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In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry.Key Points• Pulmonologists and radiologists both have key roles in the set up of multidisciplinary LCS teams with experts from many other fields.• Pulmonologists identify people eligible for LCS, reach out to family doctors, share the decision-making process and promote tobacco cessation.• Radiologists ensure appropriate image quality, minimum dose and a standardised reading/reporting algorithm, together with a clear definition of a "positive screen".• Strict algorithms define the exact management of screen-detected nodules and incidental findings.• For LCS to be (cost-)effective, it has to target a population defined by risk prediction models.

In Europe, lung cancer ranks third among the most common cancers, remaining the biggest killer. Since the publication of the first European Society of Radiology and European Respiratory Society joint white paper on lung cancer screening (LCS) in 2015, many new findings have been published and discussions have increased considerably. Thus, this updated expert opinion represents a narrative, non-systematic review of the evidence from LCS trials and description of the current practice of LCS as well as aspects that have not received adequate attention until now. Reaching out to the potential participants (persons at high risk), optimal communication and shared decision-making will be key starting points. Furthermore, standards for infrastructure, pathways and quality assurance are pivotal, including promoting tobacco cessation, benefits and harms, overdiagnosis, quality, minimum radiation exposure, definition of management of positive screen results and incidental findings linked to respective actions as well as cost-effectiveness. This requires a multidisciplinary team with experts from pulmonology and radiology as well as thoracic oncologists, thoracic surgeons, pathologists, family doctors, patient representatives and others. The ESR and ERS agree that Europe's health systems need to adapt to allow citizens to benefit from organised pathways, rather than unsupervised initiatives, to allow early diagnosis of lung cancer and reduce the mortality rate. Now is the time to set up and conduct demonstration programmes focusing, among other points, on methodology, standardisation, tobacco cessation, education on healthy lifestyle, cost-effectiveness and a central registry., Competing Interests: Conflict of interest: H-U. Kauczor reports grants, personal fees for lectures and non-financial support from Siemens, grants and personal fees for lectures from Philips, and personal fees for lectures from Boehringer Ingelheim and Bracco, outside the submitted work. Conflict of interest: A-M. Baird reports personal fees and non-financial support for meeting attendance from Roche and MSD, outside the submitted work; and is a board member for Lung Cancer Europe (LuCE); LuCE have received support from Abbvie, Amgen, BMS, Boehringer Ingelheim, Lilly, Merck, MSD, Novartis, Pfizer, Roche and Takeda, and, as board member, A-M. Baird has participated on advisory boards for BMS, Takeda and Pfizer, with the fee paid directly to LuCE. Conflict of interest: T.G. Blum has nothing to disclose. Conflict of interest: L. Bonomo has nothing to disclose. Conflict of interest: C. Bostantzoglou has nothing to disclose. Conflict of interest: O. Burghuber reports grants from Boehringer Ingelheim, GSK, AstraZeneca, Menarini, Teva, Pfizer, Chiesi, Novartis and Federal State Department of Health, non-financial support (utilities and meeting facilities) from the Municipal Department of Health in Vienna and air liquid, during the conduct of the study; and personal fees for advisory board work and lectures from Boehringer Ingelheim, AstraZeneca, Chiesi, MSD, Menarini, Roche and GSK, outside the submitted work. Conflict of interest: B. Čepická is a member of the European Lung Foundation patient advisory group. Conflict of interest: A. Comanescu reports sponsorship from Merck Romania and Bristol-Myers Squibb România, during the conduct of the study; and patient advisory panel fees from Bristol-Myers Squibb, outside the submitted work. Conflict of interest: S. Couraud reports grants, personal fees and other from Roche, grants and personal fees from AstraZeneca, during the conduct of the study; and grants and personal fees from BMS, AstraZeneca, Lilly and Laidet Medical, grants, personal fees and other from Pfizer, Roche, Chugai, MSD and Boehringer Ingelheim, grants and non-financial support from Sysmex Innostics, grants from Novartis, Merck and Amgen, and personal fees from Exact Science, outside the submitted work. Conflict of interest: A. Devaraj has nothing to disclose. Conflict of interest: V. Jespersen has nothing to disclose. Conflict of interest: S. Morozov has nothing to disclose. Conflict of interest: I. Nardi Agmon has nothing to disclose. Conflict of interest: N. Peled reports consultancy for and honoraria from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Foundation Medicine, Guardant360, MSD, Novartis, NovellusDx, Pfizer, Roche and Takeda, outside the submitted work; and in addition, has patents WO2012023138, US20130150261 and WO/2015/059646 issued. Conflict of interest: P. Powell is an employee of the European Lung Foundation. Conflict of interest: H. Prosch reports grants from Siemens, outside the submitted work. Conflict of interest: S. Ravara has nothing to disclose. Conflict of interest: J. Rawlinson is a member of the patient advisory group of the ERS/European Lung Foundation (as a lung cancer patient) and a patient representative on the NHS England Screening advisory group; neither role is remunerated in any way. Conflict of interest: M-P. Revel has nothing to disclose. Conflict of interest: M. Silva has nothing to disclose. Conflict of interest: A. Snoeckx has nothing to disclose. Conflict of interest: B. van Ginneken reports grants and stock/royalties from Thirona, and grants and royalties from Delft Imaging Systems and MeVis Medical Solutions, outside the submitted work. Conflict of interest: J.P. van Meerbeeck has nothing to disclose. Conflict of interest: C. Vardavas has nothing to disclose. Conflict of interest: O. von Stackelberg has nothing to disclose. Conflict of interest: M. Gaga reports grants from Novartis, Chiesi, Elpen and Menarini, and personal fees from BMS and MSD, outside the submitted work., (This official statement of the European Society of Radiology (ESR) and the European Respiratory Society (ERS) is published jointly in European Radiology [DOI: 10.1007/s00330-020-06727-7] and the European Respiratory Journal [DOI: 10.1183/13993003.00506-2019]. The versions are identical aside from minor differences in typesetting and presentation in accord with the journal styles. ©European Society of Radiology and European Respiratory Society 2020.)