Background:
The public health impact of lung cancer screening depends on equitable uptake across populations at risk. However, real-world implementation frequently results in geographic and sociodemographic disparities that limit effectiveness at scale. Population-based screening programs therefore require systematic, data-driven approaches to identify underserved groups and guide targeted implementation. In May 2022, British Columbia (BC) launched Canada’s first province-wide lung cancer screening program, providing a unique opportunity to evaluate whether program design translates into equitable access and population impact.
Objective:
To identify geographic and sociodemographic gaps in lung cancer screening participation relative to the underlying screen-eligible population, to inform equity-oriented implementation and outreach strategies.
Methods:
Screening participants aged 55–74 years enrolled between July 1, 2022 and June 30, 2023 were compared with newly diagnosed lung cancer patients in the same age range during the same period, used as a proxy for the screen-eligible population. Screening, diagnostic, treatment, and outcomes data were prospectively collected through a centralized provincial information system. Lung cancer diagnosis data were obtained from population-based administrative and cancer registry sources. Socioeconomic context was characterized using the Postal Code Conversion File Plus, the Canadian Index of Multiple Deprivation, and rurality classification. Real-world travel time by car to screening sites was calculated using open-source routing methods. Differences between screening participants and lung cancer patients were assessed using appropriate non-parametric tests for continuous variables and chi-square or Fisher’s exact tests for categorical variables.
Results:
During the study period, 5,240 individuals participated in lung cancer screening, and 1,314 lung cancer cases were diagnosed among individuals aged 55–74 years. Screening participation was significantly lower in one of five provincial health regions compared with the distribution of lung cancer cases (22.7% vs. 30.8%, p<0.0001) and was lower in rural areas compared with metropolitan and urban settings (p=0.039). Screening participants were younger (median age 66 vs. 68 years, p<0.0001), and more likely to be male (54.8% vs. 47.9%), with lung cancers diagnosed at earlier stages (Stage I/II: 72.2% vs. 31.9%, p<0.0001). No significant differences were observed by neighbourhood income or the Canadian Index of Multiple Deprivation. Geographic access to screening was high overall, with 92.1% of participants residing within 59 minutes’ drive of a screening site. Importantly, lower participation in the underperforming health region was not explained by travel time, indicating the presence of modifiable non-geographic barriers to screening uptake.
Conclusion:
 This study demonstrates how population-level data linkage can be operationalized to guide equitable implementation of lung cancer screening in real-world programs. By explicitly identifying where screening uptake diverges from underlying need—and showing that some participation gaps are not driven by geographic access—this approach shifts policy focus toward modifiable implementation barriers such as outreach, referral pathways, engagement strategies and targeted expansion of CT scanning capacity to maximize public health impact of screening. This scalable, data-driven model provides a practical template for policymakers and screening programs to prioritize underserved populations, allocate resources strategically, and evaluate the impact of targeted interventions over time.