Lung Cancer: Not Just a Smoker's Disease: Although Lung Cancer Is Inextricably Linked to Smoking, about 25% of Lung Cancers Occur in Never-Smokers

By Sherry, Victoria | American Nurse Today, February 2017 | Go to article overview

Lung Cancer: Not Just a Smoker's Disease: Although Lung Cancer Is Inextricably Linked to Smoking, about 25% of Lung Cancers Occur in Never-Smokers


Sherry, Victoria, American Nurse Today


JILL SMITH, a 58-year-old wait ress in a local bar, comes to the clinic complaining of shortness of breath and a persistent cough for the last month. She reports she has lost 10 lbs recently, even though her eating habits (including a high meat intake and few green vegetables) haven't changed.

Mrs. Smith states that she doesn't smoke; she tried smoking one cigarette when she was 16. "That was enough for me," she says. "I couldn 't stop coughing. I don't get why people smoke. I was so glad my husband stopped smoking 6 months ago."

Based on a complete history and physical examination, the practitioner orders a chest X-ray, which reveals a lung mass. Mrs. Smith subsequently is diagnosed with lung cancer. "I don't understand it," she says. "I'm not a smoker. How can this be?"

Like Mrs. Smith's nurse, you might be surprised to encounter a patient who has lung cancer yet never smoked. Although lung cancer has long been considered a disease of smokers, rates have been rising in never-smokers. Worldwide, a surprising 25% of lung cancers occur in never-smokers, defined as people who've smoked fewer than 100 cigarettes in their lifetime.

According to the American Cancer Society, new cases of lung cancer in the United States during 2016 were estimated at 224,390; deaths from lung cancer numbered about 158,080, including about 56,000 deaths in never-smokers. Lung cancer in never-smokers (LCINS) is the seventh leading cause of cancer deaths in this country--enough to be considered a separate disease in itself. Epidemiologically, clinically, biologically, and psychosocially, LCINS differs from lung cancer in smokers.

The two main subgroups of lung cancer are non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC); the latter is rare in never-smokers. NSCLC has three primary histologic subtypes--squamous cell, adenocarcinoma, and large cell. Adenocarcinoma is the most common subtype in never-smokers.

Early-stage lung cancer carries a significantly lower mortality rate in never-smokers than in smokers. Unfortunately, most patients are diagnosed at an advanced stage; in never-smokers, the 5-year survival rate is a dismal 1%.

This article describes risk factors, assessment, and treatment of lung cancer in never-smokers; addresses the physical and psychosocial impact of the disease; and discusses the nurse's role in promoting positive outcomes, including lung cancer screening and patient education.

Risk factors

In never-smokers like Mrs. Smith, NSCLC incidence has increased steadily since 1990. One U.S. study found a twofold increase in NSCLC from 2001 to 2013; a United Kingdom study found lung cancer rates in never-smokers rose from 13% to 28% over a 6-year period.

Reasons for the increase remain speculative. Some experts believe that thanks to relentless education campaigns on the harmful effects of smoking, fewer Americans are smoking today, reflected in the all-time lowest smoking rates since 1965. Although more lung cancers seem to be occurring in never-smokers, scientists aren't sure if the LCINS rate is falsely elevated due to the sharp decline in smoking or if it's truly higher than before. Some experts propose that exposure to environmental tobacco smoke (ETS), radon, air pollution, diet, and genetic factors may contribute to higher lung cancer rates in never-smokers.

Environmental exposures

The link between ETS and lung cancer was established in 1981 when a large prospective study (n = 91,540) found that nonsmoking Japanese wives of heavy smokers had a higher risk of developing lung cancer than nonsmoking wives of nonsmoking men. Since then, dozens of studies have confirmed this connection. (See Environmental factors linked to lung cancer.)

Genetic alterations

Certain genetic mutations are much more common in never-smokers with lung cancer than in smokers with lung cancer. (See Genetic alterations in never-smokers. …

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