Background
Lung cancer remains a leading cause of cancer mortality worldwide, with particularly poor outcomes in low and middle income countries (LMICs) due to late-stage diagnosis, limited screening infrastructure, and competing health system priorities. While low-dose computed tomography (LDCT) screening has been shown to reduce lung cancer mortality in high-risk populations, implementation in LMIC settings remains challenging. There is limited real-world evidence on how risk-based lung cancer screening models can be adapted, governed, and sustained within resource-constrained health systems.
Objectives
The Iraq Healthy Lung Project (IHLP) was established to pilot a context-appropriate, risk-stratified Lung Health Check (LHC) model for early lung cancer detection in Iraq. The programme aims to evaluate the feasibility, safety, and service impact of LDCT screening when guided by validated risk prediction tools and embedded within a structured governance framework suitable for LMIC settings.
Methods
IHLP targets adults aged 50–79 years with a history of smoking, using objective eligibility criteria (≥20 pack-years, Liverpool Lung Project v3 [LLPv3] ≥1.5%, or PLCOm2012 ≥1.5%) to prioritise LDCT utilisation. Clinical implementation, governance, and operational leadership are delivered by the Authority of Health and Medical Education (AHEAD), Iraq, through Warith International Cancer Institute (Karbala) and Al-Thaqalayn Oncology Hospital (Basra). The programme applies standardised LDCT protocols, conservative nodule management thresholds, and clearly defined escalation pathways to multidisciplinary teams. Centralised oversight, protocolised workflows, and quality assurance mechanisms were embedded to support consistency and scalability across variable infrastructure. Smoking cessation referral pathways were integrated as a core preventive component (Figure 1).
Results
Between May 2024 and December 2025, 657 individuals were enrolled, of whom 207 (32%) were classified as high risk and referred for LDCT. Among 147 participants with available scan results, 75 (51%) had no detectable nodules, 47 (32%) had nodules below diagnostic thresholds, and 25 (17%) had indeterminate nodules managed through structured surveillance rather than immediate specialist referral. One potential baseline-detected lung cancer is currently undergoing multidisciplinary evaluation. These findings demonstrate that screening demand and downstream services can be managed within constrained specialist capacity when risk stratification and conservative clinical thresholds are applied.
Conclusion
IHLP demonstrates that LDCT-based early lung cancer detection is feasible in LMIC settings when underpinned by risk stratification, strong governance, and pragmatic clinical pathways. The programme identifies key enablers for LMIC implementation, including prioritised resource allocation, institutional leadership, integration with existing services, and longitudinal data collection. By generating locally relevant evidence and evaluating international risk models in a real-world LMIC context, IHLP provides a transferable framework to inform national lung cancer early detection policy in Iraq and similar settings.

Flowchart of IHLP Targeted Lung Health Check protocol