• Empyema
• lung cancer
• lung volume reduction surgery
• pleural disease
• thoracic surgery
• asbestos induced lung disease
• emphysema
• lung cancer
• lung cancer chemotherapy
• lung volume reduction surgery
• mesothelioma
• non-small cell lung cancer

Rich and colleagues have recently provided information on lung cancer in England from the National Lung Cancer Audit database (LUCADA).1 The authors concluded that LUCADA accurately describes people in England with lung cancer and can be used to drive healthcare improvements. They found that the socioeconomic status of individual patients does not affect survival and has only limited impact on patients' access to treatment. The question remained as to whether differences in service, at the level of the NHS Trust, might explain regional variation in outcome. In this issue of Thorax, they explore inequalities in outcomes and how these are influenced by clinical characteristics of the patients and the features of local cancer services. In the tables, they also show that survival (but not the proportion operated on) differs between various ethnic groups but do not comment further on this finding in the results or discussion sections. The authors conclude that there is an opportunity to increase access to thoracic surgeons for patients who present and are being cared for in non-surgical centres.2

Access to care should ideally not be dependent on where people live. There is no doubt that historically it has been and the authors quote evidence in support of the point from Scotland,3 where population density is low and thoracic units are geographically sparse. In the major cities of England whether patients are seen in a specialist thoracic centre is not determined solely by where they live. Selective routing of patients by general practitioners could contribute to the differences in utilisation of surgery reported. The authors have not presented an analysis by geography, although they refer to variation in outcome being anecdotally attributed to geographical differences …