Never-Smokers Get Lung Cancer, Too

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Every year, roughly 230,000 people are diagnosed with lung cancer, making it the second most common cancer in men and women, according to the National Cancer Institute. While that seems high, the number of people diagnosed with the disease has been declining over the last 10 years. The exception: The rate of lung cancer found in never-smokers—adults who’ve smoked fewer than 100 cigarettes in their lifetime—has increased.

“We've seen a bump in these patients over the past couple of years,” says Benjamin P. Levy, M.D., a thoracic medical oncologist and clinical director of medical oncology at Johns Hopkins Sidney Kimmel Cancer Center in Washington, D.C. Lung cancer in never-smokers now accounts for 15% to 20% of all cases, he adds. And while no one knows for sure why there’s been an uptick, researchers have identified some possible links and special considerations to be aware of if you or a family member has been diagnosed.


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You May Have Been Exposed to Second-Hand Smoke

When you live or work with a smoker, you inhale the same toxic chemicals that are known to produce cellular changes in the lungs, increasing your risk as much as 20% to 30%, according to the Centers for Disease Control and Prevention. And it’s not just lung cancer. Korean researchers found a significant risk for developing any type of cancer, including breast (by about a quarter), with exposure to second-hand smoke.

Exposure is a matter of degree, says Jacob Sands, M.D., a physician at the Thoracic (Lung) Cancer Treatment Center at Dana-Farber Cancer Institute in Boston. An occasional whiff of a cigarette probably didn’t harm you. But if you live in a state that hasn’t banned smoking in public places (Indiana, Kentucky, Mississippi, South Carolina, Texas, West Virginia, and Wyoming), your exposure may have been the tipping point.


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Your House Had—or Has—a Radon Gas Leak

Radon gas, the radioactive gas naturally released into the air by rocks and soil, is another known risk factor for lung cancer. Radon is everywhere, but it becomes a problem when it seeps into your house (via cracks in the foundation) and collects there. Breathing in the radioactive particles damages the cells in your lungs.

In never-smokers, radon gas is responsible for roughly 2,000 to 3,000 cases of lung cancer a year, according to research. If you’re concerned, buy a radon testing kit from the hardware store and make sure the concentration levels in your home aren’t over 4 pCi/L. If they are, hire a contractor to address the issue.


Your Symptoms May Be Different From a Smoker's Lung Cancer

In general, never-smokers tend not to display the usual signs of lung cancer—the persistent cough or wheeze, shortness of breath, and coughing up blood. Because never-smokers are usually healthier (and have better lung capacity), they often come to the doctor for symptoms that have nothing to do with their lungs, like bone pain or severe headaches, symptoms that are really signs that their cancer has spread to other parts of their body, says Dr. Levy. While this is scary to hear, keep in mind that this is true for the majority of lung cancer patients. It's a disease that can be frustratingly hard to catch early.


Computed Tomography (CT) of the chest
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You Were Never Screened for Lung Cancer

One reason that lung cancer tends to be advanced when it’s caught is that fewer than 5% of current and former smokers—the people most at risk and whose insurance generally pays for testing—get screened, says Dr. Sands. “Seventy to 80 percent of patients whose non-small cell lung cancer is discovered through screening have a Stage I or II diagnosis. So that’s a very curable disease at that point,” he notes.

Screenings are recommended by US Preventative Task Force for current smokers and former smokers who quit less than 15 years ago. “There is no evidence for doing lung cancer screening with CT scans among never-smokers,” says Dr. Sands. However, there is a lot of research happening in this space, and Dr. Sands anticipates the screening criteria to significantly change over the coming years, and it may become an option for never-smokers.


Micrograph of small cell lung cancer
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Your Cancer's Sub-type Tends to Be Different

Many never-smokers get the most common type of cancer across the board, which is non-small cell adenocarcinoma lung cancer. Very rarely, do never-smokers get small cell or squamous cell cancer (more common in smokers). The reason may lie in the amount of toxins a never-smoker has been exposed to. “Squamous cell and small cell lung cancers tend to have more mutations,” Dr. Sands explains.

It is much more unlikely to get these cancers without significant toxin exposure that causes greater stress to the cell and DNA, leading to mistakes and mutations in the DNA. If you don’t know already, ask your oncologist what your subtype is, recommends Dr. Sands. Knowing that will determine your treatment options and help your provider figure out if you’re a candidate for targeted therapy or a clinical trial.


ALK positive lung adenocarcinoma

Your Tumor Has Distinct Markers

“Sometimes, lung cancer in a never-smoker behaves differently than in a smoker and has a different genetic makeup,” says Dr. Levy. These ddifferences don’t correspond to genes you’re born with—they're variants that occur in the tumor’s cells and can be identified during a biopsy.

So far, scientists have identified several of these genetic markers, which include EFGR, ALK, ROS-1, where the DNA changes are simpler. In many of the EFGR mutations, for example, the mutation occurs just in the affected cells, not in the noncancerous ones, making it easier to target with treatments.


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Your Treatment Will Probably Come in a Pill

Because never-smokers tend to have the DNA mutations mentioned in the previous slide, which are genetically simpler than a smoker’s cancer, they're better candidates for targeted treatment instead of standard chemo or immunotherapy, says Dr. Sands. Usually, these drugs are quite effective at shrinking tumors or stopping cells from dividing. Many times, too, the side effects aren’t quite as severe.


You're More Than Likely a Woman

Those with lung cancer in the USA and Europe, 20% of women are never-smokers; among men, 2 to 6 percent are never-smokers, according to researchers at Massachusetts General Hospital and Harvard University. In Asia, the numbers are even higher: Between 60% to 80% of never-smokers are women, compared to 10% to 15% of men. Unfortunately, no one really has a reason for this discrepancy, though possible explanations range from genetic differences to hormones.


You Have Your Own Emotional Hurdles to Overcome

Many smokers suffer from stigma and guilt, since many folks mistakenly believe they brought their cancer on themselves. But people who’ve never smoked also are emotionally blindsided when they receive their diagnosis.

“They undergo a significantly different psychological challenge because they're like, ‘I’m healthy. I never smoked. How is this possible?’,” says Dr. Levy. “I tell patients that this is not uncommon, that a fifth of all lung cancer is never-smokers. I think that it's important for them to know that.”


You have specialized support out there.

If you’re looking for support, you can find advocacy groups that are geared to never-smokers or even based on the specific mutation you have, says Dr. Levy. A good starting point is the LUNGevity Foundation, an organization dedicated to funding scientific research in early detection and therapeutics.