A Game-Changing 20 Years: Progress and Future Directions in Lung Cancer Screening

In the past two decades, lung cancer screening (LCS) with low-dose computed tomography (LDCT) has emerged as one of the most effective strategies for reducing lung cancer mortality. Landmark trials, including NLST and NELSON, demonstrated mortality reductions exceeding 20%, establishing LDCT as the standard of care for early detection in high-risk populations. Currently, 13 countries have implemented national or regional LCS programs, with additional nations preparing for rollout. Advances in risk-prediction models, volumetric nodule assessment, and structured management protocols have improved precision and efficiency. Integration of artificial intelligence is enhancing nodule detection, prediction of malignancy risk, individualized screening intervals, and workflow optimization. Real-world evidence confirms improved stage distribution and suggests reduction in lung cancer mortality. Initiatives such as promoting community engagement, equitable access through geospatial mapping, and mobile screening will improve screening uptake and retention. Embedding tobacco dependence treatment within LCS further augments life-years gained. Complementary incidental pulmonary-nodule programs and expanding studies in people who have never smoked are extending the reach of early detection, whereas biomarker research is progressing toward integration with imaging-based screening. The potential to use LDCT scans to detect coronary heart disease and chronic obstructive pulmonary disease may have a major impact on future health care benefits. Ongoing efforts to harmonize data collection standards, establish quality indicators, and strengthen workforce training are essential to sustain high-quality implementation. As LCS evolves into a cornerstone of lung cancer control, continued innovation in risk stratification, imaging technologies, and biomarker integration will be key to maximizing global benefit and equity.