Personalizing Veterans' Lung Cancer Screening and Diagnosis

Inclusion Criteria:

1. Date of birth and sex recorded
2. Active user of VA (at least 1 primary care encounter in prior 2 years) at Nashville, Denver, Louisville, Chicago Jesse Brown, Kansas City, Salisbury or Seattle VAMC
3. Tobacco Use: Self-reported tobacco use of at least 100 cigarettes in lifetime
4. Additional Risk Factor

   1. Self-reported history of military service exposure: direct contact with asbestos- containing material, agent orange, ionizing radiation or burn pit
   2. Chronic obstructive pulmonary disease (COPD) defined as one of the two definitions below:

1.Forced expiratory volume during the first second/forced vital capacity (FEV1/ FVC) ratio of below 70% predicted 2.FEV1/FVC greater than 70% predicted or pulmonary function test (PFT) unavailable plus respiratory symptoms (chronic cough, sputum production, shortness of breath, chest tightness, wheezing) plus any one of the following functional abnormalities on PFTs or structural abnormalities on imaging:

1. Functional abnormalities on PFTs:

   I.FEV1 below the lower limit of normal II.Gas trapping defined as residual volume greater than upper limit of normal III.Hyperinflation defined as two out of three lung volumes (total lung capacity, functional residual capacity, residual volume) that are greater than the upper limit of normal IV.Reduced diffusion capacity of the lungs for carbon monoxide (DLCO) defined as DLCO lower than the lower limit of normal V.Rapid FEV1 decline defined as greater than 60ml/year or greater than or equal to 15% decline in FEV1
2. Structural abnormalities on imaging:

   I.Emphysema II.Air trapping/mosaicism
3. Self-reported prior history of tobacco-related cancer (oral cavity and pharynx, esophagus, stomach, colorectal, liver and intrahepatic bile duct, pancreas, larynx, lung and bronchus, cervix uteri, kidney and renal pelvis, urinary bladder, and acute non-lymphocytic leukemia) and without evidence of disease for at least 5 years based on chart review
4. Self-reported family history of primary lung cancer in a first degree relative 5.No exclusion criteria at study screening

Exclusion Criteria:

1. Self-reported, family-reported or electronic health record (EHR) diagnosis of dementia via chart review or failure of 3-word recall from Mini-cog during study screening
2. Self-reported or EHR documented thoracic imaging surveillance for cancer or chronic lung disease
3. Self-reported or EHR diagnosis of severe illness on chart review defined as:

   1. Hospice
   2. End Stage Pulmonary disease or continuous supplemental oxygen use
   3. Heart Failure with ejection fraction (EF) less than 25%
   4. Transplant of any organ or bone marrow
   5. Active cancer currently being treated except non-melanoma skin cancer
   6. Condition that precludes lung cancer screening due to limited ability to undergo treatment as deemed by study PI
4. Pregnancy in the second or third trimester
5. Inability to give informed consent; no minors, prisoners, or incapacitated
6. Inability to complete computed tomography (CT) scan