National trends, variation and short-term outcomes in surgery for non-small cell lung cancer in England, 2015–2023: a population-based cohort study using linked national cancer registration and hospital administrative data

Abstract

Objectives To evaluate temporal changes in surgical practice, centre-level variation and short-term postoperative outcomes among patients undergoing lung resection for non-small cell lung cancer (NSCLC) in England between 2015 and 2023. Design Population-based cohort study using linked national cancer registration and Hospital Episode Statistics data. Setting Secondary care in England, including all specialist thoracic surgical centres. Participants Adults (≥18 years) diagnosed with NSCLC in England between 1 January 2015 and 31 December 2023. Patients with linked Hospital Episode Statistics records were included and those undergoing lung resection comprised the surgical cohort. Outcome measures Annual resection rates, procedure type, operative approach, centre-level variation in segmentectomy use and robotic-assisted thoracoscopic surgery (RATS) adoption, 90-day mortality, 30-day emergency readmission and postoperative length of stay. Multivariable regression models adjusted for patient and clinical case mix. Results Among 308 117 patients with NSCLC, 54 138 (17.6%) underwent lung resection. The resection rate increased from 15.4% in 2015 to 20.9% in 2023, while the proportion of patients diagnosed with stage I disease increased from 17.4% to 26.8%. Segmentectomy use increased from 11.2% to 20.6%, pneumonectomy declined fourfold and minimally invasive surgery increased from 47.1% to 79.7%. In 2023, centre-level variation was marked in segmentectomy for small stage IA tumours (risk-adjusted range 10.7%–80.3%) and RATS use (range 0%–67%). 90-day mortality decreased from 4.03% to 2.26%, length of stay shortened and readmission remained stable at approximately 10%–12%. Each successive year of diagnosis was associated with lower 90-day mortality after adjustment for case mix (adjusted OR 0.95, 95% CI 0.93 to 0.98). Conclusions Between 2015 and 2023, surgical management of NSCLC in England changed substantially, with increased resection rates, greater use of segmentectomy and minimally invasive approaches and improved short-term postoperative outcomes. However, persistent variation in segmentectomy use and robotic adoption suggests that implementation of contemporary surgical practice remains heterogeneous across centres.