Quality statement 6	People with pulmonary nodules considered for definitive treatment but who decline or who are unsuitable for surgery are offered ablative* non-surgical treatment where safe.
Rationale	People who are unfit or decline surgery still stand to gain a lot from having early-stage lung cancer treated with curative intent. Such patients should therefore be offered alternative treatment with curative intent. The outcome of treatment is similar whether in biopsy confirmed malignancy or where unconfirmed.
	Structure: Evidence of local arrangements and written clinical protocols to ensure that people with pulmonary nodules considered for definitive treatment but who decline or who are unsuitable for surgery are offered ablative non-surgical treatment where safe.
Quality measure	Process: Proportion of people with pulmonary nodules with a > 70%  likelihood of malignancy or pathological confirmation of lung cancer who decline or are unsuitable for surgery, who are offered ablative non-surgical treatment where safe. Numerator: The number of people with pulmonary nodules with a >70% likelihood of malignancy or pathological confirmation of lung cancer who decline or are unsuitable for surgery and who are offered ablative non-surgical treatment where safe. Denominator: The number of people with pulmonary nodules with a >70% likelihood of malignancy or pathological confirmation of lung cancer who decline or are unsuitable for surgery.
Description of what the quality statement means for each audience	Service providers: Ensure there are systems and services in place for people with pulmonary nodules who decline or who are unsuitable for surgery to be offered ablative non-surgical treatment where safe.
	Healthcare professionals: Offer referral to people with pulmonary nodules who decline or who are unsuitable for surgery for ablative non-surgical treatment where safe. Commissioners: Ensure they commission services for people with pulmonary nodules who decline or who are unsuitable for surgery so that they can be offered ablative non-surgical treatment where safe. People with pulmonary nodules who decline or who are considered unsuitable for surgery Are offered ablative non-surgical treatment where safe.
Relevant existing indicators	Local MDT minutes/database/audit
National data sources	National Lung Cancer Audit, Society for Cardiothoracic Surgery Thoracic Registry
Source references	BTS Guidelines for the Investigation and Management of Pulmonary Nodules, 20153; NICE Lung Cancer: Diagnosis and Management Guideline, 20114; BTS Guidelines on the Radical Management of Patients with Lung Cancer, 20107
Other information	*Ablative treatment refers to stereotactic ablative body radiotherapy, radiofrequency ablation or microwave ablation. BTS Pulmonary Nodule Risk Prediction Calculator https://www.brit-thoracic.org.uk/standards-of-care/guidelines/bts-guidelines-for-the-investigation-and-management-of-pulmonary-nodules/bts-pulmonary-nodule-risk-prediction-calculator/ (to be read in conjunction with the relevant sections of the above guideline). NHS England Service Specification for Thoracic Surgical Services https://www.england.nhs.uk/publication/thoracic-surgery-adults/ NHS England Commissioning Guidance for the Whole Lung Cancer Pathway: https://www.brit-thoracic.org.uk/media/396232/Clinical-Advice-for-the-Provision-of-Lung-Cancer-Services-Aug-2017.pdf https://www.brit-thoracic.org.uk/media/382380/National-Optimal-LUNG-Pathway-Aug-2017.pdf NLCFN Patient Information: https://www.nlcfn.org.uk/patient-information