Abstract Background Pneumonectomy in lung cancer treatment is associated with considerable morbidity and mortality. Its use is reserved only for patients in whom a complete oncological resection by (sleeve) lobectomy is not possible. It is unclear whether a patients’ risk of receiving a pneumonectomy is equally distributed. This study examined between‐hospital variation of pneumonectomy use for primary lung cancer in the Netherlands. Methods Data from the Dutch Lung Cancer Audit for Surgery from 2012 to 2016 were used to study the use of pneumonectomy for primary lung cancer in the Netherlands. Using multivariable logistic regression, factors associated with pneumonectomy use were identified and the expected number of pneumonectomies per hospital was determined. Subsequently, the observed/expected ratio ( O / E ratio) per hospital was calculated to study between‐hospital differences. Results Of the 8446 included patients, 659 (7.8%) underwent a pneumonectomy with a mean postoperative mortality of 7.1% ( n = 47). Factors associated with receiving a pneumonectomy were age, gender, cardiac and pulmonary comorbidities, tumor side, size and histopathology. The pneumonectomy use in the Netherlands varied considerably between hospitals (IQR 5.5–10.1%). Three hospitals out of 51 performed significantly less pneumonectomies than expected ( O / E ratio < 0.5) and three significantly more ( O / E ratio > 1.7). In the latter group, severe complications were more frequent, taking other influencing factors into account (OR 1.51, 95% CI 1.05–2.19). Conclusions There is a considerable between‐hospital variation in pneumonectomy use in lung cancer treatment. To further optimize surgical lung cancer care, we suggest center‐specific feedback on pneumonectomy use and the development of a risk‐adjusted pneumonectomy indicator.