When someone is evaluated for lung cancer risk, certain questions are almost automatic: How old are you? Do you smoke? How many years did you smoke? When did you quit? Those questions matter. But there is another question that deserves far more attention: What did you do for a living?
No one begins a job anticipating that their paycheck will come with unforeseen consequences decades down the line. Tragically, for countless people who worked in North Carolina’s industrial hubs, shipyards, construction sites, and military bases, that has become a harsh reality. For much of the 20th century, asbestos was extensively integrated into industrial and military settings, prized for its ability to withstand heat, fire, and various chemicals. When its microscopic fibers are disturbed and inhaled, they can lodge permanently in the lungs — causing a malignancy up to four decades later. A worker may remember every detail of the job itself — the machines, the buildings, the tasks performed day after day — without ever knowing which materials around them contained asbestos.
America’s lung cancer screening guidelines still rely almost entirely on age and smoking history to determine eligibility. That emphasis leaves too many asbestos-exposed workers and veterans without access to early detection and potentially life-saving care — even when their occupational history, not their smoking history, may be the more telling risk factor.
Lung cancer as NC’s larger asbestos burden
Oftentimes, when people think about lung cancer, cigarette smoking understandably dominates the conversation. Yet the truth is, tobacco is only one of the many causes; numerous cases also stem from asbestos exposure. Although this public health crisis impacts the entire country, it carries even more weight in North Carolina, especially since the state has been notorious for having 46 historic mines. With this, it is not a surprise that such a component has become prevalent in manufacturing, shipbuilding, construction, and many other industries. Even the military also employed asbestos, which means a large number of more than 615,000 North Carolinian veterans – including 1,838 individuals in Richmind County – may have had contact with the mineral during their deployment in installations like Fort Bragg, where the widespread asbestos use in older buildings, barracks, and mechanical systems built before the 1980s represented a significant contamination risk.
Tragically, the aftermath of those exposures has been glaringly evident. In fact, just from 1999 to 2017, almost 6,600 North Carolinians lost their lives to asbestos-related diseases—with 40 cases occurring in Richmond County alone. Also, of the reported deaths, over 4,600 were attributed to lung cancer, while fewer than 1,200 were linked to mesothelioma. Apparently, lung cancer—not mesothelioma—has imposed the greatest asbestos-related toll on North Carolina, claiming nearly four times as many lives over the same period. This same trend now also unfolds throughout the country and appears in national data. Evidence from federal health authorities shows that asbestos exposure is associated with lung cancer, highlighting that the health consequences of asbestos exposure extend beyond mesothelioma. Yet notwithstanding this growing burden, public awareness, policy discussions, and even screening advocacy continue to center largely on mesothelioma, thus leaving a far more common illness without the attention it warrants.
The missing risk in lung cancer screening
Essentially, the long-standing issue of asbestos-related lung cancer points to a broader problem: while scientific understanding has advanced, the nation’s screening framework has not kept pace. Although occupational asbestos exposure is a well-established cause of lung cancer, current recommendations for annual low-dose CT screening continue to depend primarily on age and smoking history—neglecting the critical factor of workplace exposure. Unfortunately, such an oversight affects not only clinical outcomes but also access to vital preventive care.
Under the existing guidelines, annual screening is generally advised for adults aged 50 to 80 with a minimum of 20-pack-year smoking history—regardless of whether they still smoke or have quit within the past 15 years. Recommendations that receive an “A” or “B” rating may then be required to be covered by most private health plans without cost-sharing under the Affordable Care Act. Asbestos-exposed workers, however, do not qualify on that basis alone. Simply put, two individuals may have spent the same 30 years working in an asbestos-laden shipyard or factory, yet the patient who satisfies the smoking criteria may only be the one eligible for preventive screening. The other may not undergo imaging until symptoms like chest pain, breathing problems, and chronic cough appear—typically at a time when lung cancer is often more advanced and far harder to treat.
North Carolina’s experience demonstrates why this approach deserves renewed scrutiny. Federal health authorities should reassess lung cancer screening eligibility to account for verified occupational exposure to carcinogens—specifically asbestos—while insurers should ensure that evidence-based expansion of those criteria translates into meaningful access to annual low-dose CT screening. For workers and veterans who may have spent decades exposed to asbestos, that broader approach could mean finding a disease earlier rather than discovering it only after symptoms emerge.