Synopsis
Integrate histology, TNM stage, predictive biomarkers, physiological fitness and patient priorities to select curative local therapy, multimodality treatment or personalised systemic care.
- Non-small-cell lung cancer includes adenocarcinoma, squamous carcinoma and less common subtypes; histology influences sampling, biomarker testing and systemic therapy.
- Treatment is organised by TNM stage, anatomical resectability, cardiopulmonary fitness, performance status, molecular drivers, PD-L1 expression and the person's goals.
- Early resectable disease is considered for anatomical lung resection with systematic nodal assessment; medically inoperable disease may be treated with stereotactic ablative radiotherapy or another radical schedule.
- Stage III disease is heterogeneous and requires thoracic MDT planning across surgery, systemic anticancer therapy and radiotherapy rather than a single default regimen.
- Before non-emergency treatment of advanced non-squamous NSCLC, obtain adequate genomic and PD-L1 results because a targetable driver can change first-line therapy fundamentally.
- NICE technology appraisals and the NHS Genomic Test Directory evolve; verify current eligibility, prior-treatment and commissioning criteria at the actual prescribing decision.
- Immune-related toxicity can affect lung, bowel, liver, endocrine organs, kidney, skin, heart or nervous system and can present after the last checkpoint-inhibitor dose.
- Supportive and palliative care, smoking support, symptom control, nutrition and advance care planning should run alongside active anticancer treatment, not be reserved for its end.
Key red flags
New focal deficit, seizure, cord-compression features, severe hypercalcaemia, major haemoptysis or superior vena cava obstruction needs emergency treatment alongside oncological reassessment.
Acute hypoxaemia or diffuse lung change during immunotherapy may represent pneumonitis; withhold further doses and obtain urgent oncology and respiratory assessment rather than assuming infection alone.
Fever or shock during cytotoxic therapy may represent neutropenic sepsis and requires the local emergency antibiotic pathway without waiting for routine clinic contact.
Immune-related myocarditis, severe colitis, adrenal crisis or neurological toxicity can deteriorate rapidly and requires urgent specialist management even when the most recent dose was weeks earlier.
Do not start a non-emergency advanced-disease regimen without checking outstanding molecular and PD-L1 results, because the wrong sequence can reduce benefit or increase harm.
Investigation priorities
Confirm NSCLC subtype and adequacy for predictive testing.
Management branches
NSCLC appears confined to the lung and regional nodes with no confirmed distant disease.
- Complete PET-CT, appropriate mediastinal staging and physiological assessment, verifying any solitary finding that would remove curative intent when feasible.
- For operable resectable disease, discuss anatomical resection and systematic nodal assessment with thoracic surgery, incorporating minimally invasive approaches when appropriate.
- For a patient unsuitable for or declining surgery, consider stereotactic ablative radiotherapy or another radical radiotherapy option through the lung MDT.
- After definitive treatment, review final pathology and current NICE indications for adjuvant systemic or targeted treatment, then place the patient in a structured follow-up plan.