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Objective National guidelines recommend that people with advanced stage non-small cell lung cancer (NSCLC) and good performance status (PS 0–1) are offered systematic anticancer therapy (SACT). This study investigated patterns of SACT use among patients with advanced NSCLC within England.Methods and analysis The study used data on patients with stage 3B–4B NSCLC diagnosed between 2019 and 2022 identified from the Rapid Cancer Registration Dataset. Linkage to other national datasets provided information on SACT use and hospital admissions. Regression models were used to assess the association between patient characteristics and treatment patterns and to explore variation in practice between cancer alliances. Survival analysis was used to estimate the potential life-years gained if all cancer alliance treatment rates matched the highest rate of SACT use.Results The study analysed 60 210 patients diagnosed with advanced NSCLC in England (2019–2022). PS was good (=0/1) in 43% of patients; of these, 62% received SACT. Receipt of SACT decreased as age at diagnosis increased, in patients with stage 4 disease (vs 3B/C), among patients who lived in more deprived areas and among patients with a greater burden of comorbidity or more severe frailty. After adjusting for patient characteristics, use of SACT ranged from around 50% to 70% between cancer alliances. If all cancer alliances achieved the highest alliance treatment rate, a further 448 patients would be treated each year, with 289 life-years gained.Conclusion For English patients with advanced NSCLC (PS=0/1), use of SACT is strongly associated with age, frailty and socio-economic deprivation. Substantial variation in SACT use persists across Cancer Alliances, even after adjusting for patient characteristics. Addressing this variation could improve equity and population-level outcomes.