Lung cancer remains the leading cause of cancer-related death globally. In 2020, it accounted for an estimated 20 percent of all cancer-related deaths in the European Union, creating enormous pressure on health systems to find ways to detect the disease earlier when treatment is more effective.
Low-dose computed tomography has emerged as the screening tool of choice following two landmark trials. The National Lung Screening Trial and the Dutch-Belgian NELSON trial both demonstrated that LDCT screening can reduce lung cancer mortality in high-risk populations, providing the clinical evidence base that has driven policy discussion across Europe.
The EU Beating Cancer Plan in 2022 formally endorsed lung cancer screening as a priority, and a European Council recommendation encouraged member states to act. Despite this political backing, only three European countries had implemented formal national programs by the time of this study: Croatia and Poland in 2020 and England in 2023.
Even in countries that have launched programs, barriers persist. England faces workforce shortages, with only 8.8 CT scanners per million population compared to the OECD average of 29.5, and concerns about radiologist attrition are mounting as the program attempts to scale.
The study developed a structured framework with five dimensions to systematically assess the readiness of each country for lung cancer screening implementation. The dimensions are: policy prioritization and governance, clinical review, program design, implementation, and awareness. Each country was qualitatively scored as requiring low, medium, or high levels of action on each dimension.
Ten countries were selected to represent the full spectrum of implementation stages: Belgium, Croatia, England, France, Germany, Greece, Italy, Poland, Spain, and Sweden. Countries with active programs, ongoing pilots, and those still in exploratory stages were all included to allow cross-stage comparisons and identification of transferable lessons.
A literature search covering PubMed, government reports, NGO publications, and media reports through October 2024 was conducted in both English and local languages, yielding 128 documents included in the analysis. Studies published before 2015 or entirely theoretical in nature were excluded.
The framework assessment was validated through semi-structured one-on-one interviews with twelve country-specific experts representing policy, academic, and patient advocacy perspectives. Expert feedback was directly incorporated into the final country profiles and gap assessments.
Countries were categorized into three groups based on their implementation status. Croatia, England, and Poland form the ongoing and optimizing group with active publicly funded programs. By September 2024, England had performed 589,292 scans and diagnosed 5,271 lung cancers. Croatia had screened 22,000 people, and Poland had performed 16,946 LDCT scans.
A second group of ongoing pilot countries includes Belgium, Germany, Italy, Spain, and Sweden. Germany legalized lung cancer screening through a federal ordinance in July 2024, with a reimbursement decision pending from the Federal Joint Committee. Italy and Spain launched national academic pilots in 2021 and 2023 respectively, while regional pilots in Sweden and Belgium are expected to yield results in 2026 and 2027.
France and Greece are classified as exploratory countries still planning their first local pilots. France's National Cancer Institute was tasked with conducting a national pilot anticipated for 2025 to 2030. In Greece, pilot launches across four hospitals announced for 2023 were delayed with uncertainty about a start date.
Program design varies dramatically across countries, with eligible age ranges spanning 50 to 80 years in Spain versus the narrower 55 to 74 years in England and Sweden. Minimum tobacco pack-year requirements range from 15 to 30, and required years since quitting ranges from 10 to 20 years, creating a fragmented eligibility landscape across Europe. Only England currently uses a formal risk prediction model for eligibility determination.
Political prioritization is the single most critical barrier. In six of the seven pilot and exploratory countries, generating political momentum remains a critical gap. Belgium, Greece, Spain, and Sweden have not even included lung cancer screening commitments in their national cancer plans, limiting the government accountability structures needed to drive progress.
Clinical review gaps affect six of the ten countries. Most accepted the NELSON and NLST trials but required local data to support positive recommendations, creating a catch-22 where political will is needed to fund the local evidence that in turn generates political will. Italy has not published any formal evaluation of the international landmark trials at all.
Program design is stalled or progressing minimally in several countries. Spain's HTA body cited a lack of local cost-effectiveness data as a reason for a negative recommendation in 2023, and Greece needs to generate its own cost-effectiveness evidence through pilots before decision-makers will commit resources.
Implementation is the most underdeveloped dimension across all countries. Even in England, Croatia, and Poland where programs are active, there are unresolved concerns about whether infrastructure can sustain program expansion and whether downstream services for newly detected cancer cases have adequate dedicated funding.
Awareness represents a critical gap in three countries for physician training and four countries for public awareness. Knowledge of lung cancer screening remains concentrated among respiratory and radiology specialists, limiting primary care uptake, while public stigma around lung cancer continues to suppress participation rates.
Countries that have implemented programs share a pattern of political commitment translated into concrete national goals. In Croatia and England, lung cancer outcome targets were incorporated into national health plans, establishing a clear goalpost and elevating screening as a tool to address the pressing mortality burden rather than treating it as a peripheral issue.
A local network of well-connected medical and patient champions was consistently present in successful countries. In Poland, clinical experts published a consensus paper for implementation recommendations. In Croatia, the thoracic society and radiology group directly shaped national guidelines. Patient groups in England participated in the National Screening Committee, gaining a formal role in decision-making.
Countries that overcame the local evidence requirement succeeded by designing pilots specifically to generate decision-making data. Germany's HANSE feasibility study compared the NELSON and PLCOm2012 risk scores and concluded that PLCOm2012 was more reliable for the German context, providing the specific local evidence needed to move forward.
The decentralization of healthcare in countries like Belgium, Spain, and Sweden creates additional complexity. When screening decisions are made at regional rather than national level, programs can emerge in some regions while others remain without any initiative, creating inequitable access patterns as seen with colorectal cancer screening in Belgium where implementation in one region lagged another by over a decade.
Political will is the first and most critical prerequisite for any national lung cancer screening program. Governments must explicitly incorporate lung cancer as a national health priority through measurable outcome targets in national cancer control plans, creating the accountability framework that elevates screening from a debate topic to a funded commitment.
Committed funding to support local feasibility pilots is essential in countries where decision-making bodies require domestic evidence. While Croatia showed that international clinical data can in some cases be sufficient for a positive recommendation, most European health systems require locally generated data to justify investment, making pilot funding a necessary upstream step.
A local network of well-connected experts from both patient and clinical communities is needed to sustain political momentum. These champions must evolve beyond raising awareness to playing active advisory roles in screening committees and contributing directly to the design and operationalization of pilot programs.
Scalability planning must begin at the pilot stage, not after national rollout is announced. Countries need to plan explicitly for how they will expand pilot programs, secure long-term funding channels, and build the downstream capacity for cancer care services that will inevitably surge as more lung cancers are detected at earlier, more treatable stages.