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Enter the stage, what your breathing tests showed and whether you want an operation, and read the statements that apply, quoted word for word from NICE NG122. An educational aid to prepare for the conversation with your team, not advice. Nothing you enter leaves this page.
Answer the 3 questions and the statement that applies to that combination appears here, quoted word for word from NICE NG122: lung cancer, management (March 2019, last updated March 2024) and the sources listed below, with a plain line on what it means and the questions to take to your surgeon.
Without JavaScript, every statement the aid can show is listed further down the page. This is an educational aid, not advice.
The aid picks from these 14 cards; each quotes its source word for word. Read them all here, with or without the questions above.
“For people with NSCLC who are well enough and for whom treatment with curative intent is suitable, offer lobectomy (either open or thoracoscopic).”
“Offer people surgery if they have a forced expiratory volume in 1 second (FEV1) within normal limits and good exercise tolerance.”
“Offer more extensive surgery (bronchoangioplastic surgery, bilobectomy, pneumonectomy) only when needed to obtain clear margins.”
What this means: Removing the lobe containing the cancer, either through a keyhole approach or an open operation, is what NICE offers first when your breathing and general fitness allow it. Its own reasoning is that a lobectomy gives better survival than stereotactic radiotherapy and is a good compromise between keeping lung function and taking out all the cancer. Anything larger than a lobe should have a stated reason, which is clear margins.
“For people with stage 1 to 2a (T1a to T2b, N0, M0) NSCLC who decline lobectomy or in whom it is contraindicated, offer radical radiotherapy with stereotactic ablative radiotherapy (SABR) or sublobar resection.”
“if they decline lobectomy or it is contraindicated, sublobar resection and SABR both provide better survival outcomes than conventionally fractionated radiotherapy, although it is not clear which of these 2 is better”
What this means: Where a full lobectomy is too much, NICE puts two options side by side and says openly that the evidence does not establish which is better. A sublobar resection takes less lung but is still an operation; stereotactic radiotherapy is a handful of outpatient visits with no anaesthetic. This is a genuine choice, so the honest question is which one your team is better set up to do and what each would cost you in recovery.
“For people with stage 1 to 2a (T1a to T2b, N0, M0) NSCLC who decline surgery or in whom any surgery is contraindicated, offer SABR. If SABR is contraindicated, offer either conventional or hyperfractionated radiotherapy.”
“SABR is non-invasive, so if it is as effective as surgery then it may be a preferable option for many people with lung cancer. There are also various factors that may make SABR less costly than surgery. For example, it is usually delivered as outpatient treatment.”
“If using SABR, follow the SABR Consortium guidance on fractionation.”
What this means: Declining an operation is a recognised position in the guideline rather than a refusal of treatment: NICE writes a recommendation specifically for it. Stereotactic radiotherapy is given over a small number of outpatient visits, needs no anaesthetic and no hospital stay, and NICE notes that people often prefer it for exactly that reason. It also says the comparison with surgery has not been settled by randomised trials, which is why it has an open research recommendation on it.
“Nivolumab in combination with chemotherapy is recommended as an option for neoadjuvant treatment of resectable (tumours at least 4 cm or node positive) NSCLC.”
“Durvalumab in combination with platinum-based chemotherapy is recommended as an option for neoadjuvant (then continued alone as adjuvant) treatment of resectable (tumours at least 4 cm or node positive) NSCLC without epidermal growth factor receptor (EGFR) mutations or anaplastic lymphoma kinase (ALK) rearrangements.”
“Offer postoperative systemic anticancer therapy to people with good performance status (WHO 0 or 1) and T1a to 4, N1 to 2, M0 NSCLC.”
“For people with stage 3a N2 NSCLC who are having chemoradiotherapy and surgery, ensure that their surgery is scheduled for 3 to 5 weeks after completion of the chemoradiotherapy.”
What this means: Above the smallest tumours an operation is usually part of a sequence rather than the whole treatment. NICE recommends immunotherapy with chemotherapy before surgery for tumours of at least 4 cm or with nodes involved, chemotherapy after surgery for node-positive disease with good performance status, and a tablet instead where the tumour carries an EGFR or ALK change. Note the durvalumab recommendation excludes EGFR and ALK disease, which is why those results should be back before this is decided.
“Consider chemoradiotherapy for people with stage 2 or 3 NSCLC whose condition is not suitable for or who decline surgery. Balance potential benefit in survival with the risk of additional toxicities.”
“Durvalumab is recommended as an option for treating locally advanced unresectable NSCLC with PD-L1 expression on 1% or more of tumour cells if disease has not progressed after concurrent platinum-based chemoradiation.”
What this means: Declining surgery for a larger tumour does not mean giving up on cure. NICE names chemoradiotherapy for exactly this situation and, unusually, says in the recommendation itself that the survival benefit has to be balanced against the extra toxicity, which is an invitation to have that conversation rather than a formality.
“Ensure that all people whose condition is potentially suitable for multimodality treatment (surgery, radiotherapy and systemic anticancer therapy in any combination) are assessed by a thoracic oncologist and by a thoracic surgeon.”
“Multidisciplinary teams that provide chemoradiotherapy with surgery should have expertise in multimodality treatment and in all of the individual components.”
What this means: Being seen by both a surgeon and an oncologist is the standard for anyone who might have more than one kind of treatment, not a second opinion you have to argue for. If you have only met one of them and both surgery and radiotherapy are being discussed, that is a fair thing to raise.
“Consider chemoradiotherapy for people with stage 2 or 3 NSCLC whose condition is not suitable for or who decline surgery. Balance potential benefit in survival with the risk of additional toxicities.”
“Durvalumab is recommended as an option for treating locally advanced unresectable NSCLC with PD-L1 expression on 1% or more of tumour cells if disease has not progressed after concurrent platinum-based chemoradiation.”
What this means: Where the cancer cannot be removed but has not spread beyond the chest, the intent is still cure. Chemotherapy and radiotherapy are given together, and if the scan afterwards shows the disease has not progressed and PD-L1 is on 1 percent or more of tumour cells, immunotherapy follows. The side effect that defines this route is inflammation of the lung, which both the radiotherapy and the immunotherapy can cause, with identical symptoms.
“Consider radical radiotherapy (either conventional or hyperfractionated) for people with stage 3a NSCLC who: are eligible for this treatment and cannot tolerate, or decline, chemoradiotherapy (with or without surgery).”
“If conventionally fractionated radical radiotherapy is used, offer either: 55 Gy in 20 fractions over 4 weeks or 60 to 66 Gy, in 30 to 33 fractions, over 6 to 6.5 weeks.”
“people who cannot tolerate chemoradiotherapy may also be unable to tolerate radical radiotherapy, so this will not be an option for everyone with stage 3a or 3b NSCLC”
What this means: Radiotherapy without chemotherapy is a recognised alternative for people who cannot manage or do not want the combination, and NICE names the two standard schedules. It also says plainly that it will not suit everyone who cannot manage chemoradiotherapy, which is worth knowing before you ask for it.
“Offer people with predicted postoperative FEV1 or TLCO below 30% the option of treatment with curative intent if they accept the risks of dyspnoea and associated complications.”
“Before surgery, perform a functional segment count to predict postoperative lung function.”
“Consider shuttle walk testing (using a distance walked of more than 400 m as a cut-off for good function) to assess the fitness of people with moderate to high risk of postoperative dyspnoea.”
What this means: Low predicted lung function after surgery is not an automatic refusal. NICE says the option of treatment aimed at cure should still be offered if you accept the risk of being more breathless afterwards, which makes this your judgement to make with the numbers in front of you. Ask for the numbers: the predicted FEV1 and transfer factor after the operation, and how far you walked on the shuttle test.
“Perform spirometry and transfer factor (TLCO) testing before proceeding with treatment with curative intent.”
“Consider cardiopulmonary exercise testing to measure oxygen uptake (VO2 max) and assess lung function in people with moderate to high risk of postoperative dyspnoea, using more than 15 ml/kg/minute as a cut-off for good function.”
“A clinical oncologist specialising in thoracic oncology should determine suitability for radiotherapy with curative intent, taking into account performance status and comorbidities.”
What this means: Four numbers decide most of this: how much air you can blow out in a second, how well your lungs move oxygen into the blood, how far you can walk, and what the first two are predicted to be once part of a lung has gone. NICE also asks for pulmonary function tests before radical radiotherapy, so the tests are not only about surgery. Ask for your results in plain language rather than waiting for them to be summarised as fit or unfit.
“When evaluating surgery as an option for people with NSCLC, consider a global risk score such as Thoracoscore to estimate the risk of death. Ensure the person is aware of the risk before they give consent for surgery.”
“Seek a cardiology review for people with: an active cardiac condition or 3 or more risk factors or poor cardiac functional capacity.”
What this means: NICE asks that a risk of death from the operation is estimated for you specifically and that you are told it before you consent. That is a number, not an impression, and asking for it is following the guideline rather than being difficult. Heart problems are assessed separately, and NICE says to avoid surgery within 30 days of a heart attack.
“Ensure that all people with lung cancer who could potentially have treatment with curative intent are offered positron emission tomography CT (PET-CT) before treatment.”
“Every cancer alliance should have a system of rapid access to PET-CT scanning for people who are eligible for this.”
What this means: A PET-CT finds disease elsewhere that a CT can miss, which is the difference between an operation that cures and an operation that does not. NICE asks for it before any treatment aimed at cure, and asks local services to make it available quickly. If curative treatment is being planned and no PET-CT has been arranged, ask why.
“Inform people that smoking increases the risk of pulmonary complications after lung cancer surgery.”
“Advise people to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is important.”
“Do not postpone surgery for lung cancer to allow people to stop smoking.”
What this means: Three sentences, and the third is the one that is rarely read out. Stopping smoking is offered because it lowers the chance of lung complications after an operation, and support to do it should be offered with that reason attached. It is not a condition of being treated, and NICE says surgery must not be delayed for it. If you have never smoked, none of this applies to you and the diagnosis is not something you caused either.
“Ensure that a lung cancer clinical nurse specialist is available at all stages of care to support people and (as appropriate) their family members or carers.”
“Ensure that all people whose condition is potentially suitable for multimodality treatment (surgery, radiotherapy and systemic anticancer therapy in any combination) are assessed by a thoracic oncologist and by a thoracic surgeon.”
What this means: This aid quotes a guideline. It does not know your scan, your breathing tests, your other illnesses or what matters to you. Take the statements above to the appointment, ask which of them apply, and ask where your team's plan departs from them and why.
Each combination of answers maps to a fixed set of cards, and every card quotes the statement it implements with the page it was read from; nothing is scored or inferred. Where the sources disagree, both are quoted. The mapping is data in the OnCo repository and is tested against every combination of answers. Checked 2026-09-25.
This is an educational aid to prepare for a conversation with your surgical team. It is not medical advice, and it cannot see your scans or your history. OnCo is orientation, not medical advice.