Lung cancer is the deadliest cancer worldwide. It is the second most prevalent cancer globally and the leading cause of cancer deaths, with particularly high rates among Asian men and East Asian women. Early detection is the most powerful tool for improving outcomes: five-year survival rates exceed 77% at the earliest stage (IA) but drop to just 10% at advanced stage IVA.
LDCT screening saves lives. Low-dose computed tomography (LDCT) scanning has been shown in landmark trials - including the US National Lung Screening Trial (NLST) and the European NELSON study - to significantly reduce mortality from lung cancer. Unlike standard chest X-rays, LDCT can detect small nodules early enough to enable curative treatment.
Uptake is the limiting factor. Even highly effective screening programs can only reduce mortality if people actually participate. Understanding who is getting screened, who isn't, and why is essential for improving program design and targeting outreach efforts - especially in Asia, where lung cancer burden is high but population-level screening data have been limited.
A gap in Asian data. Despite substantial investment in lung cancer screening across Asian countries, no comprehensive pooled analysis had previously examined LDCT uptake rates or their determinants specifically for Asian populations. This systematic review and meta-analysis was conducted to fill that gap.
Comprehensive literature search. Researchers searched four major databases - PubMed, Embase, Cochrane, and Web of Science - for studies published between January 2011 (after the NLST results were released) and October 2025. Search terms covered lung cancer, cancer screening, LDCT, Asia, and participation, with no language restrictions applied.
Study selection and data extraction. From an initial pool of 794 articles, 35 studies involving 1,716,756 participants were ultimately included after removing duplicates and applying predefined eligibility criteria. Two researchers independently screened and extracted data, with disagreements resolved by consensus or a third reviewer. Only studies reporting first-round LDCT uptake rates and/or associated determinants were included.
Statistical approach. A random-effects model was used to pool uptake rates across studies, accounting for expected variation between settings and populations. The Freeman-Tukey double arcsine transformation was applied to stabilize variances. Subgroup analyses explored how program characteristics (sample size, setting, time period) affected uptake. Odds ratios were calculated for patient-level factors influencing participation.
Study quality assessment. Studies were evaluated using the Newcastle-Ottawa Scale, which assesses selection quality, comparability, and outcome measurement. Of the 35 included studies, 14 were rated high-quality and 20 moderate-quality; the Egger test confirmed no significant publication bias. The majority of studies were conducted in China (32 of 35), with the remainder from South Korea and Kazakhstan.
Pooled uptake rate of 46%. Across all 35 included studies, the pooled LDCT uptake rate for lung cancer screening in Asia was 46% (95% CI: 41-51%). This means roughly half of eligible individuals identified as high-risk actually completed the screening scan - a rate that varies considerably across settings and time periods.
Wide variation between programs. Individual study uptake rates ranged from as low as 27% to as high as 82%, reflecting substantial differences in program design, geographic context, and population characteristics. This wide range indicates that there is significant room for improvement and that context-specific factors matter considerably.
Academic versus community settings. Programs conducted in academic hospital settings had substantially higher uptake rates (68%) compared to those in community settings (43%). This gap mirrors findings from Europe and North America, where academic pilot programs achieved uptake rates of 85-89%. Academic settings likely benefit from stronger institutional infrastructure, dedicated staff, and closer patient-provider relationships.
Improvement over time. LDCT uptake rates have increased significantly over the years covered by this review - from 35% in the 2011-2015 period to 52% in the 2021-2025 period. This trend likely reflects growing public awareness of lung cancer screening, improved program infrastructure, and broader implementation of national cancer screening guidelines across Asia.
Health risk awareness drives participation. Individuals with a family history of lung cancer were nearly twice as likely to participate in screening (OR 1.95), and those with chronic respiratory diseases like COPD showed similarly elevated odds (OR 1.97). People with harmful occupational exposures - such as those working with asbestos, radon, or industrial chemicals - also had 48% higher odds of participating (OR 1.48).
Secondary risk factors also increased participation. Individuals exposed to passive (secondhand) smoking were 43% more likely to be screened (OR 1.43), and alcohol drinkers had a 20% higher likelihood of participation (OR 1.20). Those with higher BMI (above 24) were also somewhat more likely to participate (OR 1.12), possibly because overweight individuals have more frequent healthcare contacts where screening could be recommended.
Education is an important enabler. People with 12 or more years of education were 35% more likely to undergo LDCT screening (OR 1.35). Higher educational attainment is associated with greater health literacy, stronger preventive health behaviors, and more proactive use of healthcare services - all of which likely contribute to increased screening participation.
Implications for targeted outreach. Taken together, these facilitating factors suggest that individuals who are already aware of their elevated risk - through family history, occupational exposure, or chronic disease - are more likely to act on screening recommendations. Programs that effectively communicate individual risk to high-risk individuals may be best positioned to improve uptake.
Smokers are less likely to be screened - a critical paradox. Despite being at the highest risk for lung cancer, current and former smokers had 24% lower odds of participating in LDCT screening compared to non-smokers (OR 0.76). Research suggests this reflects fear of a cancer diagnosis, stigma associated with smoking, and psychological distrust of their own risk - factors that must be addressed through targeted communication and support strategies.
Men participate less than women. Despite higher lung cancer incidence in men, male participants were 39% less likely to undergo screening than women (OR 0.61). This counterintuitive finding is consistent with research from other countries and likely reflects well-documented patterns where men tend to engage less with preventive healthcare services than women.
Middle-aged individuals are less likely to participate than older adults. People in middle age had slightly lower screening odds compared to older adults (OR 0.92). This may reflect competing demands on time and attention, lower perceived urgency of cancer risk, or less frequent healthcare engagement compared to older populations who already have regular medical appointments.
Regular exercisers are less likely to be screened. Individuals who exercised frequently had lower odds of participating in screening (OR 0.89). This may reflect a "healthy invincibility" bias - people who feel healthy due to active lifestyles may underestimate their lung cancer risk or feel less urgency to seek preventive care, even if other risk factors are present.
Smaller programs achieve higher uptake. Analysis by sample size showed a clear inverse relationship - smaller screening programs consistently achieved higher uptake rates. Programs enrolling around 100 participants showed the highest rates, while those enrolling 100,000 or more showed substantially lower rates. This finding suggests that large national screening programs may benefit from being organized into smaller, locally managed units to preserve the community engagement that drives participation.
A distributed model for dense populations. The authors propose that large-scale screening initiatives in high-density Asian cities could be organized as networks of smaller, standardized screening units embedded within community hospitals and primary care clinics. Each unit would manage the full screening pathway - outreach, scanning, result reporting, and follow-up - while operating under a unified quality framework. This approach could replicate the effectiveness of academic settings within community infrastructure.
Addressing the smoker paradox requires targeted intervention. Because smokers are both the highest-risk group and the least likely to participate, screening programs need specific strategies to engage this population. This may include framing screening as an opportunity for early intervention rather than diagnosis, reducing stigma, and offering integrated support services for smoking cessation alongside screening.
Gender-sensitive approaches are needed. Men's lower participation rates despite higher disease burden represents a major opportunity for improvement. Strategies specifically designed to engage men - including workplace-based outreach, peer-led programs, and male-focused health communication - may help close the gender gap in screening uptake.
LDCT screening uptake in Asia is moderate but improving. The overall 46% uptake rate indicates that lung cancer screening is reaching a significant portion of eligible high-risk individuals in Asia, but nearly half of those identified as high-risk are not being screened. This gap represents a major opportunity to reduce lung cancer mortality through improved program implementation.
Community settings need enhancement. The gap between academic (68%) and community (43%) uptake rates highlights that real-world implementation lags behind what can be achieved in well-resourced research settings. Bringing community program design closer to academic standards - through standardized protocols, dedicated staff, and systematic follow-up - could meaningfully improve real-world screening coverage.
Key populations require focused attention. Smokers, men, and individuals with lower educational attainment are systematically underrepresented in screening programs, yet these groups carry disproportionate disease burden. Targeted outreach, culturally appropriate messaging, and removal of logistical and psychological barriers are essential to reaching these populations.
Study limitations and future directions. The review is primarily based on Chinese data, limiting generalizability across the diverse Asian region. Unmeasured factors including insurance coverage, income level, and cultural beliefs may influence uptake in ways not captured by available data. Future research should examine region-specific barriers within Asia and evaluate whether specific interventions - such as patient navigation programs or incentive structures - can increase participation among underserved groups.