Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the European Respiratory Society and European Society of Thoracic Surgeons.

Fitness for Curative Intent Treatment of Lung Cancer

European Respiratory Society

European Society of Thoracic Surgeons

Publication Date: Nov 13, 2025

Page Last Updated: Jul 16, 2026

What is the predictive impact of subjective factors (clinician gestalt/eyeballing and patient-reported outcomes) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

The panel suggests being more rigorous about collecting health-related quality of life (HRQoL) data before and after curative treatments (surgery or SBRT). The appropriate questionnaires must be chosen to measure patient-reported outcomes (PROs). Particularly, the preferred patient-reported outcome measure (PROM) tools must be applicable at baseline and at follow-up visits. Follow-up visits should extend up to 12 months post-surgery and up to 2 years post-SBRT at regular intervals for accurate longitudinal PRO assessment (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests using cancer-specific internationally validated tools such as EORTC QLQ-C30, EORTC QLQ-LC29 and the National Institutes of Health-sponsored Patient Reported Outcome Measurement Information System (PROMIS) to assess quality of life after curative treatment (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests to assess the effect of acute side-effects on HRQoL within 3 months of treatment and severe symptoms (symptoms that are grade 3 and above according to Common Terminology Criteria for Adverse Events) with appropriate questionnaires as patient-reported symptoms should be managed properly to hasten recovery time after definitive treatment (Conditional recommendation, low certainty of evidence, stemming from narrative review).
- Remarks: 1) The assessment of PROs before radical treatment for lung cancer has the potential to identify predictors of outcomes which are not captured by traditional objective parameters traditionally used to assess fitness; 2) Tailored PRO tools, timing of assessment and strategies to increase the completion rate should be considered according to the population of interest; 3) By integrating PRO assessment into clinical practice, physicians can better identify patients at high risk of decline in HRQoL domains, such as emotional and physical functioning. This can enable the implementation of targeted psychological and physical support programmes tailored to benefit these patients.

What is the predictive impact of different comorbidities (other than cardiovascular diseases) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

The panel suggests that the risk of surgery or radiotherapy is increased in patients with comorbidities and physicians need to be cautious if Charlson Comorbidity Index is increasing when providing surgery or radiotherapy with curative intent (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that patients with non-dialysed chronic kidney disease seem not at an increased risk of surgery in early-stage NSCLC. Nevertheless, an additional risk is observed in those patients >75 years old (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that patients with lung cancer and cirrhosis have an increased risk of complications and liver decompensation after surgery (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that based on the available literature, no recommendation can be proposed for curative intent treatment in patients with autoimmune diseases and early lung cancer (Conditional recommendation, very low certainty of evidence, stemming from narrative review).
The panel suggests that the risk of post-surgical complications in HIV patients with early-stage NSCLC is dependent on CD4 count, the HIV viral load and the optimal antiviral therapy (highly active antiretroviral therapy). The decision must take into account on the potential detrimental long-term prognosis related to HIV status (Conditional recommendation, very low certainty of evidence, stemming from narrative review).
Based on the available literature, no recommendation can be made for or against chemoradiotherapy or definitive radiotherapy in HIV patients (Conditional recommendation, very low certainty of evidence, stemming from narrative review).
The panel suggests adapting HIV therapy while planning chemotherapy to avoid detrimental interactions (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that stroke or cerebrovascular disease are not associated with a detrimental impact on mortality, while more post-surgical complications are observed (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests performing a pre-operative work-up to assess the risk of a cerebrovascular incident during surgical procedure (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that diabetes is associated with an increased risk for post-surgical complications. Adequate diabetes control and vascular assessment are recommended before surgery to reduce post-operative complications (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests recommending definitive radiation to unresectable or inoperable NSCLC patients with diabetes despite an increase in radiation pneumonitis (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that thoracic surgery in solid organ transplant recipients is associated with potential increase in early mortality and risk of respiratory failure but with adequate long-term survival (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests that patients with interstitial lung disease (ILD) are at increasing risk of complications after thoracic surgery and/or radiotherapy (Conditional recommendation, low certainty of evidence, stemming from narrative review).
The panel suggests considering SBRT as the treatment of choice, with RFA reserved for cases where SBRT is unavailable, contraindicated, or as a salvage treatment following SBRT. Final decisions should take into account the benefit/risk ratio for each option (Conditional recommendation, low certainty of evidence, stemming from narrative review).

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Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Implications for:	Strong Recommendation (S)	Conditional Recommendation (C)
Patients	Most individuals in this situation would want the recommended course of action, and only a small proportion would not.	The majority of individuals in this situation would want the suggested course of action, but many would not.
Clinicians	Most individuals should receive the intervention. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.	Recognize that different choices will be appropriate for individual patients and that you must help each patient arrive at a management decision consistent with his or her values and preferences. Decision aids may be useful in helping individuals to make decisions consistent with their values and preferences.
Policy	The recommendation can be adopted as policy in most situations.	Policymaking will require substantial debate and involvement of various stakeholders.

Certainty in the Evidence
High	H	Low	L
Moderate	M	Very Low	VL

Source: Grading of Recommendations Assessment, Development and Evaluation Working Group (Schunemann HJ et al. Am J Respir Crit Care Med. 2006;174:605-14. Guyatt GH et al. BMJ 2008;336:924-6).

Document Overview

Document Title: Fitness for Curative Intent Treatment of Lung Cancer

Authoring Societies

European Respiratory Society

European Society of Thoracic Surgeons

Document Publication Date: Nov 13, 2025

Page Last Reviewed/Updated: Jul 16, 2026

Document Type: Guideline

Country of Publication: European

Full Text Freely Available: Yes

Full Text Guideline: publications.ersnet.org/content/erj/66/5/2500156

Source Citation: Brunelli A, Hardavella G, Huber RM, Berghmans T, Frille A, Rodriguez M, Tietzova I, Depypere L, Asteggiano R, Batchelor T, Costantini A, Ruysscher D, Durieux V, Faivre-Finn C, Ferguson MK, Langer D, Marczin N, Nagavci B, Novoa N, Pompili C, Rawlinson J, Snoeckx A, Tonia T, van Geffen WH, Williams C, Caruana EJ, Kabalak PA, Mansmann U, Fallet V, Kauffmann-Guerrero D, Paesmans M, Tawil AA, Alhannoush N, Creamer AW, Kourouni I, Blum TG. European Respiratory Society and European Society of Thoracic Surgeons clinical practice guideline on fitness for curative intent treatment of lung cancer. Eur J Cardiothorac Surg. 2025 Nov 2;67(11):ezaf329. doi: 10.1093/ejcts/ezaf329. PMID: 41229359.

Document Scope, Criteria, and Use Cases

Document Objectives: A multidisciplinary panel of lung cancer experts with a special interest in functional evaluation of lung cancer patients, and lung cancer patient representatives, has been facilitated by the European Society of Thoracic Surgeons and the European Respiratory Society to provide healthcare professionals with practical and up-to-date recommendations for the assessment of patients’ fitness for curative intent treatments for lung cancer. The panel formulated four PICO (population, intervention, comparison and outcomes) questions and seven complementary narrative questions. Both types of questions were assigned to groups of at least two experts. A medical librarian conducted the literature searches, and the authors selected relevant studies based on predefined inclusion criteria. Risk of bias was assessed using the QUIPS (Quality in Prognosis Studies) tool. Data were summarised and the certainty of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluations) and the Evidence to Decisions framework was used to formulate recommendations. A series of multidisciplinary recommendations was formulated about the utilisation of pulmonary function tests, split lung function values, exercise tests, cardiologic testing, and the role of prehabilitation, sublobar resections, risk scores and comorbidities in selecting patients for curative intent treatment.

Scope: Assessment and Screening, Management, Treatment

Diseases/Conditions (MeSH): D008175 - Lung Neoplasms

Keywords: fitness, lung cancer

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory, Operating and Recovery Room, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

PICO Questions

Should DLCO testing be used in lung cancer patients undergoing radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?
Should predicted post-operative FEV1 be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?
Should predicted post-operative DLCO be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?
Should field exercise tests (6-min walk test/shuttle walk test, stair climbing test, BODE score) be used in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of mortality, length of stay and quality of life following treatment (compared to not using them)?
Should laboratory exercise tests (V̇O2max or V̇E/V̇CO2 measured at CPET) be used in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of morbidity, mortality or impaired quality of life following treatment (compared to not using them)?
Should laboratory exercise tests (V̇O2max or V̇E/V̇CO2 measured at CPET) be used in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of morbidity, mortality or impaired quality of life following treatment (compared to not using them)?
What is the predictive impact of subjective factors (clinician gestalt/eyeballing and patient-reported outcomes) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?
What is the predictive impact of risk scores and nomograms, nutritional status and frailty for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?
What is the predictive impact of planned extent of surgical resection (e.g. sublobar parenchymal sparing resections, lobectomy) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?
What is the predictive impact of pulmonary rehabilitation for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?
What is the predictive impact of age for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?
What is the predictive impact of performance status and sarcopenia for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?
What is the predictive impact of different comorbidities (other than cardiovascular diseases) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

Supplemental Methodology Resources: Data Supplement A Data Supplement B

Fitness for Curative Intent Treatment of Lung Cancer

Summary of Recommendations

Should D_LCO testing be used in lung cancer patients undergoing radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Should predicted post-operative FEV₁ be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Should predicted post-operative D_LCO be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Which measures should be used to minimise the cardiovascular risk in NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of subjective factors (clinician gestalt/eyeballing and patient-reported outcomes) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of risk scores and nomograms, nutritional status and frailty for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of planned extent of surgical resection (e.g. sublobar parenchymal sparing resections, lobectomy) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of pulmonary rehabilitation for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of age for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of performance status and sarcopenia for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of different comorbidities (other than cardiovascular diseases) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

Good practice statement about smoking cessation

Figure 1. General fitness evaluation flow-chart for curative treatment of non-small cell lung cancer

Figure 2. Algorithm for evaluating cardiovascular risk for curative treatment of non-small cell lung cancer

Figure 3. Algorithm for evaluating cardiorespiratory fitness for surgical treatment of non-small cell lung cancer

Table 1. Definition of high-risk patients for surgery

Table 2. Definition of high-risk patients for radiotherapy

Table 3. Definition of high-risk patients for systemic anti-cancer treatment

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Document Overview

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology

Fitness for Curative Intent Treatment of Lung Cancer

Summary of Recommendations

Should DLCO testing be used in lung cancer patients undergoing radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Should predicted post-operative FEV1 be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Should predicted post-operative DLCO be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Which measures should be used to minimise the cardiovascular risk in NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of subjective factors (clinician gestalt/eyeballing and patient-reported outcomes) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of risk scores and nomograms, nutritional status and frailty for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of planned extent of surgical resection (e.g. sublobar parenchymal sparing resections, lobectomy) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of pulmonary rehabilitation for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of age for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of performance status and sarcopenia for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

What is the predictive impact of different comorbidities (other than cardiovascular diseases) for selection of NSCLC patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy)?

Good practice statement about smoking cessation

Figure 1. General fitness evaluation flow-chart for curative treatment of non-small cell lung cancer

Figure 2. Algorithm for evaluating cardiovascular risk for curative treatment of non-small cell lung cancer

Figure 3. Algorithm for evaluating cardiorespiratory fitness for surgical treatment of non-small cell lung cancer

Table 1. Definition of high-risk patients for surgery

Table 2. Definition of high-risk patients for radiotherapy

Table 3. Definition of high-risk patients for systemic anti-cancer treatment

Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-Based Recommendations

Document Overview

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology

Should D_LCO testing be used in lung cancer patients undergoing radical treatment (surgery and/or immunochemoradiotherapy) for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Should predicted post-operative FEV₁ be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?

Should predicted post-operative D_LCO be measured in lung cancer patients, candidates for radical treatment (surgery and/or immunochemoradiotherapy), for risk stratification of mortality, length of stay, morbidity and quality of life following treatment (compared to not using it)?