Ensuring radiology reporting quality across a national lung cancer screening program

Low-dose CT (LDCT) for lung cancer screening (LCS) in high-risk individuals reduces both lung cancer-specific and all-cause mortality, supported by data from the National Lung Screening Trial, NELSON, the International Early Lung Cancer Action Program (I-ELCAP). In 2019, following a successful pilot, the UK National Health Service announced rollout of the Targeted Lung Health Check (TLHC) program, offering ever-smokers aged 55-74 an appointment with a health professional, which may lead to referral for LDCT based on individual risk of developing lung cancer assessed using validated multivariable risk-prediction models (PLCOm2012 and the Liverpool Lung Project model, LLPv2). As LCS expands, it is paramount that radiologists who participate in screening are adequately qualified and properly trained. To ensure the radiology reporting for an expanding program remains clinically and cost effective, reporters must engage with nationally-set quality assurance (QA) policies. In this article, we describe the approach taken by The HLH Imaging Group (HLH), a provider reporting ∼85% of LCS scans in NHS England (NHSE), to embed near real-time and routine double-read QA alongside the national external quality assurance (EQA) scheme (PERFECTS). We present aggregate referral-rate data from reporters in our network across the 2025-26 financial year and compare current NHSE fixed thresholds, with statistically-derived thresholds (mean ± 2SD; median ± k·MAD). We provide explicit rationale for our operational choices (a 2-consecutive-quarter outlier definition, 25-case retrospective review of flagged reporters, and 5% random sampling of negative reports for blinded double reading). We explicitly acknowledge that this describes a provider's approach within a wider radiological workforce; PERFECTS remains the only program-wide QA covering all NHSE LCS readers. We propose that the elements described could form the basis of an NHSE/Department of Health and Social Care standardized near real-time QA framework applicable across all LCS providers.