LDCT screening for lung cancer in East Asian never-smokers: balancing benefits and overdiagnosis-related harms

East Asian never-smokers exhibit higher lung cancer incidence than their Western counterparts and account for roughly 40% of regional cases; nevertheless, they remain largely excluded from organised LDCT screening guidelines due to the absence of randomised evidence. Meanwhile, opportunistic LDCT has proliferated across East Asia, improving early detection while raising concerns regarding overdiagnosis. In this Viewpoint, we argue that ecological estimates may overstate overdiagnosis by overlooking evolving non-tobacco exposures and therapeutic advances, whereas targeted LDCT for well-defined high-risk never-smokers may yield net benefit if indolent lesions are managed conservatively. We therefore advocate for a risk-stratified, harm-conscious approach that avoids both indiscriminate expansion and categorical refusal, and propose four priorities: (i) population-specific risk stratification to refine screening eligibility; (ii) terminological reclassification of indolent lesions to reduce psychological and clinical burden; (iii) optimising the "surgical curative window" for early lung adenocarcinoma to minimise overtreatment; and (iv) accelerated randomised trials to inform East Asian-specific guidelines.