Lung cancer screening with a low radiation dose chest CT scan has been shown to reduce the number of people, in a well-defined very high-risk cohort, who die from lung cancer. Many potential screening-related harms have been identified, including anxiety and morbidity related to the evaluation of screen-detected findings. A favorable balance of the benefit and harms of lung cancer screening requires careful implementation of a screening program, with a focus on several obstacles to the success of the program. In this review, evidence to support the benefit and harms of lung cancer screening is provided, followed by a discussion of 11 obstacles to the development of a high-quality program. For each obstacle, an approach is suggested, based on evidence and mandates as well as practicality and lessons learned. The approach to each of these obstacles highlights the multi-disciplinary nature of lung cancer screening, and the value of considering lung cancer screening a program rather than a test.