• Lung Cancer
• Imaging/CT MRI etc
• COPD epidemiology

Commonly in medicine we encounter situations where a potential intervention may not be in the patient’s best interests due to the balance of benefits and harms. In screening, there is the additional goal of the intervention being beneficial to the screened population as a whole.1 With the recent endorsement from the UK National Screening Committee for lung cancer screening (LCS) with low-dose CT (LDCT) in the UK,2 and with LCS efforts stepping up worldwide, it is imperative we understand how best to offer screening to the ‘correct’ individuals.

The benefits of LCS have been well demonstrated in the literature, most notably in the National Lung Screening Trial (NLST) and the Nederlands-Leuvens Longkanker Screenings Onderzoek study.3–5 The overall relative reduction (RR) in lung cancer-specific mortality is estimated at 21% and certain groups (eg, women) may benefit from LCS more than others. Eligibility into many of the randomised studies was by age and smoking history and, as with many research studies, there was a degree of selection bias that favoured recruitment from more affluent and educated individuals. Almost a decade ago, studies using NLST data demonstrated that focusing on those at higher risk of lung cancer could lead to a better screening efficacy, efficiency and cost-effectiveness and reduce screening-related harms.6 7 Later studies supported the use of lung cancer risk prediction scores to better select individuals to LCS, and enhance benefit–harm balance to individuals and populations.8 9

Results from ‘real-world’ LCS studies, focusing on recruitment of socioeconomically deprived individuals reported higher smoking and lung cancer prevalence, and demonstrated the feasibility of LCS in these populations without compromising early stage diagnosis and curative intent treatments.10–12 These studies have also reported high prevalence rates of ‘undiagnosed’ chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) risk in …