Summary

Lung cancer is the fourth most common cancer in Estonia and the leading cause of cancer-related deaths.1 To address this issue and the associated healthcare costs, Estonia is implementing a national screening programme, focused on detecting lung cancer earlier. During its pilot phase, the programme achieved up to 80% participation among eligible individuals by embedding enrolment within primary care.2 This efficient approach leverages the trust between patients and family physicians or nurses, and offers a scalable model for other countries. To ensure equitable access when expanding nationally, complementary invitation methods could be integrated alongside enrolment through primary care.

Challenge

Lung cancer remains a major public health challenge in Estonia, ranking as the fourth most common cancer and the leading cause of cancer-related deaths.1 More than twice as many Estonian men as women die of cancer, representing one of the largest gender disparities in the European Union relating to cancer.3

In 2020, most people with lung cancer in Estonia – almost half of men and a third of women – are diagnosed at stage IV, when treatment options are limited.4 This pattern reflects a broader challenge: how to detect lung cancer early and efficiently within constrained health system resources. Traditional screening approaches can be complex and resource-intensive, requiring strong coordination among different levels of care.

Estonia has already demonstrated success with national screening programmes for breast, cervical and colorectal cancers, with participation rates above 60%.3 For breast and cervical screening, anyone in the targeted age group can participate, either by responding to an invitation or on their own initiative.5 Colorectal cancer screening follows a slightly different process: individuals who receive an invitation should contact their family physician and make an appointment to participate in the screening.6

In 2021, screening for breast, cervical and colorectal cancers became free for everyone, regardless of health insurance status, and in 2023 colorectal cancer screening coverage was 63%, an increase of 11% compared with 2022. 3 7

Solution

In 2021, Estonia conducted a small feasibility study to test whether people could be systematically enrolled into low-dose computed tomography (LDCT) screening for lung cancer through their family physicians.8 Three family physician practices systematically reviewed their patients list to identify anyone potentially eligible.8 This approach achieved a 79% participation rate (649 males and 559 females), demonstrating the potential effectiveness of this population-based approach.8

This approach was expanded in 2022 into a county-level pilot study.2 9 Family physicians and nurses identified people aged 55–74 who currently or previously smoked.2 9 They informed them about the screening programme either during routine visits or by telephone, explained the risks and benefits of LDCT screening, and obtained informed consent from those who wished to participate.2 Using this systematic yet personal approach, the pilot study again achieved high participation (80%) – confirming that invitations delivered by trusted primary care teams can support high-levels of engagement.2 9

Estonia is currently expanding the programme across the country and developing implementation guidelines.9

Embedding recruitment in primary care proved efficient: it used existing workflows, minimised duplicate outreach, and ensured eligible people were identified and invited. High uptake reduced the risk of wasted capacity and strengthened the programme’s real-world evidence base, supporting the move to national roll-out.

However, some considerations that may be beneficial for other locations when implementing this type of approach include:

  • Physician workload: not all family physicians were able to evaluate their target age group due to limited staff and high workload.2 This could increase the risk of failing to recruit individuals at high risk. Establishing an alternative invitation method, in addition to primary care outreach, could mitigate this in a large-scale programme.
  • Data and access requirements: the methodology used in the first feasibility study, systematically enrolling patients, requires adequate data in order to appropriately identify people eligible for screening based on the programme’s eligibility criteria. It also requires a well-developed primary care system, where most people have access to a family physician.8
  • Smoking cessation: neither of the studies in Estonia specifically included smoking cessation interventions, but all people who smoke were advised to quit.2 8 When developing a national screening programme, it is essential to include smoking cessation interventions as they are proven to be effective at reducing smoking-related risks and improving screening outcomes.10

Next steps

These two studies offer compelling examples of how trusted relationships with primary care can be central to achieving high participation in lung cancer screening. Embedding enrolment within family physician practices proved both feasible and effective, providing a strong foundation for scaling up the programme nationally.

As Estonia expands implementation, it will be informative to see how the following challenges can be addressed:

  • strengthening radiology capacity – through additional specialists, training and modern imaging equipment – to meet the growing volume of LDCT scans9
  • ensuring long-term financial sustainability; as Estonia has a social health insurance system that covers most of the population securing adequate and ongoing health insurance funding will help maintain equitable access as the programme expands9 11
  • exploring the perspectives and capacity of family physicians involved in screening programmes to inform sustainable scale-up, ensuring that workload and workforce constraints can be addressed.

By investing in trusted relationships between providers and people seeking care, health systems leaders can deliver more efficient care that improves early detection and survival while delivering value.9

Click here to read more about the feasibility study.

Click here to read more about the pilot study.

 

References:

  1. International Agency for Research on Cancer. 2022. ESTONIA. Available here: https://gco.iarc.who.int/media/globocan/factsheets/populations/233-estonia-fact-sheet.pdf [accessed: September 2025]
  2. Laisaar T, Kallavus K, Poola A, et al. 2025. Population-based systematic enrolment of individuals ensures high lung cancer screening uptake. Cancer Treatment and Research Communications 43: 100889 [accessed: August 2025]
  3. Organisation for Economic Co-operation and Development, European Commission. 2025. EU Country Cancer Profile: Estonia 2025. Paris: OECD Publishing [accessed: August 2025]
  4. Mari-Liis Zimmermann KI, Keiu Paapsi, Pille Härmaorg, Margit Mägi. 2023. Cancer in Estonia: incidence 2020, survival 2016–2020 and haematological tumours 2011–2020. Tallinn: National Institute for Health Development [accessed: August 2025]
  5. Tervisekassa. 2025. Screening for women. Available here: https://tervisekassa.ee/en/people/screenings [accessed: November 2025]
  6. Tervisekassa. 2025. Colon cancer screening. Available here: https://tervisekassa.ee/en/people/health-prevention/colon-cancer-screening [accessed: November 2025]
  7. Estonian Health Insurance Fund. 2023. Annual Report. Tallinn: Health Insurance Fund
  8. Kallavus K, Laisaar K-T, Rätsep A, et al. 2023. National lung cancer screening program feasibility study in Estonia. Interdisciplinary CardioVascular and Thoracic Surgery: 10.1093/icvts/ivad041: [accessed: September 2025]
  9. SOLACE. 2025. Lessons from Estonia: making lung cancer screening work. Available here: https://europeanlung.org/solace/2025/07/16/lessons-from-estonia-making-lung-cancer-screening-work/ [accessed: October 2025]
  10. IASLC Lung Cancer News. 2025. Global Insights into Smoking Cessation in Lung Cancer Screening. Available here: https://www.ilcn.org/global-insights-into-smoking-cessation-in-lung-cancer-screening/ [accessed: December 2025]
  11. Organisation for Economic Co-operation and Development, European Observatory on Health Systems and Policies. 2023. Estonia: Country Health Profile 2023, State of Health in the EU. Paris, Brussels: OECD Publishing, European Observatory on Health Systems and Policies