Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Making Lung Cancer Screening Work for High-Risk Australians

  Lung cancer screening is moving from evidence into routine healthcare, but implementation will determine whether the benefits reach the people most likely to develop the disease. Low-dose computed tomography (LDCT) can identify lung cancer at an earlier, more treatable stage, yet a scan alone does not create an effective screening service.

  Real-world delivery requires clear eligibility criteria, reliable risk assessment, accessible imaging, rapid follow-up and respectful communication. It also requires attention to people who may have limited contact with primary care, including rural residents, Aboriginal and Torres Strait Islander communities, people experiencing financial hardship and those who have stopped smoking but remain at elevated risk.

  In Australia, the National Lung Cancer Screening Program is reshaping expectations around early detection. Its rollout places greater responsibility on general practices, radiology providers, respiratory physicians, nurses and cancer services to create a coordinated pathway rather than treating screening as an isolated referral.

  For clinicians and health administrators, the central question is practical: how can a high-risk person move from identification to a timely, understandable and safe assessment, wherever they live?

  Defining High Risk Beyond A Single Smoking Question

  Age and smoking exposure remain central to lung cancer risk assessment. A detailed history should record current smoking, previous smoking, pack-years, years since quitting, occupational exposures and relevant personal or family history. A brief “smoker or non-smoker” question can miss people who qualify because they stopped smoking several years ago.

  A useful assessment also recognises that risk is shaped by cumulative exposure. Asbestos, silica and diesel exhaust may be relevant for construction workers, miners, transport workers and people employed in industrial settings. Chronic obstructive pulmonary disease and previous cancer can further influence clinical risk, although screening eligibility should follow the applicable national program criteria rather than informal judgement alone.

  Designing A Pathway That Patients Can Complete

  The screening journey should begin in general practice, community health services or other trusted points of care. Electronic prompts can identify eligible patients during health checks, respiratory reviews, smoking cessation appointments and medication consultations. Staff need a consistent process for documenting eligibility, discussing benefits and harms, obtaining consent and arranging LDCT.

  Access is a major implementation issue across Australia. A patient in metropolitan Sydney or Melbourne may have several imaging providers nearby, while someone in regional Queensland, Western Australia or the Northern Territory may face long travel distances and limited appointment availability. Mobile imaging, transport support, telehealth coordination and flexible booking can reduce these practical barriers.

  Making Imaging And Follow-Up Reliable

  LDCT screening depends on consistent image quality, appropriate protocols and radiologists experienced in recognising pulmonary nodules. The service should define how scans are reported, how incidental findings are managed and who contacts the patient. Clear timeframes are essential when a result requires repeat imaging, specialist review or diagnostic investigation.

  False-positive results can produce anxiety, unnecessary procedures and avoidable costs. A structured nodule management pathway helps distinguish findings that require surveillance from those needing prompt assessment. Multidisciplinary review involving radiology, respiratory medicine, thoracic surgery, oncology and pathology can support proportionate decisions, particularly when an abnormality is complex.

  Building Trust Through Culturally Safe Care

  Participation will depend on whether people believe screening is worthwhile, confidential and respectful. Some patients may associate medical imaging with a cancer diagnosis, while others may feel judged because of their smoking history. Conversations should explain that screening is for people without symptoms and that an LDCT result may be normal, indeterminate or require further review.

  Aboriginal and Torres Strait Islander patients may experience additional barriers linked to healthcare access, previous discrimination and distance from specialist services. Partnerships with Aboriginal Community Controlled Health Organisations, local Aboriginal health workers and community leaders can improve engagement. Information should be offered in plain English and adapted to local cultural and language needs.

  Privacy and consent also matter. Services must handle imaging, smoking history and follow-up information consistently with the Privacy Act 1988, Australian Privacy Principles and relevant state or territory health requirements. Trust is strengthened when patients know who will see their results, how they will be contacted and what happens if they move or change providers.

  Measuring Performance In The Real World

  A successful program should measure more than the number of scans completed. Important indicators include participation among eligible groups, time from risk assessment to imaging, time from abnormal result to specialist review, stage at diagnosis, treatment initiation and completion of recommended follow-up.

  Equity measures should be reported by location, socioeconomic status, Aboriginal and Torres Strait Islander status, age, sex and language needs where appropriate and lawful. A high participation rate in affluent metropolitan areas can conceal low uptake among people in remote communities or those without regular access to a general practitioner.

  Smoking cessation should be integrated into every screening encounter. Screening is an opportunity to offer nicotine replacement therapy, behavioural support and referral to Quitline services, without making cessation a condition of receiving care. The approach should recognise everyday realities, including shift work, vaping, household smoking patterns and the pressure faced by people in transport, mining and hospitality jobs.

  Practical Priorities For Screening Services

  • Create a single eligibility and referral checklist for general practice and community services.
  • Establish documented pathways for LDCT reporting, nodule surveillance and urgent specialist review.
  • Partner with Aboriginal health services and rural providers before launching local recruitment.
  • Track equity, follow-up and treatment measures alongside participation numbers.
  • Offer smoking cessation support at the same visit as risk assessment or imaging referral.

  Implementation also depends on the local healthcare market. Public hospitals may carry much of the diagnostic and specialist workload, while private radiology providers may deliver a substantial share of imaging in major cities. Clear agreements about reporting, costs, data transfer and follow-up responsibilities can prevent patients from being lost between sectors.

  The strongest model is a connected one: primary care identifies risk, radiology provides high-quality LDCT, specialist teams interpret significant findings and cancer services coordinate treatment. Every participating service should know the next step before the first scan is booked.

  A practical starting point is to audit one existing general practice or respiratory clinic pathway this month, recording how many eligible patients are identified, referred, scanned and followed through to a documented outcome.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)