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.