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Background: Lung cancer screening includes identification of eligible individuals, shared decision-making inclusive of tobacco cessation, and management of screening results. Adaptations to the implemented processes for lung cancer screening in situ are understudied and underreported, with potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for systematic enumeration of adaptations to implementations of evidence-based practices. We used FRAME to study adaptations in lung cancer screening processes that were implemented as part of a Veterans Health Administration (VHA) Enterprise-Wide Initiative.Methods: We conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMC) between 2019-2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, recorded and mapped to FRAME categories. Results: A total of 14 program navigators across 10 VHA lung cancer screening programs participated in 20 interviews. In year 1 (2019-2020), seven programs were operational and of these, three reported adaptations to their screening process that were either planned and in response to COVID-19. In year 2 (2020-2021), all 10 programs were operational. Programs reported 14 adaptations in year 2. These adaptations were both planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 6 of 10 programs to improve the data collection and tracking of Veterans in the screening process. Conclusions: Using FRAME, we found that adaptations occurred throughout the lung cancer screening process but primarily in the areas of patient identification and communication of results. These findings highlight considerations for lung cancer screening implementation and potential areas for future intervention.