Lung Cancer Leaves No One to Blame

Nonsmokers with disease face stigma, lack of research funding
Originally published by Susan Jenks in FloridaToday.com on February 7, 2011

A nonsmoker, Connie Brookshier of Cocoa never suspected her persistent cough might be caused by lung cancer.

Neither did Suzanne Davis, a former smoker who quit 18 years ago. The Titusville woman blamed her shortness of breath on being overweight rather than a tumor growing inside one of her lungs.

Each woman illustrates a growing trend, doctors say: a higher incidence of lung cancer among never-smokers, especially younger women, and, in former smokers of both sexes who, like Davis, quit many years ago.

Additionally, emerging evidence suggests lung cancer may develop differently in women and men, with women more susceptible to cancer-causing chemicals not only in tobacco -- still the dominant root cause of most of these cancers -- but also in the environment. For men and women, lung cancer remains the leading cancer killer in the United States, with 86,220 men and 71,080 women expected to die in 2010, according to the American Cancer Society's most recent data.

Despite such statistics, a report out of Harvard-affiliated Brigham & Women's Hospital early last year called lung cancer "the hidden women's cancer," little known, under-funded and rarely discussed. It also is "one of the only cancers where patients are routinely blamed as responsible for their condition."

According to the 27-page document, "Out of the Shadows: Women and Lung Cancer":

• Women who've never smoked are at higher risk for developing lung cancer than men who've never smoked.
• Women tend to develop lung cancer at younger ages than do men.
• Women are more likely to be diagnosed in early stages of this disease than are men.
• Women tend to respond slightly better to treatment than men once cancer has been diagnosed.

"So, 'Do you smoke?' should not be the entire sum of risk-factor analysis for lung cancer," said attorney Tracey Hyams, one of the report's co-authors and director of the hospital's women's health policy and advocacy program. "There are other relevant factors, such as whether someone is a former smoker or has been exposed to secondhand smoke."
Dana Reeve, for example, the wife of late actor Christopher Reeve and never a smoker, came from a family of physicians, she said. "Yet none of them ever thought of lung cancer" when she developed her only symptoms, a minor cough and intermittent shoulder pain. Reeve died at 44 just seven months after diagnosis.

"The perception of lung cancer as a woman's health issue is almost nonexistent," said Dana Reeve's sister, Dr. Deborah Morosini, an oncology pathologist with AstraZeneca in Boston.

Many women still fear breast cancer more than lung cancer, Morosini and others said, despite a better five-year survival rate -- 90.1 percent compared with 18.8 percent in lung cancer -- and significantly higher research funding per cancer death.

The National Lung Cancer Alliance estimates the three major federal agencies supporting medical research spend roughly $1,249 in research funding per lung cancer death compared with $27,480 per death for breast cancer research.

Although lung cancer rightly is labeled a smoker's disease, enough nonsmokers die from the disease to make it the sixth or seventh leading cancer killer in the country today, said Dr. Joan Schiller, president of the National Lung Cancer Partnership. And most in this group -- about 15 percent of lung cancers -- occur primarily in younger women who've never smoked.

The advocacy group is made up of physicians and patients' families from across the country, hoping to raise awareness about this disease. Schiller is deputy director at the University of Texas Southwestern Medical Center's comprehensive cancer center.

Nagging cough

In Brookshier's case, she developed a nagging cough, which her primary care physician treated unsuccessfully with antibiotics for four months, she said. Finally, her daughter Amanda insisted she get a chest X-ray, which showed a spot on her lungs. Further tests revealed inoperable cancer in both lungs and in her lymph nodes, clearly advanced disease.

"I definitely wasn't expecting it," the 53-year-old Brookshier said of her diagnosis. "And at the time, I really didn't understand what stage IV disease meant. I just thought it was the end."

Instead, after seven rounds of chemotherapy between February and August of 2009, Brookshier's cancer is confined to a pea-sized tumor in her right lung, which still is being treated at the Space Coast Cancer Center in Titusville.

"He mixed a good cocktail for me," she said, laughing, referring to the cancer drugs prescribed by the center's medical director, Dr. Richard Levine. Cautiously optimistic about her progress, she's had good support from family and friends, she said, including her daughter, "my event coordinator."

Hormones' role

In his practice, Levine said, he does see more nonsmokers like Brookshier with lung cancer, many of them diagnosed younger than in the past. But sex differences are not part of the decision tree for treatments at this time, he said, and "of no more importance than any other prognostic factor."

The University of Texas' Schiller suggested another theory. Women may metabolize carcinogens differently than men, breaking them down more slowly, she said, with resulting accumulations causing more damage and mutations in their lungs.

So far, at least two genetic mutations have been identified and well defined in lung cancer, with targeted or "smart drugs" beginning to take aim at these molecular changes, according to Dr. Giuseppe Giaconne, chief of the medical oncology branch at the National Cancer Institute.

The most compelling evidence for one molecular change in particular, he said, comes out of the Far East, where women don't smoke, but develop lung cancer anyway. Presumably, he said, that occurs because their husbands do smoke, exposing them to secondhand chemicals in tobacco.

In this population, the women develop abnormally high levels of a protein seen on the surface of lung cancers, which ultimately drives rapid cellular division, the hallmark of all cancer. Although the mutation also occurs in men, the strongest association is in nonsmoking women, Giaconne said, with guidelines for testing in both men and women now under development.

The other mutation is more subtle, he said, and the connection to gender less striking.

Still, "these are just the first molecular targets. We may soon test for many more," Giaconne said. "The technology is more accessible and research is moving forward pretty fast."

No blame

Davis said she smoked for roughly 30 years before quitting 18 years ago, although doctors told her the cancer was not related to her smoking history. As with so many other lung cancer patients, she had no early symptoms, except shortness of breath, which she attributed to being too heavy.

"I got diagnosed on a fluke," she said, describing a trip to her primary care physician for high blood pressure, "normal stuff." Because her breathing was so labored, the doctor recommended a chest X-ray, revealing a mass in her right lung.

Later tests showed the cancer had spread into the sac covering the heart, so it had to be rebuilt when surgeons removed three-quarters of her malignant lung in 2007. For two years, she was cancer-free, she said, before the disease returned in her trachea and the left lung.

This time, Davis, 64, said, she had chemotherapy, followed by stereotactic radiosurgery, a laser procedure that cuts out small tumors, without opening a patient up. After six months, "they told me it was gone again," she said. "It's 2-to-nothing and I'm winning."

Like Brookshier, Davis faces her disease with quiet courage and optimism. Blame, however, is something she fails to understand.

"Even if you did smoke, everybody smoked back then," she said. "Nobody deserves lung cancer; it's an evil disease."

Davis would get no argument from Reeve's sister.

"These patients deserve no less than any other cancer patient," Morosini said. "They need funding, compassion, a lack of stigma and a little better survival."

Additional Facts

Women and lung cancer

• Lung cancer kills more women than any other cancer.
• Despite a strong association with tobacco, lung cancer incidence is higher in non-smoking women than in non-smoking men. One in five women who develop the disease has never smoked, compared with one in 12 never-smoking men.
• Women appear more sensitive to cancer-causing chemicals in cigarettes and in the environment than men.
• Genetic markers and hormonal factors may influence the onset of lung cancers, particularly, in women
• Once diagnosed, women do better than men for reasons that are not yet clear. One theory is that women's cancers tend to be found earlier, with a higher proportion of women undergoing surgery than men.