“People need to know it’s not just a smoker that gets diagnosed with lung cancer,” says stage IV lung cancer survivor Stacy Foltz. And what she says holds truth: many people associate lung cancer with smoking, but it’s possible to develop lung cancer even if you’ve never smoked.
In fact, rates of lung cancer among non-smokers are on the rise, with one study showing that the incidence of the disease in “never-smokers” increased from 13 percent to 28 percent during a six-year period. Another study showed rates of lung cancer in never-smokers nearly doubled from 8.9 percent in 1990-1995 to 19.5 percent in 2011-2013.
“In general, the term ‘never-smoker’ refers to individuals who have smoked fewer than 100 cigarettes in their lifetime,” says Dr. Ashish Sangal, MD, medical director of the Lung Center at Cancer Treatment Centers of America® (CTCA) at Western Regional Medical Center in Goodyear, Arizona.
Worldwide, lung cancer in never-smokers accounts for 15 percent to 20 percent of cases in men and over 50 percent in women, Dr. Sangal says. But “there are major geographic differences, particularly in Asia, where 60 percent to 80 percent of women with the disease are never-smokers.”
Foltz, now age 47 and mother of three, had never smoked and also had no family history of lung cancer. She assumed her heavy cough early in 2016 was due to being worn out after caring for her ill mother-in-law. “I didn’t think anything of it. I’m prone to getting bronchitis every year. I went to the doctor and they treated me for bronchitis and I continued to cough,” she says.
What Are Lung Cancer Symptoms in Non-Smokers?
A cough that does not go away or gets worse, as in Foltz’s case, is a common symptom of lung cancer. In never-smokers, this symptom may not immediately trigger doctors to consider lung cancer as a diagnosis. Foltz was treated for both bronchitis and asthma (even though she doesn’t have the latter) over a period of five months before she received a diagnosis of stage IV non-small cell lung cancer (NSCLC). “It was a shocker,” she says. “It was a rare [epidermal growth factor receptor] EGFR cell that mutated.”
After undergoing three rounds of chemotherapy that caused many side effects that impacted her quality of life, Foltz switched her care to CTCA® at Midwestern Regional Medical Center in Zion, Illinois, where she received a different type of chemotherapy. When Foltz’s cancer did not respond to the chemotherapy, her medical oncologist recommended immunotherapy, which Foltz says was a game-changer in her cancer journey. Within two weeks, Foltz says, “My oxygen level was up. I was feeling better. I had been coughing from January through July nonstop. After two weeks of the treatment, it had subsided.”
Foltz has had some bumps in the road. A few months after starting the immunotherapy, her care team learned that the cancer had metastasized to her brain. Foltz had radiation to the brain, and then continued with immunotherapy. Additionally, when her cancer stopped responding to the immunotherapy after seven months, she began treatment with a new chemotherapy regimen recommended by her oncologist, a treatment she continues to receive. Today, Foltz says she is doing well with no side effects. According to Foltz and her oncologists, her scans look good.
For many patients, lung cancer symptoms do not occur until the disease is in the advanced stages or has spread to other parts of the body. That’s why it is so important to pay attention to your body. In addition to cough, symptoms may include:
- Chest pain that is often worse with deep breathing, coughing or laughing
- Persistent hoarseness
- Unexplained weight loss and loss of appetite
- Coughing up blood
- Unexplained shortness of breath
- Unexplained fatigue and weakness
- Bronchitis or pneumonia that doesn’t go away or recurs
- Pain and weakness in the shoulder, arm or hand
- Fever that comes and goes
- Severe headaches
- Body pain
Risk Factors Other Than Smoking
“The causative factors for lung cancer in never-smokers are not well understood,” Dr. Sangal says, however, gene mutations are involved in some cases. He says:
Researchers are learning more and more about what causes cells to become cancerous and how lung cancer cells differ between non-smokers and smokers. For example, an article published in Clinical Cancer Research explains that a particular kind of gene mutation is much more common in lung cancer in non-smokers than smokers.
This mutation activates a gene that normally helps cells grow and divide. The mutation causes the gene to be turned on constantly, so the lung cancer cells grow faster. Knowing which gene changes cause cancer cells to grow has helped researchers develop targeted therapies, drugs that specifically target these mutations.
Dr. Sangal also notes other risk factors for lung cancer that are considered to be most important among never-smokers, which include:
- Second-hand smoke
- Radon gas exposure, which can become concentrated in homes built on soil with natural uranium deposits
- Occupational exposures to toxins such as asbestos, chromium and arsenic
- Air pollution, both indoor and outdoor
- Prior damage to the lungs from underlying pulmonary disease or exposure to radiation or chemotherapy
- Family history of lung cancer
- Viruses; it’s possible that viruses such as the human papillomavirus (HPV) could play a role in lung cancer among never-smokers. Research is ongoing in this area
Should Non-Smokers Be Screened?
Currently, screening with low-dose chest CT screening (LDCT) is not routinely recommended for never-smokers but is recommended for current or former smokers who meet the following criteria:
- More than 30 years of tobacco smoking
- Age 55 to 74
- Quit smoking less than 15 years ago
There has, however, been an effort to identify patients at high risk of non-tobacco-smoking-related lung cancers, such as those with a family history of the disease or clear second-hand smoke exposure, Dr. Sangal says, with one study from Taiwan showing benefits in early detection with the use of LDCT. He encourages anyone who has concerns to speak with their primary care physician.
The Importance of Precision Medicine
There are important biologic differences at the molecular level between lung cancer cases in never-smokers and smokers. According to Dr. Sangal, “The best understood of these are the abnormalities in the epidermal growth factor receptor (EGFR) pathway. He notes:
These EGFR pathway abnormalities seen in never-smokers have been associated with a particular responsiveness to [certain medications like] erlotinib and gefitinib, agents that inhibit EGFR tyrosine kinase. The ALK fusion oncogene is another molecular variant in NSCLC that is seen more frequently in never-smokers and for which targeted therapy is now available.
In Foltz’s case, with EGFR mutation positive non-small-cell lung cancer, she reports having good quality of life with immunotherapy and certain chemotherapy treatments, stating, “I have my life back and I do everything I did before cancer.”
Steps to Lower Your Lung Cancer Risk
“It’s still true that staying away from tobacco is the most important thing any of us can do to lower our risk of getting lung cancer,” according to Dr. Sangal. “Non-smokers have already eliminated their greatest risk factor.”
Aside from not smoking, certain lifestyle changes may help reduce your risk even more, especially if you’re already a non-smoker. Dr. Sangal says:
Testing your home for radon, avoiding second-hand smoke, and limiting exposures at work can help avoid the leading causes of lung cancer in non-smokers. A healthy diet high in fruits and vegetables may also help reduce your risk of lung cancer.
If you or a loved one receives a lung cancer diagnosis, Foltz recommends having a good support system in place, including family, friends and your doctor. “Have a good support system and faith,” she says. “Find a doctor you trust and remember this is about you and ultimately you have the final say about your treatment.”