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.

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.