Willingness to Participate in a Program for the Early Detection of Lung Cancer With Low-Dose Computed Tomography

Data from a representative survey (DEBRA)

On 18 June 2025, the German Federal Joint Committee decided to implement lung cancer screening by means of low-dose computed tomography (LDCT), with a planned starting date of April 2026. This kind of screening procedure has the potential to reduce mortality due specifically to lung cancer and perhaps also all-cause mortality (1). The following eligibility criteria were determined: age 50–75 years, ≥ 15 pack years during at least 25 years of smoking, and, for former smokers, abstinence from smoking for no longer than 10 years. However, analysis of participation rates from the USA arouses concerns regarding sufficient future uptake in Germany (2). The purpose of this study was to investigate the willingness to participate in lung cancer screening among eligible persons in Germany.

Methods

Between January and April 2024, additional questions on lung cancer screening were added to the German Study on Tobacco Use (DEBRA; www.debra-study.info), a regularly conducted representative cross-sectional household survey on tobacco use. These questions were presented to participants aged 50 years and older who stated that they were either current or former smokers. For analysis, the sample was restricted to the age range 50–75 years. The DEBRA study was approved by the ethics committee of Heinrich Heine University Düsseldorf (HHU 5386R) (registration: DRKS00028054).

The first question, preceded by an introduction with basic information on lung cancer screening with LDCT, was “Would you take part in such a lung cancer screening?” This was followed by a multiple-choice question on the reasons for participation or non-participation (for details, see the previously published study protocol: https://osf.io/k3g7m). We calculated estimated proportions with 95% confidence intervals (95% CI) on the basis of weighted data that accounted for personal and household characteristics in order to be representative of the German population.

Results

We interviewed a total of 875 current or former smokers between the ages of 50 and 75 years (56.5% male, mean age 61.0 years [standard deviation 7.2]). Overall, 61.3% [95% CI 58.1–64.6] stated they would be willing to take part in a future lung cancer screening examination. The distribution of the response categories was as follows: “Yes, certainly:” 28.4%; “Yes, probably:” 32.9%; “I don’t know:” 12.0%; “No, probably not:” 11.1%; “No, certainly not:” 14.6%; “No response:” 0.9%. Stratification by personal and smoking characteristics revealed that willingness to participate was more frequent in younger persons; those who had already taken part in other forms of cancer screening, and those living in metropolitan areas. Willingness to participate was less frequent in people with low educational attainment and low income (Table). The two most frequently stated reasons for willingness to participate were “I believe that lung cancer can be treated better if detected earlier” (56.4%) and “I believe that such an examination has more advantages than disadvantages” (48.0%). The most frequently chosen reason for non-participation was “I’m healthy”(29.9%).

Table

Willingness to participate in lung cancer screening by means of lowdose computed tomography, overall and stratified by personal and smoking characteristics (weighted n = 875)

Discussion

This representative survey among persons who fulfill the eligibility criteria for lung cancer screening with LDCT in Germany showed that around 6 in 10 are willing to participate in future. Almost every third person stated that they would certainly take part. However, it would be rash to conclude that participation in lung cancer screening in Germany, once available, will actually be this high. Dreier et al. recently showed that the intention–behavior gap, i.e., the difference between those who intend to take part and those who actually do so could be as high as 50%. This would result in a future participation rate of approximately 30% (61% × 50%) (3). Moreover, lung cancer screening involves annual repetition of LDCT, which poses a major additional obstacle to adherence. Participation rates of 74% or 59%, as observed in Germany for breast cancer screening and colorectal cancer screening respectively, are probably unattainable at the moment (4).

We did not survey pack years. However, the fact that willingness to participate did not differ according to number of cigarettes smoked indicates that persons with the greatest lung cancer risk—those with the highest number of pack years—would not have a lower rate of participation than others. Contrary to the findings of earlier surveys indicating that risk-reducing behavior would be more widespread among former smokers, the rate of willingness to participate was not higher in this group (5).

The major limitation of our study is that prior to implementation of the lung cancer screening we were only able to measure willingness to participate. Because the DEBRA study does not collect data on pack years or time since quitting smoking, we were not able to survey exclusively those who will be eligible in future. Rather, we analyzed a somewhat larger sample.

Altogether, our results show a generally high willingness to participate in lung cancer screening. However, it remains to be seen how large the intention–behavior gap will be. Before and during implementation of lung cancer screening by means of LDCT, adequate measures need to be taken to identify and remove barriers to participation. This applies especially to persons of low socioeconomic status, those living in rural areas, and those who do not avail themselves of other forms of cancer screening.

Funding

Since 2019 (wave 19 onwards), the DEBRA study has been funded by the German Federal Ministry of Health (ZMVI1–2519DSM203, ZMI1–2521DSM209).

Benjamin Borchardt, Stephanie Klosterhalfen, Daniel Kotz

Conflict of interest statement
DK has received payments from the North Rhine–Westphalia Medical Association and the North Rhine Institute for Quality in Healthcare for a seminar on “Quitting Smoking: Counseling Methods and Motivational Communication” on 30 August 2024 and 26 March 2025.

BB and SK declare that no conflict of interest exists.

Manuscript received on 12 March 2025, revised version accepted on 12 September 2025

Cite this as:
Borchardt B, Klosterhalfen S, Kotz D: Willingness to participate in a program for the early detection of lung cancer with low-dose computed tomography: Data from a representative survey (DEBRA). Dtsch Arztebl Int 2025; 122: 697–8. DOI: 10.3238/arztebl.m2025.0163

References

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3. Dreier M, Brinkmann M, Stahmeyer JT, Hemmerling M, Krauth C, Walter U: Intended and actual participation in the colorectal cancer screening program. Dtsch Arztebl Int 2024; 121: 497–504

4. Starker A, Saß AC: [Participation in cancer screening in Germany: ­Results of the German Health Interview and Examination Survey for Adults (DEGS1)]. Bundesgesundheitsblatt Gesundheitsforschung ­Gesundheitsschutz 2013; 56: 858–67

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