PROJECT 2: OK-LUNG-SCAN OK: PROJECT SUMMARY Lung cancer is the leading cause of cancer mortality among American Indian and Alaska Native (AI/AN) populations, especially in rural Oklahoma where the AI/AN population has significantly worse lung cancer incidence rates, survival, and death than the general population. In 2011, the National Lung Screening Trial demonstrated a 20% decrease in lung cancer mortality using low-dose computed tomography (LDCT) for lung cancer screening (LCS). After more than two decades, LCS uptake remains slow in tribal communities, particularly rural ones, that often have high rates of smoking and limited access to cancer diagnostic and treatment services. To address this knowledge and implementation gap, we propose the Lung Cancer Screening to Improve Equity in Tribal Communities in Oklahoma (Lung Screen Tribal OK) study, which seeks to co-design, test, and implement a theory-driven, tribally informed health system-wide LCS program in collaboration with Cherokee Nation Health Services (CNHS) and Cherokee Nation Public Health (CNPH). CNHS is the largest tribal healthcare system in the US and operates nine health centers located in rural northeastern Oklahoma. CNPH links CNHS with smoking cessation services and has resources to address transportation and other social needs that can impede LCS receipt. Lung Screen Tribal OK features the following specific aims: (1) Identify individual, community, socio-economic, tribally informed, and health system facilitators and barriers that affect LCS implementation and access to smoking cessation services; (2) Co- design and pilot test a tailored LCS program, including the key components of system-wide LCS navigators, care process improvements, shared decision-making support, LCS registry with outreach functions, smoking cessation/referral services, and patient access/transportation support; (3) Measure the impact of the improved LCS program in a learning health system-based, sequential, pair-matched cluster implementation study, assessing implementation process outcomes at the clinician-, practice-, and health system levels using the PRISM-REAIM framework; and (4) Disseminate lessons learned and resources developed to other tribal communities and health systems in Oklahoma and beyond. Lung Screen Tribal OK will bridge the gap between evidence and clinical practice for LCS in a high-need setting by intervening at the level of the healthcare system. System-level interventions for guideline implementation tend to be understudied compared to those evaluating individual-level, behavioral interventions. However, the careful development and evaluation of an LCS screening program at the level of the healthcare system is critical to ensuring that more patients will receive LCS. Lung Screen Tribal OK will establish an effective LCS program in a tribal system and thus provide a direct benefit to the Cherokee Nation by increasing LCS participation. By increasing screening for early stage lung ca...