Table 1.

Barriers to lung cancer screening implementation and proposed solutions

Key problem	What is the barrier to implementation?	What is the solution?
1. NNS	• Higher false-positive rates and decreased cost effectiveness if the inclusion criteria are too broad	• Use of risk prediction models rather than just age and smoking cut-offs to better guide who should be screened (UKLS)
2. Radiation exposure	• Estimates suggest 1 radiation-induced lung cancer for every 22 lung cancer deaths prevented • Positron emission tomography-CT in the investigation of false-positive lesions increases radiation dose	• Low-dose CT reduces radiation dose to around one-fifth of conventional CT • Clear selection criteria for screening and robust nodule management guidelines will reduce false positives
3. False-positive scans	• In NLST, there were around 25 benign lesions for every cancer detected, with psychological and possible physical harm from further investigations	• Volumetric nodule assessment employed by NELSON and UKLS to better assess nodules and reduce false positives • Risk assessment models to guide who should be screened
4. Overdiagnosis	• Estimates suggest 10–20% overdiagnosis with screening again with associated physical and psychological harm	• Clear nodule guidelines, with a cautious approach to subsolid nodules (more likely to represent more indolent tumours)
5. Smoking cessation	• Concern regarding false reassurance with screening leading to continued/new uptake of smoking	• Combination of screening with smoking cessation programmes • Somewhat reassuring smoking cessation results from NLST (but substantially higher smoking cessation in both arms than in background rates)
6. Cost effectiveness	• Some models based on NLST are too expensive	• Careful and clear guidance regarding management of positive/indeterminate CT results • Risk profiling of the screened population to reduce the NNS • Multiple health interventions including smoking cessation
7. Hard-to-access groups	• Work suggests that those at highest risk of developing lung cancer are least likely to participate in/complete screening programmes, with consequent cost effectiveness implications	• Research is ongoing to determine how best to engage and retain these high-risk and hard-to-access groups

NLST, National Lung Screening Trial; NNS, number needed to screen; UKLS, United Kingdom Lung Screen.