Screening For Life > For Health Providers > Lung Screening Information > Alberta Lung Cancer Screening Program (ALCSP) Lung Cancer Risk Calculator and Referral Form

Alberta Lung Cancer Screening Program (ALCSP) Lung Cancer Risk Calculator and Referral Form

Alberta Lung Cancer Screening Program (ALCSP) Lung Cancer Risk Calculator and referral Form

For medical professional use only.

This tool will help you calculate a patient’s 6-year individual risk of lung cancer for the purpose of determining eligibility for lung cancer screening as part of the ALCSP. All information contributes to the risk score. Please fill out as completely and accurately as possible. No identifying personal information is retained by the program when you use this tool. A fillable PDF will be automatically generated which can be used as a referral to fax to the ALCSP. This risk calculator is not designed for individuals who have never smoked cigarettes. Individuals with a calculated risk ≥1.5% may be eligible for screening if they meet the following additional criteria:

• 50 to 74 years of age AND are someone who smokes cigarettes or quit smoking after smoking for many years. For example, you smoked 1 pack per day for at least 15 years, or less than 1 pack per day but for more than 15 years.
• No recent (<12 months) CT scan of the chest or other requiring imaging on clinical grounds.
• Life expectancy of more than 10 years/absence of significant comorbidities that would preclude aggressive treatment if lung cancer was
detected. Examples may include but are not limited to:
o Prior invasive cancer diagnosis active or present in the past 5 years unless curative treatment completed.
o Severe heart or lung disease (NYHA III-IV, MMRC grade 3-4, requiring home oxygen).
o ECOG II-IV, inability to climb 2 flights of stairs.

years

INELIGIBLE: You are outside the age range of eligibility (50-74 years) for the ALCSP. You may still calculate your risk estimate, but will not be eligible to participate.

Current cigarette smoking status (do not consider vaping, or other tobacco use)
Did the patient stop smoking for at least a year at any time during this period?
cigarettes

Please make sure to enter number of cigarettes smoked per day and not number of packs.

Body mass index (BMI) calculation. Select what units you want to use to provide this information
kg
cm
lbs
ft
in
Patient race or ethnicity? This should be self-identified by patient and not assigned

We appreciate your choice. Keep in mind that the calculation will underestimate your lung cancer risk if you are Black or Indigenous. The demographic information collected above is used to calculate lung cancer risk and program eligibility. It will be used exclusively for this purpose and monitoring program implementation. Individuals may elect not to provide certain information and still be referred to the program. This may result in underestimating personal risk and impact their screening eligibility.

Highest grade of school obtained?
Does patient have a personal history of any type of cancer?
Does patient have a first-degree family relative (parent or sibling) with a history of lung cancer?
Does patient have a diagnosis of chronic obstructive pulmonary disease (COPD, chronic bronchitis or emphysema)?