“Do you smoke?”
That’s the question Meryl Bralower, a lifelong nonsmoker, was almost invariably asked after she told people she’d been diagnosed with stage 2A lung cancer. “You know why they asked me that?” says the 63-year-old Boston activist, who has been symptom-free since 2006. “Cause these nonsmokers wanted to put themselves in a category that’s safe.”
But the truth is that nonsmokers are not at all immune to lung cancer, a deadly disease with an estimated five-year survival rate of only 16 percent. And for reasons that are not at all clear, women nonsmokers are at far greater risk than their male counterparts: About one in five American women diagnosed with lung cancer has never lit up, compared to one in 12 men, says Uniting Against Lung Cancer, an advocacy and research group.
Still, the smoking-lung cancer connection remains strong in most people’s minds. “There is the perception that lung cancer is a self-inflicted disease. But the vast majority of patients we see today have managed to quit smoking. And it’s wrong to think that anyone—a smoker or nonsmoker—deserves to get cancer. We need a different mindset,” says Pasi A. Jänne, MD, PhD, associate professor of medicine at Harvard Medical School.
The stigma surrounding lung cancer may partially explain why this disease receives comparatively little funding for research. For instance, even though lung cancer kills twice as many women each year as breast cancer, nine times more dollars are devoted to research on the breast disease than to studies on lung cancer, notes Christina Baik, MD, MPH, staff scientist at the Fred Hutchinson Cancer Research Center in Seattle. Looked at another way, in 2011, the National Institutes of Health spent an estimated $19,089 on research per each breast cancer death versus $1421 per lung cancer death.“Breast cancer has had wonderful advocates, but there are not many with lung cancer,” Baik says. (Pfizer Oncology, the drug company, has recently teamed up with six lung cancer advocacy groups to produce a campaign, Lung Cancer Profiles, that is intended to raise awareness about the diversity of people who suffer from the disease.)
Recent advances in treatments mean that the prognosis of a lung cancer patient—especially one who has never smoked or who smoked for just a short period of time—has become far rosier. “In the last few years, we’ve put a great emphasis on the biology of the disease. We are much more focused on finding genetic mutations in the cancer cells that drugs can work against,” says Jänne. Much of the research relates to adenocarcinoma, a type of non-small cell cancer that is the most common form of lung cancer among smokers (accounting for 40 percent of cases in women) as well as nonsmokers (80 percent of cases in women), according to the College of American Pathologists.
Never-smokers and former light smokers with this form of lung cancer are especially likely to have specific mutations in a protein called epidermal growth factor receptor (EGFR), which tells cells to divide. The drug erlotinib (Tarceva) has been shown to inhibit EGFR and thus cancer cell growth in a majority of nonsmokers with advanced lung cancer. A similar drug, crizotinib (Xalkori), targets a much less common gene, ALK (abnormal anaplastic lymphoma kinase), that also causes cancer cell growth. This medication, too, tends to work best in never-smokers and former light smokers. “What’s going to change is that we’re no longer going to be talking about lung adenocarcinoma,” says Jänne. “We’re going to subdivide it into different diseases based on genetics.”