FormalPara Key Points

  • Limited evidence addresses barriers to lung cancer screening (LCS) among Indigenous peoples.

  • Barriers to LCS include limited awareness, communication difficulties, low health insurance coverage, financial concerns, mistrust of health services, time constraints, insufficient capacity of LCS programs, distance to LCS, inaccessible buildings, and lack of culturally informed guidelines.

  • Evidence related to enablers for LCS among Indigenous peoples is important but remains underinvestigated.

  • Strategies to improve LCS include increasing program awareness, expanding program capacity and access, scaling up health insurance coverage, understanding Indigenous peoples’ communication preferences, offering training for health professionals, using co-design principles and practices, funding, and promoting inclusive research efforts.

Lung cancer is the most common cancer and the leading cause of death worldwide. Indigenous peoples are more likely to be diagnosed and die from lung cancer than their non-Indigenous counterparts [1]. Lung cancer screening (LCS) is a core strategy to enhance early lung cancer detection, which has the potential to reduce disparities in lung cancer outcomes [2]. A key advancement in the early detection of lung cancer is the use of low-dose computed tomography (LDCT). Several countries have initiated national or regional LCS programs using LDCT, with other countries expected to follow. Australia has committed to a national LCS program, which is due to commence in July 2025 [3].

Due to the elevated risk of lung cancer among Indigenous peoples, LCS programs should be designed and implemented in ways that enable equity of access and participation. For this reason, potential barriers and methods to support Indigenous peoples’ participation need to be identified during LCS program development. Here, we describe the limited international literature regarding LCS participation, barriers, and potential strategies to improve LCS uptake among Indigenous and Tribal peoples worldwide.

The LCS participation rate among Indigenous peoples worldwide is underreported, with limited evidence from the United States and Canada [4,5,6]. In 2023, 4.7% of American Indian or Alaska Native veterans participated in LCS [4]. Of all individuals reported to have screened at Ontario Health LCS sites, 5.5% (174/3178) were Indigenous Canadians [6]. Given that Indigenous Canadians constitute 2.9% of the Ontario population, this finding may be cautiously and optimistically interpreted.

Barriers to Lung Cancer Screening Participation

Multiple barriers to LCS participation have been extensively described for general populations [7]. These include lack of health insurance, other financial concerns, low awareness of LCS, limited access to LCS information, low educational attainment, fear of cancer, time constraints, communication barriers, low screening facility capacity, and limited accessibility (due to transportation issues and distance to LCS services, especially in remote and rural areas). Factors shown to enable LCS include mobile screening initiatives, referrals by healthcare providers, relevant LCS advertising (e.g., mailing), community acceptance, positive peer pressure for screening, availability of educational materials, and patient navigator assistance [7].

For Indigenous and Tribal populations, however, evidence of enabling factors is lacking, and limited evidence addresses the barriers and potential strategies to improving LCS participation [7,8,9]. Critically, none of the randomized controlled trials used to develop LCS guidelines in the United States reported the effectiveness of LCS by Indigenous status; thus, such data were not available to inform US LCS programs and guidelines [10].

Barriers identified by Indigenous people include a lack of health insurance awareness and coverage, as well as other financial challenges, including transportation costs and loss of earnings associated with attending screening [10]. Likewise, the distance to LCS services challenges timely access and may contribute to reduced participation [7,8,9].

Additional barriers identified as relevant for healthcare providers or screening programs in the United States include inadequate LCS service workforce and program resources, low levels of awareness of LCS among health professionals, poor communication between health professionals and patients, and insufficient time allocated to LCS appointments [9]. Patients may also experience challenges in navigating the health system. Cancer screening programs, which typically involve multiple touch points (including assessing eligibility, screening, result notification, and follow-up) may be particularly complex and cause confusion. Additionally, patients may have difficulty navigating physical buildings, if unfamiliar with the city and hospital grounds where screening typically occurs [7, 9].

At an individual level, a lack of awareness of lung cancer or LCS and time constraints may prohibit making and attending LCS appointments [7,8,9]. This may be exacerbated by a lack of LCS information in Indigenous languages. One study reported that only 3% (7/257) of websites containing LCS information gave options for non-English language resources [8].

Psychological factors (e.g., fear of cancer diagnosis and distress associated with undergoing the screening test and attending follow-up appointments) and concerns regarding LCS effectiveness have been reported by Indigenous patients [9]. Designers of LCS programs should also recognize the mistrust of sociopolitical institutions, including healthcare systems, felt by many Indigenous peoples as a result of colonization, systemic and interpersonal racism, and cultural insensitivities [9, 11]. Barriers and possible strategies to enhance LCS participation relevant for Indigenous peoples are summarized in Fig. 38.1 [7, 9, 12].

Fig. 38.1
A table has 2 columns for barrier to L C S and potential strategies for L C S. Barriers to L C S include limited awareness, financial concerns, and mistrust of health services. Potential strategies for L C S include increase awareness and expand L C S program capacity and access.

Summary of barriers to lung cancer screening and strategies to improve screening uptake

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Opportunities to Increase LCS Participation Rates

Ensuring optimal levels of LCS participation among Indigenous peoples is possible [7, 9, 12]. Health systems need to consider their capacity for supporting Indigenous LCS participation. As shown in Fig. 38.1, key strategies may include increasing individual awareness via LCS awareness campaigns, co-designing tailored and inclusive health education resources, advancing healthcare providers’ LCS knowledge, improving identification and referral for the screening of eligible individuals, improving staff communication skills, and providing culturally safe practices in LCS. Services must also ensure that physical LCS facilities are accessible to all and that program staff and health professionals are culturally competent and have built trusting relationships with Indigenous people, families, and communities in their service area. This may be achieved through implementing a service provision model that includes recruiting Indigenous health professionals, expanding health insurance coverage and options, and encouraging and funding further research to enhance monitoring and evaluation.

It is crucial to strengthen awareness-raising campaigns for the general public by including relevant information on the benefits of LCS, what to expect from the screening program, where to find a local LCS service, and cost and insurance options [7, 9]. Additionally, improving communication through multilingual interpreters and multiple language information and education resources could further boost LCS participation. Advocating for adequate resources for health service managers and health professionals ensures sufficient time and appropriate staff availability to support optimal LCS for Indigenous patients [7, 9].

Successful implementation of an LCS program requires education and training resources for health professionals both in general practice and LCS-specific services. This should include cultural competency training to improve the understanding of Indigenous peoples’ cultural values and perspectives and how these relate to LCS testing and care. In particular, training is required to ensure the determination of patient eligibility for LCS programs and the communication of outcomes to patients. Indigenous peoples’ communication preferences need to be considered by LCS services; for instance, Indigenous peoples in the United States often prefer written notification of screening results [7, 9].

To ensure that the most marginalized in society participate in LCS, governments need to identify and implement sustainable funding schemes to cover costs associated with LCS participation. Such costs may include travel and parking costs, loss of income incurred while attending screening, and childcare. Likewise, existing health insurance schemes that cover LCS need to be identified and communicated to the general population [7, 9].

Expanding LCS programs by providing mobile outreach screening programs may help overcome distance barriers experienced in more rural and remote areas [7, 12]. Moreover, placing LCS facilities in community health services (e.g., Aboriginal Community Controlled Health Services in Australia) may help overcome barriers relating to system and service mistrust as patients typically are more familiar with and trust these services and their staff [12].

Increasing the capacity of LCS facilities to provide information, education, and psychosocial support can help enhance LCS participation [7, 13]. This may be achieved through increased staffing, developing education information and educational resources, and using technological support during referral and follow-up appointments (e.g., embedding an automatic reminder system into the LCS program). In the United States, LCS programs with these resources had higher monthly screening rates (17.7 per 1000 eligible persons) than those without (0.3 per 1000 eligible persons) [13].

Another strategy to enhance the effectiveness and efficiency of LCS programs could involve research. Strengthening cancer screening registries, which are an important element of screening programs, can be achieved by establishing data collection at the point of service. Indeed, most existing LCS screening participation studies from the United States and Canada used administrative databases, such as LCS registers, as the primary sources of data [5, 6]. However, the availability and usability of such data sources could be affected by factors including limited infrastructure to collect and maintain data (particularly in low- and middle-income countries) [14], as well as variations of data release policies for research across countries [15]. Moreover, for such data to be reliable, Indigenous identification information must be collected completely and accurately recorded [5, 6]. Administrative databases are not primarily collected for research purposes. As a result, they cannot provide comprehensive data on individual, provider, or system-level factors related to LCS. Therefore, strengthening ongoing initiatives to commence, maintain, and further expand Indigenous-focused clinical trials and prospective cohort studies can support the implementation, monitoring, and evaluation of LCS services.

Conclusion

LCS programs must be designed to be relevant for those with the greatest need if they are to work for the broader society. To do so, Indigenous communities must be engaged in the design and implementation of LCS programs, guided by principles of co-design [11]. By embracing from the outset the insights and cultural backgrounds of stakeholders, and Indigenous community members in particular, culturally responsive LCS programs may be developed to overcome LCS barriers. Notably, in Australia, a trial is underway to investigate the feasibility of an LCS program for Indigenous Australians, which can inform the new Australian program due to launch in 2025 [16].