Localized lung cancer: barriers to a cure

A 71-year-old retired driver has a chest CT because of a pneumonia that was slow to improve. The pneumonia resolves, but the radiologist describes a 2.5-centimeter nodule in the left upper lobe. The clinician orders the biopsy, which takes five weeks to be scheduled. The result shows adenocarcinoma, and staging finds no disease outside the lung. The patient lives two hours from the referral center, depends on his son for transport and says he is fine, that he just gets a little tired climbing the hill. At the next visit, he asks whether surgery is worth it at his age. Three months after the finding, there is still no date for any treatment. The scene is fictional and was written for teaching.

This text uses the case as a scenario for clinical reasoning for students and health professionals. The question comes from Dr. Alexei's list for the oncology series: which factors keep patients with localized disease from reaching curative treatment? The answer is not in a drug or a surgical technique. It is in the path between the first exam and the first day of treatment, where the patient can get lost without anyone noticing. The text does not replace your country's guideline or your service's protocol. If you play the case of the day on NEXO, you will recognize the idea: sometimes the most important clue is the time that passed between two steps.

Key points

• Early-stage non-small cell lung cancer has treatment with curative intent, by surgery or by stereotactic radiotherapy.
• Without treatment, early disease is usually fatal within a few years, which makes every patient lost along the way a concrete loss.
• Delays accumulate at several steps: unreported symptoms, slow tests, referrals, surgical risk assessment and shared decision.
• Distance, income, health insurance, social support and race appear linked to less curative treatment and more delay in several studies.
• Simple interventions, such as alerts for patients without treatment and nurse navigation, nearly eliminated a racial difference in a pragmatic study.
• Age and comorbidity are not enough to deny treatment: stereotactic radiotherapy offers a curative alternative for those who cannot have surgery.

Why this is a reasoning scenario

When people talk about clinical reasoning in oncology, the common image is a technical decision: which surgery, which regimen, which dose. Dr. Alexei's question shifts the focus. It asks the professional to look at the patient who never reached the decision table, because he got lost before. That patient does not appear in clinical trials, does not appear in team meetings and often does not even appear in the referral center's records. He stays along the way.

Lung cancer is a good example because early stage is the window in which cure is possible, and because that window is narrow. Most patients are still diagnosed with advanced disease. The few who are lucky enough to find a small tumor, through screening or by chance, need to go through a sequence of steps: confirm the diagnosis, stage, assess lung function and surgical risk, discuss with the team, decide with the patient and schedule treatment. Each step has a queue, a cost and a chance of dropout.

The reasoning here has three layers. The first is to recognize that time is part of the diagnosis, not an administrative detail. The second is to identify who is at greater risk of getting lost, based on known clinical and social factors. The third is to know what to do when the patient seems not to want or not to be able to proceed, without confusing barrier with choice. The post about the multidisciplinary team in lung cancer shows how service organization helps in these three layers.

Why this error goes unnoticed

Each professional sees only one stretch of the path. The radiologist describes the nodule and moves on to the next exam. The pulmonologist requests the biopsy and waits for the result. The surgeon receives the referral when it arrives. No one is responsible for the interval between the steps, and it is exactly in that interval that the patient disappears. A system that does not measure the total time does not notice the loss.

What is at stake when treatment does not happen

The justification for treating the patient with localized disease urgently lies in the prognosis without treatment. A German review of stereotactic radiotherapy notes that 5-year lung cancer-specific survival is below 20 in every 100 in patients with stage I who receive no treatment (Guckenberger and colleagues, 2014). The ACCURE study, carried out at five cancer centers in the United States, describes early lung cancer without treatment as almost always fatal within 4 years (Cykert and colleagues, 2019).

With treatment, the picture changes. Surgery with anatomic resection is the standard for those with the clinical condition for it, and stereotactic radiotherapy, known by the English acronym SBRT, became the standard treatment for those who cannot undergo surgery. Phase II trials with SBRT in inoperable patients reported local control of 84 to 98 in every 100 tumors (Guckenberger and colleagues, 2014). The difference between treating and not treating is therefore enormous.

How many do not get there

In a California registry with 22,821 patients with early-stage non-small cell lung cancer, about 81 in every 100 received the treatment recommended by the guidelines, and only 58 in every 100 of those received it in adequate time (Obrochta and colleagues, 2022). In a study with 8,501 patients in stages I to III in the United States, the median time between diagnosis and any treatment was 41 days, and this time increased as the county's social vulnerability increased (Hu and colleagues, 2025). These numbers come from systems with many resources. In places with fewer referral centers, the path tends to be longer.

The first barrier: the symptom no one reports

The path begins before the diagnosis. An English qualitative study interviewed 20 patients awaiting resection of early lung cancer and found a consistent pattern: most had health changes that could indicate the disease and that had never been brought to the family doctor (Brindle and colleagues, 2012). Episodic symptoms, or symptoms that seemed explained by age or smoking, were treated as normal.

The most useful finding for those who see patients is about the form of the question. Open questions about health in general did not bring these symptoms to light. They only appeared with closed questions about specific changes. Questions that used disease labels, such as pain or shortness of breath, worked worse than questions in everyday language, such as discomfort or getting out of breath (Brindle and colleagues, 2012).

What this teaches about history taking

The patient who says they are fine does not necessarily have no symptoms. They may have adjusted their life to the symptom without noticing, walking up the hill more slowly or no longer carrying groceries. In the opening picture, the retired driver says he just gets a little tired. That sentence deserves a second question: since when, compared with what, what have you stopped doing. The post about simulated consultations covers how to train these questions.

• Ask about concrete changes: climbing stairs, carrying weight, sleeping, appetite.
• Use everyday words, not disease terms.
• Ask again about symptoms the patient attributes to age or cigarettes.
• Record the approximate start date, because it helps measure the delay later.

The time between diagnosis and treatment

The question of how long one can wait has an answer in the data. A study of 9,904 American veterans operated on for stage I lung cancer showed that the mean time to surgery was 70.1 days. From 12 weeks onward, each additional week of delay increased the risk of recurrence (Heiden et al., 2021). The same study found factors linked to delay, among them Black race and greater socioeconomic deprivation of the residential area.

Guidelines cited in the Louisiana study recommend that surgery take place within 6 to 8 weeks after diagnosis (Neroda et al., 2021). In that study, with 3,616 patients operated on in stages I to IIIA, the median time to surgery was 27 days in White patients and 42 days in Black patients. Surgery took longer than 6 weeks in about 29 out of every 100 White patients and in about 48 out of every 100 Black patients (Neroda et al., 2021).

Wait for surgery or irradiate right away

During the COVID-19 pandemic, a practical question arose: if surgery will take a while, is it worth switching to immediate SBRT? An analysis of the American national database compared wedge resection performed 90 to 120 days after diagnosis with SBRT performed in the first 30 days, in operable patients with stage IA. After matching, 5-year survival was 53 out of every 100 with delayed surgery and 31 out of every 100 with early SBRT (Mayne et al., 2020). The study is observational, and those who received SBRT may have been sicker in other ways. Even so, it shows that switching modality just because of the queue calls for caution.

The reasoning that remains is twofold. Time matters, and long delays worsen the outcome. But the response to delay is not to choose any fast treatment, it is to organize the service so that the right treatment happens in time.

Indicator	Finding	Source
Mean time to surgery, stage I, veterans	70.1 days	Heiden 2021
Point from which delay increased recurrence	12 weeks	Heiden 2021
Deadline recommended by the cited guidelines	6 to 8 weeks	Neroda 2021
Surgery after 6 weeks, White and Black patients	29 and 48 out of every 100	Neroda 2021
Start of treatment at 8 weeks or more, stage I	24 and 34 out of every 100	Holmes 2018
5-year survival, delayed surgery and early SBRT	53 and 31 out of every 100	Mayne 2020
Median time to any treatment, stages I to III	41 days	Hu 2025

Distance, income and social support

The driver in the opening case lives two hours from the referral center. Distance seems an obvious barrier, but the data show that it acts together with other factors. In the California study, the effect of travel time varied by group. Among Black patients, each additional 15 minutes by car was associated with a higher risk of treatment below the recommended level. Among residents of the poorest neighborhoods, each additional 15 minutes of travel by car or public transport was associated with more undertreatment and more delay (Obrochta et al., 2022).

The correct reading is that distance weighs more on those with fewer resources. Those who have a car, free time and money for lodging cross the distance. Those who depend on a relative, on public transport or on missing work face each trip as a new obstacle. A treatment that requires five trips to the hospital before the first day may be unfeasible for that person.

The weight of insurance and social support

In the Louisiana study, having social support, having private insurance and living in an area with less poverty were associated with surgery in adequate time. Social determinants explained about a quarter of the racial difference in surgical delay (Neroda et al., 2021). In Hu's national study, the proportion of patients operated on was higher in counties with lower social vulnerability, higher income and no shortage of primary care physicians, and among patients with private insurance (Hu et al., 2025).

• Ask how the patient will get to each appointment and test.
• Ask who accompanies them and whether that person can miss work.
• Check plan coverage or the public system flow before scheduling.
• Group tests on the same day whenever possible.
• Notify social services early, not after the first missed appointment.

These factors do not appear on the CT scan, but they change the outcome as much as tumor size. The post on clinical decision-making discusses how to include the patient's context in the choice of tests.

Racial inequality and system bias

Several American studies show that Black patients with early-stage lung cancer receive less curative surgery and wait longer for treatment. A narrative review summarizes these data and concludes that the difference persists even after adjustment for clinical factors, and that lower socioeconomic status is also associated with less surgery and worse outcomes (Evans et al., 2021). The same review notes that strategies exist to reduce this difference.

In the American national database, with 119,184 stage I patients, Black patients had longer time to treatment in all three modalities: surgery, SBRT and conventional radiotherapy. About 34 in every 100 Black patients started treatment 8 weeks or more after diagnosis, against 24 in every 100 White patients (Holmes and Chen, 2018).

What a reader from another country can take from this

The data come from the United States, where race mixes with insurance, income and geography in a particular way. In other countries, the lines of inequality may be different: region, origin, language, schooling, employment relationship, distance from a high-complexity center. The lesson that crosses borders is that the system loses more patients from some groups than from others, and that this only shows up when someone measures it. An analysis of barriers in early-stage lung cancer cites stigma, implicit bias among professionals and therapeutic nihilism as targets for intervention (Zarinshenas et al., 2023).

Nihilism deserves special attention. Lung cancer carries the idea of an always fatal disease and, for smokers, the idea of blame. A professional who thinks this way, even without saying it, may present treatment with less enthusiasm, and the patient notices. The post about diagnostic pause helps to recognize this kind of mental shortcut.

Age, comorbidity and the patient's decision

Elderly patients and those with chronic obstructive pulmonary disease are the most likely to go without treatment. In the Netherlands, only 40 in every 100 patients aged 75 or older with stage I underwent surgery, and the proportion of elderly patients without treatment reached 30 in every 100 (Guckenberger et al., 2014). Part of this difference is appropriate, because some patients truly cannot tolerate surgery. But not indicating surgery should not mean absence of treatment, since SBRT is the standard for those who cannot be operated on.

When the patient refuses

A Dutch study with patients treated by surgery or SBRT assessed the patient's role in the decision. About 40 in every 100 reported decisional conflict, and about 36 in every 100 felt they did not have enough information (Mokhles et al., 2018). Some of them said alternatives were not discussed. These numbers show that refusal or hesitation are not always informed choices. They are often the reflection of an incomplete conversation.

In the initial picture, the patient asks whether it is worth operating at this age. The question is legitimate, but it is also a clue. It may hide fear, lack of information about SBRT, worry about the child who will miss work or a bad experience with a relative. Answering only with survival data misses these layers.

• Ask what the patient already knows and what worries them most.
• Present surgery, SBRT and observation with the same criteria.
• Explain the prognosis without treatment clearly and without alarm.
• Offer a second conversation with the family, if the patient wants it.
• Record the decision and the reason, so the team knows whether it was a choice or a barrier.

The post about diagnostic uncertainty brings strategies for talking about risks when the numbers do not answer everything.

What works to avoid losing patients

The best evidence that the problem has a solution comes from the ACCURE study. At five cancer centers in the United States, the researchers combined three measures: a real-time registry, fed by the electronic health record, that alerted when a patient missed an appointment or did not reach the expected treatment; feedback to clinical teams on complete treatment rates broken down by race; and a nurse navigator who checked the alert system every day (Cykert and colleagues, 2019).

Before the intervention, the curative treatment rate was about 78 per 100 white patients and 69 per 100 Black patients. With the intervention, the rates rose to about 96.5 and 95 per 100, and the difference practically disappeared (Cykert and colleagues, 2019). The study was not randomized and used historical and concurrent controls, but the size of the change is hard to ignore.

Why these measures work

They target exactly the blind spot described at the start: the gap between steps. The automatic alert makes the patient who vanished visible. The feedback by group shows the team an inequality it did not see. The navigator turns the alert into action, calling the patient, rescheduling, sorting out transportation. None of the three requires expensive technology.

• An active list of patients diagnosed with early-stage lung cancer and with no treatment date.
• A named person responsible for tracking the total time, not just each step.
• A multidisciplinary meeting with a short deadline after staging.
• Surgical risk tests grouped and scheduled together.
• Time and treatment indicators broken down by social group.
• Active outreach to those who missed, before considering them lost to follow-up.

The team profiles at NEXO, such as Curators and case creators, show how to turn this kind of flow into teaching cases.

How NEXO helps train this reasoning

At NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues, and you propose the diagnosis by searching for the ICD-10 code. Dr. Alexei's question is a good exercise because it forces you to think beyond the diagnosis. Knowing that the patient has early-stage lung cancer is only half the work. The other half is noticing what can stop them from reaching treatment. The post on differential diagnosis shows how to train reading clues, and the post on case-based learning explains why this format works.

Three exercises with cases

Change the distance. Say what changes in the plan if the patient lived ten minutes from the hospital, but had no one to accompany them.

Change the lung function. Say how you would present the options if spirometry showed severe obstructive disease.

Change the response. Say what you would do if the patient missed the appointment with the surgeon and did not answer the phone.

The post on interprofessional clinical reasoning helps you think about the role of nursing and social work along this path. The limits on using the game are described on the NEXO Economy page. If you research the teaching of clinical reasoning, the page for Researchers explains how to get in touch, and the Closer page shows how to bring NEXO to your institution.

Frequently asked questions

What is the acceptable time between diagnosis and surgery?

Guidelines cited in the literature recommend 6 to 8 weeks (Neroda and colleagues, 2021). In a large study, the risk of recurrence began to rise after 12 weeks (Heiden and colleagues, 2021).

If the patient cannot have surgery, is there still curative treatment?

Yes. Stereotactic radiotherapy is the standard for inoperable stage I patients, with high local control in phase II trials (Guckenberger and colleagues, 2014).

Is it worth swapping surgery for radiotherapy just because the waiting list is long?

With caution. An observational analysis showed higher survival with surgery even when delayed than with early SBRT in operable patients (Mayne and colleagues, 2020). The decision should be discussed by the team.

How can you tell whether a refusal is a choice or a barrier?

Ask what motivates the refusal, check whether all the options were explained, and look into transport, cost and family support. Many patients report decisional conflict and a lack of information (Mokhles et al., 2018).

Does patient navigation really work?

In the ACCURE study, automatic alerts, feedback to the teams and a nurse navigator raised curative treatment to nearly 95 out of every 100 patients and almost eliminated the racial gap (Cykert et al., 2019).

Final checklist

• I recorded the date of the finding, the diagnosis and the referral.
• I asked about symptoms using everyday words.
• I grouped biopsy, staging and risk tests whenever possible.
• I asked about transport, a companion, work and coverage.
• I took the case to the multidisciplinary meeting without waiting for all the tests.
• I presented surgery and SBRT as curative options, along with the prognosis without treatment.
• I distinguished informed refusal from an unresolved barrier.
• I put the patient on an active list until the treatment date.

Want to practice your reasoning with progressive clues? Play the case of the day.

References

1. Brindle L, Pope C, Corner J, et al. Eliciting symptoms interpreted as normal by patients with early-stage lung cancer: could GP elicitation of normalised symptoms reduce delay in diagnosis? Cross-sectional interview study. BMJ Open. 2012. PMID 23166137.
2. Cykert S, Eng E, Walker P, et al. A system-based intervention to reduce Black-White disparities in the treatment of early stage lung cancer: A pragmatic trial at five cancer centers. Cancer Med. 2019. PMID 30714689.
3. Evans N, Grenda T, Alvarez NH, Okusanya OT. Narrative review of socioeconomic and racial disparities in the treatment of early stage lung cancer. J Thorac Dis. 2021. PMID 34277067.
4. Guckenberger M, Andratschke N, Alheit H, et al. Definition of stereotactic body radiotherapy: principles and practice for the treatment of stage I non-small cell lung cancer. Strahlenther Onkol. 2014. PMID 24052011.
5. Heiden BT, Eaton DB, Engelhardt KE, et al. Analysis of Delayed Surgical Treatment and Oncologic Outcomes in Clinical Stage I Non-Small Cell Lung Cancer. JAMA Netw Open. 2021. PMID 34042991.
6. Holmes JA, Chen RC. Racial Disparities in Time From Diagnosis to Treatment for Stage I Non-Small Cell Lung Cancer. JNCI Cancer Spectr. 2018. PMID 31360839.
7. Hu X, Kao YH, Arunachalam A, et al. Trends in initial primary treatment approach and biomarker testing across social determinants of health in early-stage non-small cell lung cancer. Future Oncol. 2025. PMID 41257359.
8. Mayne NR, Lin BK, Darling AJ, et al. Stereotactic Body Radiotherapy Versus Delayed Surgery for Early-stage Non-small-cell Lung Cancer. Ann Surg. 2020. PMID 33074904.
9. Mokhles S, Nuyttens JJME, de Mol M, et al. Treatment selection of early stage non-small cell lung cancer: the role of the patient in clinical decision making. BMC Cancer. 2018. PMID 29334910.
10. Neroda P, Hsieh MC, Wu XC, et al. Racial Disparity and Social Determinants in Receiving Timely Surgery Among Stage I-IIIA Non-small Cell Lung Cancer Patients in a U.S. Southern State. Front Public Health. 2021. PMID 34150706.
11. Obrochta CA, Parada H, Murphy JD, et al. The impact of patient travel time on disparities in treatment for early stage lung cancer in California. PLoS One. 2022. PMID 36197902.
12. Zarinshenas R, Amini A, Mambetsariev I, et al. Assessment of Barriers and Challenges to Screening, Diagnosis, and Biomarker Testing in Early-Stage Lung Cancer. Cancers (Basel). 2023. PMID 36900386.