Adherence to annual low-dose computed tomography was 95% in the National Lung Screening Trial and must be replicated in order to achieve mortality benefit from screening.Determine adherence rates within the Veterans Affairs Lung Cancer Screening Demonstration Project (LCSDP) and identify factors predictive of adherence.and Methods: A secondary data analysis of the LCSDP conducted at 8 VA medical centers was performed to determine adherence to follow-up imaging and determine factors predictive of adherence.A total of 2103 patients were screened. The adherence to screening from baseline scan (T0) to first follow-up scan (T1) was 82.2% and 65.2% from T1 to second follow-up scan (T2). Logistic regression modeling showed that presence of a nodule and the site of lung cancer screening were predictive of adherence. After three rounds of screening, 1343 (64%) that underwent baseline screening underwent both subsequent annual LDCT scans, 225 (11%) only had one subsequent LDCT, 0.4% did not have a T1 scan but did have a T2 scan, 70 (3%) died, and 36 (1.7%) were diagnosed with lung cancer. There was significant variation in screening adherence across the eight sites ranging from 63 to 94% at T1 and 52 to 82% at T2 (p<0.05).Despite a centralized program design with dedicated navigator and registry to assist with adherence to annual lung cancer screening, variations between sites suggest that active follow-up strategies are needed to optimize adherence. For the mortality benefit from lung cancer screening to be recognized, adherence to annual screening must achieve higher rates.