Early detection of nononcologic disease and cancer in healthy and at-risk patients can improve patient outcomes, decreases health care expenditures, and improve mortality. ^,, Both well-established screening programs as well as newer and emerging imaging applications exist for screening with the goal of identifying the specified conditions at treatable stages. As technology improves and evidence accumulates and undergoes re-evaluation, imaging may be added to established general population screening. In addition, there are evolving concepts of screening based on the level of risk for individual patients. Imaging may be performed in response to abnormal screening test results that have very low specificity, for example, with MR imaging of the prostate in patients with elevated prostate-specific antigen (PSA), or with the modality selection based upon patients’ genetic, familial, and lifestyle factors (eg, high-risk breast cancer screening with MR imaging). Furthermore, there has been growing interest in characterizing risk for health outcomes that are secondary or not directly related to the indication for the imaging test. ^,, Radiologists have an established role in early diagnosis and thus enabling intervention upon conditions associated with morbidity and mortality. We review fundamental principles of established and emerging imaging-based screening or screening pathways, technical considerations in performing these studies, and population-level economic evaluation of such programs.

Technical considerations for imaging-based screening include parameters for image quality, imaging acquisition, patient positioning, and modality-specific requirements. First, image quality is essential for adequate diagnostic accuracy and reliable performance of screening. Technologists and radiologists must be trained to recognize and address issues like patient motion, incomplete anatomic coverage, or artifacts. In terms of acquisition, imaging parameters such as radiographic exposure time, voltage, and focal spot size, for example, are basic considerations for ensuring technical optimization, and may need to be adjusted based on the specific modality and patient’s characteristics. Technologists are ideally trained to optimize the acquisition and also the patient’s positioning. Such positioning is, perhaps, fundamental for adequate imaging quality in mammography but also contributes to the quality of acquisition for all other modalities. For each imaging modality, there are unique additional technical requirements and considerations that can be innovated and investigated. For example, most screening MR imaging examinations will require intravenous (IV) contrast, and for computed tomography (CT) colonography, the patient lies in both prone and supine scanning positions sequentially to increase the likelihood of viewing all surfaces sufficiently. Later, we provide examples of screening and early detection efforts by organ system with application of screening principles and technical considerations.

We first review breast cancer screening as a well-established program. Breast cancer is the most commonly diagnosed cancer in women, exceeding 310,000 cases in 2024 and representing more than 1 in every 7 new cancer diagnoses in the United States; it is second only to lung cancer with respect to cancer deaths. ^, While the breast cancer death rate has been decreasing steadily over several decades, the rate of new age-adjusted breast cancer diagnoses has slowly increased over the past decade up to 132.9 per 100,000 in 2023. It is recognized that breast cancer mortality has been improved through screening by detecting smaller cancers at less advanced stages of nodal metastasis. ^, However, guidelines continue to vary across organizations, leading to confusion and discrepant recommendations, particularly for patients of average-risk and intermediate-risk. For example, the United States Preventive Services Task Force (USPSTF) recommends that all female individuals receive screening for breast cancer every other year, starting at the age of 40 years and continuing to the age of 74 years. The American College of Radiology (ACR) encourages patients to undergo breast cancer risk evaluation by the age of 25 years to guide screening, and recommends annual screening for average-risk female individuals starting at the age of 40 years.

Screening mammography is the cornerstone of early detection of breast cancer. Tumors found by screening mammography are smaller and less likely to have node-positive disease when compared to tumors detected by physical palpation, and reduction in breast cancer deaths has been demonstrated with screening. Minority female patients in the United States face higher incidence and more aggressive subtypes of breast cancer at an earlier age, and in part this phenomenon influenced the USPSTF recommendation to start screening at the age of 40 years.

In terms of technical considerations, several factors can affect acquisition and interpretation of screening mammography. Dense breast tissue may mask tumors on a mammogram, leading to decreased sensitivity, increased recall rates, and higher incidences of interval tumor development between screening examinations. Breast density is inversely correlated with age and body mass index, which some suggestion of decreased sensitivity of mammography for female patients aged younger than 50 years compared to those aged over 70 years and older. Larger breasts may be difficult to position within the mammogram imaging plate, leading to insufficient compression, increased blurring, and decreased image sharpness. More common mistakes include improper positioning of the nipple, pectoralis, and lower quadrants.

Digital breast tomosynthesis (DBT) shows stacked images together with digital mammographic views. These views can be reconstructed from the acquired DBT images or full-field digital mammograms. Many studies have shown increased cancer detection rate when compared DBT to mammographic images alone, but there is evidence of similar limitations in detection in dense breast tissue. ^,, Lesion margins and conspicuity are improved on DBT, leading to fewer additional views and reductions in further workup including ultrasound and biopsy. Magnification views are still required to fully evaluate calcifications when identified ^, ( Fig. 1 ).

A 89 year old female patient with right breast mass seen on prior CT chest. ( A ) craniocaudal (CC) and ( B ) mediolateral oblique (MLO) views show almost entirely fatty breasts. There is a 1.4 cm dense irregular mass with a few internal calcifications in the right upper outer quadrant ( arrows ), BI-RADS 5. Biopsy revealed poorly differentiated invasive ductal carcinoma.

Lung cancer is the most commonly diagnosed cancer that affects both genders and is the leading cause of cancer-related death for men and women in the United States, with over 125,000 deaths in 2024. While recent studies have shown a decreased incidence, disability burden, and overall mortality of lung cancer in the United States over the past 3 decades, results vary when evaluating patients by sex and geography, emphasizing the need for interventions aimed at reducing disparity. Low-dose CT (LDCT) screening for lung cancer in over 53,000 patients evaluated by the National Lung Screening Trial Research Team showed a 20% relative reduction in mortality compared to single-view PA radiograph. Annual lung cancer screening has been covered for qualified patients since 2015 based on USPSTF recommendations. The most recent update in 2021 states that patients aged from 50 to 80 years with at least a 20 pack year smoking history and currently smoke or have quit within the past 15 years are eligible for screening, increasing the number of female, underrepresented minority, and lower socioeconomic status patients that qualify. ^,

LDCT of the chest without contrast is the only imaging modality recommended for lung cancer screening as per the ACR Appropriateness Criteria. Evidence for other modalities such as fluorodeoxyglucose (FDG)-PET and MR imaging is lacking. There is disagreement about whether performance of MR imaging is comparable to LDCT, with probable decreased sensitivity in detecting semisolid and ground glass nodules on MR imaging. ^, Clinical information prior to imaging should include patient age, total pack-year smoking history, current or former smoker status, and any use of electronic or other smoking and inhalation devices. LDCT imaging guidelines and technical parameters have been established by the Society of Thoracic Radiology in conjunction with the ACR. Standard LDCT of the chest is performed with multidetector helical technique with a single breath-hold. The maximum axial slice thickness is 2.5 mm and is preferable at 1 mm or less with coronal and sagittal reconstruction intervals equal or less than axial slice thickness. The recommended CT dose index (CTDI) is 3 mgy or less for a standard patient. The European Society of Thoracic Imaging recommends similar parameters, with preferred axial slice thickness of 0.75 mm or less and CTDI ranges based on patient weight. ^, Studies performed on imaging phantoms at different dose levels showed sufficient diagnostic imaging quality at 0.13 mSv for an adult-sized phantom and at 0.08 mSv for a pediatric-sized phantom ( Fig. 2 ).

A 62 year old male patient with a 40 pack year smoking history presents for CT lung screening after being lost to follow-up for 4 years. ( A ) There is moderate centrilobular emphysema and a 1.6 cm spiculated mass in the left upper lobe ( arrow ). ( B ) CT lung screening from 4 years prior shows a 0.7 cm nodule in the same location ( arrowhead ). Bronchoscopic biopsy was positive for adenocarcinoma.

Colorectal cancer (CRC) mortality in the United States has decreased steadily since 2000 with screening colonoscopy showing a relative reduction in CRC death of 65%. ^, Initial USPSTF guidelines concluded with high certainty in 2016 that colon cancer screening for patients aged between 50 and 75 years has substantial net benefit (grade A). The earliest age to start CRC screening was revised down by the USPSTF to 45 years old in 2021, concluding with moderate certainty that there was a moderate benefit (grade B), a change that was also reflected by the most recent ACR Appropriateness Criteria.

While colonoscopy remains the gold standard of screening tests and is the only method that allows for the removal of precancerous and cancerous polyps, it is an invasive procedure that requires sedation. Incomplete colonoscopy rates range from 4% to 25% and are associated with an increased rate of developing interval proximal colon cancer. Common patient factors include incomplete bowel preparation, low body mass, and younger age. Common technical factors include tortuous colon and acute angulation that limits manipulation of the colonoscope, diverticulosis, and adhesions from prior surgery. These patients are suitable for evaluation with CT colonography (CTC), which requires the same bowel cleansing regimen as colonoscopy but can be performed without sedation.

CTC imaging guidelines and practice parameters have been developed by subject experts representing the ACR, Society of Abdominal Radiology, and Society for Advanced Body Imaging. Proper preparation for the study includes a cleansing laxative and an agent such as barium to tag residual stool to discern from soft tissue polyps and masses. The study is usually performed without IV contrast but can be given when there is an extracolonic indication such as disease staging. After insertion of a soft rectal tube, the patient is imaged in prone and supine positions after colonic distention, preferably by mechanical insufflation using carbon dioxide. Decubitus positioning can be used to ensure the luminal surface of each colonic segment is visualized or if the patient cannot tolerate being imaged in either the prone or supine position.

The ACR Practice Parameter suggests a size threshold of 6 mm for reporting polyps. Lesions smaller than 6 mm most likely represent adherent stool, benign tubular adenoma, or hyperplastic polyps that do not have risk for malignant transformation. Standardized reporting of CTC is detailed in a 2023 update of the CT Colonography Reporting and Data System. Common artifacts that affect CTC can be attributed to technical factors including motion artifacts, metallic artifact from adjacent clips or hip prosthesis, and retained stool or anatomic factors such as thickened colonic folds, sessile lesions, and diverticulosis. While most artifacts are visualized on both 2 dimensional (2D) and 3 dimensional (3D) images, most pseudolesions are only seen on 3D images and can be quickly dismissed since there is no 2D correlate. ^, Misinterpretation of pseudolesions on CTC will result in an unnecessary optical colonoscopy and its associated risks ( Fig. 3 ).

A 48 year old male patient with family history of colon cancer. ( A ) Supine and ( B ) prone CT colonography axial images obtained after air insufflation demonstrate a 2.2 cm semiannular soft tissue mass within the middescending colon ( arrows ). Pathology showed invasive adenocarcinoma.

Nearly 300,000 new cases of prostate cancer and 35,000 prostate cancer–related deaths were reported in 2024, ranking second only to lung cancer as a leading cause of death in male patients in the United States. Prostate cancer is a common but heterogenous disease. Diagnosed cancers can range from small, low-risk, incidentally discovered tumors that undergo active surveillance to high-risk, large, life-threatening tumors that require definitive management with chemoradiation, surgery, and systemic treatment. USPSTF recommends selectively offering prostate cancer screening to patients aged 55 to 69 years based on shared decision-making and patient preference (grade C). It does not recommend PSA-based screening for patients aged 70 years and older. The American Urological Association and Society of Urologic Oncology guideline on early detection strongly recommends prostate cancer screening every 2 to 4 years in patients aged 50 to 69 years and screening starting at the age of 40 to 45 years for patients at an increased risk for prostate cancer.

Serum PSA, digital rectal examination, systematic prostate biopsy, and pathologic evaluation of surgical specimens are all subject to various degrees of inaccuracy. MR imaging has emerged as a routine imaging test to detect lesions suspicious for clinically significant prostate cancer (grade group 2 or higher) while lowering the detection of insignificant disease prior to initial biopsy.

The first studies describing MR imaging of the prostate for cancer detection and localization were published in the 1990s and involved the use of an endorectal coil. In 2012, the Prostate Imaging Reporting and Data System (PI-RADS) was published, establishing a standardized protocol for multiparametric MR imaging (mpMRI) that combines T2-weighted images, diffusion weighted imaging (DWI), and dynamic contrast-enhanced images to characterize lesions within a 5 point scoring system. Studies show that PI-RADS successfully detects significant cancers at higher rates when lesions are assigned a higher score as well as having moderate-to-excellent interobserver agreement across different levels of reader experience and across institutions. ^, The most recent version of PI-RADS (version 2.1) was published in 2019.

Variable imaging technique and quality across different practice types is a limitation of mpMRI. Poor image quality was cited as one of the main causes of similar performance between MR imaging-guided and transrectal ultrasound-guided biopsies. PI-RADS minimum technical standards describe a standardized imaging protocol to limit image quality variance but were not widely adopted, with some standards achieving 17% adherence. Other studies showed that while a majority of sites performing prostate MR imaging had images of adequate quality, few were of high quality and there were considerably lower rates of adequate DWI images, even if there was adherence to PI-RADS minimum technical standards. The first standardized assessment of prostate imaging quality was published in 2020 and given the acronym PI-QUAL (prostate imaging quality scoring system). A revised version providing further refinement of the scoring system was published in 2024 ( Fig. 4 ).

A 75 year old male patient with elevated PSA. ( A ) Axial T2, ( B ) high b-value DWI, ( C ) ADC, and ( D ) early postcontrast images show a 1.6 × 0.3 cm ² lesion within the right posterolateral peripheral zone at the midgland ( arrows ). Pathology after transrectal ultrasound-guided prostate biopsy showed Gleason 7 (4 + 3) adenocarcinoma.

Pancreatic cystic lesions (PCLs) are frequently encountered incidental lesions on cross-sectional imaging studies. PCLs are more commonly seen on MR imaging compared to CT, on newer MR imaging systems, and in older patients. ^, As opposed to representing a widespread screening program, the incidentally found PCLs are considered a secondary finding that represents an increased risk of pancreatic cancer, and thus, the patient may enter a pathway of screening the pancreas due to the increased risk. A subset of PCLs have increased malignant potential and may either develop into pancreatic ductal adenocarcinoma (PDAC) or confer an increased risk of developing PDAC elsewhere in the parenchyma; the overall risk is very small. These precursor lesions are diagnosed through a combination of imaging, fluid analysis, and cytology, which then establishes the surveillance type and frequency. At least 5 major societal guidelines provide varying parameters for PCL surveillance and treatment recommendations, including the ACR, which published the most recent appropriateness criteria for PCLs in 2020. Because of limited data on long-term outcomes and incidence of PDAC in the pancreas, the recommended period of surveillance may vary drastically depending on the guidelines that are used. While the American College of Gastroenterology, European, and Fukuoka guidelines recommend lifelong surveillance, the American Gastroenterological Association guidelines suggest stopping PCL surveillance after 5 years of stability. The USPSTF provides no guidelines for PCL surveillance and does not recommend screening for pancreatic cancer in asymptomatic adults ( Fig. 5 ).

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