; risk factors and epidemiology. J Thorac Dis. 2025;17(3): https://jtd.amegroups.org/article/view/97981

3. Campos-Outcalt D. Lung cancer screening: USPSTF revises its recommendation. J Fam Pract. 2013;62(12):733-40.

4. Yang HC, Chang A, Visa M, et al. Age-based screening for lung cancer surveillance in the US. JAMA Netw Open. 2025;8(11):e2546222. doi:10.1001/jamanetworkopen.2025.46222

5. Young-Onset Lung Cancer Program. UT MD Anderson Cancer Center. Accessed October 19, 2026. https://www.mdanderson.org/patients-family/diagnosis-treatment/care-centers-clinics/thoracic-center/young-onset-lung-cancer-program.html

6. US Preventive Services Task Force; Krist AH, Davidson KW, Mangione CM, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

7. Tuminello S, Turner WM, Untalan M, Ivic-Pavlicic T, Flores R, Taioli E. Racial and socioeconomic disparities in non–small cell lung cancer molecular diagnostics uptake. J Natl Cancer Inst. 2025;117(1):112-119. doi:10.1093/jnci/djae225

8. Stanford A, Boykin S, Desai K, Karia PS, Ohaegbulam KC. Real-world insights on biomarker testing patterns and implications for mNSCLC therapy selection. Am J Manag Care. 2026;32(suppl 3):S27-S37. doi:10.37765/ajmc.2026.89889

9. Uprety D, Seaton R, Hadid T, et al. Racial and socioeconomic disparities in survival among patients with metastatic non–small cell lung cancer. J Natl Cancer Inst. 2024;116(10):1697-1704. doi:10.1093/jnci/djae118

10. Baker SL, Black KZ, Dixon CE, et a. Expanding the reach of an evidence-based, system-level, racial equity intervention: translating ACCURE to the maternal healthcare and education systems. Front Public Health. 2021;9:664709. doi: 10.3389/fpubh.2021.664709

11. Blom EF, Ten Haaf K, Arenberg DA, de Koning HJ. Disparities in receiving guideline-concordant treatment for lung cancer in the United States. Ann Am Thorac Soc. 2020;17(2):186-194. doi:10.1513/AnnalsATS.201901-094OC

12. Fox AH, Ward RC, Alexander M, et al; American Cancer Society National Lung Cancer Roundtable. Rates of systemic treatment for metastatic non–small cell lung cancer among older adults. JAMA Oncol. 2026;12(7):705-713. doi:10.1001/jamaoncol.2026.1080

13. Shi KS, Ji X, Yabroff KR, et al. Spillover effects of Medicaid expansion on insurance coverage, diagnosis, and survival among low-income elderly patients with cancer. J Clin Oncol. 2025;43(16 suppl):1522. doi:10.1200/JCO.2025.43.16_suppl.1522

14. Heiden BT, Eaton DB, Chang SH, et al. Racial disparities in the surgical treatment of clinical stage I non-small cell lung cancer among veterans. Chest. 2022;162(4):920-929. doi:10.1016/j.chest.2022.03.045