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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.
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.1 These are hardly new trends; COPD and lung cancer 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%.2
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).3
What is pre-COPD?
Patients who are presenting without airflow obstruction, defined as FEV1 / FVC ≥0.7 post-bronchodilator but any combination of these factors:
What is PRISm?
Patients who are presenting without airflow obstruction but decreased lung function per FEV1.
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,4 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.5
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.6 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 HCPLive, the procedure has been recommended and covered by payers for only the last decade. That’s hardly time to expect widespread adoption.7
“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 HCPLive 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 HCPLive. Screening tools require “well-performed, randomized clinical trials” to achieve buy-in from clinicians, he explained.8
“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.9
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 HCPLive that electrocardiograms are standard practice at cardiology visits — but spirometry testing is infrequent in her field.10
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 HCPLive 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.11
“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 HCPLive over the years, there is burgeoning opportunity to better understand and manage disease like COPD if it were only prioritized.
As previously covered in This Year in Medicine, 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.12
Claus Vogelmeier, MD, chair of the GOLD science committee, told HCPLive 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.13
“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.”
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