BACKGROUND:Anastomotic leak and post-operative pneumonia are major contributors to postoperative morbidity following esophagectomy and have traditionally led to delays in oral feed initiation. Newer evidence, however, suggests early initiation of feeds may be safe. The aim of this systematic review and meta-analysis is to assess the safety of initiation of oral feeds on postoperative day one versus delayed initiation. METHODS:A systematic search was conducted on six databases and studies were included if they compared safety outcomes of adult esophagectomy patients initiating feeds on postoperative day one versus delayed imitation. A random-effects meta-analysis with restricted maximum likelihood was performed and study quality was assessed with the Newcastle-Ottawa Scale. RESULTS:Ten studies with a total of 1714 patients were included. Our primary outcome of anastomotic leak showed no significant between the early and delayed oral feeding group (8 studies, OR 0.92, 95% CI 0.59-1.41, p = 0.69). For the secondary outcomes, there was no difference in length of stay (4 studies, mean difference -2.27 days, 95% CI -5.13 to 0.60, p = 0.12) and there was decreased odds of postoperative pneumonia (9 studies, OR 0.74, 95% CI 0.58-0.95, p = 0.02). CONCLUSIONS:Initiating oral intake on postoperative day one after esophagectomy does not increase length of stay or risk of anastomotic leak and postoperative pneumonia. These findings support consideration of early oral feeding as a safe component of perioperative care when applied appropriately.

Lung cancer is the most frequently diagnosed cancer and the leading cause of cancer death worldwide. Early detection of lung cancer can lead to identification of the cancer at its initial treatable stages and improves survival. Low-dose CT scan (LDCT) is currently the gold standard for lung cancer screening in high-risk individuals. Despite the observed stage migration and consistently demonstrated disease-specific overall survival benefit, LDCT has inherent limitations, including false-positive results, radiation exposure, and low compliance. Recently, new techniques have been investigated for early detection of lung cancer. Several studies have shown that liquid biopsy biomarkers such as circulating cell-free DNA (cfDNA), microRNA molecules (miRNA), circulating tumor cells (CTCs), tumor-derived exosomes (TDEs), and tumor-educated platelets (TEPs), as well as volatile organic compounds (VOCs), have the power to distinguish lung cancer patients from healthy subjects, offering potential for minimally invasive and non-invasive means of early cancer detection. Furthermore, recent studies have shown that the integration of artificial intelligence (AI) with clinical, imaging, and laboratory data has provided significant advancements and can offer potential solutions to some challenges related to early detection of lung cancer. Adopting AI-based multimodality strategies, such as multi-omics liquid biopsy and/or VOCs’ detection, with LDCT augmented by advanced AI, could revolutionize early lung cancer screening by improving accuracy, efficiency, and personalization, especially when combined with patient clinical data. However, challenges remain in validating, standardizing, and integrating these approaches into clinical practice. In this review, we described these innovative milestones and methods, as well as their advantages and limitations in screening and early diagnosis of lung cancer.

BACKGROUND & AIMS:There is limited literature evaluating muscle mass at the fourth thoracic (T4) vertebrae using computed tomography (CT) images, with no studies evaluating T4 muscle mass in esophageal cancer. METHODS:In this retrospective cohort study, body composition analysis using skeletal muscle index (SMI) was conducted at T4 and L3. Overall survival (OS) and disease-free survival (DFS) were evaluated using Kaplan-Meier curves and log-rank tests, as well as multivariable cox proportional hazards models. Correlation analysis and evaluation of fixed and proportional bias was conducted. Low muscle mass was defined by the lowest quartile of the SMI distribution from the post-neoadjuvant CT: <30.4 cm2/m2 (females) and <42.2 cm2/m2 (males) for L3, and <35.4 cm2/m2 (females) and <52.6 cm2/m2 (males) for T4. RESULTS:Of the 120 patients included, eight (8.2 %) patients had T4-low muscle mass at the staging CT which increased to 25 (25.8 %) at the post-neoadjuvant CT. On multivariable analysis, T4-low muscle mass was associated with worse overall survival (OS) (HR 2.51, 95 % CI 1.47-4.29, p = 0.001) and disease-free survival (DFS) (HR 1.88, 95 % CI 1.09-3.24, p = 0.022). T4-SMI was higher than L3-SMI at both the staging (65.4 ± 13.6 cm2/m2 versus 51.1 ± 10.0 cm2/m2, p < 0.001) and post-neoadjuvant (57.8 ± 12.7 cm2/m2 versus 45.8 ± 9.3 cm2/m2, p < 0.001) CT scans. The correlation (R-value) between T4 and L3 SMI was greater than 0.6 (0.62-0.81) for all staging intervals. CONCLUSION:Our findings support using low muscle mass at T4 as a prognostic indicator for OS and DFS. These findings can be extrapolated to tumor groups, such as lung cancer, where L3-low muscle mass status is not routinely available.

BackgroundSurgeon-industry collaboration is a key driver of advancement in surgical technology and practice. Disclosures of financial relationships between investigators and industries are important to ensure transparent and critical evaluation of literature.MethodsAll American cardiothoracic (CT) surgeons who published in three major CT surgery journals in 2019 were identified. Whether these surgeons disclosed any conflicts of interest was recorded and compared to actual payments received within 5 years of publication as reported by the Centers for Medicare and Medicaid Services data.ResultsIn the study period, there were 1079 unique manuscripts involving 885 American CT surgeons as authors, which combined for 2719 author instances. Of these, 96.2% of authors (851 of 885) received payments from companies. The authors who received payments produced 2651 author instances (97.4%). Financial disclosure was reported in only 11.4% (301 of 2651) of these instances. In total, 851 surgeons received more than $187 million over 5 years, with the highest-paid surgeon receiving an average of over $5.9 million per year. The largest individual payments were from "Associated Research Funding," with over $115 million being paid to 277 surgeons over 5 years. The top paying company issued over $96.5 million to American CT surgeons over 5 years.ConclusionsNearly all the reviewed publications in three top CT surgery journals were by surgeons who received payments from companies, but very few of these payments were recorded as potential conflicts of interest. A more consistent and robust policy of COI disclosure is needed to reduce perceptions of bias.

Anastomotic leak after esophagectomy is a major contributor to surgery-related morbidity and mortality. The purpose of this systematic review was to evaluate if positive-smoking status is associated with the incidence of this complication. A systematic search of MEDLINE, EMBASE, Scopus, Web of Science and Cochrane Library was performed on April 4th, 2023. Inclusion criteria comprised human participants undergoing esophagectomy, age ≥ 18, n ≥ 5, and identification of smoking status. The primary outcome was incidence of anastomotic leak. Sub-group analysis by ex- or current smoking status was performed. Meta-analysis was performed with RevMan 5.4.1 using a Mantel–Haenszel random-effects model. Publication bias was evaluated visually with funnel plots and through the Egger test. A total of 220 abstracts were screened, of which 69 full-text studies were assessed for eligibility, with 13 studies selected for final inclusion. This included 16,103 patients, of which 4433 were ex- or current smokers, and 9141 were never smokers. Meta-analysis revealed an increased odds of anastomotic leak in patients with a positive-smoking status (current or ex-smokers) compared to never smokers (OR 1.44, 95

Background:The coronavirus disease 2019 (COVID-19) pandemic challenged global infrastructure. Healthcare systems were forced to reallocate resources toward the frontlines. In this systematic review, we analyze the impact of resource reallocation during the COVID-19 pandemic on the diagnosis, management, and outcomes of esophageal cancer (EC) patients.Methods:PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on EC patients. Of the 1,722 manuscripts initially screened, 23 met the inclusion criteria.Results:Heterogeneity of data and outcomes reporting prohibited aggregate analysis. Reduced detection of EC and considerable variability in disease stage at presentation were noted during the COVID-19 pandemic. EC patients experienced delays in diagnostic and preoperative staging investigations but surgical resection was not associated with greater short-term morbidity or mortality. Modeling the impact of pandemic-related delays in EC care predicts significant reductions in survival with associated economic losses in the coming years.Conclusions:Amidst resource scarcity during the COVID-19 pandemic, the multidisciplinary management of patients with EC was affected at multiple stages in the care pathway. Although the complete ramifications of reductions in EC diagnosis and delays in care remain unclear, EC surgery was able to safely continue as a result of collaboration between centers, strict adherence to COVID-19 protective measures, and reallocation of healthcare resources towards the same. Ultimately, when healthcare systems are pushed to the brink, the downstream consequences of resource reallocation require judicious analysis to optimize overall patient outcomes.

Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel–Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95

INTRODUCTION:Older individuals have an elevated lung cancer risk but may also have substantial comorbidities that preclude curative treatment options and limit the survival benefits of screening. The objective of this study was to assess early stage lung cancer survival patterns among those at the upper age limit for screening and identify older individuals who have the potential to benefit from lung cancer screening. METHODS:We identified all early stage (I or II) lung cancers diagnosed in Alberta, Canada between 2010 and 2020. Overall survival (OS) was based on the time from the date of lung cancer diagnosis to the date of death (from any cause) or censoring. We estimated OS using the Kaplan-Meier method. We present OS with 95% confidence intervals (CIs) for each age group and sex and stratified by presence of comorbidities (Charlson Comorbidity Index) and receipt of surgery. RESULTS:There were 6401 early stage lung cancers (71% stage I, 29% stage II), of which 43% and 57% were among males and females, respectively. For females, the 5-year OS was 54.7% (95% CI: 50.6-58.8), 47.2% (95% CI: 42.7-51.7), and 33.7% (95% CI: 28.4-38.9) for ages 70 to 74 years, 75 to 79 years, and 80 to 84 years, respectively. For males, the 5-year OS was 47.7% (95% CI: 43.1-52.3), 38.0% (95% CI: 33.2-42.8), and 24.2% (95% CI: 19.2-29.3) for ages 70 to 74 years, 75 to 79 years, and 80 to 84 years, respectively. Across all age groups, the 5-year OS was higher for those with fewer comorbidities and for those who received surgery as part of their treatment strategy, usually surpassing that in younger cohorts with more comorbidities or those who did not receive surgical treatment. CONCLUSIONS:Age limits for lung cancer screening should consider comorbidity and fitness for curative treatment because these can significantly influence the survival after diagnosis and treatment of early lung cancer.

Introduction: During the COVID-19 pandemic, healthcare institutions increased utilization of telemedicine. The impact of telemedicine on quality of care in a surgical setting is an under researched area of the literature. The purpose of this study was to evaluate patient satisfaction with telephone follow-up after lung resection. Methods: All lung cancer patients undergoing a post-operative telephone follow-up between April to November 2020 who had also previously completed at least one in-person pre-operative visit or follow-up were invited to participate. An anonymous online questionnaire adapted from the Telehealth Useability Questionnaire was circulated to participants. Our study’s primary outcome was patient satisfaction with telephone follow-up, compared with in-person visits before COVID-19. Secondary outcomes included surveying patients’ levels of concern about COVID-19, its perceived impact on their medical care, and their views on the utility of telemedicine post-pandemic. Results: A total of 47 out of 54 patients completed the survey. Regarding COVID-19, 85% (39/46) of respondents were “somewhat” or “very” concerned about the pandemic in general and 76% (34/45) reported similar concerns about in-person healthcare appointments. There was no significant difference in participant comfort level and openness to telephone follow-ups before and after the actual encounter (p = 0.08). There was no significant difference reported between in-person and telephone appointments on all paired satisfaction questions directly comparing the two. Conclusions: Patient satisfaction with telephone follow-up after lung resection appears non-inferior to in-person appointments. The convenience of telemedicine for both patients and physicians may warrant sustained utilization of this modality of care post-pandemic.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented tolls on both economies and human life. Healthcare resources needed to be reallocated away from the care of patients and towards supporting the pandemic response. In this systematic review, we explore the impact of resource allocation during the COVID-19 pandemic on the screening, diagnosis, management and outcomes of patients with lung cancer during the pandemic. METHODS: PubMed and Embase were systematically searched for articles investigating the impact of the COVID-19 pandemic on patients with lung cancer. Of the 1605 manuscripts originally screened, 47 studies met the inclusion criteria. RESULTS: Patients with lung cancer during the pandemic experienced reduced rates of screening, diagnostic testing and interventions but did not experience worse outcomes. Population-based modelling studies predict significant increases in mortality for patients with lung cancer in the years to come. CONCLUSIONS: Reduced access to resources during the pandemic resulted in reduced rates of screening, diagnosis and treatment for patients with lung cancer. While significant differences in outcomes were not identified in the short term, ultimately the effects of the pandemic and reductions in cancer screening will likely be better delineated in the coming years. Future consideration of the long-term implications of resource allocation away from patients with lung cancer with an attempt to provide equitable access to healthcare and limited interruptions of patient care may help to provide the best care for all patients during times of limited resources.

PURPOSE:Post-operative pneumonia after esophagectomy is a major contributor to morbidity and mortality. Prior studies have demonstrated a link between the presence of pathologic oral flora and the development of aspiration pneumonia. The objective of this systematic review and meta-analysis was to evaluate the effect of pre-operative oral care on the incidence of post-operative pneumonia after esophagectomy.METHODS:A systematic search of the literature was performed on September 2, 2022. Screening of titles and abstracts, full-text articles, and evaluation of methodological quality was performed by two authors. Case reports, conference proceedings, and animal studies were excluded. A meta-analysis of peri-operative oral care on the odds of post-operative pneumonia after esophagectomy was performed using Revman 5.4.1 with a Mantel-Haenszel, random-effects model.RESULTS:A total of 736 records underwent title and abstract screening, leading to 28 full-text studies evaluated for eligibility. A total of nine studies met the inclusion criteria and underwent meta-analysis. Meta-analysis revealed a significant reduction in post-operative pneumonia among patients undergoing pre-operative oral care intervention compared to those without an oral care intervention (OR 0.57, 95% CI 0.43-0.74, p < 0.0001; I2 = 49%).CONCLUSION:Pre-operative oral care interventions have significant potential in the reduction of post-operative pneumonia after esophagectomy. North American prospective studies, as well as studies on the cost-benefit analysis, are required.

BACKGROUND:Minimal literature exists on outcomes for Canadian patients with gastroesophageal adenocarcinoma (GEA). The objective of our study was to establish a prospective clinical database to evaluate demographic characteristics, presentation and outcomes of patients with GEA.METHODS:Patients diagnosed with GEA were recruited from Jan. 30, 2017, to Aug. 30, 2020. Data collected included demographic characteristics, presentation, treatment and survival. A multivariable model for overall survival in patients treated with curative intent was created using sex, lymph node status, resection margin status, age and tumour location as variables.RESULTS:A total of 122 patients with adenocarcinoma of the stomach or gastroesophageal junction were included. Median age was 65 years (interquartile range [IQR] 59-74), 70% of patients were male and 26% were born outside of Canada. Median follow-up time was 14.5 (IQR 8.0-31.0) months. Following staging computed tomography scanning, 88% of patients were deemed to have potentially resectable disease. Eighty-one (76%) received staging laparoscopy and 74 (61%) were treated with curativeintent surgery. Forty-six (62%) patients had nodal metastases. The median number of nodes harvested was 22 (IQR 18-30). The R0 resection margin rate was 82%. The 3-year overall survival for patients who received curative-intent treatment was 63% and 38% for all patients. On multivariable analysis, female sex (hazard ratio [HR] 3.88, p = 0.01), positive nodal status (HR 3.58, p = 0.02), positive margins (HR 3.11, p = 0.03) and tumour location (HR 3.00, p = 0.03) were associated with decreased overall survival.CONCLUSION:Many of the patients with GEA in this study presented with advanced disease, and only 61% were offered curative-intent surgery. A prospective multicentre national GEA database is now being established.

Introduction: Lung cancer screening (LCS) for high-risk populations has been firmly established to reduce lung cancer mortality, but concerns exist regarding unintended downstream costs. Methods: Mean health care utilization and costs were compared in the Alberta Lung Cancer Screening Study in a cohort undergoing LCS versus a propensity-matched control group who did not. Results: A cohort of 651 LCS participants was matched to 336 unscreened controls. Over the study period (mean 3.6 y), a modest increase in the number of claims (22.4 versus 21.9 per person-year [PY]; D 0.50 [95% confidence interval: 0.15-0.86], p = 0.006) and outpatient visits (4.01 versus 3.50 per PY; D 0.51 [0.37-0.65], p <0.0001), but not in inpatient admissions, was noted in the screened cohort. Claims payments, inpatient costs, and cancer care costs were similar in the screening arm versus the unscreened. Outpatient encounter costs per participant were higher in the screened group ($2662.18 versus $2040.67 per PY; D-$621.51 [-1118.05 to-124.97], p = 0.014). Removing the additional computed tomography screening examinations rendered differences not significant. Mean total costs were not significantly different at $6461.10 per PY in the screening group and $6125.31 in the unscreened group (D-$335.79 [-2009.65 to 1338.07], p = 0.69). Conclusions: Modest increases in outpatient costs are noted in individuals undergoing LCS, in part attributable to the screening examinations, without differences in overall health care costs. Health care costs and utilization seem otherwise similar in individuals participating in LCS and those who do not. (c) 2023 The Authors. Published by Elsevier Inc. on behalf of the International Association for the Study of Lung Cancer. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

Abstract Background Despite advances in operative techniques, anastomotic leak (AL) after esophagectomy remains a dreaded complication associated with a relatively high morbidity and mortality. Identification of patient and surgical factors associated with AL are useful for risk stratification to improve patient and procedure selection. Furthermore, an adequately powered analysis for the incidence of AL after minimally invasive esophagectomy is lacking. Methods The ACS-NSQIP database was used to extract patients who underwent esophagectomy between 2016 and 2021. Categorical variables were analyzed using chi-squared tests and continuous variables were evaluated using ANOVA tests. Using a hypothesis driven purposeful selection methodology, a multivariable logistic regression model was created with the primary outcome of interest being the odds of AL. Statistical analysis was completed with StataSE 17 (STATACorp, LP, College Station, TX). The primary outcome of interest was the effect of minimally invasive surgery on AL. Secondary outcomes were the effect of patient characteristics and surgeon specialty on AL. Results Of the 6669 esophagectomies, the leak rates were 14.6% (open; 360/2451), 13.4% (MIS-abdominal; 64/478), 21.1% (MIS-chest; 69/326), 14.3% (MIS-total; 369/2590), and 20.1% (Robotic; 166/824), respectively. On multivariate analysis, positive margin (OR 1.37, 95% CI 1.01–1.85, p = 0.043), MIS-chest (OR 1.40, 95% CI 1.01–1.96, p = 0.047), MIS-total (OR 0.95, 95% CI 0.78–1.15, p = 0.595), MIS-robotic (OR 1.37, 95% CI 1.07–1.77, p = 0.014), transhiatal esophagectomy (OR 1.28, 95% CI 1.01–1.62, p = 0.040), and three-hole esophagectomy (OR 1.38, 95% CI 1.12–1.77, p = 0.014) were surgical factors associated with increased odds of AL (Table 1). Conclusion Anastomoses that were performed by certain types of minimally invasive surgery and those performed in the cervical region were associated with increased odds of AL. Consideration of this increased risk needs to be weighed against the established benefits of minimally invasive surgery when selecting the appropriate procedure for each patient. Identifying patients who are high-risk for an AL pre-operatively may prevent delay in the diagnosis and treatment of ALs in this patient population.

It has been over 10 years since the relationship between sarcopenia and lung cancer was first explored. Since then, sarcopenia research has progressed substantially, and the prognostic value of this condition is becoming increasingly apparent. Prior systematic reviews and meta-analyses have established sarcopenia to be negatively associated with disease-free and overall-survival, as well as a major risk factor for post-operative complications. The bulk of the literature has explored sarcopenia in the resectable setting, with less emphasis placed on studies evaluating this condition in advanced disease. In this up-to-date review, an examination of the literature exploring the association between sarcopenia and long-term outcomes in advanced lung cancer is provided. We further explore the association between adverse events of medical therapy and the role of sarcopenia as a predictor of tumor response. Finally, the interventions on sarcopenia and cancer cachexia are reviewed, with an emphasis placed on prospective studies.

RATIONALEInterstitial lung abnormalities (ILA) are radiographic interstitial findings that are incidentally identified on chest imaging performed for other reasons. ILAs have been identified on chest computed tomography (CT) performed as part of lung cancer screening programs.OBJECTIVESThis study characterizes the prevalence and outcomes associated with ILA in a Canadian lung cancer screening cohort.METHODSPatients were identified from the Alberta lung cancer screening trial, a 5-year cohort study. CT reports were screened for terms associated with ILA including specific radiologic features and CT patterns. These were further characterized as non-subpleural, subpleural nonfibrotic and subpleural fibrotic, consistent with published definitions. Retrospective chart review was conducted for those with ILA to define demographics, lung function, and longitudinal outcomes including subsequent investigations for interstitial lung disease (ILD), treatment, and survival.MEASUREMENTS AND MAIN RESULTSOf 806 patients in the lung cancer screening study, 30 (3.7%) were identified as having ILA, with two-thirds (67%) having subpleural fibrotic abnormalities. Half of patients were referred to a Respirologist and underwent pulmonary function testing. Over a median follow-up period of two years, none were diagnosed with an idiopathic interstitial pneumonia, or started on immunomodulatory or antifibrotic therapy. Three of 30 (10%) patients demonstrated disease progression over time, all of whom had subpleural fibrotic ILA on baseline chest CT.CONCLUSIONSThe prevalence of ILA in this Canadian lung cancer screening cohort was 3.7%. These data should inform the development of standardized reporting and follow-up for ILA as lung cancer screening programs are implemented.

The management of early-stage esophageal cancer is nuanced. A multidisciplinary approach may optimize management through selection of candidates for surgical or endoscopic therapies. The objective of this research was to examine long-term outcomes of patients with early-stage esophageal cancer who undergo treatment with endoscopic resection or surgery. Data on patient demographics, co-morbidities, pathology results, OS and RFS were obtained for both the endoscopic resection group and esophagectomy group. Univariate analysis of OS and RFS were conducted using the Kaplan–Meier method with calculation of the log-rank test. Multivariate cox-proportional hazards models were created for OS and RFS using a hypothesis-driven approach. A multivariate logistic regression model was created to identify predictors of esophagectomy among patients undergoing initial endoscopic resection. A total of 111 patients were included. The median OS for the surgery group was 67.0 months compared to 74.0 months in the endoscopic resection group (log-rank p = 0.93). The median RFS for the surgery group was 109.4 months compared to 63.3 months in the endoscopic resection group (log-rank p = 0.0127). On multivariable analysis, patients undergoing endoscopic resection had significantly worse RFS (HR 2.55, 95

Sarcopenia is a predictor of survival in patients with esophageal cancer. The objective of this research was to obtain insight into how changes in sarcopenia influence survival in resectable esophageal cancer. A retrospective cohort of patients with esophageal cancer undergoing tri-modality therapy was selected. Body composition parameters from the staging, post-neoadjuvant, and 1-year surveillance computed tomography (CT) scans were calculated. Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan–Meier method and log-rank test, as well as multivariable Cox-proportional hazards models. Of 141 patients, 118 had images at all three timepoints. The median DFS and OS were 33.2 [95

Background: Several randomized trials demonstrated have reduced lung cancer mortality with screening using computed tomography. However, there remains debate about the optimal approach for determining screening eligibility, and no evidence yet exists reporting lung cancer rates in those excluded from screening due to too low of a personalized risk.Methods: This study was based on the Alberta Lung Cancer Screening Study, which received 1737 applicants and enrolled 850 based on the NLST criteria or a PLCOM2012 risk >= 1.5%. We excluded 887 applicants who were interested in screening but deemed ineligible. We report lung cancer rates in the screened and unscreened cohorts. Results: We observed 30 and 8 lung cancers in the screened and unscreened groups, respectively. Only 1 of 8 lung cancers were among those considered too low risk (0.14%), while the remaining 7 were among those excluded for other reasons, including symptoms requiring more immediate workup. No NLST eligible but PLCO risk < 1.5% screened individual had a lung cancer detected as part of the study, so that of all applicants contacting the program with risk estimates less than 1.5%, only 1/857 (0.12%) developed lung cancer. Conclusion: Our findings indicate that a risk-based approach for screening eligibility is unlikely to miss many lung cancers.