Dr. West, just read the transcript of your study on Never smokers with lung cancer. I am asian woman 44 just surgery with BAC removed. I never smoke in my life. During past 7 years, I spent 4-5 months in China. During last 4 years, I had been exposed to mode when I went back to my Shanghai apartment. That apartment was also under Airport zone. So now think back, I wonder whether those are all related ? I will be happy to give you more information if it helps your research. Kind regards, Lei

Lung cancer is distressingly common in never-smoking Asians, especially women, and many are relatively young. The underlying cause or causes of this remain unknown, but I suspect that it has more to do with genetic predisposition and potentially hormonal differences, rather than any clear environmental effects. We certainly see many Asian women in North America who develop lung cancer despite never-smoking.

An environmental cause hasn’t been identified yet, but at least now people are asking these kind of questions far more carefully than ever before.

-Dr. West

Thank you for reconsidering your position on never-smokers being different from smokers. Two years ago I wrote to you that I thought this was right and we needed to emphasize the danger to complacent non-smokers and also that they really had a stake in investing in lung cancer research and funding because they could be at risk for lung cancer. Your reply to me then was that you did not want to separate the two groups because then the smokers might be discriminated against. Glad you can change your mind, now lets change public perception.

I don’t feel that I’ve had a real reversal. I’ve felt that lung cancer in never-smokers is biologically different, but I think that there is a danger of an “us” and “them” mentality in which never-smokers and ever-smokers could be competing for attention, funding, advocacy.

Speaking biologically, these tumors behave differently, but I felt that way years ago as well. I think some of the issues are just semantic. It’s biologically different, but there is too little awareness, research funding, and public sympathy for the lung cancer in both never-smokers and ever-smokers.

-Dr. West

Hi Dr. West,
I seriously worry for the former and current smokers diagnosed with lung cancer if people decide that lung cancer in never smokers is a “different disease” as you suggest could happen.
What little progress is being made in trying to shift attention away from blame and stigma will be completely destroyed if lung cancer is separated in this way.
I think you know this. Unfairly, lung cancer has been branded with the smoking stigma. As you and I and everyone else in the lung cancer community knows, there are so many other diseases which are affected by smoking as well - but lung cancer bears the brunt.
I think it’s completely necessary to keep following leads that seem to show different results for never smokers and the rest of lung cancer patients. If something clearly helps never smokers and not former or current smokers, follow that lead!
But to say that it’s a “different disease” would not only be incorrect, it would divide a community that needs to be brought together, not torn apart, if we’re ever going to make progress in the public perception, funding and research dollars that go into lung cancer research.
Julia

Your points are very well taken. As you can see in the string of comments above, I also feel somewhat torn, but I would also like to distinguish between the biological behavior/treatment recommendations and the social implications.

Even if I do make a mental distinction between never-smokers and current or ex-smokers, I’d think of it in the same way as NSCLC and SCLC. They have different characteristics and treatment standards, but we don’t advocate for one group over or at the expense of another. Of course, I entirely agree that we don’t need divisiveness within the lung cancer community, and it pains me to think that recognizing distinctions in the biological behavior of different cancers would lead to differences in advocacy and research funding, or pit one group against another.

Finally, I’ll say that I think we are actually moving toward a greater understanding of the underlying biology as the driver, more than smoking status or histology (squamous vs. adeno, etc.). EGFR, K-RAS, the newly discovered EML4-ALK fusion protein, ERCC1, and other molecular variables are, in my opinion, likely to be the true driver of these differences. As I had written in a post I consider to be among the most important in my own mind, the evidence is beginning to support molecular factors trumping the clinical variables.

http://cancergrace.org/lung/2008/11/03/ipass-mutation-diffs/

I really don’t mean to step into a minefield or to make a political statement, but rather to address the finding that never-smoking status is a proxy, though an imperfect one, for different biology.

-Dr. West