The lung cancer pathway, step by step

Step 1: If you smoke, get help to quit, at any age

Smoking causes about 9 in 10 lung cancers in men and 8 in 10 in women, and people who smoke have about 20 times the risk of those who don’t. Quitting helps at any age: 10 years after quitting, lung cancer risk is 30% to 60% lower. Quit-smoking medicines and counseling together give you the best chance.

In randomized trials, more people quit with nicotine e-cigarettes than with nicotine patches or gum (9 vs 6 in 100), but their long-term safety is unknown: the longest follow-up was two years. They are a quitting aid for people who smoke, not for anyone who doesn’t.

Step 2: Check whether you qualify for yearly low-dose CT

Yearly low-dose CT finds lung cancer early in the people at highest risk. The U.S. Task Force recommends it from 50 to 80 for people with a 20 pack-year history (for example, a pack a day for 20 years) who smoke now or quit within the past 15 years. The American Cancer Society drops the 15-year limit. Yet only 18.7% of eligible people were up to date with screening in 2024.

Step 3: Never smoked? Lower the risks around you

People who never smoked get lung cancer too. Radon is linked to about 26% of lung cancer deaths in people who have never smoked, so test your home. Secondhand smoke, outdoor air pollution and workplace exposures such as asbestos also raise risk.

Step 4: If diagnosed: test the tumor before treatment starts

About 77% of lung cancers are non-small cell and 13% small cell. For early non-small cell cancer, surgery is the main treatment, with focused radiation (stereotactic body radiation therapy) for people who can’t or choose not to have surgery. Stage III is often treated with chemotherapy and radiation together.

Before treatment starts, ask whether the tumor has been tested for gene changes: many non-small cell lung cancers have one with a matched drug. Immunotherapy before and after surgery, and targeted pills after surgery for EGFR or ALK changes, lower the chance of the cancer coming back.

Step 5: Advanced or small cell lung cancer: what’s new

For advanced EGFR-mutated cancer, amivantamab plus lazertinib as first treatment lived longer than osimertinib alone, with more side effects. For small cell lung cancer, durvalumab after chemoradiation lengthened survival in limited-stage disease, and tarlatamab outlived chemotherapy when the cancer came back. Ask whether a clinical trial fits too.