Most patients with lung cancer are fit for surgery — including many who have been told otherwise. Current UK national guidance (NICE NG122, last updated March 2024) is explicit that low predicted post-operative lung function does not, by itself, exclude curative lung cancer surgery if the patient accepts the risks. Modern technique, prehabilitation, and a combined cancer-and-lung-volume-reduction pathway for selected patients with COPD or emphysema extend the surgical option to patients who would have been declined a decade ago. Dr Lawrence Okiror sees patients privately at London Bridge Hospital and The Lister Hospital Chelsea. Appointments within 2–3 days. Self-referrals welcome.
Last reviewed: May 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
NICE NG122 (March 2024) is the UK national framework. The thresholds are more permissive than older guidance — predicted post-op lung function below 30% does not, by itself, close the door to curative surgery.
For selected patients with cancer in destroyed emphysematous lung, surgery can deliver cancer cure and improved breathing — the combined cancer-and-lung-volume-reduction pathway.
Borderline-fitness surgery is made safe by a combination of high volume, minimally invasive technique, regional analgesia, ERAS, and prehabilitation — reflected in independently audited SCTS data.
The question that matters is whether your cancer sits in destroyed lung. A quantitative ventilation-perfusion scan answers it. If it does, the operation can remove the cancer and improve your breathing at the same time — selected patients leave with better lung function than they had before.
This is an imaging-led pathway, not a paragraph of advice. It needs to be applied to your scan. Most centres do not run it. Dr Okiror does. Request an appointment within 2–3 days →
UK national guidance (NICE NG122, last updated March 2024) sets out this three-part framework. It is the framework used at every major UK thoracic centre, including Guy’s and St Thomas’ where Dr Okiror is based. Most patients are clearly fit, a small number are clearly unfit for any major surgery, and the clinically interesting group sits in between — that is where modern decision-making, prehabilitation, and surgical technique combine to expand who can have curative treatment.
The risk that surgery or recovery triggers a cardiac event. This is assessed from your history, an ECG, and where indicated an echocardiogram or stress test. Significant findings prompt cardiology review before any final surgical decision. A previous heart attack or coronary intervention does not in itself rule out lung surgery — it is the current state of your cardiac function and your stability on therapy that matter.
The probability of not surviving the operation and the early months after. This is modelled from large national datasets — in a high-volume robotic centre, operative survival is now over 99%. The 2024–25 SCTS National Audit reports operative survival of 99.59% at Dr Okiror’s NHS base, against the national benchmark of 98.5%.
The most common concern patients raise. This is assessed through lung function testing, exercise capacity, and where lung function is borderline, more detailed functional imaging. If breathlessness is the reason your fitness is being questioned, this page may also be useful →
Pre-operative fitness assessment is built from a small number of focused tests. Each measures a different aspect of how your lungs and circulation are working — and how they will cope with surgery.
Spirometry measures how much air you can move and how fast — the standard test for lung capacity (FEV1) and obstruction. Transfer factor (TLCO, sometimes written DLCO) is the more sensitive measurement: it reflects how well your lungs transfer oxygen from the air sacs into the bloodstream. Both are required for every patient considered for lung cancer surgery (NICE NG122, 2024). Some patients have entirely normal FEV1 but a low transfer factor — both tests are needed to capture the full picture, especially in emphysema.
Spirometry and transfer factor are ordered at your first appointment.
CPET is the gold-standard test of cardiopulmonary fitness for major surgery. It measures how efficiently your heart, lungs, and muscles use oxygen during graduated exercise on a bike, with continuous breath-by-breath gas analysis.
The key number is VO2 max — the maximum rate of oxygen uptake. NICE NG122 takes a VO2 max above 15 mL/kg/min as good function, and patients in this range are usually suitable for lobectomy. Between 10 and 15 mL/kg/min, a smaller anatomical operation — segmentectomy or wedge resection — is generally preferred over lobectomy. Below 10 mL/kg/min, surgery is uncommon and other treatments are usually considered. CPET also reveals whether the limit on exercise is primarily cardiac or pulmonary in origin — useful when the picture is mixed.
CPET is organised at London Bridge Hospital where indicated, typically for patients whose spirometry or transfer factor is borderline.
Three accessible tests correlate well with CPET and are widely used as a first-pass screen.
Shuttle walk test — distance walked at progressively faster pace. Above 400 m is good function (NICE NG122). Six-minute walk test — distance walked at your own pace in six minutes. Stair climb — the number of flights climbed without stopping.
Patients can self-screen before consultation. Climbing two full flights of stairs without stopping is a useful real-world indicator — though it does not replace formal testing.
When standard lung function is borderline, and the question is whether surgery can be done safely, a quantitative ventilation-perfusion (VQ) SPECT scan maps which parts of your lung are working and which are not. In emphysema, lung function is rarely uniform — destroyed, hyperinflated lung contributes little to gas exchange. SPECT shows this directly.
The implication matters. If a cancer sits in lung that is already not working, removing it costs less in lung function than the simple numbers would suggest. SPECT imaging routinely shows that selected patients gain lung function after surgery rather than lose it.
This imaging is central to the combined cancer-emphysema pathway described in section 4.
NICE national guidance sets out the thresholds that define modern surgical decision-making in the UK. Patients are often surprised by how permissive the modern guidance is.
| Category | Thresholds & operation type |
|---|---|
| Fit for lobectomy | FEV1 within normal limits and good exercise tolerance — most patients fall here. Predicted post-operative FEV1 or transfer factor above 30%. VO2 max above 15 mL/kg/min on CPET, or shuttle walk above 400 m. |
| Sublobar resection considered | VO2 max between 10 and 15 mL/kg/min. Lobectomy carries higher risk in this group, so a smaller anatomical operation — segmentectomy or wedge resection — is considered instead. For patients with COPD or emphysema, the combined cancer-and-lung-volume-reduction pathway may also apply. |
| Surgery offered with informed consent | Predicted post-operative FEV1 or transfer factor below 30% — NICE 2024 is explicit: surgery with curative intent should still be offered if the patient accepts the risks of breathlessness and complications. The 30% threshold is not a closed door, and quantitative VQ SPECT often changes the calculation in patients with emphysema. |
| Other approaches typically considered | VO2 max below 10 mL/kg/min, or multiple major thresholds crossed with significant frailty. Stereotactic radiotherapy, ablation, or systemic therapy are usually the appropriate routes here. |
The 30% NICE threshold is more permissive than older guidance, and the shift matters. Patients told elsewhere that their lung function precludes resection should know that current UK guidance frames this as a conversation about risk and informed consent — not a structural exclusion.
Lung cancer and emphysema commonly co-exist. They share the same primary cause — long-term smoking. At Guy’s and St Thomas’, lung cancers identified in the COPD and emphysema clinics are routinely discussed at the chest multidisciplinary team meeting and referred onward to Dr Okiror, who leads the Trust’s lung-cancer-in-emphysema pathway. He is the Trust’s sole operator for lung volume reduction surgery and for endobronchial valve therapy, has performed over 100 LVRS and EBV procedures since 2019, and chairs the monthly Advanced Emphysema MDT. Dr Okiror is also the sole designated lung volume reduction surgery operator at London Bridge Hospital, which is what makes the combined pathway available privately.
In severe emphysema, lung tissue is not damaged uniformly. Some lobes are heavily destroyed and contribute little to breathing — the destroyed lung is hyperinflated, taking up space without doing useful work. Removing this lung does not reduce capacity; it can actually improve breathing because the remaining lung can expand more effectively. This is the principle behind lung volume reduction surgery, and it has been the standard treatment for advanced heterogeneous emphysema for over twenty years. More on lung volume reduction surgery and emphysema treatment →
When a lung cancer happens to sit within an already-destroyed area of lung, the surgical resection performed for cancer cure delivers a lung volume reduction effect at the same time. The operation removes the cancer and removes the worst of the destroyed lung. Selected patients leave the operation with better lung function than they had before.
This is not theoretical. The combined approach was first described by Cooper and colleagues in 1998 (Journal of Thoracic and Cardiovascular Surgery) and formally established by Choong and colleagues in 2004 in a 21-patient series with no hospital deaths and 100% one-year survival, with every patient demonstrating improved lung function after surgery. Subsequent series have replicated these findings.
The pathway is not for every patient with COPD. The cancer must be located in lung that is already significantly destroyed by emphysema, and the destruction has to be heterogeneous — concentrated in one or two zones rather than uniform across all lobes. This is determined by:
High-resolution CT of the chest — to map the distribution of emphysematous destruction. Quantitative ventilation-perfusion SPECT — to confirm which lobes are contributing meaningfully to gas exchange and which are not. Pulmonary function testing — spirometry, transfer factor, and lung volumes. Cardiopulmonary exercise testing where borderline. Multidisciplinary discussion at the Advanced Emphysema MDT and the chest cancer MDT.
For patients who fit, the pathway provides a curative cancer operation that other surgical centres often decline because they read lung function in isolation, without the quantitative imaging that distinguishes functioning from destroyed lung.
Surgery is typically performed by robotic or VATS keyhole approach to minimise the chest wall trauma that compounds lung function loss. In selected cases, a combined cancer resection plus additional lung volume reduction in a separate, more destroyed lobe is performed at the same operation. Detailed planning rests on the SPECT and HRCT imaging.
Surgery on patients with reduced reserve is not made safe by any single factor. It is made safe by the combination of factors below, applied together. This is the answer to the question patients with COPD, prior cardiac disease, or borderline lung function reasonably ask: how, exactly, is this going to be safe for me?
Volume and personal experience
Over 1,000 anatomical lung cancer operations as a consultant; 153 in 2024–25 alone. Sole designated lung volume reduction surgery and endobronchial valve operator at GSTT and at London Bridge Hospital. Over 100 LVRS and EBV procedures since 2019. Operative outcomes audited annually within the SCTS National Thoracic Surgery Audit.
Minimally invasive surgery
Over 80% of Dr Okiror’s anatomical resections are performed by robotic (RATS) or keyhole (VATS) approach. Both preserve respiratory mechanics, reduce post-operative pain, and protect chest wall function — disproportionately important for patients with limited reserve. Robotic share of anatomical resections at GSTT in 2024–25: 71.3% (SCTS National Audit).
Lung-sparing technique
Robotic segmentectomy where the tumour permits — landmark trials (JCOG0802 and CALGB 140503) have established equivalent cancer control with more lung preserved. The combined LVRS effect for selected patients with cancer in destroyed emphysematous lung. The smallest appropriate operation, in every case.
Regional analgesia
Paravertebral catheters and local anaesthetic intercostal blocks deliver targeted pain relief without the drowsiness, respiratory depression, and constipation of opioid-based regimens. The result: earlier mobilisation, deeper breathing, fewer chest infections, and a recovery that does not depend on heavy painkillers.
ERAS, HDU and ICU access
Enhanced Recovery After Surgery (ERAS) protocols — published as a thoracic-specific guideline by the European Society of Thoracic Surgeons in 2019 — structure the entire pathway from admission to discharge for early mobilisation and rapid recovery. High Dependency Unit step-up where indicated; ICU available at London Bridge Hospital.
Independently audited outcomes
Operative outcomes are reported annually to the SCTS National Thoracic Surgery Audit. The 2024–25 audit reports operative survival of 99.59% at GSTT, against the national benchmark of 98.5%. The combination of factors above is reflected in those numbers — outcomes are not compromised by operating on borderline-fitness patients.
No single one of these factors makes the difference. It is the combination — surgical experience and high volume, the right operative platform, the right scale of resection, regional rather than opioid pain control, structured peri-operative care, and the safety net of HDU and ICU access — that allows surgery to be offered safely to patients other centres might decline.
For patients in the borderline category — and for patients with significant other medical conditions — pre-operative optimisation is part of the surgical pathway, not an afterthought.
The framework is set by the Centre for Perioperative Care (CPOC) Perioperative Care of the Older Person undergoing Surgery model, published in 2021 and now standard at UK thoracic centres. The Manchester regional Prehab4Cancer programme (Bradley and colleagues, British Journal of Anaesthesia, 2022) provides the largest UK real-world dataset, with meaningful improvements in fitness, complication rates, and length of hospital stay across hundreds of patients in its first year.
Significant chronic respiratory disease (COPD, emphysema, breathlessness, secretions). Significant cardiac history — previous heart attack, exertional or rest angina, congestive cardiac disease. Underlying neurological disease affecting mobility or breathing. Age over 80, or under 80 with frailty. Falls in the past year, or use of a walking aid. Current smoking — smoking cessation alone halves complication rates if achieved more than four weeks before surgery. Unintentional weight loss. Mental health or cognitive issues that affect recovery readiness. Patients receiving chemoimmunotherapy before surgery — referred for prehab as early as possible.
A high-risk multidisciplinary team coordinates pre-operative optimisation: physiotherapy, perioperative medicine, cardiology liaison, vascular and respiratory liaison, interstitial lung disease assessment where relevant, smoking cessation, and nutritional optimisation. Members of the same multidisciplinary team practising at Guy’s and St Thomas’ also work at London Bridge Hospital and The Lister Chelsea — so the framework that designs the GSTT pathway carries through to private practice.
The standard pre-operative optimisation window is two to six weeks. Patients receiving chemoimmunotherapy before surgery can be optimised in parallel with their oncology pathway, so surgery is not delayed. More on the chemoimmunotherapy-then-surgery pathway →
Three patient profiles where a second opinion is most often productive:
The combined cancer-and-LVRS pathway described in section 4 is uniquely positioned for this group. Quantitative imaging often shows that the cancer sits in already-destroyed lung — meaning the operation costs less in function than predicted by simple segment counting.
A previous heart attack, angina, coronary intervention, or valvular heart disease is not in itself a reason to decline lung surgery. Patients with established coronary or valvular disease are routinely reviewed in collaboration with cardiology — with stress echocardiography, myocardial perfusion imaging, or cardiac-protocol cardiopulmonary exercise testing where indicated — and proceed to lung cancer surgery once the cardiac assessment is optimised. The high-risk multidisciplinary team that coordinates this liaison at Guy’s and St Thomas’ uses the same approach for private patients at London Bridge Hospital and The Lister Chelsea.
Age in itself is not a determinant. Frailty, exercise tolerance, and physiological reserve are. A fit 78-year-old will tolerate a robotic segmentectomy better than a sedentary 62-year-old with significant other medical conditions.
In each case, the structured assessment described on this page — together with current NICE thresholds and the modern pathway tools — will give a clearer answer than a single number reviewed in isolation.
A second-opinion appointment can usually be arranged within 2–3 days at London Bridge Hospital or The Lister Chelsea, or by video consultation within 24 hours. Bring all scans, lung function tests, and previous letters. Self-referrals welcome. Request a second opinion →
The first consultation is built around your specific question — typically whether surgery is possible, and if so, which operation.
Forward any imaging, lung function tests, biopsy results, and specialist letters in advance. Practice contact: Jo Mitchelson, 020 7952 2882, pa@lungsurgeon.co.uk.
Dr Okiror will personally review your scans, take a focused clinical and respiratory history, examine you, and discuss the surgical options. Where pre-operative testing is incomplete, spirometry and transfer factor are organised the same day. Where CPET, quantitative VQ SPECT, or specialist cardiology review is needed, the appropriate tests are arranged at London Bridge Hospital — typically within one to two weeks for self-pay patients, or as your insurance pathway permits.
A clear surgical recommendation — including the choice between robotic lobectomy, segmentectomy, the combined cancer-and-emphysema pathway, the single-anaesthetic biopsy-and-resection pathway for selected fit patients with peripheral lesions, or non-surgical alternatives — is made at the appointment when sufficient information is available. Where further testing is needed first, the next decision point is scheduled, typically within a fortnight.
Every cancer case is discussed at the London Bridge Hospital chest multidisciplinary team meeting before any operation proceeds. No treatment plan is made by a single doctor.
From decision to operation is typically two to four weeks for self-pay or insured patients, depending on the optimisation plan. More on lung cancer surgery in 2026 → · Robotic lung surgery overview →
I have been told my FEV1 is too low for surgery. Is that final?
Not necessarily. Current UK national guidance (NICE NG122, last updated March 2024) is explicit that surgery with curative intent should still be offered to patients with predicted post-operative FEV1 or transfer factor below 30% if they accept the risks of breathlessness and complications. For patients with emphysema or COPD, a quantitative VQ scan often shows the cancer sits within already-destroyed lung — meaning the operation costs less in lung function than the simple numbers predict. A formal reassessment is reasonable.
What is the difference between FEV1, transfer factor, and VO2 max?
FEV1 measures how much air you can blow out in one second — a measure of airway obstruction. Transfer factor (TLCO, sometimes called DLCO) measures how efficiently your lungs transfer oxygen into the bloodstream — more sensitive than FEV1, especially in emphysema. VO2 max, measured during cardiopulmonary exercise testing, is the rate at which your body uses oxygen during exercise — the best single measure of cardiopulmonary fitness for major surgery.
What is combined lung cancer and lung volume reduction surgery?
It is a single operation that removes a lung cancer located within heavily destroyed emphysematous lung. Because the destroyed lung was contributing little to breathing, the operation delivers cancer cure and a lung volume reduction effect at the same time. Selected patients have better lung function after surgery than before. The pathway depends on careful imaging — high-resolution CT and quantitative VQ SPECT — to confirm the cancer location and the pattern of emphysema make the approach safe and appropriate.
Will I need cardiopulmonary exercise testing (CPET)?
CPET is recommended for patients whose spirometry or transfer factor is borderline, or where it is not clear whether the limit on exercise is cardiac or respiratory. It is organised at London Bridge Hospital where indicated, typically within one to two weeks of the first consultation.
How long is prehabilitation before lung cancer surgery?
Two to six weeks is standard for elective surgery. Patients receiving chemoimmunotherapy before surgery are referred for prehabilitation in parallel with the oncology pathway, so surgery is not delayed.
Can I get a second opinion if I have been told I am not fit elsewhere?
Yes. A second-opinion appointment can usually be arranged within 2–3 days at London Bridge Hospital or The Lister Chelsea, or by video consultation within 24 hours. Please bring your scans, lung function results, and previous letters. Self-referrals welcome.
How is borderline-fitness surgery made safe?
Through a combination of factors: high operative volume and personal experience; minimally invasive surgery (robotic and keyhole) which preserves chest wall function and breathing mechanics; lung-sparing techniques including segmentectomy and the combined LVRS effect for selected patients; regional anaesthesia (paravertebral catheters and intercostal blocks) which reduces opioid burden, drowsiness, and chest infections; ERAS protocols and HDU step-up at London Bridge Hospital; and pre-operative optimisation through prehabilitation. Outcomes are reflected in independently audited SCTS data.
What if I have a heart condition?
A previous heart attack, angina, coronary intervention, or valvular heart disease is not in itself a reason to decline lung surgery. Patients with established coronary or valvular disease are routinely reviewed in collaboration with cardiology — with stress echocardiography, myocardial perfusion imaging, or cardiac-protocol cardiopulmonary exercise testing where indicated — and proceed to lung cancer surgery once the cardiac assessment is optimised. The high-risk multidisciplinary team coordinates this cardiology liaison as part of the pre-operative pathway.
Dr Okiror sees private patients within 2–3 working days at London Bridge Hospital and The Lister Hospital Chelsea. Video consultation within 24 hours for international and out-of-London patients. Self-referrals welcome.
Request a consultation →Disclosures
This guide describes Dr Lawrence Okiror’s clinical practice in pre-operative fitness assessment for lung cancer surgery as of May 2026. It is intended as patient information, not as medical advice for any individual case. Decisions about fitness for surgery and surgical treatment are always made on a case-by-case basis after appropriate clinical evaluation and multidisciplinary review. Dr Okiror is a Consultant Thoracic and Robotic Surgeon at Guy’s and St Thomas’ NHS Foundation Trust, with private practising privileges at London Bridge Hospital and The Lister Hospital Chelsea. The thresholds and recommendations cited reflect current UK national guidance (NICE NG122, last updated March 2024) and the wider evidence base referenced.
Robotic lobectomy, segmentectomy, and bronchial sleeve resection for primary lung cancer
Emphysema Surgery in 2026Endobronchial valves and lung volume reduction surgery
Robotic SegmentectomyLung-sparing cancer surgery for tumours under 2 cm — equivalent cancer control with more lung preserved
Robotic LobectomyThe standard cancer operation for tumours larger than 2 cm or with nodal involvement
Combined Biopsy & SurgeryFor selected fit patients with a small peripheral lesion — biopsy and curative resection under one anaesthetic
Specialist Second OpinionIndependent review for patients seen elsewhere — within 2–3 days