The benefits and risks of lung cancer treatments

Who is this document for and what is it about?

This document explains the recommendations in the clinical guidelines on treatment and care for early-stage lung cancer produced by the European Respiratory Society (ERS)/European Society of Thoracic Surgeons (ESTS). It is for people with lung cancer who are considering treatment, their family or carers.

What are clinical guidelines?

Clinical guidelines are produced after a scientific process used to gather the latest evidence on a condition or symptom. Guidelines also take into account the opinions of experts and the priorities of patients and carers who have experience of a condition. Clinical guidelines are written for healthcare professionals. They use them as a best practice document on how to diagnose, manage and treat a condition.

What does this page include?

This page summarises the key points from the clinical guideline. It explains these guidelines in a way that is easier to understand for people who do not work in a medical field. It describes the recommendations for how healthcare professionals can check how suitable a treatment is for each person. This includes looking at a person’s overall health, their lung health and the risks and benefits of each treatment option.

It also includes information on the standards to aim for to ensure that care works well. These recommendations are divided into:

Strong recommendations, where there is good evidence and/or general agreement from the authors of the guideline.

Conditional recommendations, where there is a lack of evidence on the topic. This means that healthcare professionals may suggest different treatment options in discussion with individuals.

The authors of the guideline were unable to make a recommendation.  

Recommendation against, where there is good evidence and/or agreement against a particular treatment or approach.

By providing this information in an accessible way, this document aims to help people with early -stage lung cancer to understand more about the care they should receive before and after treatment for lung cancer. This can help them to feel informed when making decisions about their treatment options.

Lung cancer is a cancer of the trachea (windpipe), bronchi (airways) or lung air sacs (alveoli). The two main types of lung cancer that occur most often are:Nonsmall cell lung cancer (NSCLC): around 70–80% of people with lung cancer have NSCLC. The most common forms of NSCLC are adenocarcinoma or squamous cell carcinoma.

Small cell lung cancer (SCLC): around 20% of people with lung cancer have SCLC.

Treatment plans are based on the type and stage of lung cancer a person has, their general health, and their personal preferences.

Treatments may be focused on either curing the lung cancer (curative treatments), or on helping people with lung cancer to live longer and with a better quality of life (palliative treatments). These guidelines refer to treatments that are focused on curing lung cancer that is at an early stage.

Treatment for lung cancer can include:

• surgery
• radiotherapy
• chemotherapy
• targeted therapies (sometimes called immunotherapy)
• a combination of the above therapies.

Treatment has improved in many ways in recent years. These developments mean a better prognosis for people with lung cancer. The possibility of combining treatments in different ways can mean that there are more risks of side-effects from the treatments. Careful assessments should be made for people considering treatment for early-stage lung cancer before treatment.

Surgery using less invasive techniques mean there is less damage to the tissues around the tumour. Recovery from surgery is quicker, and means that surgery is possible for more people. During the procedure, the surgeon removes only the part of the lung that contains cancer and any glands (lymph nodes) around the lung. It is sometimes carried out using keyhole techniques (called video-assisted thoracic surgery (VATS) or robotic surgery), which involves a small video camera placing a small video camera through a small cut in the chest for guidance during the operation.

Recovery programmes have streamlined and improved care around the time of surgery. These shorten the time patients stay in hospital after surgery, and improve the results of the surgery.

Radiotherapy uses high-energy X-rays to destroy cancer cells. It can be given either as a standalone treatment, or in combination with other treatments. After surgery to remove a tumour, radiotherapy may be given as an additional treatment to make sure any remaining cancer cells are killed. It may also be given together with chemotherapy.

New techniques used in some early-stage lung cancers apply a high dose of radiation directly to the tumour. This means that the tissues around it receive a much lower dose. This lowers the risk of side-effects.

• Stereotactic body radiotherapy (SBRT): the radiotherapy beams are applied from many different angles around the body, meeting at the tumour.
• Intensity-modulated radiotherapy (IMRT): the radiotherapy beams are shaped to fit around the tumour.

Chemotherapy uses drugs to treat cancer. It works to slow down the growth of the cancer. Depending on where the tumour is and the stage of cancer, chemotherapy may be given before or after surgery, or together with radiotherapy (this is called chemoradiotherapy).

Targeted therapies come in tablet form and work by blocking the growth of cancer cells.

Immunotherapy is a treatment approach that works by enhancing our natural immune system to fight cancers.

Induction therapy is an initial course of treatment. It might be used to cure the disease, or it might be an initial step. For example, a type of chemotherapy that contains platinum may be given in order to shrink the tumour as much as possible before the operation. This makes it easier to remove using surgery.

There is a lower risk of complications from lung cancer treatments if the lungs are working well and if a person has a good level of fitness. A number of tests will be carried out to test both fitness and lung health.  These tests could include:

• The gas transfer test
• Spirometry testing
• Field exercise tests, which measure how far a person can walk in a short amount of time, for example, or measure a person’s ability to climb stairs. Examples of these tests include:
  • 6-minute walk test
  • Incremental shuttle walk test
  • Stair climb test
  • BODE score
• Cardiopulmonary exercise tests collect information about how the heart and lungs respond to exercise. They are performed using treadmill or cycling equipment at a clinic, and can involve a blood test, an ECG, blood pressure measurements as well as breathing tests.

The guidelines recognise the importance of involving people with lung cancer in making decisions about their treatment. The risks and benefits of treatment should be discussed with people with lung cancer and their family or carers.

None of the forms of testing in the studies evaluated by the panel were found to be harmful.

Minimising the risk to heart and lung health in NSCLC patients who are candidates for surgery and/or immunochemoradiotherapy (known as radical treatment)

An assessment of heart health should be carried out in patients with NSCLC who are candidates for radical treatment and who have a history of heart and lung diseases. This includes coronary artery disease, atrial fibrillation, pulmonary arterial hypertension, left ventricular dysfunction and heart failure, right ventricular dysfunction or valvular heart diseases. Any other appropriate diagnostic tests should be carried out as well.

Patients with pulmonary hypertension should be evaluated in a pulmonary arterial hypertension expert centre. The evaluation should include right heart catheterisation.

The assessment should be done at the same time as other pre-treatment testing, to avoid a delay to starting treatment for lung cancer. The decision to have further testing should take into account:

• avoiding delays to lung cancer treatment
• the risk of complications from invasive heart and lung tests
• the patients’ needs and wishes.

Other factors that should be considered in people with NSCLC who are candidates for surgery and/or immunochemoradiotherapy (known as radical treatment)

Patient-reported factors

Information about quality of life should be gathered before and after curative treatments for lung cancer. Patients should be followed-up for a year after surgery, and up to 2 years after SBRT. Questionnaires used to collect information about outcomes of treatment should be appropriate for use before and after treatment. The impact of side-effects on quality of life should be assessed within 3 months of treatment. Symptoms reported by patients must be managed properly to speed up recovery time.

Lung sparing surgery

Lung-sparing surgery offer similar outcomes to lobectomies and should be considered as an option for high-risk patients.

Better screening programmes mean that more people with suspected early-stage lung cancer will be detected in future. When this happens, lung-sparing procedures can be used to remove only small parts from the surface of the lung that are affected. This helps to keep the lungs working as normal and means that in the future, patients will be able to have treatments to cure cancer.

Prehabilitation involves following a programme of breathing exercises or using a device to strengthen the respiratory muscles before surgery. People who follow a prehabilitation programme are half as likely to develop a pulmonary complication after surgery. It may help to reduce the length of time a person has to stay in hospital after surgery. Even relatively short preoperative interventions (less than 3 weeks) appear to be effective to prevent complications after surgery. There needs to be more research into the role of rehabilitation before, during and after radiotherapy and chemotherapy.

Pulmonary rehabilitation after treatment can improve the quality of life of patients undergoing lung surgery, including those who have followed prehabilitation interventions

Pulmonary rehabilitation

Pulmonary rehabilitation before treatment (also called prehabilitation) can protect against complications resulting from treatment. This may increase the number of people who are able to have treatment.

Prehabilitation involves following a programme of breathing exercises or using a device to strengthen the respiratory muscles before surgery. People who follow a prehabilitation programme are half as likely to develop a pulmonary complication after surgery. It may help to reduce length of time a person has to stay in hospital after surgery. Even relatively short preoperative interventions (less than 3 weeks) appear to be effective to prevent complications after surgery. There needs to be more research into the role of rehabilitation before, during and after radiotherapy and chemotherapy.

Pulmonary rehabilitation after treatment can improve the quality of life of patients undergoing lung surgery, including those who have followed prehabilitation interventions.

Nutritional status and frailty

Nutritional status considers a person’s overall health, based on amount and type of nutrients they get from the food they eat. Frailty describes a person’s ability to recover from illness – being frail means that it may take someone longer to recover from more minor health problems.

Nutritional status and frailty should be checked in lung cancer patients before any type of treatment.

Age

Age should not be used on its own to make decisions about radical treatment for lung cancer. The age of a person with lung cancer can be combined with performance status, comorbidities and a person’s lung cancer stage to work out the most suitable treatment.

• Appropriate assessments must be made in older people before lung cancer surgery. Older patients take longer to recover after surgery than younger patients. They stay in hospital for a similar length of time, but a quarter transfer to specialised care facilities. The extent of the surgery and whether a person has comorbidities has a significant impact on risk of death in older patients.
• Chemotherapy should not be withheld from elderly patients with NSCLC based on age only.
• Radiotherapy appears to be as effective in early-stage NSCLC in older patients as in younger patients.
• Chemoradiotherapy in elderly patients caused worse overall survival and higher rate of death during treatment than younger patients. Survival following chemoradiotherapy is worse for patients aged 75 or older.

The effects of other conditions or illnesses

Other conditions and illnesses that exist alongside a disease are called comorbidities. These can have an effect on a person’s suitability for lung cancer treatment. People with comorbidities have an increased risk of complications in the year following surgery and/or radiotherapy.

People with interstitial lung disease (ILD) are at an increased risk of a worsening of the condition after surgery and radiotherapy. This should not stop them from having local therapy (that is, treatment that is directed to a specific organ or limited area of the body). Specific conditions or situations such as kidney dialysis, transplantation, HIV and interstitial lung disease should be treated in expert centres that have a dedicated department.

The balance of risks and benefits of treatment should be assessed in lung cancer patients who have comorbidities.

Smoking

People with lung cancer who give up smoking at or around the time of diagnosis live longer. Patients who quit smoking before surgery have lower risk of complications following the surgery, even if they have only given up a short time before the surgery. People preparing to have surgery for lung cancer should be given help to give up smoking in order to reduce the risk of complications.

This guideline was produced by the European Respiratory Society and the European Lung Foundation. You can find out more about these organisations and access the full professional guideline using the links below:

Full clinical guideline – published in the European Respiratory Journal in 2025.

• ERS/ESTS clinical practice guideline on fitness for curative treatment of lung cancer

Further resources for patients and carers:

• Lung tests and procedures
• The benefits of quitting smoking

About ERS

The European Respiratory Society (ERS) is an international organisation that brings together physicians, healthcare professionals, scientists and other experts working in respiratory medicine. It is one of the leading medical organisations in the respiratory field, with a growing membership representing over 140 countries. The ERS mission is to promote lung health in order to alleviate suffering from disease and drive standards for respiratory medicine globally. Science, education and advocacy are at the core of everything it does. ERS is involved in promoting scientific research and providing access to high-quality educational resources. It also plays a key role in advocacy – raising awareness of lung disease amongst the public and politicians. www.ersnet.org

About ELF

The European Lung Foundation (ELF) was founded by ERS to bring together patients and the public with professionals. ELF produces public versions of ERS guidelines to summarise the recommendations made to healthcare professionals in Europe, in a simple format for all to understand. These documents do not contain detailed information on each condition and should be used in conjunction with other patient information and discussions with your doctor. More information on lung conditions can be found on the ELF website: www.europeanlung.org

People with lived experience of lung cancer helped healthcare professionals put this guideline together. In this video, Janette shares her perspective of living with lung cancer. She discusses her experience of the guideline process and lung cancer treatments:

This video features a patient representative. At their request, it is intended for viewing on this website only and should not be shared on social media or other platforms. We appreciate your respect for privacy.

BODE index (BMI, airflow Obstruction, Dyspnoea and Exercise capacity index): This is a measure of lung health that combines different factors to give a score. Doctors use measurements of weight and height, breathlessness, how much air a person can blow out in the first second of the test (FEV₁) compared to healthy lungs, and how far they can walk in 6 minutes, to give a combined score.

ECG (electrocardiogram): a test to record a person’s heart rate and rhythm using electrical signals.

Follow-up: observation over a period of time of a person, group or defined population to observe changes in health status, or health- and social care-related variables.

Health-related quality of life: a combination of a person’s physical, mental and social wellbeing; not just the absence of disease. This can include emotions, sleep, social life, how energetic a person feels, and general life satisfaction. In respiratory illness, health-related quality of life is measured using questionnaires such as the St George’s Respiratory Questionnaire and the Chronic Respiratory Questionnaire.

Induction therapy: the first treatment given for a disease. It is often part of a standard set of treatments, such as surgery followed by chemotherapy and radiation. When used by itself, induction therapy is the one accepted as the best treatment. If it doesn’t cure the disease or it causes severe side-effects, other treatment may be added or used instead. Induction therapy is also called first-line therapy, primary therapy, or primary treatment.

Perioperative care: care that is given around the time of surgery, usually from the time the patient goes to the hospital for the surgery until the patient goes home.

Prognosis: the likely outcome of an illness. In cancer, a prognosis covers the likelihood of fully recovering and being cured, how likely it is that the cancer will come back (recurrence), or how long someone might be expected to live with incurable cancer.

Radiation-induced pneumonitis: inflammation of the lungs caused by radiotherapy to the chest. Symptoms include breathlessness, a fever, or cough. Patients are given medicine to help manage the symptoms, and can be given oxygen to help with breathing.

Right heart catheterisation: a procedure used to take measurements of blood pressure in the heart and the blood vessels in the lungs. It involves a small tube (catheter) being passed into a vein and guided to the heart. It is used to diagnose pulmonary hypertension, and to make decisions about the best treatment for the patient.

Shuttle walk test: measures a person’s maximum walking capacity by monitoring how far they can walk, and gradually increasing the pace. The test continues until the patient cannot keep up with the set pace, or becomes too short of breath to continue. A sensor placed on the forehead or finger measures the patient’s heart rate and oxygen levels.

6-minute walk test: a simple exercise test that measures the distance a person can walk around two cones over 6 minutes along a 30-metre flat corridor. A sensor placed on the forehead or finger measures the patient’s heart rate and oxygen levels.

Stereotactic body radiotherapy (SBRT): where radiotherapy beams are applied from many different angles around the body, meeting at the tumour.

TNM: a system using letters and numbers to describe the stage of a cancer. T describes the size of the tumour, N describes whether there are any cancer cells in the lymph nodes, and M describes whether the cancer has spread to a different part of the body.

This guideline was jointly published by European Respiratory Society and European Society of Thoracic Surgeons.