Young Women, Never-Smokers, and Lung Cancer

Lisa Schulmeister, RN, MN, APRN-BC, OCN®, FAAN

Editor-in-Chief OncLive Nursing

Oncology Nursing Consultant, Adjunct Assistant Professor of Nursing Louisiana State Health Sciences Center in New Orleans, Louisiana

How can it be lung cancer? asked my neighbor. I don’t smoke. My 36-year-old neighbor added that she’s never smoked, and in fact, has never even taken a single puff of a cigarette.

The American Cancer Society estimates that of the 221,200 new cases of lung cancer which will be diagnosed in the United States this year, 105,590 are women,¹ and of these, 1 in 5 are women like my neighbor—“never-smokers”—those who have literally never lit up or who have smoked fewer than 100 cigarettes in their lifetime. Over the past decade, lung cancer among never-smokers has increased 33%, and if lung cancer in nonsmokers was its own category, it would rank among the ten deadliest cancers in the United States.

Only 15% of lung cancers are diagnosed at an early stage, and for many young women who are nonsmokers, like my neighbor, lung cancer symptoms often are initially attributed to something other than lung cancer. My neighbor had been treated with antibiotics for over a month for what her primary care physician thought was an upper respiratory tract infection.

She told me that when healthcare providers see the diagnosis of lung cancer in her medical record, they ask her if she’s still smoking. “I want to scream that I’ve never smoked!” she tells me. The American Cancer Society reports that people with lung cancer often are judged negatively—by both the public as well as some healthcare providers—because lung cancer is so strongly linked to smoking. Even people with lung cancer who have never smoked may be subjected to this stigma.

The causes of lung cancer among never-smokers are not fully understood. According to the US Environmental Protection Agency (EPA), the leading cause of lung cancer in people who have never smoked is exposure to radon gas. Radon occurs naturally outdoors in harmless amounts, but can become concentrated in houses built on soil with natural uranium deposits. The risk of lung cancer is higher for people who have lived for many years in a radon-contaminated house. Because radon gas cannot be seen or smelled, the only way to know if excessive radon levels are present is to test for it.

Both the EPA and the Surgeon General recommend testing all houses below the third floor for radon, and test kits are available online, at home improvement stores, and via the National Radon Program Services at Kansas State University (http://sosradon.org/). It’s thought that about 20,000 deaths per year are caused by radon-induced lung cancer.

Each year, an estimated 3400 nonsmokers die of lung cancer as a result of breathing secondhand smoke. For many nonsmokers, this exposure occurs in the workplace. Laws that ban smoking in public places are expected to reduce the prevalence of secondhand smoke, and will likely reduce the incidence of lung cancer caused by secondhand smoke. Other workplace-related causes of lung cancer include exposure to asbestos and diesel exhaust. Work-related exposure to these carcinogens has decreased in recent years as a result of increased governmental and industrial measures to protect workers. It’s also thought that both indoor and outdoor air pollution increase the risk of lung cancer among never-smokers.

Lung cancer among never-smokers is twice as common in women compared with men. Genetic mutations associated with non-small cell lung cancer in non-smokers (EGFR. ALK, and ROS1 mutations) are more common among women than men, and these mutations are associated with a more favorable prognosis and a better response to treatment with targeted agents.

My neighbor has been diagnosed with adenocarcinoma, the most common type of lung cancer found in young, nonsmoking women. By the time it was diagnosed, it had spread to her liver. The 5-year survival rate for metastatic lung cancer is a dismal 4%.

The average age of a lung cancer diagnosis is 70. Only 2%-3% are younger than age 40. Several studies are in the works to better determine how and why lung cancer occurs in young, nonsmoking women. My neighbor does not have single risk factor for lung cancer, and wonders why it happened to her. Her oncologist told her that we now know that anyone with lungs is at risk for lung cancer.

Reference

1. American Cancer Society. What are the key statistics about lung cancer? http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-key-statistics. Accessed September 23, 2015.