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Lung cancer remains the leading cause of cancer death worldwide. While prevention strategies such as tobacco control remain crucial, differences in survival outcomes between high-income countries suggest that access to effective treatment also plays a key role.1 These differences occur despite similar healthcare expenditure and universal coverage systems, indicating that structural, cultural and clinical factors influence lung cancer care delivery.In this population-based analysis, Barclay et al examine chemotherapy and radiotherapy use for patients with lung cancer across 16 jurisdictions in Australia, Canada, Norway and the UK between 2012 and 2017.2 Using data from over 275 000 patients in the International Cancer Benchmarking Partnership (ICBP), they provide one of the largest comparative assessments of treatment practices.The study reveals substantial variation in treatment use between jurisdictions. Chemotherapy use ranged from 23% in Northern Ireland to 45% in Norway, while radiotherapy ranged from 32% in England to 50% in Newfoundland and Labrador. These differences persisted even after stratifying by age, sex and stage, suggesting that factors beyond disease severity and demographics influence treatment patterns.One striking finding is the sharp decline in chemotherapy use with increasing age. Over half of the patients aged 15–64 received chemotherapy compared with 4% among those aged 85–99 years. Radiotherapy use also declined with age, though this pattern was more variable.Although Barclay et al stratified treatment use by stage group, the lack of directly linked surgical data limits full understanding of treatment pathways, particularly for early-stage disease where surgery is usually first-line. Differences in stage distribution may also influence treatment rates and outcomes, as nations with earlier diagnosis have more patients eligible for curative therapies.The authors also explored the relationship between treatment rates and survival outcomes, finding weak but consistent associations suggesting that jurisdictions with higher chemotherapy and radiotherapy use may achieve better lung cancer survival. However, this finding should be interpreted with caution as it may reflect other factors such as stage at diagnosis, treatment quality or broader health system differences.While age alone should not determine treatment decisions, older patients often have higher rates of frailty, comorbidity and reduced physiological reserve, making treatment risk–benefit assessments more complex.3 4 The lack of comorbidity or frailty data in this study means it is unclear whether low treatment rates in older adults represent good personalised care or systematic undertreatment. Shared decision-making processes, where patient preferences, values and tolerance for potential side effects are explicitly considered, may contribute to lower treatment rates, reflecting informed choices rather than clinical limitations.5 6The observation that Norway, Ontario and New South Wales had higher treatment rates across age groups compared with UK nations prompts further exploration. Do these higher rates reflect healthier older populations, better geriatric assessment integration or greater willingness to treat despite comorbidity? Conversely, are lower rates elsewhere due to more cautious risk assessment, limited service capacity or therapeutic nihilism? International differences in medical culture, guideline implementation and resource allocation may all contribute.Another limitation is the lack of treatment intent and quality data. Chemotherapy and radiotherapy may be administered with curative or palliative goals, and the benefits, risks and decision-making processes differ accordingly. Without this context, it is challenging to interpret whether high treatment rates represent aggressive but appropriate care, or potential overtreatment with limited patient benefit.7 Furthermore, treatment quality, including adherence to recommended regimens, dose intensity and completion rates, was not captured, yet these factors substantially affect outcomes.A further issue is the historical nature of the data, with many patients diagnosed and treated over a decade ago. Since 2012–2017 lung cancer treatment has been transformed by widespread uptake of immunotherapy and targeted therapies, multimodality treatment and wider access to stereotactic ablative radiotherapy.8Despite these limitations, the use of large, population-based datasets across multiple countries enables robust comparisons and is a significant contribution to our understanding of international lung cancer care. Clinically, it highlights potential inequities in access to evidence-based treatments between and within countries. Health systems must examine and address barriers to treatment, whether logistical, cultural or clinical, to ensure patients are not denied potentially beneficial therapies due to age, geography or service capacity.These findings emphasise the importance of integrating geriatric assessment tools into oncology to ensure older patients are assessed holistically rather than by age alone.4 They also reinforce the need for linked, population-based datasets combining information on stage, comorbidity, treatment intent and outcomes to enable more meaningful evaluations of healthcare performance and equity. Moreover, they support the value of international benchmarking to identify gaps in care and drive improvements in treatment access and delivery.Future studies should explore whether higher treatment rates translate into better outcomes for all patients, particularly older adults, or reflect overtreatment in some contexts. Evaluating the impact of treatment on quality of life and survival, stratified by age and comorbidity, will be crucial to inform optimal, equitable care. International collaborations like the ICBP remain vital in identifying best practices and driving improvements.Ultimately, as Barclay et al demonstrate, understanding who receives treatment, and why, is essential to ensure that everyone with lung cancer is offered care that is effective, evidence-based and tailored to their individual health status and preferences, wherever they live.