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The authors of this editorial are patients, advocates and founders of communities representing people living with oncogene-driven non-small cell lung cancer (NSCLC). From the patient-advocacy perspective, we wish to stimulate debate and facilitate discussion among UK thoracic oncologists, surgeons and policymakers regarding the potential role of surgical local consolidation therapy (LCT) before disease progression in selected patients with stage IV oncogene-driven NSCLC. Such proactive surgical LCT (also called salvage surgery or conversion surgery) involves resection of the primary lung tumour site. The LCT may be expanded to locoregional therapy and involve systematic lymph node dissection or lobe-specific lymph node dissection. Furthermore, treatment of isolated distant lesions (oligometastases), such as brain or adrenal metastases, may be considered. The extent of the procedures is to be decided on an individual basis and tailored to the patient's specific needs.This is a topical and pressing subject for us as we are representative of the many patients who achieve stable oligometastatic NSCLC on targeted therapy, including those with a long disease history. We believe it is now time, in the light of the effectiveness of systemic anti-cancer therapy (SACT), that surgical LCT before progression in oncogene-driven stage IV NSCLC should at least be considered.Oncogene-driven NSCLC is a biologically distinct subtype of lung cancer characterised by genomic alterations in oncogenes; specific examples include EGFR mutations, ALK rearrangements and others.1 These cancers most commonly present with stage IV disease. Patients are frequently never-smokers, often younger, physically fit, with few comorbidities, and may be in the midst of careers and family life. Targeted SACT, particularly tyrosine kinase inhibitors (TKIs), can achieve durable disease control for months or years. However, acquired resistance is almost inevitable and disease progression occurs, with the most common anatomic site of TKI failure being intrathoracic.2 Within this context globally, but not in the UK, various LCTs, including surgery, radiotherapy and ablation as strategies to delay progression by eradicating residual disease, are being explored.The current treatment landscape is evolving rapidly, especially in oncogene-driven disease. A growing body of literature, beginning with the seminal paper by Gomez et al in 2016,3 has shown improved outcomes with LCT in oligometastatic NSCLC, including progression-free survival (PFS) and, in some studies, overall survival (OS) (2 4–6 and also online supplemental table 1A). The NORTHSTAR clinical trial in EGFR-mutated metastatic NSCLC demonstrated a median PFS of 25.4 months with osimertinib plus LCT (radiation and/or surgery), compared with 17 months for osimertinib alone.7 Similarly, in the BRIGHTSTAR trial of ALK-rearranged metastatic NSCLC, median PFS reached 66 months with brigatinib, followed by brigatinib plus LCT (radiation and/or surgery), compared with a median PFS of 29.4 months as reported in historical trials of brigatinib monotherapy.8 Notably, surgery accounted for a minority of LCT cases in both trials (29% and 9%, respectively) and while these data support the concept of LCT before progression, they do not yet permit conclusions regarding the independent contribution of surgery. In this context, it is worth mentioning encouraging results of a retrospective review of patients with oligometastatic stage IV NSCLC who underwent surgical LCT.9 Analysis included patients’ genetic alterations (EGFR, TP53, EGFR, KRAS, ALK, multiple alterations) and no alterations. Systemic therapy was commonly administered in the preoperative setting to all patients who then underwent pulmonary resection as part of comprehensive LCT. The median PFS of 43.1 months and OS of 88.9 months were reported for patients with EGFR alteration (19.1 months and 30.8 months, respectively, for the other alteration status group combined). These data support the concept of LCT before progression; however, they do not permit conclusions regarding the contribution of surgical LCT to the groups receiving targeted therapy. We surmise that, overall, LCT trial outcomes are to be interpreted as supporting multimodality local treatment strategies, including surgery rather than any single LCT modality.SP110.1136/bmjonc-2025-000974.supp1Supplementary dataIt is important to recognise the value of LCT radiotherapy as an effective therapeutic modality offering better PFS and OS in selected patient populations, as demonstrated by the results of clinical trials such as ATOM, SINDAS, COMET and others summarised in a recent review.10 In the UK, the HALT trial is evaluating radiotherapy for oligoprogression in patients with oncogene-driven NSCLC otherwise stable on SACT to assess potential benefits and risks of toxicity.11 Results are awaited and may further clarify the role of radiotherapy not only in managing oligoprogressive disease, but also potentially before overt disease progression occurs. (Due to space limitation, it is not feasible to broaden the debate to include radiotherapy as the LCT modality. However, a separate project for oncogene-driven NSCLC and radiotherapy as the LCT before progression is currently being discussed and is intended to be submitted as a separate paper in the future.)With respect to surgery, the global Society of Thoracic Surgeons (STS) published a clinical practice guideline in 2025 reviewing the available evidence on the surgical management of oligometastatic NSCLC.12 The guideline highlights potential benefits in selected patients, but critically emphasises a multi-disciplinary team (MDT) evaluation and careful patient selection rather than routine surgical intervention. Similarly, ESMO-MCBS Clinical Practice Guidelines acknowledge a role for LCTs in selected oligometastatic NSCLC patients.13 The ASTRO/ESTRO 2023 guideline further specifies that surgery may be favoured as LCT in carefully selected patients when large-volume tissue sampling is required to guide systemic therapy and minimally invasive surgical techniques are feasible.14In contrast, current National Institute for Clinical Excellence (NICE) guidance in the UK does not address surgery for stage IV NSCLC, and UK surgical guidelines have not been revised in the era of modern SACT and substantially improved PFS and OS. Interestingly, in 2020, NICE reached a favourable conclusion in relation to the question of surgical removal of the asymptomatic primary tumour for people with incurable metastatic colorectal cancer despite limited evidence.15 The committee considered low and very low quality evidence from 13 retrospective cohort studies, noted the lack of quality of life and economic evidence, and a failure of relevant trials to recruit, but accepted that there was evidence of an improved OS in the cohort receiving surgery. They concluded that surgery should be considered provided that the benefits, harms and options were carefully discussed with the patient. We would contend that surgical removal of the asymptomatic primary tumour in incurable metastatic oncogene-driven NSCLC should at least be afforded the same NICE consideration and review.In line with the STS guideline, any consideration of surgery before progression would require a robust MDT framework involving thoracic oncologists, surgeons, radiation oncologists, radiologists and molecular pathologists. Current evidence does not isolate the independent contribution of surgery before progression, and as such, it cannot be advocated as standard of care, but surgery is of proven benefit in oligometastatic disease at acceptable risk.6 12 As patients, we are also keenly aware that the current practice of ‘watchful waiting’ with three monthly scanning to detect progression carries psychological harm. Our aim is not to assert superiority of surgical resection over other LCT modalities, but rather to argue that surgery should be discussed as a potential option within MDTs for carefully selected patients. The critical role of the MDTs is emerging as a common theme in this process; they are essential to avoid inappropriate extrapolation of evidence and to ensure equitable access to expert opinion. Disease biology, response to systemic therapy, patient preference, opportunity cost and health-system impact must all be weighed transparently.The UK RAMON Trial was opened in 2023 and was designed to assess combined LCT (surgery, radiotherapy and ablation) in patients with advanced NSCLC stable on first-line SACT.16 Outcomes were intended to include feasibility, clinical effectiveness and cost-effectiveness. However, the trial closed early due to poor recruitment. The failure of RAMON underscores the challenges of delivering complex multimodality trials for the relatively small numbers of patients in the oncogene-driven NSCLC population within the UK, including referral pathways and clinician engagement. Its closure leaves UK patients who are keen to be considered for surgery without a trial-based route and perpetuates the lack of an NHS evidence base.As patients and advocates, we recognise that the UK thoracic community holds divergent views about surgical LCT, with some experts supporting surgery, some expressing caution about premature adoption and others who are resolutely against, as exemplified in these articles.17 18 Based on published reports and personal communications, we have attempted to summarise and weigh the available information in support or against surgery (online supplemental table 1). These arguments may be considered, for example, during the MDT discussions. From our perspective, this is an evolving document open to debate and revision, discussions and considerations, with the expectation that current qualitative entries on both sides of the argument will be supported or otherwise by quantitative data in the future.With these points in mind, we assert that surgery before progression for patients with stable oligometastatic NSCLC is at risk of remaining undiscussed and unduly delayed while the UK thoracic oncology community continues to be so divided about its potential role.Within our patient communities are patients who want to:Challenge the current paradigm that stage IV lung cancer precludes surgery and allow consideration of surgery for stage IV patients with lung cancer, including those with a long disease history.Be active partners in shared decision-making with clinicians, including surgeons.Be assessed transparently for eligibility and allowed to weigh the risks of surgery in the context of published data, their own values and life circumstances.We recognise that evidence remains incomplete and uncertainty substantial. Our call is not for routine adoption of surgery before progression, but for informed discussion, access to MDT evaluation, and honest appraisal of risks and benefits. Rare UK cases of surgery performed following TKI response in initially unresectable oncogene-driven NSCLC19 20 (and also personal communications about similar cases) demonstrate feasibility, though currently this should be viewed as hypothesis-generating rather than practice-changing. As patients and advocates, our role is to ensure that this debate remains active, balanced and grounded in evidence as it evolves. This is not only about data, but also about how we live, how long we live, and whether our voices are part of decisions that shape our care.