← Locally Advanced Lung Cancer
If you or someone you care about has been diagnosed with locally advanced lung cancer — specifically non-small cell lung cancer (NSCLC), the type that accounts for approximately 85% of lung cancers — the treatment plan may sound complex. This guide walks through what happens at each step — from the first scans, through chemotherapy and immunotherapy, to surgery and recovery — in plain language. It is written for patients and families, not for doctors.
Last reviewed: April 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Before any treatment begins, your team needs to know exactly where the cancer is, how large it is, and whether it has spread. This usually requires two types of scan.
A CT scan shows the tumour and nearby structures in detail. A PET-CT scan uses a small injected tracer to highlight cancer activity anywhere in the body, picking up disease that might not be visible on CT alone.
You may also have a procedure called an EBUS — a small ultrasound camera passed through the airways under sedation, which takes tiny samples of lymph nodes in the chest to confirm whether cancer has spread to them.
Together, these tests tell the team the stage of the cancer — which determines the treatment plan.
The stage of lung cancer is described using the letters T, N and M.
Locally advanced lung cancer means the T and N numbers are higher, but M is zero. The cancer has not spread to distant organs — which is why curative treatment remains possible.
Before any drug treatment starts, three tests on the cancer tissue itself must be done. These tests tell the team which drugs will work for your cancer.
The tests look for specific genetic changes in the tumour cells (called EGFR and ALK) and measure how the tumour interacts with the immune system (called PD-L1).
These are not optional. Skipping them risks giving the wrong drug to the wrong patient. If you have been offered treatment without these results, ask whether the tests have been done.
A genetic change found in some lung cancers. Cancers with this change respond very well to tablets taken once a day (a drug called osimertinib) given after surgery.
Another genetic change. Cancers with this change respond to different targeted tablets rather than to chemotherapy or immunotherapy.
A protein on the tumour that helps it hide from the immune system. Higher levels predict a stronger response to immunotherapy drugs.
MDT stands for Multidisciplinary Team. It is a meeting where specialists from different fields discuss your case together before agreeing on a treatment plan.
For lung cancer, the MDT includes thoracic surgeons, medical oncologists (who give chemotherapy and immunotherapy), clinical oncologists (who specialise in radiotherapy), thoracic radiologists (who read the scans), pulmonologists (lung specialists), and pathologists (who analyse tissue samples).
Your scans, biopsy results, and biomarker tests are reviewed together. The team then agrees on the best treatment sequence for your cancer.
Dr Okiror is one of the thoracic surgeons at the London Bridge Hospital lung cancer MDT. Every private patient under his care is discussed at this meeting. No treatment plan is made by a single doctor.
If the MDT recommends chemotherapy combined with immunotherapy before surgery, treatment usually runs over about three months. Here is what most patients can expect.
Cycle 1 · Weeks 1–3
Starting treatmentAn intravenous infusion of platinum chemotherapy combined with an immunotherapy drug (usually nivolumab or pembrolizumab). The infusion takes a few hours in the oncology day unit. You go home the same day. Some tiredness and mild nausea are common in the following days, managed with anti-sickness tablets.
Cycle 2 · Weeks 4–6
Second infusionBlood tests before each cycle check the body is tolerating treatment. Most patients continue daily activities with reduced energy. Hair thinning can occur — hair usually regrows after treatment. The team watches for signs of immunotherapy-related inflammation in the skin, thyroid, bowel, or lungs, which is treated quickly if it appears.
Cycle 3 · Weeks 7–9
Third infusionThe third cycle is usually the final pre-surgery cycle in the CheckMate 816 pathway. Some protocols (KEYNOTE-671, AEGEAN) give a fourth cycle. Cumulative tiredness is usual by this point. Most patients still manage work and exercise at reduced levels.
Weeks 10–12
Recovery and restagingTwo to three weeks after the last cycle, a repeat CT scan and sometimes a PET-CT show how the cancer has responded. Most patients feel stronger by now — energy returns as the chemotherapy clears. The MDT reviews the restaging scans before confirming the surgical plan.
The repeat CT or PET-CT after chemoimmunotherapy is often the hardest moment of the whole treatment. You have been through months of infusions, fatigue, and uncertainty. The scan is the first objective answer about whether the treatment has worked.
For most patients, the scan shows significant shrinkage of the tumour and, often, resolution of cancer in involved lymph nodes. This is expected based on the trial data. It does not mean the cancer is cured — but it means surgery can proceed with a much better chance of removing all the disease.
A smaller proportion of patients show partial response or stable disease. The MDT reviews these cases carefully. Most still proceed to surgery. A very small number will have progressed, and the treatment plan is adjusted accordingly.
Whatever the result, Dr Okiror or your oncologist will review it with you in person. No important result is communicated by letter or voicemail.
In the large international trials of chemoimmunotherapy before surgery:
These figures were reproduced in the 2025 Guy's Cancer Centre real-world series (Toki et al., Lung Cancer 2025) which Dr Okiror co-authored.
Surgery after chemoimmunotherapy is more demanding than surgery on an untreated tumour. The treatment causes inflammation and scarring inside the chest — called fibrosis — which makes the tissues stick together.
In a straightforward case, a surgeon dissects along clean planes between anatomical structures. After chemoimmunotherapy, these planes may be obliterated. Many centres respond by switching to open thoracotomy — a much larger operation that spreads the ribs apart.
This matters because you have already spent months on chemotherapy and immunotherapy. You are tired. You are the least able to tolerate a big open operation. Keyhole surgery — when it can be done — shortens hospital stay, reduces pain, and gets you home faster.
Dr Okiror operates at a high-volume robotic centre where these cases are common. The magnified 3D vision and wristed instruments of the robotic platform are designed for exactly this kind of precise dissection through scarred tissue.
Most patients who come to Dr Okiror for surgery after chemoimmunotherapy have keyhole surgery. A minority require conversion to open surgery during the operation if the anatomy is too distorted to continue safely — this decision is always made in the interests of safe cancer clearance.
Most patients having keyhole surgery stay in hospital for three to five days. You will have a chest drain for a day or two. Pain is managed with a combination of nerve blocks, regular analgesia, and gentle mobilisation from the first day.
Recovery at home takes several weeks. You will see the physiotherapy team before leaving hospital and continue breathing exercises at home. Most patients are back to gentle daily activities within two to three weeks and back to work, if office-based, by six to eight weeks.
For patients on the perioperative pathway (KEYNOTE-671, AEGEAN), immunotherapy continues after surgery for up to one year. These are monthly infusions with a side-effect profile usually milder than the pre-surgery combination, because there is no chemotherapy alongside.
Follow-up scans continue for five years after surgery, initially every few months, then annually.
For patients whose tumour tests positive for an EGFR mutation or ALK rearrangement, the treatment pathway is different — and equally powerful.
Chemoimmunotherapy is generally avoided for these patients because the international trial data shows less benefit than for other types of lung cancer. Instead, surgery is usually the first step, followed by targeted therapy given as tablets.
For EGFR-positive patients, the tablet is called osimertinib, taken once daily for three years after surgery. The ADAURA trial — a large international study — showed that this approach achieved 5-year survival of 85% compared to 73% with placebo. That is a 51% reduction in risk of death.
A more recent phase 3 trial called NeoADAURA, presented at ASCO 2025 and published in the Journal of Clinical Oncology, tested giving osimertinib before surgery — either alone or combined with chemotherapy. It showed significantly higher rates of tumour shrinkage at the time of surgery compared to chemotherapy alone. This suggests that in future, some EGFR-positive patients may be offered osimertinib as part of the pre-surgery plan, not only after surgery. However, at the time of writing, neoadjuvant osimertinib is not licensed in the UK and has not been appraised by NICE for pre-surgery use. The established UK pathway therefore remains surgery followed by three years of adjuvant osimertinib. Dr Okiror will discuss what is available to you as part of the MDT plan.
For ALK-positive patients, similar targeted therapy approaches are being established. Your oncologist will discuss the current options.
"Has my tumour been tested for EGFR, ALK, and PD-L1?"
If the answer is no or "not yet", treatment should not start until results are available.
"Has my case been discussed at an MDT?"
NICE guidance NG122 requires this for all resectable lung cancers.
"Is chemoimmunotherapy an option for me?"
If the answer is "no" without a clear reason, ask why not. The criteria have expanded significantly.
"Am I a candidate for robotic or keyhole surgery?"
If you have been told open surgery is required, a second opinion at a robotic centre may provide alternatives.
"Do I need a pneumonectomy, or could a smaller operation achieve the same result?"
Pneumonectomy rates vary significantly between centres. At high-volume centres, lobectomy is often possible even in complex cases.
A private second opinion with Dr Okiror is typically available within 2–3 days of contacting the practice. Whether you wish to continue care elsewhere or transfer to Dr Okiror is entirely your decision.
A note on insurance: Multi-modality treatment involves several components and hospital stays. Some insurance policies require prior authorisation for specialist cancer treatments. Patients are advised to check with their private medical insurer early in the pathway. Self-pay options are available for all elements of treatment; Jo Mitchelson can provide an estimate on request.
You can see Dr Okiror at either London Bridge Hospital or The Lister Hospital in Chelsea — whichever is more convenient.
For most lung cancer surgery, either hospital works well.
For more complex cases — for instance, surgery forming part of multi-modality treatment — Dr Okiror will usually recommend London Bridge Hospital, which has more experience with complex thoracic surgery and the full support these operations need.
If you prefer, you can have your consultation and follow-up at The Lister, and surgery at LBH. Dr Okiror will make the recommendation that matches your case.
Questions often asked by patients and families starting or considering multi-modality treatment for lung cancer.
Book a Consultation →Or call Jo Mitchelson:
020 7952 2882
Appointments within 2–3 days. Self-referrals welcome. Surgery at London Bridge Hospital (complex cases) and The Lister Hospital Chelsea.
Jo Mitchelson, Private PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas' Hospital #1 UK · Guy's Hospital #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026
The evidence-based clinical page on locally advanced lung cancer — trials, NICE guidance, outcomes
Second Opinion ServicePrivate second opinion appointments within 2–3 days — how to prepare and what to bring
Robotic Lung SurgeryThe robotic lung cancer surgery service — including post-chemoimmunotherapy cases