Inequalities in access to surgical resection for non-small cell lung cancer in England: evaluation of the 'hub and spoke' model

Abstract

Introduction Surgical resection offers the best chance of cure in non-small cell lung cancer (NSCLC). In England, thoracic surgery is delivered via a hub-and-spoke model, with 26 thoracic surgical centres (TSCs) providing specialist services for surrounding trusts. We examined patient- and service-level factors associated with access to surgery, including first-seen trust type. Methods Adults diagnosed with NSCLC in England (2015-2023) were identified from national Cancer Registration Data linked to Hospital Episode Statistics and Office for National Statistics mortality records. Logistic regression examined associations between surgical resection and age, sex, ethnicity, stage, performance status (PS), comorbidity, deprivation, frailty (SCARF index), diagnosis year, trust first-seen TSC status. Cox models assessed survival following surgery. Results Among 306,022 patients diagnosed with NSCLC between 2015 and 2023, 93,959 (30.7%) underwent curative-intent treatment with 53,928 (17.6%) undergoing surgical resection. Resection rates increased from 15.4% (2015) to 21.5% (2023), with a temporary decline in 2020 (16.0%). Patients first seen at TSCs had higher resection rates than those first seen at non-surgical trusts (21.7% vs 16.5%, p < 0.001). Increasing age, advanced stage, poorer PS, higher comorbidity burden, greater deprivation, and higher frailty were all associated with substantially reduced odds of treatment (all p < 0.001). After adjustment for these factors, first-seen TSC status remained associated with higher odds of curative-intent treatment (adjusted Odds Ratio (aOR) 1.22, 95% CI 1.19-1.25, p < 0.001) and surgery (aOR 1.19, 95% CI 1.15-1.23, p < 0.001). Overall, 40,031 patients (13.1%) underwent radical radiotherapy as an alternative curative-intent treatment. First-seen radiotherapy-centre status was not associated with curative-intent treatment (aOR 1.03 (95% CI: 0.94-1.13), p = 0.479) or radical radiotherapy (aOR 1.08 (95% CI 0.95-1.22), p = 0.254). Conclusions Receipt of lung cancer surgery in England was associated with whether patients were first managed at a surgical hub or referring spoke trust. Referral pathways for the current hub-and-spoke model require review to ensure equitable access to resection. Disclosure No significant relationship. [Formula presented] Copyright © 2026 Elsevier B.V.