C2.6 Incidental findings (National Lung Cancer Screening Program)

The Australian National Lung Cancer Screening Program (NLCSP) launched in July 2025 introduces a new opportunity for early identification of COPD. The NLCSP is a government-funded initiative offering biennial low-dose CT (LDCT) scans to asymptomatic individuals aged 50–70 years with a ≥30 pack-year smoking history, including individual who currently smoke and those who quit within the past 10 years. While the program is designed to detect lung cancer, LDCT scans may incidentally reveal structural lung changes such as emphysema or airway wall thickening.

All individuals with LDCT findings suggestive of emphysema must undergo formal spirometry to confirm or exclude airflow limitation, regardless of symptomology or smoking status. Management decisions should not be made based solely on radiological findings, as pharmacological interventions may not be appropriate in the absence of demonstrable airflow limitation. Spirometry remains essential to confirm COPD diagnosis and guide evidence-based treatment.

In individuals with radiological emphysema but no airflow limitation on spirometry, pharmacological COPD treatment is not recommended. Even in individuals with no airflow limitation in spirometry, emphysema on CT is a prognostic marker associated with increased mortality risk and warrants regular clinical attention (Gutiérrez 2025). In the absence of symptoms, it may be reasonable to repeat spirometry alongside the lung cancer screening cycle (i.e. every 2 years). Earlier follow-up spirometry may be warranted, especially if symptoms develop or risk factors change.

Although inhaled pharmacotherapy is not recommended in the absence of spirometric airflow limitation, individuals with emphysema identified on LDCT should still receive proactive care to reduce risk and support lung health. Non-pharmacological interventions should be prioritised to reduce risk and prevent deterioration. These include smoking cessation support, vaccinations, optimised treatment of comorbidities, physical activity and nutrition guidance, and education on symptom monitoring.