Cost-effectiveness of lung cancer screening: insights from risk stratification, guidelines, and emerging technologies—a systematic review

Lung cancer is the leading cause of cancer-related mortality worldwide, with most patients diagnosed at advanced stages. Early detection through screening can significantly reduce mortality, making cost-effectiveness evidence crucial for guiding policy decisions. This systematic review aimed to evaluate the cost-effectiveness of lung cancer screening across various modalities, populations, and settings. A comprehensive search of PubMed, EMBASE, Web of Science, and Cochrane Library was conducted for studies up to March 18, 2025, adhering to PRISMA guidelines. A total of 79 studies from 21 countries were included, with model-based analyses prevalent and 89.9% rated as high quality. Low-dose computed tomography (LDCT) emerged as the primary screening modality, although evidence on artificial intelligence (AI) and biomarkers is limited. Fourteen studies comparing LDCT with no screening showed incremental cost-effectiveness ratios (ICERs) ranging from $8376 to $200,921 per quality-adjusted life-year (QALY) gained. Notably, 90.3% of LDCT strategies were cost-effective by national thresholds, particularly in older adults and high-risk groups. Biennial screening often proved more cost-effective than annual in many scenarios. Overall, LDCT screening demonstrated favorable cost-effectiveness, necessitating further evaluation for emerging technologies in underserved regions.