Case Studies

Recognizing high prevalence of smoking and concerning incidence of lung cancer, Croatia took proactive steps in integrating a lung cancer screening programme into its national healthcare framework. Designed to enhance early diagnosis, particularly among high-risk individuals, the programme also aims to increase five-year survival rates and improve treatment outcomes.

The implementation of the screening programme began with the establishment of a National Committee, bringing together experts from the various fields, including pulmonologists, radiologists, thoracic surgeons, general practitioners, Croatian Ministry of Health representatives, the Croatian National Health Insurance Fund, the Croatian Institute for Public Health, patient advocacy groups, IT solution providers, and administrative personnel. This diverse team ensured a comprehensive approach to the programme’s design and implementation, addressing all critical aspects of the patient pathway.

The screening programme targets individuals aged 50 to 75, with a smoking history of at least 30 pack-years, who currently smoke or have stopped smoking within the past 15 years. Family doctors are tasked with identifying these individuals and referring them via a digital platform to one of 23 radiology centres for a low-dose CT scan. Involvement of the family doctors helps streamline access to radiology services and further diagnostics. The programme is fully reimbursed by the Croatian Health Insurance Fund, and the family doctors also receive a financial incentive for the consultation and referral to the screening.

Programmes incorporates following components, which help its optimization:

1. Modified i-ELCAP guidelines: The program follows adapted guidelines from the International Early Lung Cancer Action Program (i-ELCAP), specifically tailored to the Croatian population (Henschke et al., 2023).
2. Volumetric analysis: AI-powered tools precisely measure lung nodules, allowing for close monitoring of their growth patterns and enhancing early detection.
3. Digital integration: The program is fully integrated into Croatia’s health information system (CEZIH), enabling coordination between primary care, radiology and pulmonology departments as well as efficient data management and communication.
4. GP involvement: General practitioners play a crucial role in the programme by identifying eligible patients and facilitating early detection.

In 2024–2025, the comprehensive evaluation of the programme’s outcomes had started. With more than 45 000 scans performed, and approximately 35 000 individuals enrolled from October 2020 to October 2024, the analysis will assess the programme’s cost effectiveness and impact on early detection and survival rates. By the time of publishing (May 2025), the Croatian program has enrolled over 43 000 participants with more than 60 000 LDCT scans.

Currently, all participants receive a smoking cessation brochure.

Enablers: Strong political commitment, clear policy direction and dedicated funding have been key to the successful implementation of this screening programme (Financing, Governance, Resources). While some experts raised concerns about the absence of pilot and feasibility studies, a robust body of scientific evidence informed both the planning and implementation phases of the programme. The introduction of the programme was further strengthened by multidisciplinary stakeholder engagement (Service Delivery and Governance).

To ensure quality assurance in screening, radiologists receive specialized training. In addition, general practitioners are supported through a structured instructional guide in the form of a video guide available on the Ministry of Health’s website, offering continuous assistance for participant enrolment (Resources).

Barriers: The barriers are being discussed at this point.

Lessons learned: Involving family doctors in the pathway and expanding screening services to 23 centres helped to improve the geographic coverage allowing more individuals to benefit from the screening services. The programme optimizes resource use by integrating with the national healthcare and e-health systems and leveraging existing infrastructure while maintaining a fully digitalized and paperless approach. Although long-term data are still under analysis, early findings indicate the program’s effectiveness in detecting early-stage cancers, highlighting its potential to reduce mortality rates.