Kevin Kunzmann

Chronic lower respiratory diseases like COPD were the fourth leading clinical cause of death among Americans as of 2023, and lung cancer remains the deadliest cancer today.

 have continually ranked among the greater drivers of disease burden and mortality.

The signs and symptoms of each are clearly understood, and non-invasive screening tools including low dose computed tomography (CT) scans and spirometry tests are proven safe, effective options for patients who meet disease risk criteria.

All this accounts to very little in the effort to curb deaths from COPD or lung cancer. The American Lung Association’s 2025 State of Lung Cancer report showed that, despite invasive care being most effective in cases with early-stage diagnosis, only 28.1% of cases are diagnosed at a stage when five-year survival rates are approximately 65%. Instead, patients with lung cancer are 50% more likely to be diagnosed at a later stage when survival rate is approximately 10%.

The 2025 edition of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guide for health care professionals paints a similar situation in missed opportunities for timely COPD detection and intervention. The guide this year highlighted environmental factors beyond tobacco smoking that may heavily influence COPD risk, as well as precursor conditions like pre-COPD and Preserved Ratio Impaired Spirometry (PRISm).

Patients who are presenting without airflow obstruction, defined as FEV

 / FVC ≥0.7 post-bronchodilator but any combination of these factors:

Structural lung lesions such as emphysema

Physiological abnormalities such as low FEV

, gas trapping, hyperinflation, reduced lung diffusing capacity, or rapid FEV

Patients who are presenting without airflow obstruction but decreased lung function per FEV

Despite these broadening opportunities to flag COPD risk, as well as major pharmaceutical milestones that have 

introduced targeted therapies and biomarker-specific agents to the field

 the GOLD committee acknowledges that there remains a major challenge in getting new cases diagnosed.

“COPD is a common, preventable, and treatable disease, but extensive under-diagnosis and misdiagnosis leads to patients receiving no treatments or incorrect treatment,” they wrote. “Appropriate and earlier diagnosis of COPD can have a very significant public-health impact.”

Lung cancer screening criteria has similarly been broadened in recent years to encourage a greater rate of diagnostic opportunities. The US Preventive Services Task Force (USPSTF) redefined its standard for “high-risk” individuals in 2021 — moving the qualification from individuals ≥55 years old with ≥30 pack years of cigarette smoking, to those aged 50 – 80 years who smoked ≥1 pack of cigarettes daily for 20 years or who quit smoking within the last 15 years.

Again, the State of Lung Cancer report showed approximately only 1 in 6 high-risk individuals were screened last year.

Experts have significantly widened the eligibility for COPD and lung cancer screening and evidence advocating for the efficacy of timely treatment has only improved in that time. So, what is it going to take to get more patients through the door in 2026?

The most apparent issue in lung cancer and COPD screening is the disparate access to such opportunities in the current healthcare system. Nearly 6 million Americans live in a “pulmonology desert” as of 2025, defined as areas that are ≥1 hour drive from the nearest pulmonologist, according to healthcare services provider GoodRx.

 These individuals predominately reside in Midwest states like Wyoming, where only 9.7% of high-risk individuals were screened for lung cancer in the last year. These residents have an approximate 50% decreased likelihood of 5-year survival compared with states like Rhode Island and Connecticut, which do not experience such challenges with clinician access.

Given that spirometry is the primary diagnostic tool in COPD — with results supported by patient questionnaires regarding symptoms and quality of life measures — the lack of in-person care opportunities persists the limit of timely COPD diagnoses in these deserts as well. 

Lung cancer screening has also been hampered by a slow buy-in to new processes. Despite being recommended as a standard strategy, low dose CT scans are a relatively newer procedure, and systemic buy-in is very gradual. As Douglas Wood, MD, the Henry N. Harkins Professor and Chair of the Department of Surgery at University of Washington, told 

, the procedure has been recommended and covered by payers for only the last decade. That’s hardly time to expect widespread adoption.

“If we’re just pragmatic, it does take time for the culture, policies, and procedures to get people to shift,” Wood said.

Regarding both low dose CT scans for lung cancer and lung function testing for COPD, multiple experts have stressed to 

 the need for more robust data supporting the approaches and their association with significant treatment outcomes — not for their own sake, but to assuage any lingering doubts among their colleagues.

This is a highly common issue not just in pulmonary medicine, but all of medicine in general, Graham Barr, MD, DrPH, Chief of the Division of General Medicine at NewYork-Presbyterian and Columbia University Irving Medical Center, told 

. Screening tools require “well-performed, randomized clinical trials” to achieve buy-in from clinicians, he explained.

“And we have that — two very good ones for lung cancer screening showing not just mortality reduction from lung cancer deaths, but all-cause mortality reduction too,” Barr said. “And that’s unique [among cancer screening tools].”

Whereas low dose CT scans have quickly accumulated top-down recommendation, supporting clinical evidence and cost coverage, pulmonary function testing remains a circumstantial tool in COPD screening. The USPSTF does not recommend its use to diagnose asymptomatic COPD, and debates persist on its cost-effectiveness relative to the screening setting.

Many experts want to see COPD screening become more widely adopted at the primary care level. But there’s concerns about the knowledge and perception of COPD among many clinicians.

The most common argument supporting the increase of respiratory disease screening is perhaps the simplest one to make: these rates would be unacceptable for any other disease. Barr noted the significantly better rates of breast cancer and cervical cancer screening for high-risk individuals relative to the more deadly lung cancer. Meredith McCormack, MD, director of the Division of Pulmonary & Critical Care Medicine at Johns Hopkins University School of Medicine, made the point to 

 that electrocardiograms are standard practice at cardiology visits — but spirometry testing is infrequent in her field.

The reality is that there is a significant need for these tools, and there are data and supports advocating for their use. Clinicians just are not using them.

From McCormack’s perspective, a crucial barrier in pulmonary function testing is getting clinicians more comfortable with conducting and analyzing results.

“The test can feel complicated, and part of what makes it feel complicated is some of the nuances of how we interpret the findings,” McCormack said. “We’re trying to make that simpler and show how to interpret a person’s numbers.”

Francesca Polverino, MD, PhD, professor of pulmonary medicine at Baylor College of Medicine, told 

 that advanced COPD education is much needed among their primary care peers. There’s a persistent mindset that it is a more homogeneous condition than it truly is — and ironically, that single-track mindset of what COPD is limits the field’s capability to learn more about it.

“The [primary care physicians] need to understand that COPD can occur in absence of cigarette smoke, it can occur in younger people, and there is a lot more beyond oral corticosteroids [to treat] because usually when we get a patient after an exacerbation who had been to the PCP, the patient has already been through a couple of rounds of oral corticosteroids already, which is a problem for the pulmonologist,” Polverino explained.

What limits clinicians from screening for lung cancer and COPD most, though, is the stigma attached to both diseases. Cigarette smoking is the most common trait of respiratory disease, and there remains a persistent perception among clinicians that COPD and lung cancer are self-inflicted — and as such, there’s less drive to identify and intervene on new cases.

An understated impact of the stigma surrounding COPD and lung cancer is that it causes clinicians to miss cases among younger, non-smoking patients. Polverino advocated for her primary care colleagues to more actively seek out the early signs of COPD in younger patients, including dyspnea, an inability to walk, chronic cough, chest tightness, and excess mucus.

“[There is] an aspect of lung cancer that it is the fault of the individual, even though there's many individuals who get lung cancer that never had a smoking history,” Wood said. “The stigma associated with lung cancer is another problem with getting it to be accepted at the level that we have for breast or colon cancer screening.”

Wood added that the patient demographic most affected by lung cancer and COPD is one that is not “well advocated for.” This includes older individuals, minorities, and those from lower socioeconomic status. This is why screening recommendation groups have moved toward a race neutral approach — described by McCormack as a “one size fits all” standard for pulmonary function rather than defining standards by race-specific averages.

Another driver of COPD and lung cancer under-diagnosis is, ironically, the high mortality rate associated with each. Wood described a “nihilism” among his colleagues that, even if lung cancer was detected during an early stage, the likelihood of survival is not promising enough to warrant the procedure and follow-up care. Coupled with the blame placed on patients for their role in smoking, there’s little resolve to intervene.

Polverino added that there’s a lack of urgency surrounding these conditions. Despite its high mortality rate, COPD “doesn’t kill you fast enough,” she explained — whereas a major adverse cardiovascular event could escalate care and improve a patient’s adherence to lifestyle modifications, COPD is chronic and debilitating over years of worsening condition.

Ironically, this singular and defeatist perspective of lung cancer and COPD is what most perpetuates their status as slow marches to death. As many experts have stressed to 

 over the years, there is burgeoning opportunity to better understand and manage disease like COPD if it were only prioritized.

, the identification of COPD biomarkers helped introduce the first targeted biologics to clinically relevant patients: dupilumab and mepolizumab are indicated and proven to benefit specific patients based on blood eosinophil counts, complementary to maintenance therapy. These agents have helped reduced the rate and burden of exacerbations in patients with COPD — and have encouraged clinicians like Polverino to continue seeking more widely implicative biomarkers of the disease.

“There are big changes coming in the next 10 years,” she said. “COPD is going into the spotlight again, after it was considered an untreatable disease.”

The 2026 GOLD Report, presented last month, acknowledged the role of targeted biologic intervention in COPD going forward. Most notably, the new report discussed the opportunity to define “disease stability” in patients with COPD relative to the adoption of more endotype-based diagnostics and targeted treatment initiation following the first exacerbation.

Claus Vogelmeier, MD, chair of the GOLD science committee, told 

 his expectation is treatment escalation with a growing armamentarium of therapies could provide patients this new standard of disease stability. What’s needed, though, is timely diagnosis.

“If we are able to identify patients earlier in a state where not most of the lung is destroyed, and then select the right patient based on their endotype and give them the drugs that are targeted to this endotype...then we have a very high likelihood that we are able to change the natural cause the disease, and that that was not possible 20-30 years ago,” Vogelmeier said. “We didn't have the management strategies, we didn't have the assessment strategies, we weren't able to diagnose earlier. I think this is the time to try."

McCormack perceives an opportunity to altogether prevent COPD development in at-risk individuals with a greater adoption of pulmonary function testing at the primary care level. She described an evolved system where baseline testing is conducted at a younger age and monitored regularly throughout an individual’s life to interpret their likelihood of respiratory disease — and to help inform the greater global standard for lung health and timely interventions.

“That’s something to aspire to: where people could be trending their values relating to their historic values, rather than trying to understand their values relative to other healthy people,” McCormack said.

Similarly to GOLD, McCormack also sees an opportunity to incorporate the numerous determinants of respiratory health to provide a fuller picture of an individual’s risk: merging data from spirometry, CT scans, endotype tests, as well as notable lifestyle factors including smoking, vaping device use, and harmful air exposure to profile a person’s lung health.

“[Spirometry] is a fairly simple maneuver, and we should continue to use that value but also integrate it with other information we have about that individual so we can make specific, personalized medical decisions,” McCormack said.

It is also understated how widely beneficial CT scans can be to fulfilling that specific patient profile, Barr said. Screening for lung cancer often helps diagnose emphysema in patients who have never received a spirometry.

“Lung CT gives us a massive amount of information that going forward is going to be very helpful for guiding therapy and patient selection,” Barr said. “We should be using this as part of our diagnostic algorithm…and it’ll help a lot with the management of our COPD patients.”

The situation at hand is not without cause for optimism. The State of Lung Cancer report did note that the national survival rate has increased from 26% to 29.7% over the last 5 years, and again, the therapy pipeline for COPD looks very promising over the next decade.

But as it stands in 2025, lung cancer and COPD remain among the deadliest diseases in the US. That fact is clearly known. There are tools to detect these diseases, evidence supporting their effect, recommendations for their use, and supports to use them. They just need to be used.

“It’s sort of staggering that we’re still in this position,” Barr said. “We have to straighten this out.”

Ahmad FB, Cisewski JA, Anderson RN. Leading Causes of Death in the US, 2019-2023. JAMA. 2024;332(12):957-958. doi:10.1001/jama.2024.15563

American Lung Association. State of Lung Cancer. 2024. Accessed December 10, 2025. https://www.lung.org/research/state-of-lung-cancer

Venkatesan P. GOLD COPD report: 2025 update. Lancet Respir Med. 2025;13(1):e7-e8. doi:10.1016/S2213-2600(24)00413-2

Johnson V, Campbell P. Rewriting Airway Disease With Trait-Based Care: 2025’s Convergence of Asthma and COPD Management. 

. Published online December 1, 2025. https://www.hcplive.com/view/rewriting-airway-disease-with-trait-based-care-convergence-asthma-copd-management

US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

Guttentag S. Mapping Pulmonology Deserts in 2025: Where Are Americans Having Trouble Getting Lung Care? 

. Published online September 25, 2025. https://www.goodrx.com/healthcare-access/research/pulmonology-deserts-update

Kunzmann K. What Ails Lung Cancer Screening, with Douglas Wood, MD. 

. Published online October 20, 2025. https://www.hcplive.com/view/what-ails-lung-cancer-screening-douglas-wood-md

Kunzmann K. Bettering CT Scan Rates in Pulmonology, with Graham Barr, MD, DrPH. 

. Published online December 2, 2025. https://www.hcplive.com/view/bettering-ct-scan-rates-pulmonology-graham-barr-md-drph

US Preventive Services Task Force. Screening for Chronic Obstructive Pulmonary Disease: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2022;327(18):1806–1811. doi:10.1001/jama.2022.5692

Kunzmann K. The Case for More Spirometry, Pulmonary Function Testing, with Meredith McCormack, MD. 

. Published online October 20, 2025. https://www.hcplive.com/view/the-case-for-more-spirometry-pulmonary-function-testing-meredith-mccormack-md

Kunzmann K. The Practical Hurdles in COPD Detection, with Francesca Polverino, MD, PhD. 

. Published online November 14, 2025. https://www.hcplive.com/view/practical-hurdles-copd-detection-francesca-polverino-md-phd

Venkatesan P. GOLD COPD report: 2026 update. Lancet Respir Med. Published online November 26, 2025. doi:10.1016/S2213-2600(25)00432-1

Kunzmann K. Breaking Down the 2026 GOLD Report, with Claus Vogelmeier, MD. 

. Published online November 14, 2025. https://www.hcplive.com/view/breaking-down-2026-gold-report-claus-vogelmeier-md

Articles

Chronic lower respiratory diseases, including COPD and lung cancer, remain leading causes of death in the US, despite advancements in screening and treatment. Disparities in healthcare access, clinician buy-in, and persistent stigmas contribute to underdiagnosis and late-stage detection. Efforts to broaden screening criteria and introduce targeted therapies have been made, yet systemic and cultural barriers persist. Experts emphasize the need for earlier diagnosis, improved clinician education, and a shift in perception to enhance patient outcomes. The potential for personalized medicine and targeted interventions offers hope for future advancements.

2025 data show the US is still failing to adequately identify and initiate care for deadly lung disease. Experts discuss what it will take to turn the tide on this public health issue.

Getting Through the Door: How COPD, Lung Cancer Screening Remains Minimal

Hanania explains how IL-33 inhibitors including itepekimab and astegolimab may uniquely benefit COPD exacerbation.

Prospecting the IL-33 Pathway for COPD Care, with Nicola Hanania, MD, MS

Mepolizumab (Nucala) and dupilumab (Dupixent) made history as the first biologic therapies indicated to treat eligible patients with 

 The recency of those pharmaceutical breakthroughs highlights not only the previous dearth of treatment advancement for patients with obstructive lung disease — it also showed how much more clinicians must uncover about the pathophysiology of COPD.

As one leading expert explains, similar pathway-targeting agents may be on the horizon for an even wider population of patients with COPD.

Chronic Obstructive Lung Disease (GOLD) International COPD Conference

 in Philadelphia, PA, Nicola Hanania, MD, MS, professor of medicine and director of the Asthma Clinical Research Center at Baylor College of Medicine, discussed the potential of IL-33 inhibitors to treat patients with COPD.

COPD is driven by 3 epithelial cytokines, Hanania explained: interleukin 33, 25 (IL-33; IL-25), and thymic stromal lymphopoietin (TSLP). IL-33 is released when the epithelium is harmed.

“And we know COPD patients [suffer] exposure to smoke, exposure to microbes and pollution, and all these can trigger injury to the epithelium,” Hanania said. “And thus, IL-33 has been shown to be expressed at a higher level in COPD and actually correlates with increased risk of exacerbation.”

IL-33 is associated with the trigger of type 1, 2, and 3 inflammation in patients with COPD. Whereas the IL-4 and IL-13-targeting dupilumab solely benefits exacerbations in patients with type 2 inflammation, an IL-33 inhibitor hypothetically may positively impact most patients with COPD.

Early clinical trials assessing 3 different IL-33 inhibitors — including itepekimab, tozorakimab and the ST2 receptor inhibitor astegolimab — suggest this approach may particularly benefit COPD exacerbations in patients who previously smoked.

“I think the jury is still out regarding blocking IL-33, but certainly it's a plausible pathway,” Hanania said. “I think there's been lots of discussion here and excitement that we're looking outside the box now for COPD. Certainly, type 2 pathway [targeting]…is very important, but blocking other inflammatory pathways is also very plausible.”

Johnson V, Iapoce C. FDA Approves Mepolizumab for Eosinophilic COPD. 

. Published online May 22, 2025. https://www.hcplive.com/view/fda-approves-mepolizumab-for-eosinophilic-copd

Smith T. FDA Approves Dupilumab (Dupixent) for Treatment of COPD. 

. Published online September 27, 2024. https://www.hcplive.com/view/fda-approves-dupilumab-dupixent-for-treatment-of-copd

Rabe KF, Martinez FJ, Bhatt SP, et al. AERIFY-1/2: two phase 3, randomised, controlled trials of itepekimab in former smokers with moderate-to-severe COPD. ERJ Open Res. 2024;10(5):00718-2023. Published 2024 Sep 23. doi:10.1183/23120541.00718-2023

Singh D, Guller P, Reid F, et al. A phase 2a trial of the IL-33 monoclonal antibody tozorakimab in patients with COPD: FRONTIER-4. Eur Respir J. 2025;66(1):2402231. Published 2025 Jul 14. doi:10.1183/13993003.02231-2024

Greening N, Brightling C, Tal-Singer R, et alS1 Randomised, placebo-controlled trial of astegolimab for COPD with frequent exacerbations: ALIENTOThorax 2025;80:A7.

Videos

Barr discusses the means to encourage systemic adoption of low dose CT scans to help curb the deadliest cancer in the US.

Bettering CT Scan Rates in Pulmonology, with Graham Barr, MD, DrPH

Despite there being highly determinable clinical and behavioral risk factors, access to Medicare-covered screening measures, and a severe mortality risk in cases diagnosed too late, the frequency of 

 screening remains precipitously low among eligible patients in the US.

The matter of improving this recurring trend — as has been previously discussed by experts — requires behavioral shifts from clinicians in the position to seek out a diagnosis.

 in Philadelphia, PA, Graham Barr, MD, DrPH, Chief of the Division of General Medicine at NewYork-Presbyterian and Columbia University Irving Medical Center, discussed the continually minimal use of low dose computed tomography (CT) scans on patients at determined risk of lung cancer.

As Barr emphasized, low dose CT scan is not some novel, unevidenced diagnostic tool — is it covered by Medicare and private insurers and is recommended for use in eligible patients based on criteria factors by the United States Preventive Services Task Force (USPSTF). Despite it being available and endorse like any standard screening tool, only about one-fourth (28.1%) of US patients are diagnosed at an early lung cancer state during which they experience a 65% five-year survival rate. US patients are primarily diagnosed (43%) in late-stage lung cancer, when survival rate is approximately 10%.

From Barr’s perspective, the common reasons why a colleague may not prescribe a primary cancer test do not apply to low dose CT scans: it is neither costly like a full pulmonary function test, nor is it linked to a high risk of adverse events like initially believed.

“It's a dramatically underused test and it's sort of staggering that we're still in this position,” Barr said. “It would not be acceptable if we were talking about breast cancer screening, if we were talking about pap smear screening, and so forth. We have to straighten this out.”

Barr disagreed with the theory that patient follow-through on screening referrals have a major impact on the utility of low dose CT scans. Instead, he said systems have been slow to adopt it as standard practice and clinicians are still struggling with the stigma tied with smoking.

“We still have a habit of saying, ‘Somebody got into this trouble by smoking’,” Barr said. “But whether or not they have quit [the habit], they’re still eligible [for screening] in the most part, and we should be pushing it aggressively.”

As Barr looks at the checklist of hurdles his colleagues must still clear to streamline low dose CT scans in pulmonology practices, he highlights “evidence.” There are mortality reduction-based data supporting the tool but even more robust randomized clinical trial data showing the benefit of timely lung cancer screening in the continuum of care for eligible patients. Healthcare systems can play their role by implementing quality control programs to assess their own outcomes and refine their internal processes to both clinician and patient satisfaction.

More supporting data, and a system tailored to their practice and patients, may help to overcome the stigmas surrounding both lung cancer and low dose CT scans.

“There’s not an inherent resistance to mammography screening, colon cancer screening…there’s really no reason we shouldn’t get this done,” Barr said.

Wood D, Kunzmann K. What Ails Lung Cancer Screening, with Douglas Wood, MD. 

. Published October 20, 2025. https://www.hcplive.com/view/what-ails-lung-cancer-screening-douglas-wood-md

American Lung Association. State of Lung Cancer 2025: Lung Cancer Key Findings. Web page. Last updated November 3, 2025. https://www.lung.org/research/state-of-lung-cancer/key-findings

Halpin reviews the state of triple therapy inhaler prescribing strategies in the era of new biologic options.

COPD Inhaler Use in the Biologic Era, with David Halpin, MBBS, DPhil

Single inhaler triple therapy options reached the US market in the last decade, providing clinicians a number of options to effectively treat the common symptoms of 

 without tasking a patient to adhere to multiple devices; options like fluticasone furoate / umeclidinium / vilanterol (Trelegy Ellipta)

 and budesonide / glycopyrrolate / formoterol (Breztrai Aerosphere)

 have simplified a patient’s means to receive a regular dose of inhaled corticosteroid (ICS), long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA).

But this drug class hasn’t come without its own practical hang-ups.

 in Philadelphia, PA, this month, David Halpin, MBBS, DPhil, Clinical Lead of Respiratory Medicine at the University of Exeter, discussed the advantages and challenges alike that have emerged in the era of multiple-therapy inhaler devices to treat COPD.

While there are more opportunities to now fit a suitable device to a patient with COPD, the amplification of choices warrants an adequate understanding of each option.

“It's confusing for clinicians about how you should use them optimally,” Halpin said. “And so even though many devices are available, many clinicians default to a limited number that they're familiar with.”

There’s even differing methodology between single inhaler multiple therapy options — some warrant a twice-daily administration, others only one. Some do require an add-on treatment, others do not.

“Patients get very confused, and as a result, don't take it as well as they should and are more likely to have exacerbations and not get as good symptom control as they could achieve,” Halpin said. “There’s still a lot of work to do to educate the prescribers and to train the patients that having a single inhaler is much more convenient — patients are going to be more adherent and more likely to get the benefits from that treatment.”

Halpin also discussed general prescribing strategy trends in COPD. He noted that some of his colleagues may initiate a long-acting bronchodilator, wait to assess its benefit, then add a second bronchodilator, wait again, and finally add an ICS to a patient’s regimen. He stressed that this strategy is only delaying the time to optimal care — and time is everything in COPD treatment.

“The evidence suggests that if a patient needs the treatment, the sooner you start all of the components together, the better the outcomes will be,” he said.

The advent of biologic therapies to treat COPD further evidences the need to start timely, robust maintenance treatment as soon as the patient needs it; an add-on biologic is now available for most patients with severe cases.

“Biologics offer an opportunity to add on to the triple therapy, to further reduce those exacerbation rates,” Halpin said. “And they have to be tailored to the individual patient. But if you've got the right patients with the right biomarkers to indicate the need for a biologic, the biologics really offer something new.”

Walter K. FDA Approves COPD Triple Therapy. 

. Published July 24, 2020. https://www.hcplive.com/view/fda-approves-copd-triple-therapy

Hoffman M. FDA Grants New Indication to Trelegy Ellipta for COPD. 

. Published online April 24, 2018. https://www.hcplive.com/view/fda-grants-new-indication-to-trelegy-ellipta-for-copd