Let me see him
What perioperative chemoimmunotherapy changed about who reaches the operating theatre

The criteria for operating on locally advanced lung cancer have not widened. What has changed is the price of being turned down, and who is doing the turning down.

Two things have to be true

Before a patient with locally advanced lung cancer is offered chemotherapy and immunotherapy ahead of surgery, two things have to be true. The tumour has to be resectable, meaning we can take it out with clear margins. And the patient has to be operable, meaning they will survive the operation the tumour needs.

Both are settled at diagnosis, and the second one is settled against the operation the tumour needs now. Not the smaller one it might need in four months. If a man is not fit for the pneumonectomy his tumour currently demands, we do not start him on treatment and hope it shrinks into a lobectomy. That sounds harsh. It is the right rule, and I would not want it loosened.

What changed was the cost of a no

Ten years ago, being judged unfit cost a patient an operation, and the alternative was chemoradiotherapy. It is not that any more. Chemotherapy with immunotherapy before surgery, and immunotherapy again afterwards, is now part of standard care for resectable stage II and III disease, and there is no neoadjuvant treatment without a planned resection. So the fitness assessment no longer decides whether a patient has surgery. It decides whether a whole arm of modern treatment is open to them at all. The funding guidance reflects this without admitting it: the appraisals that pay for these regimens specify tumour size, nodal status and biomarker, and say nothing about the one thing that has to be true for a perioperative regimen to make sense.

What sits on the other side of that decision is not nothing. In a series from our unit of 2,566 resections between 2009 and 2019, median overall survival among patients with N2 disease in the specimen was 27.9 months, against 41.7 months for N1. Those are not triumphant numbers. They are also not a rounding error, and they are what a patient forfeits when the pathway closes before it opens.

The assessment is not a threshold

Here is the part that gets missed. Fitness for lung surgery is not a line you cross. It is a process, and how far the process goes depends on how much trouble somebody decides to take. Spirometry and a transfer factor take twenty minutes and will exclude a proportion of patients outright. Cardiopulmonary exercise testing shows what the patient can actually do rather than what they measure at rest. Quantitative V/Q SPECT-CT shows what the lung you are planning to remove is contributing, which is sometimes almost nothing, in which case the arithmetic changes entirely.

None of those tests returns a verdict. They return inputs. A peak oxygen uptake of 12 argues against a lobectomy and towards a smaller anatomical resection; on its own it does not say no. And the mistake is asymmetric, which is why this matters more than it sounds. A patient assessed thoroughly and still declined has been declined on good evidence. A patient declined on two resting numbers never generates the data that would have overturned the decision. The file closes and nothing in it looks wrong. That falls hardest on the people already most likely to be written off: those with borderline lung function, and older patients whose age keeps being read as a verdict rather than a starting point.

Whose judgement is it

I am not arguing that respiratory physicians assess patients badly. They usually know the patient far better than I do, having met them, which I often have not. I am arguing something narrower and, I think, harder to disagree with: operability is defined against a specific operation, so it belongs to whoever is planning that operation.

The field already accepts this logic for the other gate. The Society of Thoracic Surgeons consensus on locally advanced disease states that resectability is discussed by the multidisciplinary team but that the decision rests with the thoracic surgeon (Ann Thorac Surg 2025;119:16–33). Operability is the same kind of judgement for exactly the same reason. The difference is that nobody has written it down.

An international consensus published this month puts a number on how unsettled that is. Eighty-nine thoracic oncology experts voted on ninety-six statements about non-metastatic lung cancer (J Thorac Oncol 2026, doi:10.1016/j.jtho.2026.104111). On the definition of resectability, 92 per cent agreed. On whether formal operability assessment is even required before induction or surgery, they split 50–50 and reached no consensus. Two adjacent rows of the same table. The same panel rejected, at 13 per cent, the idea that patients who will not make it to surgery after induction can be identified in advance, while accepting that between 15 and 25 per cent of them do not make it. So the field concedes that a sixth to a quarter fall out along the way, denies they can be spotted beforehand, and cannot agree that we should assess them properly at the start. Those three positions do not sit together.

The operation that got smaller

There is a second reason to keep marginal patients in the room, and it is one no oncology review will make, because it does not appear in a trial table. When treatment before surgery works, the operation frequently shrinks. Pneumonectomy becoming lobectomy is the version that got counted, because it is binary and codeable. It is not the common version. Bilobectomy becomes lobectomy. A chest wall resection that looked unavoidable in January is avoidable in May. Three ribs instead of five. Occasionally an anatomical segmentectomy where a lobe was planned. None of it reaches an endpoint, and all of it is the difference between a patient back on their feet in a fortnight and one who is not.

This is an argument for assessing more patients, not operating on more of them. The two are easily confused. I turn people down, and some of the assessments I am asking for will end in exactly the answer the referring physician already gave. What I object to is the version where the answer arrives without the assessment, in a patient for whom surgery after chemoimmunotherapy was the only route to a cure.

What I would ask

If you are sitting in a lung cancer meeting and the tumour is resectable but the patient looks marginal, the useful next step is not to record that they are unfit for surgery. It is to establish which operation is being contemplated, and then ask the person who would be doing it. That costs a fortnight and a proper functional assessment, and it will sometimes end where it started. The alternative costs the patient a pathway that never appears in the notes as having been considered, because the decision that closed it was taken before anybody defined what they were being judged fit for.

So when a colleague tells me they do not think a patient is fit for an operation, the answer I try to give is not I agree, and not I disagree. It is: let me see him.

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