Management | Lung cancer: diagnosis and management | Guidance

1.3 Stop smoking interventions and services

1.3.1

Inform people that smoking increases the risk of pulmonary complications after lung cancer surgery. [2011]

1.3.2

Advise people to stop smoking as soon as the diagnosis of lung cancer is suspected and tell them why this is important. [2011]

1.3.3

Do not postpone surgery for lung cancer to allow people to stop smoking. [2011]

Follow the section on stop-smoking interventions in NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence.

1.4 Assessing people with non-small-cell lung cancer (NSCLC) for treatment with curative intent

Perioperative mortality

1.4.1

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. [2011]

Cardiovascular function

1.4.2

Avoid surgery within 30 days of myocardial infarction. [2011]

1.4.3

Seek a cardiology review for people with:

an active cardiac condition or
3 or more risk factors or
poor cardiac functional capacity. [2011]

1.4.4

Offer surgery without further investigations to people with 2 or fewer risk factors and good cardiac functional capacity. [2011]

1.4.5

Optimise any primary cardiac treatment and begin secondary prophylaxis for coronary disease as soon as possible. [2011]

1.4.6

Continue anti-ischaemic treatment in the perioperative period, including aspirin, statins and beta‑blockers. [2011]

1.4.7

For people with coronary stents, discuss perioperative anti-platelet treatment with a cardiologist. [2011]

1.4.8

Consider revascularisation (percutaneous intervention or coronary artery bypass grafting) before surgery for people with chronic stable angina and conventional indications for revascularisation. [2011]

Lung function

1.4.9

Perform spirometry and transfer factor (TLCO) testing before proceeding with treatment with curative intent. [2011, amended 2019]

1.4.10

Offer people surgery if they have a forced expiratory volume in 1 second (FEV1) within normal limits and good exercise tolerance. [2011]

1.4.11

Before surgery, perform a functional segment count to predict postoperative lung function. [2011]

1.4.12

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. [2011, amended 2019]

1.4.13

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. [2011]

1.4.14

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. [2011]

Assessment before radiotherapy with curative intent

1.4.15

A clinical oncologist specialising in thoracic oncology should determine suitability for radiotherapy with curative intent, taking into account performance status and comorbidities. [2011]

1.5 Surgery and radiotherapy with curative intent for NSCLC

Terminology used for cancer staging classification changes over time. The guideline recommendations were developed using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system.

Surgery

1.5.1

For people with NSCLC who are well enough and for whom treatment with curative intent is suitable, offer lobectomy (either open or thoracoscopic). [2019]

1.5.2

Offer more extensive surgery (bronchoangioplastic surgery, bilobectomy, pneumonectomy) only when needed to obtain clear margins. [2011]

1.5.3

Perform hilar and mediastinal lymph node sampling or en bloc resection for all people having surgery with curative intent. [2011]

1.5.4

For people with T3 NSCLC with chest wall involvement who are having surgery, aim for complete resection of the tumour using either extrapleural or en bloc chest wall resection. [2005]

Surgery or radiotherapy for people not having lobectomy

1.5.5

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. [2019]

Radical radiotherapy for people not having surgery

1.5.6

Offer pulmonary function tests (including lung volumes and transfer factor) before radical radiotherapy for NSCLC. [2005]

1.5.7

Include people receiving radiotherapy with curative intent in a national quality assurance programme. [2011]

1.5.8

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. [2019]

1.5.9

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). [2019]

1.5.10

For people with stage 3b NSCLC who cannot tolerate or who decline chemoradiotherapy, consider radical radiotherapy (either conventional or hyperfractionated) if they are eligible for this treatment. [2019]

Radiotherapy fractionation

1.5.11

If using SABR, follow the SABR Consortium guidance on fractionation. [2019]

1.5.12

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. [2019]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on surgery and radiotherapy with curative intent for NSCLC.

Full details of the evidence and the committee's discussion are in evidence review D: radiotherapy with curative intent for NSCLC.

1.6 Multimodality treatment for NSCLC with curative intent

Terminology used for cancer staging classification changes over time. The guideline recommendations were developed using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. For the AJCC staging system used in a NICE technology appraisal, see the relevant technology appraisal guidance.

1.6.1

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. [2011]

1.6.2

Treat Pancoast tumours in the same way as other types of NSCLC. Offer multimodality treatment according to resectability, stage of the tumour and performance status of the person. [2011]

1.6.3

For people with operable stage 3a N2 NSCLC who can have surgery and are well enough for multimodality treatment, consider chemoradiotherapy with surgery. [2019]

1.6.4

Discuss the benefits and risks with the person before starting chemoradiotherapy with surgery, including that it:

improves progression-free survival
may improve overall survival. [2019]

1.6.5

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. [2019]

1.6.6

Multidisciplinary teams that provide chemoradiotherapy with surgery should have expertise in multimodality treatment and in all of the individual components. [2019]

1.6.7

Centres performing lung resections for lung cancer should validate their data for the National Lung Cancer Audit. [2019]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on management of operable stage 3a to N2 NSCLC.

Full details of the evidence and the committee's discussion are in evidence review C: management of NSCLC stage IIIA-N2.

Perioperative systemic anticancer therapy for potentially resectable NSCLC

Neoadjuvant treatment

1.6.8

Nivolumab in combination with chemotherapy is recommended as an option for neoadjuvant treatment of resectable (tumours at least 4 cm or node positive) NSCLC. For full details, see NICE's technology appraisal guidance on nivolumab (TA876, 2023).

Neoadjuvant and adjuvant treatment

1.6.9

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. For full details, see NICE's technology appraisal guidance on durvalumab (TA1030, 2025).

1.6.10

Pembrolizumab in combination with platinum-based chemotherapy is recommended as an option for neoadjuvant (then continued alone as adjuvant) treatment of resectable NSCLC with a high risk of recurrence. For full details, see NICE's technology appraisal guidance on pembrolizumab (TA1017, 2024).

Adjuvant treatment

1.6.11

Offer postoperative systemic anticancer therapy to people with good performance status (WHO 0 or 1) and T1a to 4, N1 to 2, M0 NSCLC. [2011]

1.6.12

Consider postoperative systemic anticancer therapy for people with good performance status (WHO 0 or 1) and T2b to 4, N0, M0 NSCLC with tumours greater than 4 cm in diameter. [2011]

1.6.13

Offer a platinum-based combination chemotherapy regimen for adjuvant chemotherapy. [2011]

1.6.14

Osimertinib is recommended as an option for adjuvant treatment of completely resected stage 1b to 3a NSCLC with EGFR exon 19 deletions or EGFR exon 21 (L858R) substitution mutations. It should be stopped at 3 years, or earlier if there is disease recurrence or unacceptable toxicity. For full details, see NICE's technology appraisal guidance on osimertinib (TA1043, 2025).

1.6.15

Alectinib is recommended as an option for adjuvant treatment of completely resected stage 1b (tumours at least 4 cm) to 3a ALK-positive NSCLC. For full details, see NICE's technology appraisal guidance on alectinib (TA1014, 2024).

1.6.16

For medicines recommended as options for adjuvant treatment of completely resected NSCLC with a high risk of recurrence after platinum-based chemotherapy in some people, see NICE's technology appraisal guidance on:

Locally advanced unresectable NSCLC

1.6.17

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. [2011]

1.6.18

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. For full details, see NICE's technology appraisal guidance on durvalumab (TA798, 2022).

1.7 Systemic anticancer therapy for advanced non-small-cell lung cancer

We have produced treatment pathways bringing together NICE-recommended treatment options from this guideline and relevant technology appraisal guidance on advanced non-small-cell lung cancer (NSCLC; squamous and non-squamous). The treatment pathways cover the recommended treatment options at each decision point.

These are available to view as individual pathways (linked below), or grouped together in a single interactive PDF of all treatment pathways for squamous and non-squamous advanced non-small-cell lung cancer.

We have also produced fully accessible summaries of the treatment pathways.

Also see the section on multimodality treatment for NSCLC with curative intent.

Squamous NSCLC

Non-squamous NSCLC

No targetable mutations, PD-L1 below 50%

Systemic anticancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 below 50%

Fully accessible summary of systemic anticancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 below 50%

No targetable mutations, PD-L1 50% or higher

Systemic anticancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 50% or higher

Fully accessible summary of systemic anticancer therapy: treatment options for people with non-squamous non-small-cell lung cancer, with no targetable mutations and PD-L1 50% or higher

RET fusion positive, PD-L1 below 50%

Systemic anticancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 below 50%

Fully accessible summary of systemic anticancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 below 50%

RET fusion positive, PD-L1 50% or higher

Systemic anticancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anticancer therapy: treatment options for people with RET fusion positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

KRAS G12C positive, PD-L1 below 50%

Systemic anticancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 below 50%

Fully accessible summary of systemic anticancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 below 50%

KRAS G12C positive, PD-L1 50% or higher

Systemic anticancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anticancer therapy: treatment options for people with KRAS G12C positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

METex14 skipping alteration, PD-L1 below 50%

Systemic anticancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 below 50%

Fully accessible summary of systemic anticancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 below 50%

METex14 skipping alteration, PD-L1 50% or higher

Systemic anticancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anticancer therapy: treatment options for people with METex14 skipping alteration non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

BRAF V600 positive, PD-L1 below 50%

Systemic anticancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 below 50%

Fully accessible summary of systemic anticancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 below 50%

BRAF V600 positive, PD-L1 50% or higher

Systemic anticancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

Fully accessible summary of systemic anticancer therapy: treatment options for people with BRAF V600 positive non-squamous non-small-cell lung cancer, with PD-L1 50% or higher

ROS-1 positive

Systemic anticancer therapy: treatment options for people with ROS-1 positive non-squamous non-small-cell lung cancer

Fully accessible summary of systemic anticancer therapy: treatment options for people with ROS-1 positive non-squamous non-small-cell lung cancer

EGFR-TK positive

Systemic anticancer therapy: treatment options for people with EGFR-TK positive non-squamous non-small-cell lung cancer

Fully accessible summary of systemic anticancer therapy: treatment options for people with EGFR-TK positive non-squamous non-small-cell lung cancer

ALK positive

Systemic anticancer therapy: treatment options for people with ALK positive non-squamous non-small-cell lung cancer

Fully accessible summary of systemic anticancer therapy: treatment options for people with ALK positive non-squamous non-small-cell lung cancer

Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours

1.7.1

Larotrectinib is recommended as an option through the Cancer Drugs Fund for treating locally advanced or metastatic NTRK fusion-positive solid tumours when there are no other satisfactory treatment options. For full details, see NICE's technology appraisal guidance on larotrectinib (TA630, May 2020).

Treatments not recommended for squamous and non-squamous advanced NSCLC

1.7.2

For medicines not recommended for treating advanced NSCLC in some people, see NICE's technology appraisal guidance on:

1.8 Assessing people with small-cell lung cancer (SCLC)

1.8.1

Arrange for people with SCLC to have an assessment by a thoracic oncologist within 1 week of deciding to recommend treatment. [2011]

1.9 Surgery for early-stage SCLC

Terminology used for cancer staging classification changes over time. The guideline recommendations were developed using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system.

1.9.1

Consider surgery in people with early-stage SCLC (T1 to 2a, N0, M0). [2011]

1.10 First-line treatment for limited-stage SCLC

Terminology used for cancer staging classification changes over time. The guideline recommendations were developed using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. For the AJCC staging system used in a NICE technology appraisal, see the relevant technology appraisal guidance.

1.10.1

Offer people with limited-stage SCLC (broadly corresponding to T1 to 4, N0 to 3, M0) 4 to 6 cycles of cisplatin-based combination chemotherapy. Consider substituting carboplatin in people with impaired renal function, poor WHO performance status (score of 2 or more) or significant comorbidity. [2011]

1.10.2

Offer twice-daily radiotherapy with concurrent chemotherapy to people with limited-stage SCLC (broadly corresponding to T1 to 4, N0 to 3, M0) and a WHO performance status of 0 or 1, if they present with disease that can be encompassed in a radical thoracic radiotherapy volume. Start the radiotherapy during the first or second cycle of chemotherapy. [2019]

1.10.3

If the person declines or is unable to have twice-daily radiotherapy, offer once-daily radiotherapy. [2019]

1.10.4

Offer sequential radical thoracic radiotherapy to people with limited-stage SCLC (broadly corresponding to T1 to 4, N0 to 3, M0) who are not well enough for concurrent chemoradiotherapy but who respond to chemotherapy. [2019]

1.10.5

Offer prophylactic cranial irradiation at a dose of 25 Gy in 10 fractions to people with limited-stage SCLC and a WHO performance status of 0 to 2, if their disease has not progressed on first-line treatment. [2011, amended 2019]

1.10.6

Durvalumab is recommended as an option for treating limited-stage SCLC that has not progressed after platinum-based chemoradiotherapy in adults. For full details, see NICE's technology appraisal guidance on durvalumab (TA1099, 2025).

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on first-line treatment for limited-stage SCLC.

Full details of the evidence and the committee's discussion are in evidence review F: chemoradiotherapy for limited stage SCLC.

1.11 First-line treatment for extensive-stage SCLC

Terminology used for cancer staging classification changes over time. The guideline recommendations were developed using the 7th edition of the American Joint Committee on Cancer (AJCC) staging system. For the AJCC staging system used in a NICE technology appraisal, see the relevant technology appraisal guidance.

1.11.1

Offer platinum-based combination chemotherapy to people with extensive-stage SCLC (broadly corresponding to T1 to 4, N0 to 3, M1a/b – including cerebral metastases) if they are fit enough. [2011]

1.11.2

Assess the person's condition before treatment for extensive-stage SCLC (broadly corresponding to T1 to 4, N0 to 3, M1a/b) and offer up to a maximum of 6 cycles of chemotherapy, depending on response and toxicity. [2011]

1.11.3

For medicines recommended as options for untreated extensive-stage SCLC in people who have an Eastern Cooperative Oncology Group performance status of 0 or 1, see NICE's technology appraisal guidance on:

1.11.4

Consider thoracic radiotherapy with prophylactic cranial irradiation for people with extensive‑stage SCLC who have had a partial or complete response to chemotherapy within the thorax and at distant sites. [2019]

1.11.5

Consider prophylactic cranial irradiation for people with extensive-stage SCLC and a WHO performance status of 0 to 2, if their disease has responded to first-line treatment. [2019]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on thoracic radiotherapy and prophylactic cranial irradiation in SCLC.

Full details of the evidence and the committee's discussion are in evidence review G: thoracic radiotherapy for extensive stage SCLC and evidence review H: prophylactic cranial irradiation for extensive stage SCLC.

1.12 Subsequent treatment for SCLC that has relapsed after first-line treatment

1.12.1

Offer people with SCLC that has relapsed after first-line treatment assessment by a thoracic oncologist. [2011]

1.12.2

Inform people whose disease has not responded to first-line treatment that there is very limited evidence that second-line chemotherapy will be of benefit. [2011]

1.12.3

Offer people with relapsed SCLC in whom chemotherapy is suitable treatment with an anthracycline-containing regimen or further treatment with a platinum-based regimen to a maximum of 6 cycles. [2011]

1.12.4

Oral topotecan is recommended as an option for treating relapsed SCLC in some people. For full details, see NICE's technology appraisal guidance on topotecan (TA184, 2009).

1.12.5

Offer radiotherapy for palliation of local symptoms to people with SCLC that has relapsed after first-line treatment. [2011]

1.12.6

Tarlatamab is not recommended for treating extensive-stage SCLC in adults whose cancer has progressed after 2 or more lines of treatment, including platinum-based chemotherapy. For full details, see NICE's technology appraisal guidance on tarlatamab (TA1091, 2025).