In the past, once lung cancer was diagnosed, it was a virtual death sentence. Today, the statistics on smoking and lung cancer are being recognized and re-addressed.

In 40 years, lung cancer’s prevalence and distribution among the sexes have changed. More women are developing lung tumors than ever before, the disease is still largely undiagnosed in its early stages, and women who smoke may be even more susceptible, according to Carolyn Dresler, MD, Director of Medical Affairs for Smoking Control at Smith Kline Beecham, Parsippany, NJ. Studies have directly linked smoking with lung tumors for decades, Dresler says, but statistics for women are beginning to be scrutinized because they are so alarming.

While lung cancer kills more men and women annually than breast, prostate, and colon cancers combined, lung cancer deaths for women increased almost 150 percent from 1974 to 1994, compared to a 20 percent increase for men. Few medical professionals and even fewer women are aware of the numbers. “For the last 11 years, lung cancer deaths among women have exceeded those of breast cancer,” Dresler says. “But about 60 percent of women think that breast cancer is the number one cancer killer among women.”

Awareness in the medical community has been absent, as have any good, recommended methods for early detection of lung tumors, according to Peggy McCarthy, executive director of the Alliance for Lung Cancer Advocacy, Support and Education (ALCASE), based in Vancouver, Wash. McCarthy started the organization to bridge a great gap in lung cancer advocacy and education not covered by the American Cancer Society and the American Lung Association as smoking and lung cancer continued to rise over the last 30 years. Both organizations do smoking cessation programs, McCarthy says, “but 170,000 people are diagnosed with lung cancer each year, and we’re doing nothing for these people. Millions more are living at risk.”

For years, lung cancer, once it was diagnosed, was a virtual death sentence, McCarthy says, and while the diagnosis was rare for men and women in 1950, the statistics today about smoking and lung cancer need to be recognized and readdressed. “We should be trying to screen anyone at risk for early detection,” McCarthy says. Dresler adds that medical knowledge about tumors tells us that survival rates dramatically increase if tumors are found in their early stages.

Only over the last decade has the medical community taken notice, McCarthy says, but still few dollars are spent on lung cancer, compared with research dollars that are poured into programs on breast, colon, and prostate cancer.

As a creator of medical education programs, McCarthy was first alerted to the misinformation among physicians while developing an educational videotape on small cell lung cancer in 1990. “We put in something about women, and a leading oncologist who was part of the video looked at the script and said, ‘This is a man’s disease.’ ” she says. ALCASE grew out of that encounter.

As part of the Lung Cancer Awareness Campaign, a collaborative awareness effort sponsored by ALCASE, Cancer Care Inc, the Cancer Research Foundation of America, and the National Coalition for Cancer Survivorship, Dresler and McCarthy hope to increase awareness of lung cancer’s growing prevalence, particularly among women (the campaign’s Web site is at “Not considering the diagnosis of lung cancer may have been justified in the 1950s,” McCarthy says, “but lung cancer killed 65,000 women in 1998.”

More Women Smoking
Clearest is lung cancer’s connection with smoking, which is directly linked to more than 85 percent of all lung cancer deaths. While rates of lung cancer among men still outnumber those among women, the fact is that more women are smoking today than 30 years ago, Dresler says. Since the Surgeon General’s 1964 report linking smoking with lung cancer, the total number of smokers in the United States has decreased, “but women have not been quitting in the same numbers as men,” she says. “For men, the numbers are going down quite significantly; for women, they are going down slowly.” Today the number of women and men who begin smoking is about equal.

So while ballooning statistics for women over the last 40 years have been ignored, more women have begun smoking over that time. With current numbers of new male and female smokers split equally and a lag phase of 20 to 30 years before tumors develop, Dresler says a potential wave of new female lung cancer victims is silently cresting unless early detection programs are instituted.

Women Possibly More Susceptible
The increase in lung cancer deaths among women is more disturbing because until recently, studies showed that female smokers smoked less and began smoking later in life than their male counterparts. “It’s been known for the past 15 years that women don’t smoke as much,” Dresler says.

What is puzzling is matching the numbers of new cases among women with the fact that women actually smoke less. “Women are more likely to get breast cancer than men for an obvious reason. But what’s going on with lung cancer?” Dresler asks. “Why should women have an apparent greater increase in susceptibility to lung cancer due to cigarette smoke than men?”

Research is focusing on gender differences in the manner in which cigarette smoke carcinogens are metabolized, and in the potential susceptibility of female smokers to develop lung tumors.

“Women tended to have a greater susceptibility to small cell carcinoma,” Dresler says; it accounts for about 20 percent to 30 percent of all lung cancers. The remaining 70 percent of lung cancers are non-small cell, a category divided into subsets: squamous cell carcinoma, adenocarcinoma, large cell carcinoma, undifferentiated carcinoma, and a list of more obscure types. The distinction between small and non-small cell tumors is generally in their treatment regimens. “Small cell tumors usually require chemotherapy and radiation, while non-small cell tumors require surgery in their early stages and chemotherapy in their late stages,” Dresler says.

The types of lung tumors presenting in men and women are changing, however. “Researchers recently noticed that women tend to have more adenocarcinomas than men,” she says. “Since men got more squamous cell carcinoma and more men were getting lung cancer, it looked like the most frequent cancer was squamous cell carcinoma.”

But if the numbers for women were broken out, Dresler says, “[the most prevalent type has] always been adenocarcinoma for women by a significant percentage. Now for a variety of reasons, men tend to be getting more adenocarcinomas–it’s about fifty-fifty for squamous cell versus adenocarcinoma for men.” That, paired with the numbers for women, is making adenocarcinoma the most frequent lung cancer.

Researchers are analyzing lung tissue and sputum to find some biological marker for the development of lung tumors. The hope, Dresler says, is to identify early genetic changes as a precursor to lung cancer and hopefully a genetic identifier of high-risk people. “How can we identify those people who are at risk for lung cancer?” she asks.

Cessation and Detection
More efforts are being made to get people to stop smoking and to examine why women and men begin smoking, which encompass social, physiological, and even gender and race distinctions. Most significant, Dresler says, is the marketing of tobacco specifically to women and to young people in general. “When you ask teenage boys or girls, they say they’re going to smoke for only 4 or 5 years,” Dresler says. “They don’t get that nicotine is a very addictive drug–right up there with crack as one of the most addictive drugs.”

Smoking cessation is important, McCarthy says, but still not enough. Physicians are relying on old studies, recommendations, and guidelines rather than finding a better way of detecting tumors early. “Twenty or 30 years ago, the technology wasn’t as good as it is today,” she says.

Helical CT scans can provide a single enhanced chest radiograph that can detect a tumor 5 years before old, conventional chest radiographs could, according to McCarthy. “They have worked out a method at Cornell where you can essentially do a single helical CT screening scan of the patient and the cost can be kept under $100,” she says. Essentially, helical CT equipment could be set up like mammography equipment to conduct quick, less costly, and more complete diagnostic screens of high-risk individuals.

For now, McCarthy says, little is being done in research or early detection because few dollars are being allocated to lung cancer. Moreover, outdated guidelines are preventing early detection. “The symptom that the American Cancer Society has always listed for lung cancer is a bloody cough,” McCarthy says, this symptom develops in the disease’s later stages. Because lung cancer’s symptoms–increased cough and sputum discharge, back pain, and shortness of breath–overlap other physiological causes, lung cancer goes largely undiagnosed. “Early studies stated that annual chest radiography did not increase survival rates for lung cancer diagnosis,” Dresler says. “Those studies have been more recently challenged.”

“Up through the 1970s, a chest x-ray was part of an annual exam,” McCarthy adds. “Then in 1981, the American Cancer Society made a statement based on old studies, which were not designed to show what was a good screening mechanism for lung cancer. The recommendation was that chest x-rays were not a good screening method.” Since that time, fewer people are being screened, she says.

Reinstating annual chest radiography for early detection of tumors, especially for higher risk people, would be the best solution, McCarthy says, adding, “All the health plans are very worried about anybody instituting anything for lung cancer, because it will be costly.”

However, with new technologies, more research, and a consensus about lung cancer diagnosis, there is a greater opportunity to change the lung cancer trend. Sadly, the disease has been a death sentence because of misdiagnosis and few methods of successful treatment. “Until this decade, there haven’t been many good cures for lung cancer; there still aren’t very many good cures,” McCarthy says, “particularly if you have late-stage lung cancer.”

ALCASE is filling the gap from both the physician and patient ends. While it sponsored a 2-day international physicians’ meeting in Italy to examine reasons why lung cancer is being misdiagnosed, the organization is also working to educate individuals with diagnoses of lung cancer and those at risk. The hope, McCarthy says, is that patients will demand screenings if they are more high-risk. “It’s just going to have to be between the patient and physician,” she says.

Bill McGovern is a contributing writer for RT.