Sketching the roadmap for Asian lung cancer management: Expert consensus on lung cancer screening practices in Asian populations

16 Nov 2023

Dr. Lam, Chi-Leung David

Chief of Respiratory Medicine Division Clinical Associate Professor, Department of Medicine, 
Li Ka Shing Faculty of Medicine,
The University of Hong Kong 

J Thorac Oncol. 2023.

Lam D. C. L., Liam C. K., Andarini S., Park S., Tan D. S. W., Singh N., Jang S. H., Vardhanabhuti V., Ramos A. B., Nakayama T., Nhung N. V., Ashizawa K.,  Chang Y. C., Tscheikuna J., Van C. C., Chan W. Y., Lai Y. H., Yang P. C. Lung Cancer Screening in Asia: An Expert Consensus Report. J Thorac Oncol. 2023;18(10):1303-1322.

Lung cancer (LC) is regarded as the most lethal form of cancer in Asia.1 In 2020, the World Health Organization (WHO) ’s Global Cancer Observatory (GLOBOCAN) estimated that 60% of global LC cases and 62% of global LC-related mortality were from Asian countries.1 With such alarming statistics, a timely diagnosis for LC becomes of utmost importance since early-stage LC is acquiescent  towards treatment.1 According to the International Early Lung Cancer Action Program (I-ELCAP), a staggering 10-year survival rate of 92% was observed in stage I LC patients who underwent surgical resection within 1 month after diagnosis, further assuring the importance of early detection for LC.1

Despite the existence of guidelines on LC screening, these recommendations are targeted towards Western populations, which are composed of Caucasian patients.1 Since there are discernible epidemiological differences in LC between European and Asian countries, the current LC screening clinical guidelines may not apply to Asian populations.1 In particular, the epidemiology of LC in Asia is characterized by an elevated proportion of non-smokers (up to 33%), an early age of onset (≤45 years old), and a higher prevalence of epidermal growth factor receptor (EGFR) mutations (40%-55% in Asians vs. 15% -25% in Caucasians).1 As such, there is a need for LC screening practices tailored towards Asian populations.

Multiple virtual meetings of the Steering Committee (SC), composed of 19 LC experts from 11 Asian countries, were commenced to draft a series of LC screening recommendations dedicated to Asian countries.1 Throughout the SC meetings, the members discussed the strategies to implement LC screening practices that are tailored towards the ‘at-risk’ population with considerations for resource availability of local health care systems in mind.1

The consensus recommendations for LC screening in Asian countries

Risk factors for LC


Smoking history quantified in pack-years, is the most prominent risk factor for LC among smokers


In never-smokers, family history of LC, especially among first-degree relatives, is a risk factor for LC


Risk factors for LC and the distribution of driver mutations in patients with LC may vary across countries


History of pulmonary TB should be considered as an independent risk factor for LC, especially in high TB burden countries in Asia Pacific


Asbestos exposure and biomass fuel exposure have a significant association with LC in certain regions

LC screening criteria and interval

While selecting high-risk patients for LDCT screening, smoking history and age must be taken into consideration. This assessment of risk on the basis of age and pack-year smoking history has also been recommended by USPSTF:

  • Age range of 50-75
  • Smoking history of ≥20 pack-years
  • Years after quitting smoking: Individuals who quit smoking ≤15 years are still at risk

In addition to the above USPSTF criteria,

  • In Asia, nonsmokers aged 50 to 75, with a family history of LC among first-degree relatives, should be included for lung screening program with LDCT thorax as the main screening too

The frequency of LDCT screening should be usually every year for high-risk patients and should not exceed >2 years. Those with any detected abnormality should be followed up between 6 and 12 months with reference to Lung-RADS or Fleischner Society guidelines


Discontinue screening in individuals who are >80 years old

LC screening methodology and related programs

LDCT screening is recommended for high-risk individuals (according to the smoking history, years since smoking cessation, family history of cancer, etc.), annually or biannually


Implementation of risk prediction models and AI-supportive modalities to boost the efficacy of screening and follow-up with LDCT


Incorporation of smoking cessation programs along with the LC screening program is necessary


Improve access to LC screening programs and subsequent health care

Lung nodule management and surveillance

The updated Fleischner guidelines (2018) are recommended for IPN management and follow-up procedures in Asians


For the reporting of radiological parameters in LC screening programs, Lung-RADS or modified Lung-RADS is recommended


Involvement of a multidisciplinary team for LC screening and management of IPN is recommended

AI: Artificial intelligence; IPN: Incidental pulmonary nodules; LC: Lung cancer; LDCT: Low-dose computed tomography; Lund-RADS: The American College of Radiology Lung Computed Tomography Screening Reporting and Data System guidelines; TB: Tuberculosis; USPSTF: The United States Preventive Services Task Force

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