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For years, this relentless disease was a death sentence for more than nine of 10 people diagnosed too late for effective treatment. But now a new chapter is being written, thanks to Claudia Henschke and David Yankelevitz's innovative use of advanced low-dose CT scans for early lung cancer screening—and crucial support from actuary Bruce Pyenson and his colleagues at Milliman.
In the late 1990s, lung cancer screening faced formidable challenges. Chest X-rays offered limited diagnostic benefit for what was (and remains) the world’s most lethal cancer; like today, most people were diagnosed at a late stage with a grim prognosis. Yet Henschke and her team saw potential in a new technology.
“We had these new CT scanners that detected tiny nodules early in the progress of the disease,” recalls Henschke, a radiologist and Clinical Professor of Diagnostic, Molecular and Interventional Radiology at Mount Sinai in New York. “We knew there had to be a way to leverage this technology to detect lung cancer when it was curable.”
Henschke’s team launched a pioneering study with a thousand high-risk individuals with significant smoking history—a gamble that would eventually challenge prevailing skepticism. Published in The Lancet in 1999, their results ignited significant interest. “It was a game-changer,” says Henschke. “We knew we were on the brink of something major.”
Turning promising research into widespread screening adoption, however, proved to be another challenge, and convincing the medical community and insurance companies required more than positive clinical results.
Enter Pyenson, a Milliman principal with nearly four decades of experience in healthcare financing. In the early 2000s, he was tasked with proving that this new, effective screening approach could also be cost effective. “Bruce’s analysis was crucial,” says Yankelevitz, Professor of Radiology and Director of the Lung Biopsy Service at Mount Sinai’s Icahn School of Medicine. “Insurance companies needed hard numbers, not just academic models.”
Pyenson, whose credits include publishing numerous peer-reviewed studies, contributing regularly to lung cancer conferences, and undertaking research funded by leading organizations such as the GO2 Foundation, the Prevent Cancer Foundation, and the Legacy Foundation, anticipated the challenges that awaited.
“We had to demonstrate that the upfront screening costs were justified by the lives and life-years saved,” says Pyenson, whose work has helped lung cancer screening become a reality in many countries. “It wasn’t just about presenting data—it was about addressing the concerns of insurers and policymakers about financial risk and value. We showed that relatively modest investments in early lung cancer detection could lead to huge mortality gains.” Since CT screening is relatively inexpensive and low-risk, and the population is well-defined—smokers and ex-smokers— “it was also a sensible approach from an actuarial perspective,” Pyenson explains.
Despite the promise, broader adoption of proactive lung cancer screening remains a challenge.
“There’s a gap between those who need screenings and those who actually get them,” Henschke laments. Barriers include limited reimbursement, a lack of enthusiasm among radiology centers, and public advocacy that lags behind other types of screenings, such as breast cancer.
But there is also reason for optimism, according to renowned lung cancer specialist Dr. Jim Mulshine, Professor of Medicine at Rush University Medical Center in Chicago. Mulshine, recognized for his tireless advocacy in early lung cancer detection and prevention, notes that greater public awareness and eligibility, evolving insurance coverage, technology upgrades, and educational campaigns have contributed to a rise in screening participation.
“A recent study from the American Cancer Society and published in JAMA suggests that, nationally, participation of at-risk patients could be as high as 18%, though it varies by state,” says Mulshine. “But that’s up from around 5% to 8% just a few years ago. Compared to mammography screening’s first 10 years, that's a profound uptake."
Further accelerating the rise in proactive preventive screening will take more than improving technology or bolstering education—it will require breaking down silos and integrating health information more robustly than ever before. “Improving care means going far beyond isolated tests,” says Henschke. “And because imaging for lung screening is digital, it’s a great case for using AI for integration.”
“It’s not just about proving that screening works,” echoes Mulshine, “it’s about aligning an array of fields and disciplines—from insurance companies and policy makers to health practitioners—to make high-quality screening widely accessible.”
Another key to keeping the momentum going will be the deepening use of quality metrics. HEDIS (Healthcare Effectiveness Data and Information Set) measures, for example, are crucial for evaluating and improving healthcare. By tracking preventive screenings and chronic disease management, HEDIS can enhance lung cancer screening programs by monitoring screening rates, adherence to guidelines, and outcomes.
“Effective quality measures like HEDIS, yield metrics, or Medicare’s star ratings will help demonstrate the economic value of early detection and guide improvements in screening practices,” says Pyenson. “They are essential for ensuring that preventive screenings are effective, efficient, and widely adopted.”
As collaboration between radiologists and actuaries continues to evolve, the promise of a more connected, effective approach to preventive health becomes clearer: the revolution in lung cancer detection, supported by Milliman’s critical analysis, is just the beginning. With ongoing innovation and cross-disciplinary partnerships, the future of healthcare holds the potential for profound transformation.
“We now know that early detection of lung cancer can save more life-years than all of the known breakthrough cancer treatments,” says Pyenson. “So the work we’re doing here is critical.”
Mulshine agrees. “Five years from now, we could routinely be intercepting today’s most lethal cancer, along with many other deadly conditions,” adds Mulshine. “It would be a very exciting time, and an unbelievable step forward for medicine."
This article was written by Matthew DeMaio, a contributing writer for Milliman.
