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This prospective, multicentre, randomized controlled trial tested whether immediate AI prioritization of primary care-requested chest X-rays (CXR) influenced time to computed tomography (CT) and lung cancer diagnosis, the primary outcomes. Secondary outcomes included the number of urgent suspected lung cancer referrals, incidence and stage of lung cancer, times to urgent referral and treatment, concordance between AI and radiology reports, and algorithm accuracy. AI was available in both study arms, with AI prioritization randomized by day. Of 97,731 participant CXRs, 4,405 were excluded due to data compliance issues or failure of randomization, resulting in 93,326 CXRs analyzed (45,987 and 47,339 in the prioritization \u2018on\u2019 or \u2018off\u2019 arms, respectively). A total of 13,347 CTs were identified, with 2,766 performed within 14 days of CXR. Median (interquartile range) times to CT were 53 days (17\u2013145) and 53 days (19\u2013141), with and without AI prioritization, corresponding to a ratio of geometric means of 0.97 (95% confidence interval (CI)\u2009=\u20090.93\u20131.02;\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.31). When restricted to CTs performed within 14 days of CXR, the median time to CT was 8 days (5\u201311) in both groups. Lung cancer was diagnosed in 558 people (0.6% of CXRs). Median times to diagnosis were 44 days (26\u201390) and 46 days (24\u2013105) respectively, with a ratio of geometric means of 0.98 (95% CI\u2009=\u20090.83\u20131.16;\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.84). No significant differences were observed in time to lung cancer referral (14 versus 15 days;\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.13), time to treatment (76 versus 72.5 days;\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.99) or stage at diagnosis (\n                    <jats:italic>P<\/jats:italic>\n                    \u2009=\u20090.34). Discordance between AI and radiology reports occurred in 28,261 CXRs (30.3%) and expert radiology review identified actionable findings in 6,750 cases (23.9%). AI prioritization of CXR requested by UK primary care has no significant impact on the lung cancer pathway. Therefore, CXR AI deployments should not include worklist prioritization in this context. Future research should differentiate between primary pathway changes and the direct impact of AI. ISRCTN registration:\n                    <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"https:\/\/www.isrctn.com\/ISRCTN78987039\" ext-link-type=\"uri\">78987039<\/jats:ext-link>\n                    .\n                  <\/jats:p>","DOI":"10.1038\/s41591-026-04253-5","type":"journal-article","created":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T10:02:06Z","timestamp":1774346526000},"page":"1737-1744","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["AI-based chest X-ray prioritization in the lung cancer diagnostic pathway: the LungIMPACT randomized controlled trial"],"prefix":"10.1038","volume":"32","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9598-189X","authenticated-orcid":false,"given":"Nick","family":"Woznitza","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lesley","family":"Smith","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9536-9809","authenticated-orcid":false,"given":"Janette","family":"Rawlinson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-6422-7752","authenticated-orcid":false,"given":"Iain","family":"Au-Yong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-8006-9575","authenticated-orcid":false,"given":"Bindu","family":"George","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3408-1411","authenticated-orcid":false,"given":"Madava G.","family":"Djearaman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arjun","family":"Nair","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8368-3406","authenticated-orcid":false,"given":"Richard W.","family":"Lee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6412-7516","authenticated-orcid":false,"given":"Neal","family":"Navani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siyabonga","family":"Ndwandwe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4676-1257","authenticated-orcid":false,"given":"Caroline S.","family":"Clarke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Creeden","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josh","family":"Newsome","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Indrajeet","family":"Das","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5031-111X","authenticated-orcid":false,"given":"Sylvia","family":"Abaokporo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Tucker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Hathorn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8410-7160","authenticated-orcid":false,"given":"David R.","family":"Baldwin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,3,24]]},"reference":[{"key":"4253_CR1","doi-asserted-by":"publisher","first-page":"378","DOI":"10.1136\/thoraxjnl-2020-216555","volume":"77","author":"M Araghi","year":"2022","unstructured":"Araghi, M. et al. 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He has received research grants from the National Institute of Health Research, Cancer Research UK, Horizon Europe, Ruth Strauss Foundation, SBRI, Innovate UK, Yorkshire Cancer Research, the Royal Castle Foundation, and UK Research and Innovation. N.W. declares consultancy fees from InHealth, Apollo Radiology (UK) and SMR Health & Tech unrelated to the current study and a travel grant from Qure.ai Technologies to attend the European Congress of Radiology 2023. R.W.L. is funded by the Royal Marsden National Institute for Health and Care Research (NIHR) Biomedical Research Centre and The Royal Marsden Cancer Charity; his institution receives compensation for time spent in a secondment role with NHS England for the Lung Health Check Programme and as National Specialty Lead for the National Institute for Health and Care Research; he has received research funding from Cancer Research UK, Innovate UK (cofunded by GE Healthcare, Roche Diagnostics, Optellum, Elliptica and RNA Guardian), SBRI (including as a co-applicant with Qure.ai), RM Partners Cancer Alliance and NIHR (including co-applicant on grants with Optellum); he has received honoraria, speaker and advisory fees, and\/or hospitality and travel expenses from Cancer Research UK, Roche Diagnostics, Johnson & Johnson, Guardant Health, AstraZeneca and King Faisal Specialist Hospital and Research Centre, Saudi Arabia; and he also undertakes private medical practice. These activities are unrelated to the present study, aside from the SBRI funding received in collaboration with Qure.ai. N.N. is supported by a Medical Research Council Clinical Academic Research Partnership (MR\/T02481X\/1). N.N. has also received grant funding from the National Institute of Health Research, Cancer Research UK, Horizon Europe, Ruth Strauss Foundation, and the Engineering and Physical Sciences Research Council. This work was partly undertaken at University College London Hospitals NHS Foundation Trust\/University College London, which received a proportion of funding from the UK Department of Health\u2019s NIHR Biomedical Research Centre\u2019s funding scheme. N.N. reports honoraria for nonpromotional educational talks, conference attendance or advisory board participation from Amgen, AstraZeneca, AXANA, BeiGene, Boehringer Ingelheim, Bristol Myers Squibb, EQRx, Fujifilm, Guardant Health, Intuitive, Janssen, Eli Lilly and Company, Merck Sharp & Dohme, Olympus Corporation, Roche and Sanofi. The remaining authors declare no competing interests.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}