Detection of Early Emphysema During Lung Cancer Screening: Opportunities to Optimize Health

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James L. Mulshine, MD

James L. Mulshine, MD

In an article in Annals of the American Thoracic Society, James L. Mulshine, MD, of the Center for Healthy Aging, Department of Medicine, Rush University, and colleagues maintained that the high frequency of emphysema newly identified during low-dose computed tomography (CT) lung cancer screening presents an important opportunity to engage individuals with such findings in conversations and practices aimed at optimizing overall health.1

Frequency of Emphysema in Lung Cancer Screening

As related by the authors, two large studies, together including more than 79,000 participants, have identified a high frequency of emphysema during lung cancer screening. In the International Early Lung Cancer Program (I-ELCAP), baseline lung cancer screening scans detected emphysema in 23.8% of participants. Among the 12,542 participants found to have emphysema, 9,595 (76.5%) had no prior diagnosis of emphysema or chronic obstructive pulmonary disease (COPD). In the National Lung Screening Trial (NLST), baseline scans identified emphysema in 31% of participants. Among them, 82% had no history of COPD or emphysema. As stated by the authors, “Therefore, [lung cancer screening] participation resulted in frequent detection of emphysema in these two screening cohorts and typically, screening participants had no prior awareness of this pulmonary disease.”

Potential Benefits of Early Detection of Emphysema During Lung Cancer Screening

As related by the authors, the early detection of emphysema during lung cancer screening presents opportunities to benefit the health of affected individuals. These opportunities are summarized here.

• Provides additional personalized motivation for tobacco cessation in current smokers to mitigate lung cancer risk, limit emphysema progression, and preserve lung tissue from further destruction, as well as to limit progression of other tobacco-related chronic diseases such as coronary artery disease

• Provides earlier recognition for primary care providers to identify individuals who would benefit from detailed symptom screening to prompt spirometric assessment for COPD detection, as well as to encourage screening compliance to detect early lung cancer

• May also provide additional motivation by reinforcing other existing preventive recommendations such as increasing physical activity or complying with vaccination to reduce the burden of respiratory infections

• Empowers screening subjects to use their personalized health information obtained from the analysis of CT scans to improve their own health, which in turn may improve annual lung cancer screening adherence

• May allow for personalizing additional nonpharmacologic interventions for subsequent rounds of lung cancer screening to evolve the annual lung cancer screening encounter to a more screening participant–engaging annual health check.

Next Steps in Formally Addressing Lung Cancer Screening–Detected Emphysema

As noted by the authors, efforts are needed to integrate the detection of emphysema during lung cancer screening into a strategy that addresses both emphysema and other tobacco-related comorbidities in the population eligible for lung cancer screening.The strategy includes efforts to educate the public about the implications of thoracic imaging–based screening in the heavily tobacco-exposed population, particularly by enlisting clinicians and professional societies in the effort to define broader tobacco-related thoracic management. The next steps in these efforts, as identified by the authors, are summarized and reproduced here.

• Communicate to the public and medical community that there is already frequent detection of emphysema in the course of lung cancer screening

• Engage relevant bodies such as the U.S. Preventive Services Task Force and professional societies to recognize the research and preventive intervention opportunities with combined detection of lung cancer and emphysema with thoracic CT screening in the high-risk population

• Establish standardized reporting with pulmonary and other thoracic professional societies to assist referring clinicians moving forward to appropriately tailor the management of the different extent of emphysema found on screening thoracic CT scans

• Support additional research on improving thoracic CT detection and management, including workflows, on emphysema and other tobacco-related conditions identifiable with thoracic CT scans

• Support further research on using annual screening results to investigate both pharmacologic interventions as well as nonpharmacologic interventions in diverse populations—such as with programs for iterative tobacco cessation approaches and increased physical activity

• Promote the measurement of screening outcomes for relevant tobacco-related conditions and include appropriately selected outcomes in payers’ population-based reimbursement and quality models to incentivize continued evolution of effective, economical, and equitable detection within thoracic CT screening.

The authors represent a broad spectrum of advocates, clinicians, radiologists, imaging scientists, behavioral scientists, and other relevant experts. They concluded: “Recent publications demonstrate that emphysema can be frequently detected by thoracic CT scans performed for lung cancer screening. The joint detection of these two frequent lethal tobacco-related diseases provides a new opportunity to manage these diseases in a more cohesive fashion that may enhance the public investment related to the delivery of national lung cancer screening.”

They continued: “For individuals considering participation in annual lung cancer screening, information about the frequent detection of other significant imaging findings such as emphysema must be routinely discussed, as it is a major health determinant. Detecting emphysema, like detecting early-stage lung cancer, may allow important opportunities for tobacco-exposed individuals to manage their lung health using safe and economical preventive interventions.” 

DISCLOSURE: Dr. Mulshine reported no conflicts of interest.


1. Mulshine JL, Aldigé CR, Ambrose LF, et al: Emphysema detection in the course of lung cancer screening: Optimizing a rare opportunity to impact population health. Ann Am Thorac Soc 20:499-503, 2023.