NLCA State of the Nation Report 2025
Source: data.gov.uk (2025-04-11)

National Lung Cancer Audit State of the Nation Report 2025. The National Lung Cancer Audit (NLCA) evaluates how the care received by people diagnosed with lung cancer in England and Wales compares with recommended practice and provides information that supports healthcare providers, commissioners, and regulators to improve the care for patients. The NLCA reports a set of process and outcome measures that cover important aspects of the care pathway for people diagnosed with lung cancer.
In the NLCA State of the Nation report 2025, we give an overview of the patterns of care and outcomes for 37,750 people diagnosed with lung cancer in England in 2023. A separate section provides describes results for 2,334 people diagnosed in Wales in 2023.
The report describes summarises the performance of lung cancer services in 2023 and compares this to the situation in 2020, 2021 and 2022.

National Lung Cancer Audit
State of the Nation 2025
An audit of care received by people diagnosed with lung cancer in England and Wales 
during 2023
Published April 2025

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
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Citation for this document: 
National Lung Cancer Audit. State of the 
Nation 2025. London: National Cancer Audit 
Collaborating Centre, Royal College of 
Surgeons of England, 2025.
This document was prepared by members of the NLCA project team:
Neal Navani, NLCA Senior Clinical Lead
John Conibear, NLCA Oncology Lead
Doug West, NLCA Thoracic Surgical Lead
Lauren Dixon, NLCA Clinical Fellow
Ella Barber, NLCA Data Scientist
Joanne Boudour, NLCA Senior Project Manager
Adrian Cook, NLCA Senior Statistician
Sarah Cook, NLCA Methodologist
David Cromwell, NLCA Lead Methodologist
With review and input from:
NLCA Clinical Reference Group
NATCAN Executive Team
The Royal College of Surgeons of England (RCS) is an independent professional body committed 
to enabling surgeons to achieve and maintain the highest standards of surgical practice and 
patient care. As part of this it supports audit and the evaluation of clinical effectiveness for surgery. 
Registered Charity no: 212808.
The National Cancer Audit Collaborating Centre (NATCAN) is commissioned by the Healthcare 
Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes 
Programme (NCAPOP). NATCAN delivers national cancer audits in non-Hodgkin lymphoma, bowel, 
breast (primary and metastatic), oesophago-gastric, ovarian, kidney, lung, pancreatic and prostate 
cancers. HQIP is led by a consortium of the Academy of Medical Royal Colleges and the Royal College 
of Nursing. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase 
the impact that clinical audit, outcome review programmes and registries have on healthcare quality in 
England and Wales. HQIP holds the contract to commission, manage and develop the National Clinical 
Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care 
provided to people with a wide range of medical, surgical, and mental health conditions. The programme 
is funded by NHS England, the Welsh Government and, with some individual projects, other devolved 
administrations and crown dependencies. https://www.hqip.org.uk/national-programmes
 
The British Thoracic Oncology 
Group (BTOG) is the multi-
disciplinary group for healthcare 
professionals involved with 
thoracic malignancies throughout 
the UK. Registered Charity no: 
1166012
The SCTS is the representative body 
for cardiothoracic surgery in Great 
Britain & Ireland. Registered Charity 
no: 1113536
This work uses data that has been provided by patients and collected by the NHS as part of their care 
and support. For patients diagnosed in England, the data is collated, maintained and quality assured 
by the National Disease Registration Service (NDRS), which is part of NHS England. Access to the 
data was facilitated by the NHS England Data Access Request Service.
NHS Wales is implementing a new cancer informatics system. As a result, the quality and 
completeness of data from Wales is likely to have been impacted due to implementation of this new 
system across multiple NHS organisations (Health Boards), which has resulted in data being supplied 
by both old and new systems. Additionally, and reflecting the uncertainty of data quality, the data 
submitted to the audit may not have undergone routine clinical validation prior to submission to the 
Wales Cancer Network (WCN), Public Health Wales.
© 2025 Healthcare Quality Improvement Partnership (HQIP)
Copyright All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether 
or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written 
permission to reproduce any part of this publication should be addressed to the publisher. 

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Contents
1.	
Introduction	
5
Infographic: Summary of results for patients diagnosed in England 2023	
6
2.	
Results for England (2023)	
7
2.1	
Data completeness in England 	
7
2.2	
Patient characteristics in England 	
8
2.3	
Diagnosis, staging and treatment planning in England	
9
2.4	
Time to the start of treatment in England	
10
2.5	
Curative treatment for non-small cell lung cancer in England	
11
2.6	
Systemic anti-cancer therapy rates for people with NSCLC stage 3B-4 with good performance 
status in England	
11
2.7	
Systemic Anti-Cancer Therapy for small cell lung cancer in England	
12
Infographic: Summary of results for patients diagnosed in Wales 2023	
13
3.	
Results for Wales (2023)	
14
3.1	
Source of Welsh data and data completeness	
14
3.2	
NLCA performance indicators in Wales	
14
4.	
Survival after cancer diagnosis	
15
5.	
Commentary	
16

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2.	 Recommendations
Recommendation
Audience
Key results
Quality Improvement 
Goal
National Guidance/ Standards/ Resources
1.	 Ensure services maximise the uptake of lung 
cancer screening for people aged 55 to 74 
who are at high risk of lung cancer. 
England: Cancer 
Alliances working with 
NHS trusts
Wales: Local Health 
Boards
In England, the percentage of people 
with lung cancer diagnosed with 
stage 1/2 disease was 36.7% in 2023. 
In Wales, the percentage was 33.9% 
in 2023.
Goal 1: Improve early 
diagnosis of lung 
cancer
NHS England
https://www.england.nhs.uk/wp-content/
uploads/2019/02/B1646-standard-protocol-
targeted-lung-health-checks-programme-v2.pdf
2.	 Ensure providers have sufficient thoracic 
surgery capacity to accommodate the larger 
number of people with Non-Small Cell Lung 
Cancer (NSCLC) who are candidates for 
curative surgery.
England: Cancer 
Alliances working with 
NHS trusts
Wales: Local Health 
Boards 
In England, 7,018 people with NSCLC 
had surgery with curative intent 
in 2023, up from 5,865 in 2022. In 
Wales, 364 people had surgery in 
2023, up from 276 in 2022.
Goal 2: Increase the 
proportion of patients 
who have treatment 
with curative intent
NICE Guideline NG122
https://www.nice.org.uk/guidance/ng122 
3.	 Identify opportunities for increasing the 
proportion of people with NSCLC stage 
3B-4 (PS 0-1) to have Systemic Anti-Cancer 
Therapy (SACT) as per NICE guidance, such 
as help people maintain their fitness for SACT 
throughout the care pathway.
England: Cancer 
Alliances working with 
NHS trusts
Wales: Local Health 
Boards
In England during 2023, 61.6% of 
people with NSCLC (stages 3B-4, 
PS 0–1) had SACT, little changed 
from 2021. In Wales during 2023, the 
proportion was 55.2%, a fall from 
2022 (=60.1%).
Goal 3: Increase the 
proportion of people 
receiving SACT and 
reduce variation in 
access 
NICE Guideline NG122
https://www.nice.org.uk/guidance/ng122 
4.	 Ensure NHS hospitals have the necessary 
resources and capacity to meet the timelines 
for patients to start primary treatment.
England: Cancer 
Alliances working with 
NHS trusts
Wales: Local Health 
Boards
In England and Wales, among key 
subgroups, most people diagnosed 
in 2023 did not start treatment within 
the recommended timeframes.
Goal 4: Improve the 
quality of the patient 
pathway
NHS England. National Optimal Lung Cancer 
Pathway (NOLCP)
https://rmpartners.nhs.uk/wp-content/
uploads/2024/09/national-optimal-lung-cancer-
pathway_v4_01jan2024.pdf
NHS Wales. National optimal pathway for lung 
cancer: 2nd Edition (2022)
5.	 Ensure NHS hospitals have the necessary 
resources and capacity so that biomarker test 
results are delivered within 14 calendar days 
of the test being performed, as defined in the 
National Optimal Lung Cancer Pathway.
England: NHS England, 
ICBs, 
Cancer Alliances
Wales: Local Health 
Boards.
England: Between 2017 and 2021, 
approximately 25% of people with 
stage 4 (PS 0-1) had genomic testing.
Goal 4: Improve the 
quality of the patient 
pathway
NHS England. National Optimal Lung Cancer 
Pathway (NOLCP)
https://rmpartners.nhs.uk/wp-content/
uploads/2024/09/national-optimal-lung-cancer-
pathway_v4_01jan2024.pdf
NHS Wales. National optimal pathway for lung 
cancer: 2nd Edition (2022)
Lung Cancer Clinical Expert Group. National 
commissioning guidance. (2024)

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
5
The aim of the National Lung Cancer Audit (NLCA) 
is to evaluate the patterns of care and outcomes for 
people with lung cancer in England and Wales, and 
to support NHS services to improve the quality of 
care for these individuals. 
In this State of the Nation report, we present 
information on the care received by adults 
diagnosed with lung cancer during 2023 in England 
and Wales. The management of people with lung 
cancer is informed by various national guidelines 
and the NLCA evaluates current patterns of care 
against the standards that these set. Specific 
standards were defined in: Quality Standard QS17 
from the National Institute for Health and Care 
Excellence (NICE), the national commissioning 
guidance from the Lung Cancer Clinical Expert 
Group, and the National Optimal Lung Cancer 
Pathway. The NLCA has developed quality 
improvement goals and indicators using these 
standards and after consultations with its clinical 
reference group and Patient and Public Involvement 
(PPI) forum. The goals and indicators are described 
in the {NLCA Quality Improvement Plan}. To 
produce the indicator values, the NLCA analyses 
data that is routinely collected by the NHS as part 
of the care given to people diagnosed with lung 
cancer. This approach is designed to minimise the 
burden of data collection on hospital staff.
Additional materials that accompany this report are 
available at: www.lungcanceraudit.org.uk.
An interactive dashboard that contains results for 
individual NHS organisations, data tables and a 
description of the audit methods is also available. 
Since January 2025, information at organisation level 
is presented where a patient was first seen rather 
than the place of diagnosis. We encourage NHS lung 
cancer services to review the findings of this report 
and their results on the dashboard, and to explore 
reasons for unwarranted differences in practice.
A summary report for people living with lung cancer 
and the public will be available on the NLCA website. 
The website also provides access to:
•	 Links to resources that support local services’ 
quality improvement initiatives such as a local 
action plan template.
•	 Quarterly reports that provide more recent 
information for each NHS lung cancer unit in 
England.
•	 Links to other sources of information about lung 
cancer. 
The NLCA is one of ten national cancer audits 
commissioned within the National Clinical Audit and 
Patient Outcomes Programme (NCAPOP) which is 
funded by NHS England and the Welsh 
Government. More information about the national 
cancer audits for England and Wales can be found 
at: www.natcan.org.uk.
1.	 Introduction

Infographic: Summary 
of results for patients 
diagnosed in England 
2023
≥
≥
≥
≥

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2.	 Results for England (2023)
The results for England NHS services (January-
December 2023) were derived using data from the 
Rapid Cancer Registration Dataset (RCRD) provided 
by the National Disease Registration Service (NDRS). 
The RCRD provides more up-to-date information 
on people diagnosed with cancer than the National 
Cancer Registration Data (NCRD and hence the 
former source of data is used in this analysis).
We analysed RCRD data on 37,750 people 
diagnosed with lung cancer in England during 2023. 
For earlier years, the dataset contained data on 
36,149 people in 2022, 34,999 in 2021, 32,947 in 
2020 and 35,516 in 20191. There were 124 English 
NHS trusts which cared for people with lung cancer 
in 2023. The RCRD data were linked by NCRAS 
to other national health care datasets that provide 
additional information on hospital admissions and 
cancer treatments (see methodology supplement).
2.1	 Data completeness in England 
 Key messages:  
NHS trusts should improve the completeness 
of key data items submitted for the Rapid 
Cancer Registration Dataset. Completeness 
was below the target of 90% for patient 
smoking status (44.8%) and whether a patient 
saw a lung cancer nurse specialist (LCNS) 
at or close to the time of diagnosis (66.1%). 
Completeness of data on tumour morphology, 
disease stage, and performance status items 
also needs to be improved at some NHS trusts.
Several data items are essential for analyses 
designed to assess patterns of care. To highlight 
this, the audit defines targets for completeness for 
these data items. The completeness of demographic 
data items (age, ethnicity, social deprivation) was 
excellent, being complete for over 95% of records. 
However, completeness on other items was below 
the target levels (Table 1), and there was substantial 
variation between NHS trusts in the completeness 
of some items, which can be explored on the 
{online dashboard}. The completeness of tumour 
morphology at an organisation can reflect the 
number of people whose diagnosis was based on 
cytology or histology more than the data from these 
examinations being missing.
1	
These figures differ from the numbers published in previous reports as the RCRD is updated on a regular basis as new information is uploaded by NHS trusts
Table 1. Completeness of key data items for people diagnosed in 2023 in England
Data item
Overall Completeness
Target level
No. of NHS trusts 
above target (n=124)
TNM (Tumour, Nodal, Metastasis) stage
91.4
90%
86
Performance Status (PS)
86.0
90%
65
Basis of diagnosis
91.1
90%
88
Morphology* 
64.9**
75%
26
Contact with lung cancer nurse specialist (LCNS)
66.1
90%
0
Smoking status
44.8
90%
0
* Morphology refers to the type of lung cancer
**96.3% complete for people whose diagnosis included microscopic examination (cytology/histology) 

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2.2	 Patient characteristics in England 
Key messages: The percentage of people 
with lung cancer who are diagnosed with 
stage 1/2 disease has continued to increase, 
from 30.5% in 2021 to 36.7% in 2023. Cancer 
Alliances should promote the uptake of lung 
cancer screening for people aged 55 to 74 
who are at high risk of lung cancer.
Table 2 summarises the characteristics of the 
37,750 people diagnosed in 2023. The proportion 
of lung cancers identified as small cell lung cancers 
(SCLC) was 6.8% in 2023, unchanged from 2022. 
The median age at diagnosis was 74.2 years overall 
(interquartile range (IQR): 66.6 – 80.3); for non-small 
cell lung cancer (NSCLC), the median age was 74.5 
years, while for small cell lung cancer (SCLC), it was 
71.0 years. A similar number of men and women were 
diagnosed; 50.1% of these were male and 49.9% 
female. The median age at diagnosis was 74.2 years 
among both men and women. Stage 4 disease was 
reported in 43% (n=14,858) of people with staging 
data in 2023, down from 47% (n=15,188) in 2022. 
The distribution of disease stage has changed 
between 2019 and 2023 (Figure 1). The increase in 
the number of people diagnosed with stage 1/2 
disease in recent years reflects the impact of lung 
cancer screening and other early diagnosis 
initiatives. The NHS Targeted Lung Health Check 
Programme reported to the NLCA that there were 
5,271 people diagnosed with lung cancers among 
those aged 55-74 years invited for a health check 
between April 2019 and November 2024; the 
majority of these were diagnosed after April 2022 
as the programme extended across the country 
(1284 in 22/23; 1819 in 23/24; 1304 in 24/25 (until 
November 2024))2. Of people staged after a 
diagnosis by screening, three-quarters (77.2%) had 
stage 1/2 disease overall, with the proportion in 
each English cancer alliance being typically 
between 71 and 80%.
2	
We thank Jessica Abell, Charlie Graham, Richard Lee, Arjun Nair, Charlotte Smith, and Haarini Sridhar at the TLHC Programme for providing these figures.  
See also https://www.england.nhs.uk/2024/11/thousands-of-cancers-caught-early-through-nhs-lung-checks/
Table 2. Characteristics of people diagnosed with lung cancer in England during 2023
Overall 
percentage
Percentage 
among known
Overall 
percentage
Percentage 
among known
Smoking status
Type of Lung cancer*
Never smoked
4.3
9.6
Non-small cell (NSCLC)#
56.3
Current / Ex-smoker
40.5
90.4
Small cell (SCLC)
6.8
Unknown
55.3
Carcinoid
1.8
Type not assessed**
35.1
Stage at diagnosis
Performance status
Stage 1
25.9
28.4
0
20.4
23.8
Stage 2
7.6
8.3
1
29.0
33.7
Stage 3A
10.8
11.8
2
16.9
19.6
Stage 3B-C
7.7
8.4
3
15.2
17.7
Stage 4
39.4
43.1
4
4.5
5.2
Unknown
8.6
Unknown
14.0
*Data is complete for ‘Type of Lung cancer’; ** analysed together with NSCLC elsewhere
 # Among people with known NSCLC disease, 55% were adenocarcinoma, 23.0% were squamous cell, with the remaining 21.4% being a mix of other cell types.

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2.3	 Diagnosis, staging and treatment 
planning in England
Key messages: The proportion of people with 
a pathological diagnosis of lung cancer was 
83.7%, which is below the NLCA target of 
90%. NHS trusts with low rates of pathological 
diagnosis should explore opportunities to 
increase it. In 2023, 30.9% of people were 
diagnosed after an emergency admission. 
Among people with data recorded for this 
item, 93.1% saw a lung cancer nurse specialist 
(LCNS) around the time of diagnosis in 2023, 
but actual levels of performance are uncertain 
due to poor data completeness (see section 
2.1). 
Rates of diagnosis following an emergency 
admission were slightly lower in 2023 (30.9%) 
compared with 2022 (33.5%) but remained high and 
continue to show substantial regional variation (see 
NLCA dashboard). 
Access to a LCNS around the time of diagnosis 
is a core expectation (NICE quality statement 3). 
Among people diagnosed in 2023 who had this data 
entered, 93% were reported to have had contact 
with a LCNS (Table 3). This exceeded the 90% target 
adopted by the NLCA. However, this figure should 
be treated with caution because data completeness 
overall was only 66.1% and exceeded 70% for only 
66 NHS trusts.
Figure 1. Distribution of cancer stage among people 
diagnosed with lung cancer in England between 2019 and 
2023.
10
20
30
40
2019
2020
2021
2022
2023
missing
1
2
3A
3B/C
4
 
Number of lung cancer diagnoses (x1000)
Table 3. Indicators by English NHS trusts for people diagnosed in 2023
NLCA target
2023*
No. of NHS trusts
above target 
(n=124)
Diagnosis after an emergency admission
N/A
30.9%
No target set
Proportion of people with pathological diagnosis (PS 0-1)
≥90%
83.7%
46
Proportion of people who had contact with a Lung Cancer 
Nurse Specialist (LCNS) around the time of diagnosis
≥90%
93.1%**
92
* 2023 finding amongst known (missing data excluded) 
** Data completeness for data item “contact with LCNS” was 66.1% overall

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10
2.4	 Time to the start of treatment in 
England
Key messages: Among key subgroups, most 
people are not starting treatment within the 
recommended timeframes. The time from 
referral to surgery exceeded 49 days for 
seven out of eight people with NSCLC stage 
1/2. Among people diagnosed with stage 3B-4 
NSCLC in 2023, the median time from referral 
to systemic anti-cancer therapy (SACT) was 
66 days (IQR: 51 – 87), and the times for the 
majority of people exceeded National Optimal 
Lung Cancer Pathway (NOCLP) targets. For 
people diagnosed with SCLC in 2023, the 
median time from diagnosis to SACT was 15 
days (IQR: 9 – 25). NHS trusts should actively 
monitor these “time to treatment” metrics to 
improve compliance with the targets. Delays 
risk compromising patient fitness, potentially 
rendering them ineligible for anti-cancer 
therapies, particularly for rapidly progressing 
conditions like SCLC.
The NHS England benchmark defined for cancer 
waiting times from ‘decision to treat’ to treatment is 
31 days, though the National Optimal Lung Cancer 
Pathway (NOLCP) recommends a shorter 21 day 
time-frame. In 2023 the median waiting time was 16 
days, with 64% of patients starting treatment within 21 
days (from 16,305 patients who had surgery, SACT or 
curative radiotherapy). The median waiting time was 
also less than 21 days within every cancer alliance.
The NOLCP suggests the time between referral 
to the start of treatment should be no longer than 
49 days, Table 4 shows that the time from referral 
to surgery exceeds 49 days for seven out of eight 
people with NSCLC stage 1/2. This is of concern 
because of the growing number of these patients 
(due to screening) and suggests that surgical 
services are not keeping up with the demand.
Timely diagnosis and treatment for people with 
SCLC is also crucial as these tumours are highly 
aggressive, rapidly progressive, and can quickly 
spread, ultimately leading to fatal outcomes. In 2017, 
the NLCA set a standard that at least 80% of people 
with SCLC should receive SACT within 14 days of 
pathological diagnosis. In 2023, the median time 
from diagnosis to treatment was 15 days (compared 
to 17 days in 2022). 
Table 4. Times to the start of treatment at English NHS trusts for people diagnosed in 2023
NOLCP Target
Number of 
individuals
Median (Inter 
Quartile 
Range)
% people 
who started 
treatment 
within target
Surgery in Non-Small Cell Lung Cancer (NSCLC) 
Stage 1/2 - from referral to treatment
49 days
4150
83 days
(63 to 111)
11%
Systemic anti-cancer therapy (SACT) in NSCLC Stage 3B-4
- from referral to treatment
49 days 
2996
66 days
(51 to 87)
 23%
SACT in people with Small Cell Lung Cancer (SCLC) 
- from diagnosis to treatment
14 days
1355
15 days
(9 to 25)
48%

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11
2.5	 Curative treatment for non-small cell 
lung cancer in England
Key messages: The number of people with 
NSCLC who had surgery with curative intent 
was 7,018 in 2023, an increase from 5,865 
people in 2022. This corresponds to 20.4% 
of people with NSCLC diagnosed in 2023 
having surgery compared with 17.8% in 2022. 
The rates of surgical resection within Cancer 
Alliances ranged from 15% to 39% (IQR 18-
22%).  
The proportion of people with stage 1/2 
disease and a good performance status (PS 
0-2) who had curative treatment was 80.0%, 
meeting the NLCA standard of 80%. Cancer 
Alliances with comparatively low curative 
intent treatment rates for stage 1–3A patients 
could benefit from exploring ways to ensure 
that these individuals are offered the most 
appropriate curative intent treatments.
People with stage 1/2 lung cancer, and a good 
performance status (PS 0-2) are candidates for 
treatments with curative intent. The proportion of 
people treated with curative intent has been 
unchanged since 2021 at 80%. There was 
substantial variation across NHS trusts (Table 5).
People with stage 3A NSCLC and a good 
performance status (PS 0-2) can be considered for 
treatment with curative intent. In 2023, only 60% of 
these individuals were offered curative intent 
treatments with the remaining 40% receiving either 
palliative intent therapies or best supportive care. 
Table 5. Performance on curative intent treatment indicators for people diagnosed with non-small cell lung cancer (NSCLC) in 
England in 2023
NLCA target
2023
No. of NHS 
trusts above 
target (n=124)
Proportion of people with NSCLC undergoing resection surgery
≥17%
20.3%
58
Proportion of people with NSCLC who had curative treatment 
(Stage 1/2, PS 0–2)
≥80%
80.0%
71
Proportion of people with NSCLC who had curative treatment 
(Stage 3A, PS 0–2)
N/A
60.3%
 N/A
2.6	 Systemic anti-cancer therapy rates for 
people with NSCLC stage 3B-4 with 
good performance status in England
Key messages: The proportion of people with 
NSCLC (stages 3B-4, PS 0–1) who received 
systematic anti-cancer therapy has changed 
little between 2021 and 2023, with 61.6% of 
these people having SACT in 2023. The NLCA 
audit standard of 65% for this indicator was met 
or exceeded by 55 of 124 NHS trusts (44%). 
NHS trusts should monitor their performance 
against the NLCA standard and ensure there is 
adequate capacity to deliver SACT for people 
who are sufficiently fit to receive SACT.
Clinical trials have demonstrated that systemic 
anti-cancer therapy can extend survival, improve 
cancer related symptoms, and quality of life for 
people with advanced NSCLC. In 2017, the NLCA 
set an audit standard that at least 65% of people 
with NSCLC stages 3B-4 and a good performance 
status (PS 0–1) should receive SACT. The 
proportion of people diagnosed with advanced 
NSCLC receiving SACT was 61.6% in 2023, 
compared with 61.1% in 2021 and 60.7% in 2022. 
The proportion of people with advanced NSCLC 
with fair/good performance status (PS 0-2) that had 
SACT was 51.5% in 2023. See NLCA dashboard for 
regional and organisational figures.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
12
2.7	 Systemic Anti-Cancer Therapy for 
small cell lung cancer in England
Key messages: In 2023, 73.3% of people with 
SCLC received systemic anti-cancer therapy 
(SACT), and 66 out of 103 eligible NHS trusts 
(61%) met or exceeded the NLCA target (=70%). 
NHS trusts should monitor their performance 
against the NLCA standard and ensure there 
are necessary resources for timely access to 
SACT, particularly in relation to diagnostic and 
molecular pathology capacity.
Small cell lung cancer (SCLC) is a particularly 
aggressive type of lung cancer and people with 
SCLC are often diagnosed at an advanced stage. 
In 2017, the NLCA set an audit standard that at least 
70% of people with SCLC should receive SACT. 
Overall, 73.3% of people with SCLC had SACT in 
2023, which was little changed from the level in 
2022 (73.2%). There was some variation in treatment 
patterns across NHS trusts, with 66 out of 103 
eligible NHS trusts (61%) having more than 70% of 
patients having SACT (See NLCA dashboard).
Genetic testing for people with stage 4 non-small cell lung cancer in England 2017-2021
The NLCA was supplied with information on genomic testing among people with non-small cell lung 
cancer (NSCLC) linked to gold standard cancer registration data. We used these data to explore the 
use of genomic testing in people with stage 4 NSCLC and describe oral targeted tyrosine kinase 
inhibitor (TKI) treatments which patients received if identified with either an epidermal growth factor 
receptor (EGFR) mutation or anaplastic lymphoma kinase (ALK) gene rearrangement. Data was 
provided from genomic testing hubs only and not from local testing.
Between 2017 and 2021, approximately 25% of people with stage 4 NSCLC (PS 0-1) were recorded 
as having undergone genomic testing each year. The use of next-generation sequencing (NGS) 
increased from 11% of tests done in 2017 to 23% in 2021.
•	 In people with stage 4 EGFR mutation positive NSCLC, 79% of those with good performance status 
(PS 0-1) received either gefitinib, erlotinib, afatanib, or osimertinib.
•	 In people with stage 4 ALK gene rearrangement positive NSCLC, 45% of those with good 
performance status (PS 0-1) received either crizotinib, ceritinib, alectinib, brigatinib, or lorlatinib.

Infographic: Summary 
of results for patients 
diagnosed in Wales 2023
unchanged from 222
Summary of results for patients diagnosed in Wales 0
People diagnosed
2,067
2,244
2,2
2,4
2020
202
2022
202
0
2,000
4,000
Audit standard
≥80%
of patients with NSCLC (stage 1
2, 
Performance Status PS	 2	 
received treatment with curative 
intent* 
Treatment with curative intent for Non-Small Cell Lung Cancer NSCLC
≥70%
Audit standard
Diagnosis  staging
Surgery for Non-Small Cell Lung Cancer NSCLC
of patients with NSCLC 
had surgical treatment 
for their cancer
18%
Audit standard
≥17%
14% in 222
1% in 221
11% in 22
20%
 
Treatment allocation
of patients with SCLC received 
treatment with SACT
65%
Audit standard
≥70%
2,334
people were diagnosed with 
lung cancer in 223
of patients presented with 
stage 4 lung cancer
47% in 222, 50% in 221  
49% in 22
of patients were diagnosed after 
emergency admission
39% in 222, 24% in 221  
28% in 22
years
of patients were diagnosed at 
stage 12 
30% in 222, 24% in 221  
27% in 22
34%
45%
27%
of patients with NSCLC 
(stage 3B  4, PS 1	 
received SC
55%
77%
of patients with 	SCLC  stae 
3A, PS 0-2) received treatment 
with curative intent**
67%
N/A
Median survival
2,334 patients were diagnosed between 1 January and 
31 December 223 For these patients: 
Survival outcomes
**surgery, radical radioteray or multimodal treatment 
*surgery or radical radioteray 
One year survival
46%
301
days
 
262 days in 
222 days in 
224 days in  
Data quality
Comleteness of key routine data items***
59%
 
Performance status
Stage
90%
Audit standard
Basis of diagnosis
Morphology
Lung Clinical Nurse 
Specialist at diagnosis
 
76% in 222
67% in 221
68% in 22 
 
71% in 222
71% in 221
58% in 22 
 
61% in 222
61% in 221
48% in 22 
 
6% in 
57% in 
5% in  
 
43% in 
39% in 
4% in  
improving from 222
worsening from 222
Key
Waiting times in NSCLC
Median time from 
referral to surgery in 
NSCLC stage 1
2
Median time from 
referral to SC
 in 
NSCLC stage 3B4
97 days
Median time from 'decision to treat' to start SACT: 15 days
Systemic Anti-Cancer Theray SACT for Small Cell 
Lung Cancer SCLC
Systemic Anti-Cancer Theray SACT for Non-Small 
Cell Lung Cancer NSCLC
78 days
100%
100%
69%
***information on smo	in status unavailable
90%
Audit standard
90%
Audit standard
75%
Audit standard
90%
Audit standard
98%
99%

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
14
3.	 Results for Wales (2023)
3.1	 Source of Welsh data and data 
completeness
The Welsh results contained in this report were 
derived using the standard dataset collected through 
the Cancer Network Information System Cymru 
(CANISC). The figures should not be compared to 
the English data which is derived from the Rapid 
Cancer Registration Dataset (RCRD).
The analysis included 2,334 people diagnosed with 
lung cancer in Wales in 2023. The completeness of 
the key data items in the Welsh data was excellent. 
The levels of completeness for the 2,334 patients 
analysed were: 99.1% for disease stage, 99.8% for 
performance status, 100% for basis of diagnosis 
and 69.2% for morphology among all patients 
(99.8% complete among people with histology 
diagnosis). 98.1% of records had data on whether a 
lung cancer nurse specialist was present at 
diagnosis. Data was not provided for the ethnicity 
or smoking status data items.
In 2023, the proportion of lung cancers proven to 
be small cell lung cancers (SCLC) was 9.3%. The 
median age at diagnosis was 74 years overall (IQR: 
67 – 80) and was 74 and 72 years for patients with 
NSCLC and SCLC tumours. 49.4% of patients were 
male and 50.6% female. Among patients with known 
values in 2023, the proportion of patients with stage 
4 disease was 44.8% (50.3% in 2021, 47.0% in 
2022), while the proportion with stage 1/2 disease 
was 33.9% (24.0% in 2021, 30.0% in 2022). The 
proportion of patients with performance status 0-1 
was 43.4% (40.6% in 2021, 41.9% in 2022).
3.2	 NLCA performance indicators in Wales
Key messages: The analysis of data from 
2,334 patients diagnosed with lung cancer in 
2023 found:
•	 The percentage of people with lung cancer 
who are diagnosed with stage 1/2 disease 
was 33.9%, an increase on 24.0% in 2021 and 
30.0% in 2022. The percentage of people 
diagnosed with stage 4 disease was 44.8% 
(46.9% in 2022). 
•	 The proportion of people with lung cancer 
diagnosed after an emergency admission was 
26.6%, compared to 29.4% in 2022.
•	 The proportion of people with a pathological 
diagnosis of lung cancer was 94.2%, above 
the NLCA target of 90%. 
•	 The proportion of patients seen by a LCNS 
was 94.9% (92.4% in 2022).
•	 Curative treatment rates of NSCLC patients 
with stage 1/2 and good performance status 
(0-2) was 76.5% (76.2% in 2022). For NSCLC 
patients with stage 3A disease, curative 
treatment rate was 66.7% (61.2% in 2022).
•	 The surgical resection rate for people with 
NSCLC was 17.5%, up from 14.0% in 2022.
•	 The use of systemic anti-cancer therapy 
(SACT) for stage 3B-4 NSCLC patients (PS 
0–1) was 55.2% in 2023, below the audit 
standard (70%) and a fall from 60.1% in 2022.
•	 The proportion of people with SCLC who had 
SACT in 2023 was 64.5% (71.0% in 2022). 
•	 The median time from diagnosis to SACT for 
patients with SCLC was 21.5 days (IQR: 14-33).
•	 The median time from referral to surgery in 
patients with NSCLC Stage 1/2 was 97 days 
(IQR: 74 to 126); the median time from referral 
to SACT in patients with NSCLC Stage 3B-4 
was 77.5 days (IQR: 60 to 101).

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
15
4.	 Survival after cancer diagnosis
In this report, we describe survival for the 18,653 
people diagnosed in England between 1st January 
and 30th June 2023. Median survival was 358 days 
(95% CI: 343 to 373). The proportion of people 
who survived at least one year was 49.6% overall 
(95% CI: 48.9% to 50.3%). Figure 2A shows survival 
by stage at diagnosis and Figure 2C shows the 
risk-adjusted 1-year mortality rates for the cancer 
alliances. There were no outlying cancer alliances.
Survival estimates for England should be interpreted 
cautiously as the most recent rapid cancer 
registration data may have incomplete mortality data 
and miss people who do not have hospital-based 
treatment. Last year we reported median survival of 
327 days for people diagnosed in England between 
January and June 2022; repeating this analysis 
of the same time period using current data gives 
median survival of 281 days.
For patients diagnosed with lung cancer in Wales 
during 2023, the median survival was 301 days (95% 
CI: 279 to 326) and 1-year survival in this cohort 
was 46.4%. Survival by stage for 2023 is shown 
in Figure 2B. The median survival for patients with 
stage 4 disease was 100 days (CI: 84 to 117). Figure 
2D also shows risk-adjusted 1-year survival rates for 
the Welsh hospitals for patients diagnosed in 2023; 
there were no outlying hospitals in Wales. See NLCA 
website for more details.
Figure 2. Kaplan Meier survival curves from people diagnosed in England (January to June 2023) and Wales (January to 
December 2023) stratified by disease stage and risk-adjusted estimates for English Cancer Alliances and Welsh hospitals.
(A) England (Jan–June 2023*), by disease stage
(B) Wales (Jan–Dec 2023), by disease stage
0.00
0.25
0.50
0.75
1.00
Proportion of patients alive
60
120
180
240
300
360
Time from diagnosis (days)
1
2
3A
3BC
4
0.00
0.25
0.50
0.75
1.00
Proportion of patients alive
0
60
120
180
240
300
360
Time from diagnosis (days)
1
2
3A
3BC
4
(C) English Cancer Alliances (Jan – Jun 2023)
(D) Welsh hospitals (Jan-Dec 2023)
0
20
40
60
80
100
1 year survival (%)
0
500
1000
1500
2000
2500
Number of patients
English provider
National value
99.8% limit 
95% limit 
0
20
40
60
80
100
1-year survival (%)
0
100
200
300
400
500
600
Number of patients
Welsh provider
National value
99.8% limit 
95% limit 

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
16
This State of the Nation report describes the 
patterns of care received by people with lung cancer 
diagnosed in England and Wales during 2023. 
People are analysed based on their place first seen, 
either an English NHS trust or Welsh hospital (see 
methodology supplement), which is a change from 
the previous report. The report also incorporates 
cancer waiting times and genomics data. The report 
has focused on the overall national figures. The 
indicator values for the NHS organisations can be 
found on the online dashboard. It is essential that 
NHS trusts and cancer alliances in England and 
NHS hospitals and health boards in Wales use the 
dashboard and additional online materials to review 
their performance and, where necessary, initiate 
local quality improvement activities. The dashboards 
should also be used to monitor data quality. 
Particularly attention should be given to ‘smoking 
status’, and ‘patient seen by lung cancer CNS’ in the 
English Rapid Cancer Registration Dataset. 
An important and encouraging finding from this 
report is that the proportion of people diagnosed 
with stage 1/2 lung cancer has continued to 
increase; in England, the proportion was 36.7% in 
2023, an increase from 30.5% in 2021. For Wales, 
the proportion increased from 24.0% in 2021 to 
33.9% in 2023. The stage information in the 
English RCRD combines both clinical and 
pathological stage information, and this needs to be 
recognised when interpreting the figures. 
Nonetheless, this increase is likely to reflect the 
introduction of the Lung Cancer Screening 
Programme in England as well other early diagnosis 
initiatives in England and Wales. 
The proportion of people with early-stage lung 
cancer (stage 1/2) who had curative treatment 
reached 80% among those with good performance 
status (PS 0-2). This means the NLCA standard of 
80% has been met for the first time since before 
the COVID-19 pandemic in 2019. The proportion of 
people with NSCLC who had surgery also exceeded 
pre-pandemic levels. This change has occurred in 
conjunction with the increase in people diagnosed 
with stage 1/2 cancer, and represents a significant 
increase in demand. There were 7,382 people 
with NSCLC who had surgery with curative intent 
in England and Wales during 2023, which was up 
from 6,141 in 2022. However, this growth in demand 
is likely to be one of the reasons why the time to 
surgery exceeded 49 days for seven out of eight 
people with NSCLC (stage 1/2) in England. With the 
continued rollout of the Lung Cancer Screening 
programme, NHS lung cancer services should 
urgently review thoracic surgery capacity to ensure 
the likely increase in demand for surgical resection 
can be accommodated.
The time from referral / diagnosis to treatment 
remains a concern in other parts of the care 
pathway. In England, the median time was 36 days 
among people who had surgery, SACT or curative 
radiotherapy, and the median time from diagnosis 
to treatment exceeded 31 days in 16 Cancer 
Alliances. A possible contribution to the delays are 
changes in the treatment pathways due to 
expanded demand for molecular testing among 
some patient subgroups. Additional resources are 
required to allow NHS trusts to achieve the latest 
service specification and NOLCP standards, 
particularly in relation to diagnostic and molecular 
pathology. Other areas in which clinical 
performance requires improvement include: 
curative intent treatment rates for people with stage 
3A NSCLC and good performance status (PS 0-1), 
and importantly SACT treatment rates for people 
with advanced disease and good performance 
status (PS 0-1). 
For the first time, the NLCA State of the Nation 
report has featured data on genomic testing and 
oral tyrosine kinase inhibitor (TKI) treatment rates 
for people with stage 4 NSCLC in NHS England. 
The report highlights a rise of NGS testing within 
NHS England between 2017 and 2021, but that 
extent of testing was below expected levels. This 
may reflect that testing can be carried out locally 
(as well as in “Genetic Laboratory Hub” services) 
and our data source did not cover local testing. 
NICE guidance [NG122] recommends testing for 
mutations in the EGFR gene and assessing for 
ALK fusion oncogenes in all people with advanced 
non-squamous NSCLC. Molecular testing in 
NSCLC is essential for identifying specific genetic 
alterations, such as EGFR mutations and ALK 
rearrangements, which can be effectively targeted 
by oral TKIs which have shown superiority to 
traditional SACT such as chemotherapy. This 
report has also revealed that 20% of EGFR 
mutation positive patients, and 55% of ALK 
positive patients (with PS 0-1) did not receive gold 
standard oral targeted TKI treatments. These oral 
targeted therapies offer a personalised approach 
to NSCLC management which enhances treatment 
efficacy and improves patient outcomes. Without 
molecular testing, patients may receive less 
effective standard treatments, leading to 
suboptimal results and unnecessary side effects. 
Therefore, it is imperative that adequate resources 
are directed towards molecular diagnostic services 
within the NHS (whatever configuration of local or 
Hub testing is used) to ensure optimal patient 
identification, treatment selection, and to reduce 
inequity in care. The NHS needs to embed a 
modern, individualised and scientific approach to 
the care of people with NSCLC.
5.	 Commentary