Category Archives: Lung Cancer

Alcohol and Cancer

Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

The link between and alcohol and cancer may surprise you. A 2017 statement by the American Society of Clinical Oncology (ASCO) reports that drinking alcohol increases the risk of cancer of the mouth and throat, vocal cords, esophagus, liver, breast, and colon. The risks are greatest in those with heavy and long-term alcohol use. Even so, moderate drinking can add up over a lifetime, which could be harmful.[1]

What is Moderate Drinking? Heavy Drinking?

According to the National institute of Alcohol Abuse and Alcoholism (NIAAA), “moderate” drinking is 1 drink per day for women and 2 drinks per day for men, but not all “drinks” are equal. A drink is defined as approximately 14g of alcohol, which equals: 1.5 ounces of distilled spirits (e.g., vodka, gin, tequila, etc), 5 ounces of wine, 12 ounces of beer, and 8 ounces of malt liquor.[1,2] (Click here to see the CDC’s fact sheet.)

Heavy drinking is defined as 8 or more drinks per week OR 3 or more drinks per day for women and 15 or more drinks per week OR 4 or more drink per day for men. Most adults who engage in high-risk drinking started as teens.[1] (Click here to see our article on teen drinking.)

Drinking Amount and Cancer Risk

According to the International Agency for Research on Cancer (IARC), a branch of the World Health Organization (WHO), alcohol is a “group 1 carcinogen.” That means it can cause cancer in humans. Group 1 carcinogens include cigarette smoke, UV solar radiation, radon, and asbestos, for example.[3] Alcohol is known to cause six types of cancer, including cancer of the mouth and throat, vocal cords, esophagus (squamous cell), liver, female breast, and colon/rectum. Alcohol may also be tied to cancer of the pancreas, stomach, and lung, but more research is needed to find out for certain.[4] (Click here to see the National Cancer Institute’s Fact Sheet.)

Some of these cancers, such as mouth and throat cancer, are rare (about 1% lifetime risk), while colon cancer and breast cancer are much more common. [7] Depending on the amount a person drinks, he or she can increase the risk for even rare cancers. For example, moderate drinkers can almost double their lifetime risk of mouth and throat cancer to almost 2%, while heavy drinkers have a 500% increased risk of having mouth or throat cancer, from 1% to 5%.

Scientists believe that when alcohol comes into direct contact with tissue through drinking and swallowing, it causes more damage. For example, in the heaviest drinkers, alcohol raises the lifetime risk of esophagus cancer from about 0.5% to about 2.5%.[1,7]

Women need to be more cautious when drinking any amount of alcohol. The World Cancer Research Fund estimates that for every additional average drink per day, breast cancer risk goes up by 5% pre-menopause and up by 9% after menopause. Alcohol affects the amounts of certain sex hormones circulating in the body. For women who have had hormone receptor-positive breast cancer, 7 or more weekly drinks increased the chances of having a new cancer diagnosed in the other breast from about 5% to about 10%.[1]

How Alcohol Causes Cancer

Scientists believe that alcohol causes cancer in several ways:[1, 4]

  • Alcohol (ethanol) is broken down into a toxic substance called acetaldehyde. Acetaldehyde is directly toxic to the body’s cells.
  • Alcohol causes damage to cells through a process called free-radical oxidation.
  • Alcohol causes the body to absorb less folate (an important B vitamin) and other nutrients (antioxidant vitamins A, C, and E), which naturally repair damage and fight off cancers.
  • Alcohol increases the body’s level of estrogen (a sex hormone associated with breast cancer).

Does Quitting Change Your Chances of Developing Cancer or Cancer Recurrence?

Yes, drinking less alcohol on a regular basis reduces cancer risk, even in people who were already diagnosed with cancer. Research has shown that heavy or moderate drinkers who substantially reduce their alcohol consumption will slowly reduce their risk of developing mouth, throat, vocal cord, and esophagus cancer, but it would take 20 years of abstention to reduce the chances of developing those cancers to the lower chances of someone who never drank so frequently.  It is not clear whether reducing or giving up drinking after years of moderate or heavy drinking will have much impact for other alcohol-related cancers.[1]

In those who survived an esophagus cancer, drinkers tripled their risk for a new primary cancer diagnosis. On average, the risk of a new cancer diagnosis after esophagus cancer is removed is 8 % to 27%, and continuing heavy drinking will triple that risk.[5]

Among all cancer survivors, heavy drinking caused an 8% increased risk in dying and a 17% increased risk of cancer recurrence. Patients with cancer who abuse alcohol do worse because alcohol causes poorer nutrition, a suppressed immune system, and a weaker heart.[1]

What You Can Do to Lower Cancer Risk for You and Your Family

  1. . If you drink alcohol, limit drinks to an average of 1 a day for women and 2 a day for men.
  2. Recognize heavy drinking in a loved one, because the more a person drinks, the greater his or her chances of developing cancer. The “CAGE” questionnaire can help spot heavy drinking. Has the person tried to Cut back? Has the person been Annoyed when asked about drinking? Has the person felt bad or Guilty? Has the person needed a drink first thing in the morning (Eye opener)? Each “yes” counts as 1 point. A score of 2 or more suggests problem drinking.[6]
  3. Talk with your doctor about your risk. Doctors can refer or offer counseling and treatment services to patients with risky drinking habits.
  4. Seek help early. Problem drinking can’t be wished away. There are many resources to access information and help. The Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the U.S. Department of Health and Human Services (HHS) has a toll free hot-line and website. Call 1-800-662-HELP (4357) or visit https://findtreatment.samhsa.gov/  today.
  5. Practice healthy habits. Eating a diet rich in cancer-fighting nutrients (i.e., fruits and vegetables), exercising, maintaining a healthy weight, reducing stress, and getting restful sleep can all help to lower cancer risk. Don’t smoke, and quit if you do. Drinking and smoking increases cancer risk more than either one alone.

The Bottom Line

To prevent cancer, try to limit your drinking by sticking to a maximum average of 1 a day if you’re a woman and 2 a day if you’re a man.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

Footnotes:

  1. LoConte, NK. et al. Alcohol and Cancer: A Statement of the American Society of Clinical Oncology. Journal of Clinical Oncology. published online before print November 7, 2017. DOI: 10.1200/JCO.2017.76.1155. Available online: http://ascopubs.org/doi/full/10.1200/JCO.2017.76.1155
  2. Centers for Disease Control and Prevention. Alcohol and Public Health. Fact Sheets- Moderate Drinking. Accessed November 16, 2017. Available online: https://www.cdc.gov/alcohol/fact-sheets/moderate-drinking.htm

 

The Unknown Health Risks of Air Pollution

Hannah Kalvin and Alex Pew, Cancer Prevention & Treatment Fund

Air pollution is a hot topic in the media. Here is what you need to know about the causes of air pollution and how it can increase the risk of cancer and other serious diseases in adults and children.

Types of Air Pollution and the Impact on Your Health

The Environmental Protection Agency (EPA) has classified six air pollutants that are the most common and the most dangerous. They are:[1]Air pollution

  • Ozone
  • Particulate Matter
  • Carbon Monoxide
  • Nitrogen Oxides
  • Sulfur Dioxides
  • Lead

Each of these can cause breathing problems and can increase asthma symptoms. Children, the elderly, and people with asthma are the most likely to be harmed by air pollutants.

Ozone is commonly known as the layer of gas that protects the Earth from UV rays. However, only ozone in the atmosphere has this protective effect. Ozone located on the ground level is a health hazard. Ground level ozone is the result of industrial plants, electric utilities, motor vehicle exhaust, gasoline vapors, and chemical solvents. Each of these causes the release of invisible molecules that react with each other and create ozone on the ground level when it is warm and sunny outside.[2] Inhaling ozone can cause chest pain, coughing, throat irritation, and congestion. If someone has bronchitis, emphysema, or asthma, ground level ozone makes it even more difficult to breathe. Eventually, repeated exposure to ground level ozone can scar the lungs.[3]

Particulate Matter is made up of very small particles and liquid droplets. They can be acids, organic chemicals, metals, soil, or dust particles. Particulate matter forms when gasses from power plants, industries, and/or automobiles react in the air. This form of air pollution is found near roads, in smoke, in haze, and in forest fires. When these particles are 10 micrometers or less in diameter, they are small enough to go through the nose or throat, resulting in major health problems.[4] When inhaled, particulate matter can cause serious lung damage, since the particles are small enough to go deep into the lungs. Particulate matter can cause premature death in people with heart or lung disease. Particulate matter has also been linked to nonfatal heart attacks, irregular heartbeat, and difficulty breathing. While individuals who already have health problems are more likely to be harmed by particulate matter, healthy people can be injured by these small particles as well.[5]

Carbon Monoxide is a gas that you cannot see or smell. It is released into the air by motor vehicles, so it is more likely in cities where there are many motor vehicles.[6] Carbon Monoxide is harmful when inhaled because it results in blood not being able to carry as much oxygen. Since we need oxygen to live, carbon monoxide pollution can be harmful to anyone, but it is most harmful for people with already low oxygen levels.[7]

Nitrogen Oxides are another type of air pollutant, also from emissions from cars, trucks, buses, power plants, and off-road equipment.[8] Nitrogen oxide can cause inflammation of the airways in healthy people, breathing problems in people who have asthma or other lung problems, and worsen existing heart disease. Anyone who lives within 300 feet of a major highway, railroad, or airport, will be exposed to higher levels of Nitrogen Oxides. Unfortunately, that includes about 16% of housing in the United States.[9]

Sulfur Dioxides are gases created from the burning of fossil fuels at power plants and industrial facilities. They also result from burning fuels containing high levels of sulfur, by locomotives, large ships, non-road equipment, and other industrial processes.[10] They cause breathing problems and increase other asthma symptoms.[11]

Lead is also considered to be a type of air pollutant. Lead used to be released into the air from gasoline, but while laws currently prevent lead from being in gasoline, lead from past pollution is still commonly found in dirt, especially in urban areas.[12] Lead is especially dangerous for children, and can cause behavioral problems, lower IQ, and learning problems. In adults, lead exposure is linked to high blood pressure and heart disease.[13]

Often, smog is mentioned as a sign of air pollution. While it is an obvious sign of air pollution, most smog is invisible to the human eye.

Recent Findings

In 2015, researchers used mathematical models to find out how many deaths were caused by air pollution in 2010. They concluded that particulate matter air pollution caused adults to die earlier from chronic obstructive pulmonary disease (COPD), heart disease, and lung cancer, and for infants to die from acute lower respiratory illnesses (such as pneumonia, bronchitis, or flu). They estimated that 3.3 million deaths in 2010 were a result of particulate matter air pollution. If nothing is done to reduce particulate matter air pollution, the authors anticipated that in 2050 6.6 million people will die earlier as a result of air pollution. The authors found that “residential and commercial energy use” contributed most to the amount of deaths worldwide from particulate matter air pollution in 2010. However, the major contributors to particulate matter air pollution in the United States are emissions from vehicles and power generation.[14] This is the first study to calculate the number of deaths caused by a type of air pollution.

A different study published in late 2015 concluded that airborne coal particles result in more fatal heart attacks than other particles in the air.[15]

In 2017, a Harvard study that looked at 22 million deaths in the U.S. found that people 65 and older are more likely to die on days when air quality is poor. This means that even short-term exposure to air pollution can be dangerous as we get older. The EPA’s Clean Air Act Amendments have decreased the levels of pollutants in the air, which experts estimate has saved at least 30,000 lives in the U.S. Keeping and improving these amendments could save more lives and improve air quality even more.[16,17]

The Bottom Line

Air pollution will continue to harm adults and children unless drastic changes are made. While some air pollution is visible to the human eye, most cannot be seen. You can use a website or an app to monitor air quality, in order to reduce your exposure to all types of air pollution. Below are some websites and apps for monitoring air quality. On days when the air quality index is bad, it is best to avoid the risks and stay indoors. While pollution is risky for everyone, children, elderly, and people with heart or lung problems need to be especially careful.

If you would like to learn more about how you can reduce air pollution, click here.

Air Quality Index Websites

http://www.airnow.gov/

http://aqicn.org/map/world/

Air Quality Index Apps

EPA AIRNow

Global Air Quality Monitoring & Forecast

Air Bubbles: Air Quality in Real Time

Global Air Quality – Real Time Air Pollution Indices

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.

References

  1. What Are the Six Common Air Pollutants? (2015, September 18). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/urbanair/
  2. Ground Level Ozone | US Environmental Protection Agency. (2015, October 1). Retrieved December 4, 2015, from http://www3.epa.gov/ozonepollution/
  3. Health Effects- Ozone Pollution. (2015, October 1). Retrieved December 4, 2015, from http://www3.epa.gov/ozonepollution/health.html
  4. Particulate Matter | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/pm/
  5. Health Effects- Particulate Matter. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/pm/health.html
  6. Carbon Monoxide | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/carbonmonoxide/
  7. Health Effects- Carbon Monoxide. (2015, September 10). Retrieved December 4, 2015, from l http://www3.epa.gov/airquality/carbonmonoxide/health.html
  8. Nitrogen Oxides | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/nitrogenoxides/
  9. Health Effects- Nitrogen Oxides. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/nitrogenoxides/health.html
  10. Sulfur Dioxide | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/sulfurdioxide/
  11. Health Effects- Sulfur Dioxide. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/sulfurdioxide/health.html
  12. Lead | US Environmental Protection Agency. (2015, September 10). Retrieved December 4, 2015 from http://www3.epa.gov/airquality/lead/
  13. Health Effects- Lead. (2015, September 10). Retrieved December 4, 2015, from http://www3.epa.gov/airquality/lead/health.html
  14. Lelieveld, J., Evans, J., Fnais, M., Giannadaki, D., & Pozzer, A. (2015). The contribution of outdoor air pollution sources to premature mortality on a global scale. Nature, 367-371. Retrieved December 4, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/26381985
  15. Thurston, G., Burnett, R., & Turner, M. (2015). Ischemic Heart Disease Mortality and Long-Term Exposure to Source-Related Components of U.S. Fine Particle Air Pollution. Environ Health Perspect. doi:DOI:10.1289/ehp.1509777
  16. Di, Q., Dai, L., Wang, Y., et al. (2017). Association of Short-Term Exposure to Air Pollution with Mortality in Older Adults. JAMA. 318(24): 2446-2456. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/2667069?redirect=true. Accessed on January 5, 2018.
  17. Ridley, D., Heald, C., Ridley, K., and Kroll, J. (2017). Causes and Consequences of Decreasing Atmospheric Organic Aerosol in the United States. PNAS. doi.org/10.1073/pnas.1700387115. Retrieved from http://www.pnas.org/content/early/2017/12/18/1700387115. Accessed on January 5, 2018.

Third-hand smoke

Noy Birger and Celeste Chen, Cancer Prevention & Treatment Fund

You know that smoking and being exposed to other people’s cigarette smoke (second-hand smoke) is dangerous, but did you know that residue from cigarette smoke, which remains on just about every surface exposed to that smoke, is also harmful? This is called third-hand smoke.

Third-hand smoke or smoke residue clings to hair and fabrics, including clothing, carpets, drapes, and furniture upholstery.[1]  The residue reacts with other chemicals and materials in the air, combining to form substances that cause cancer.[2] This toxic mix is then breathed in or absorbed through the skin.

One particular chemical found in third-hand smoke, NNA, has been scrutinized because it can directly interact with and damage DNA, possibly paving the way for cancer to grow. Researchers believe that NNA behaves similarly to a byproduct of nicotine called NNK, which has long been known to cause cancer.

In a 2014 study, researchers confirmed that NNA not only breaks up DNA just like NNK does, but also attaches itself to DNA. By breaking up and attaching to DNA, NNA is able to produce cells that grow when they shouldn’t, creating tumors and causing damaging genetic mutations.[3]

Third-Hand Smoke Is Sneaky

Many public buildings ban indoor smoking, and the majority of people who smoke are aware of the health risks–to them and everyone around them–and therefore confine their smoking to outdoors, away from children and non-smokers. But even after the cigarette has been put out, you can carry dangerous nicotine residue back inside on your hair and clothes, and consequently put others at risk of developing cancer.[1]

Children are particularly vulnerable. Like adults, they can absorb the tar and nicotine leftovers through their skin. The effect on children is greater because they are smaller and still developing. Also, children are more likely to put their residue-covered hands on their nose or in their mouth.[4] Chemicals such as NNA that are produced when smoke residue mixes with chemicals in the air can cause developmental delays in children.[1] Parents should know that if they smoke in the car, their children can absorb the cancer-causing chemicals from the car upholstery, even if the children weren’t inside the car when the parent was smoking

Third-hand smoke is a new health concern.  While we know that the residue combines with the air and other pollutants, like car exhaust fumes, to make a cancer-causing substance, we don’t yet know for certain that it causes cancer in humans and if so, how much exposure is dangerous.[5] Figuring out the answer will be challenging, because most people exposed to third-hand smoke are also exposed to second-hand smoke. We know that non-smokers develop lung cancer, for example, but we usually don’t know if a non-smoker developed cancer because he or she was exposed to third-hand smoke, or for other reasons unrelated to smoking.

Bottom Line

Smokers with children or who live with non-smokers should never smoke inside the home or in their car, and clothing worn while smoking should be washed as soon as possible. If you smell cigarette smoke in a place or on someone, it means you are being exposed to third-hand smoke. An expert on helping people quit smoking recommends that after quitting, people should thoroughly clean their homes, wash or dry clean clothing, and vacuum their cars to remove the dangerous smoke leftovers.[2] Ideally, it would be best to replace furnishings that may have absorbed the chemicals from third-hand smoke, such as sofas, and re-carpet floors, re-seal and re-paint walls, and replace contaminated wallboard. Even if a smoker hasn’t quit yet, it’s a good idea to vacuum and wash clothes, curtains and bedding regularly to reduce their and their loved ones’ exposure to the dangerous chemicals that form when smoke residue mixes with the air.[3]

All articles on our website are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

References

  1. “The dangers of thirdhand smoke.” Mayo Clinic. Mayo Foundation for Medical Education and Research, 13 July 2017. http://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/third-hand-smoke/faq-20057791.
  2. Sleiman M, Gundel LA, Pankow JF, Peyton J, Singer BC, Destaillats H. Formation of carcinogens indoors by surface-mediated reactions of nicotine with nitrous acid, leading to potential thirdhand smoke hazards. Proceedings of the National Academy of Sciences. January 6, 2010 www.pnas.org/cgi/doi/10.1073/pnas.0912820107.
  3. American Chemical Society (ACS). “Major ‘third-hand smoke’ compound causes DNA damage and potentially cancer.” ScienceDaily. ScienceDaily, 16 March 2014. www.sciencedaily.com/releases/2014/03/140316203156.htm.
  4. Winickoff JP, Friebely J, Tanski SE, Sherrod C, Matt GE, Hovell MF, et. al. Beliefs About the Health Effects of “Thirdhand” Smoke and Home Smoking Bans. Pediatrics. (123.1)74-79.
  5. Ballantyne C, What is third-hand smoke? Is it hazardous? Scientific American. January 6, 2009. http://www.scientificamerican.com/article.cfm?id=what-is-third-hand-smoke.

Are E-Cigarettes Safer Than Regular Cigarettes?

Brandel France De Bravo, MPH, Sarah Miller, Jessica Becker, and Laura Gottschalk, PhD, Cancer Prevention & Treatment Fund

Electronic cigarettes, or e-cigarettes, are being marketed as the “safe” new alternative to conventional cigarettes. But are e-cigarettes safe?  What does the FDA think about them?  Are e-cigarettes going to reverse the decline in smoking—giving new life to an old habit—or can they help people quit smoking? Here is what you need to know before picking up an e-cigarette.

What Are E-Cigarettes?

E-cigarettes are battery-operated devices shaped like cigarettes that provide a way to get nicotine. Nicotine is an addictive drug (it stimulates and relaxes) that is naturally found in tobacco. The most popular way for people to take in nicotine is to inhale it by smoking cigarettes. E-cigarettes also allow nicotine to be inhaled, but they work by heating a liquid cartridge containing nicotine, flavors, and other chemicals into a vapor. Because e-cigarettes heat a liquid instead of tobacco, what is released is considered smokeless.[1]

Are E-Cigarettes Safer Than Traditional Cigarettes?

The key difference between traditional cigarettes and e-cigarettes is that e-cigarettes don’t contain tobacco.  But, it isn’t just the tobacco in cigarettes that causes cancer. Traditional cigarettes contain a laundry list of chemicals that are proven harmful, and e-cigarettes have some of these same chemicals.

Since 2009, FDA has pointed out that e-cigarettes contain “detectable levels of known carcinogens and toxic chemicals to which users could be exposed.”[2] For example, in e-cigarette cartridges marketed as “tobacco-free,” the FDA detected a toxic compound found in antifreeze, tobacco-specific compounds that have been shown to cause cancer in humans, and other toxic tobacco-specific impurities.[3] Another study looked at 42 of these liquid cartridges and determined that they contained formaldehyde,  a chemical known to cause cancer in humans.[4] Formaldehyde was found in several of the cartridges at levels much higher than the maximum EPA recommends for humans.

The body’s reaction to many of the chemicals in traditional cigarette smoke causes long-lasting inflammation, which in turn leads to chronic diseases like bronchitis, emphysema, and heart disease.[5f] Since e-cigarettes also contain many of the same toxic chemicals, there is no reason to believe that they will significantly reduce the risks for these diseases.

There are no long-term studies to back up claims that the vapor from e-cigarettes is less harmful than conventional smoke. Cancer takes years to develop, and e-cigarettes were only very recently introduced to the United States. It is almost impossible to determine if a product increases a person’s risk of cancer or not until the product has been around for at least 15-20 years. Despite positive reviews from e-cigarette users who enjoy being able to smoke them where regular cigarettes are prohibited, very little is known about their safety and long-term health effects.

Can E-Cigarettes Be Used to Cut down or Quit Smoking Regular Cigarettes?

If a company makes a claim that its product can be used to treat a disease or addiction, like nicotine addiction, it must provide studies to the FDA showing that its product is safe and effective for that use. On the basis of those studies, the FDA approves or doesn’t approve the product. So far, there are no large, high-quality studies looking at whether e-cigarettes can be used to cut down or quit smoking long-term. Most of the studies have been either very short term (6 months or less) or the participants were not randomly assigned to different methods to quit smoking, including e-cigarettes. Many of the studies are based on self-reported use of e-cigarettes. For example, a study done in four countries found that e-cigarette users were no more likely to quit than regular smokers even though 85% of them said they were using them to quit.[6] Another year-long study, this one in the U.S., had similar findings.[7] People may believe they are smoking e-cigarettes to help them quit,  but 6-12 months after being first interviewed, nearly all of them are still smoking regular cigarettes.

Until there are results from well-conducted studies, the FDA has not approved e-cigarettes for use in quitting smoking.[8]

Teenagers, Children, and E-Cigarettes

The percentage of teenagers who have tried e-cigarettes has almost quadrupled in just four years, from 5% in 2011 to 19% in 2015.  Three million U.S. students in middle school and high school tried e-cigarettes in 2015, according to the National Youth Tobacco Survey.  And, 1 in 5 middle schoolers who said they had tried e-cigarettes also said they had never smoked conventional cigarettes.[9]

E-cigarette use by young people is worrisome for a number of reasons:

1) The younger people are when they begin smoking, the more likely it is they will develop the habit: nearly 9 out of 10 smokers started before they were 18.[10]

2) Nicotine and other chemicals found in e-cigarettes might harm brain development in younger people.[11]

3) E-cigarettes may introduce many more young people to smoking who might otherwise never have tried it, and once they are addicted to nicotine, some may decide to get their “fix” from regular cigarettes. Whether e-cigarettes end up being a “gateway” to regular cigarettes or not, young people who use them risk becoming addicted to nicotine and exposing their lungs to harmful chemicals.

The sharp rise in young e-cigarette users highlights the need to stop manufacturers from targeting teenagers with candy-like flavors and advertising campaigns.

Even children who are too young to smoke have been harmed by e-cigarettes. The liquid used in e-cigarettes is highly concentrated, so absorbing it through the skin or swallowing it is far more likely to require an emergency room visit than eating or swallowing regular cigarettes. In 2012, less than 50 kids under the age of six were reported to poison control hotlines per month because of e-cigarettes. In 2015, that number had skyrocketed to about 200 children a month, almost half of which were under the age of two![12]

How Are E-Cigarettes Regulated?

The FDA was given the power to regulate the manufacturing, labeling, distribution and marketing of all tobacco products in 2009 when President Obama signed into law the Family Smoking Prevention and Tobacco Control Act and in 2010 a court ruled that the FDA could regulate e-cigarettes as tobacco products.[13]

It wasn’t until 2016 that the FDA finally announced a rule to regulate e-cigarettes.[14] Under the final rule, the FDA plans to ban the sale of e-cigarettes to anyone under the age of 18.  The rule also requires all makers of e-cigarettes sold after February 15, 2007 to go through a “premarket review.” This is the process that the FDA uses to determine whether potentially risky products are safe. However, companies are allowed to have anywhere from 18 months to two years to prepare their applications. And it will take another year for the FDA to actually approve these applications. So don’t expect e-cigarettes currently on the market to be officially allowed to be sold by the FDA for another couple of years.

In the meantime, individual states have always had the power to pass laws restricting the sale and use of e-cigarettes. For example, in May 2013, the California state senate proposed a law making all e-cigarettes subject to the same regulations and restrictions as traditional cigarettes and tobacco products.  However, that did not become law.

The Bottom Line

E-cigarettes have not been around long enough to determine if they are harmful to users in the long run.  Unfortunately, many people, including teenagers, are under the impression that e-cigarettes are safe or that they are effective in helping people quit smoking regular cigarettes.  Neither of these assumptions has yet been proven. Studies by the FDA show that e-cigarettes contain some of the same toxic chemicals as regular cigarettes, even though they don’t have tobacco.  The big three tobacco companies—Lorillard, Reynolds American, and Altria Group—all have their own e-cigarette brands, so it’s not surprising that e-cigarettes are being marketed and advertised much the way regular cigarettes used to be.  Here are the 7 Ways E-Cigarette Companies Are Copying Big Tobacco’s Playbook.

Unless you want to be a guinea pig, hold off on e-cigarettes until more safety information is available.  And if you need help quitting or reducing the number of cigarettes you are smoking, check out the smokefree.gov website.

Related Content:

Quitting smoking: women and men may do it differently
Third-hand smoke
Smoking cessation products

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff. 

References

  1. Richard J. O’Connor Non-cigarette tobacco products: What have we learned and where are we headed? Tob Control. Author manuscript; available in PMC 2013 July 19. Published in final edited form as: Tob Control. 2012 March; 21(2): 181–190. doi: 10.1136/tobaccocontrol-2011-050281.
  2. “Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA.” FDA News & Events. FDA, 22 July 2009. http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm.
  3. “Summary of Results: Laboratory Analysis of Electronic Cigarettes Conducted By FDA.” FDA News & Events. FDA, 22 July 2009. Web. 09 Aug. 2013. http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm173146.htm.
  4. Varlet et al. (2015) Toxicity of refill liquids for electronic cigarettes. International Journal for Environmental Research and Public Health. 12:4796-4815.
  5. Stoller, JK & Juvelekian, G; Chronic Obstructive Pulmonary Disease; 2010 Cleveland Clinic Center for Continuing Education. https://my.clevelandclinic.org/departments/respiratory/depts/chronic-obstructive-pulmonary-disease.
  6. Adkison SE, O’Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med. 2013;44(3):207-215.
  7. Grana RA, Popova L, Ling PM. A Longitudinal Analysis of Electronic Cigarette Use and Smoking Cessation. JAMA Internal Medicine, published online March 24, 2014
  8. “Electronic Cigarettes” FDA News & Events. FDA, 25 July 2013. http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm
  9. Singh T, Arrazola RA, Corey CG, et al. Tobacco Use Among Middle and High School Students – United States, 2011-2015. CDC Morbidity and Mortality Weekly Report. April 15, 2016. 65(14);361-367.
  10. Centers for Disease Control and Prevention. Fact sheets: Youth and tobacco use.  http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/.
  11. US Department of Health and Human Services. Preventing tobacco use among youth and young adults. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm.
  12. Kamboj A, Spiller HA, Casavant MJ, et al. Pediatric Exposure to E-Cigarettes, Nicotine, and Tobacco Products in the United States. Pediatrics. May 2016. In Press.
  13. “Regulation of E-Cigarettes and Other Tobacco Products.” FDA News & Events. FDA, April 25, 2011. http://www.fda.gov/newsevents/publichealthfocus/ucm252360.htm.
  14. Deeming Tobacco Products To Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Restrictions on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. 21 CFR Parts 1100, 1140, and 1143 (2016).

Lung cancer: who is at risk and can they be screened?


By Tiffanie L. Hammond and Amrita Ford, MA

Risk Factors for Lung Cancer
The Face of Lung Cancer
Symptoms of Lung Cancer
Screening for Lung Cancer
Biomarker Tests for Diagnosis
What We Still Need to Know and Change

Lung cancer is the second most commonly diagnosed cancer in both men and women in the U.S., but it is the #1 cancer killer. In 2012, it was estimated that approximately 226,160 men and women would be diagnosed with lung cancer and about 160,340 men and women would die from it.1 That is more deaths than from breast, prostate, colon, and cervical cancers combined. One of the reasons for the disproportionate death rate is that while these other cancers have screening guidelines issued by U.S. public health agencies aimed at increasing early diagnosis, no such formal guidelines exist for the early diagnosis of lung cancer. The most common causes of lung cancer are well known, and changes in behavior can reduce the risk, but many men and women without risk factors are diagnosed with lung cancer every year.

Risk Factors for Lung Cancer

Smokers

Smoking is the leading cause of lung cancer. It is responsible for 90% of lung cancer deaths in men and 80% in women. Today, there are over 90 million current and former smokers living in the U.S. Most are men, but while the number of new cases of men diagnosed with lung cancer is declining every year, the number of new diagnoses among women was increasing annually until very recently.2 The percentage of women who smoke began to increase in the 1940s during World War II and peaked in the 1960s.3 Decades later, lung cancer cases began rising in women, and stayed high, due to the long delay between starting to smoke and being diagnosed with lung cancer. Over the last few decades, smoking declined in popularity among women and men, resulting in a gradual decline in new cases of lung cancer.

Non-smokers

About 15% of lung cancer cases occur among nonsmokers, and each year about 20,000 people who never smoked die of lung cancer.4 Non-smoking women are at higher risk for lung cancer than non-smoking men: one in five women who develop lung cancer are non-smokers whereas only one in twelve men with lung cancer are non-smokers.5  Other causes of lung cancer in non-smokers include exposure to second-hand smoke, radon, asbestos, benzene or other cancer-causing agents, air pollution, and genetic vulnerability.

It is unclear why non-smokers develop lung cancer. One study found that about 30% of non-smokers who developed lung cancer had the same rare variation in a tumor-suppressor gene. This variation limits the gene’s ability to protect certain cells from cancer.6  Several molecular and genetic markers are thought to predispose some people to lung cancer but more research is needed to understand precisely how these markers influence the development of the disease.

The Face of Lung Cancer

Lung cancer patients are typically former or current smokers over the age of 65.  Most are men. African-American men are 37% more likely than Caucasian men to be diagnosed with lung cancer and 22% more likely to die from lung cancer, despite similar smoking rates.7 Research studies have examined smoking behavior, workplace and environmental exposures, biological and genetic differences, and cultural influences as potential causes for increased susceptibility and mortality of African Americans to lung cancer without a definitive answer.

Women accounted for 46% of new lung cancer cases in 2009, the most recent statistics available.8  Studies indicate that biological and genetic differences between men and women may play a role in differences in susceptibility to lung cancer and risk of dying from lung cancer.  Some research shows that estrogen, a hormone found in men and women that is much higher in women, may cause certain lung cancer cells to grow and spread throughout the lungs.  For example, a 2009 study based on the Women’s Health Initiative showed that post-menopausal women who took combined estrogen and progesterone replacement therapy (HRT) had an increased risk of dying from lung cancer, although they were not more likely to be diagnosed with lung cancer.9  In contrast, a 2010 study indicated that HRT may also increase the risk of developing lung cancer.10 In 2011, a study showed that women who take tamoxifen or other estrogen-blocking hormones to prevent breast cancer are at reduced risk for lung cancer death.11 For more on women’s risk of lung cancer, see Lung Cancer is a Women’s Health Issue.

Symptoms of Lung Cancer

One of the reasons why lung cancer is so deadly is that symptoms usually appear during the later stages, when treatment is least effective. General symptoms include:

  • a persistent cough that may worsen over time, including coughing up blood
  • breathing trouble, such as shortness of breath
  • chest pain
  • raspy or hoarse voice
  • frequent lung infections, such as pneumonia
  • extreme and constant fatigue
  • unintentional weight loss

Most lung cancers are detected by accident when testing for other health problems, or when the lung cancer is so advanced that symptoms are relatively obvious. The majority of lung cancer patients are diagnosed with late-stage lung cancer, when the cancer has usually already spread to other parts of the body, and at this point the 5-year survival rate is only 3.7%.12

Screening for Lung Cancer

The purpose of screening for cancer is to diagnose it early before symptoms appear. Cancer screening is only recommended when there is a method that is low-risk and accurate, and when the cancer can be detected early on.

There is currently no approved screening test for lung cancer.

Because of this, only 16% of lung cancer patients are diagnosed before their cancer has metastasized (spread to other parts of the body) compared to over 60% of breast cancer patients and over 90% of prostate cancer patients whose cancers are detected early-on through screening.13

Three major clinical trials in the 1970s evaluated two potential screening methods: chest x-ray and sputum cytology, an examination of cells found in the mucus of the lungs. The Johns Hopkins Lung Project, the Memorial Sloan-Kettering Lung Study, and the Mayo Lung Project evaluated men screened annually with only a chest x-ray (control group) against men screened with an annual chest x-ray plus sputum cytology (an analysis of their spit) every four months (intervention group). The studies found that screening men more often and with both screening tests resulted in more lung cancer diagnoses in one of the projects (the Mayo Lung Project), but there was no difference in the rate of lung cancer deaths.14  15
In 1992 the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial evaluated nearly 155,000 men and women, comparing those who got an annual chest x-ray screening for 4 years to those who did not undergo any screening. More lung cancer cases were detected in the screening group, but after 13 years of follow-up the study found that annual chest x-ray screening did not reduce lung cancer deaths.16

In 1999, the Early Lung Cancer Action Project found that low-dose computerized tomography scans (low-dose CT) were four times more likely than chest x-rays to detect a cancerous tumor. Most of the cancers detected (85%) were very early lung cancers (Stage I).17

In 1999, Stephen J. Swensen and his colleagues at the Mayo Clinic found that having a low-dose CT scan every year for 5 years increased survival times, but it did not reduce mortality rates. Survival is a measure of how long a person lives once cancer is diagnosed. If mortality does not change, it means a person might be aware of his or her diagnosis for a longer period of time than someone who did not undergo screening, but he or she does not live any longer.18

The National Lung Screening Trial (NLST), which started in 2002, evaluated the use of chest x-rays and low-dose CT scans in men and women who were heavy smokers. Each randomized group was screened annually for three years. Researchers found that using low-dose CT scans could reduce lung cancer deaths by 20%. Based on a 2011 report of the trial,19 low-dose CT screening could potentially increase the 5-year lung cancer survival rate to 70% if it allowed lung cancer to be detected in its earliest stage (stage 1A), when the tumor is still relatively small, still in the lung, and can be removed easily through surgery.17 18
20

Low-Dose CT Scans

Prior to these most recent low-dose CT scan findings, the U.S. Preventive Services Task Force, which is the government agency that reviews scientific evidence and makes recommendations on health care services, had concluded that there was insufficient evidence to recommend for or against screening people who do not have symptoms with low-dose CT, chest x-ray, sputum cytology, or any combination of these tests. 21 It is expected that the Task Force will re-visit their conclusions.

Who is recommending them?

Although no U.S. public health agency has recommended screening for lung cancer, in January 2013 the American Cancer Society (ACS) did so for the first time, saying that annual screening with low dose CT scans “could save many lives.”22  ACS has recommended that people at highest risk for lung cancer, as defined by the National Lung Screening Trial, have a discussion with their doctor about the benefits and risks of annual screening. They advised doctors to have this conversation only with patients who match the profile of the people who were enrolled in the National Lung Cancer Screening Trial: current and former smokers who are 55 to 74 years old and have a 30-pack-year history of smoking (20 cigarettes a day for 30 years, 40 cigarettes a day for 15 years, and so on. To calculate your pack years, visit http://smokingpackyears.com/). If the patients are former smokers, they should have quit within the last 15 years.  Doctors should discuss screening with patients only if low dose CT scans and high quality treatment are available in their area, and only if the patient seems healthy and able to undergo treatment in the event that cancer is found.  For all other patients, “there is too much uncertainty regarding the balance of benefits and harms …”

In 2012, the American Lung Association became the first national lung organization—devoted to lung health as opposed to lung cancer—to endorse low dose CT scans for lung cancer screening. Three other organizations have issued guidelines for lung cancer screening on the basis of the National Lung Screening Trial results. Most of the guidelines are fairly similar but there are some key differences. The National Comprehensive Cancer Network (NCCN), a group of the nation’s major cancer centers, for instance, has a broader definition of high risk. Unlike the American Cancer Society, the NCCN allows people to skip annual screenings for an unspecified period of time if they have had 3 years in a row of normal results. The NCCN uses the same definition of high risk as the American Cancer Society but they also have a second definition that includes people as young as 50 and as old as 79 with only a 20-pack-year history—provided they have one other risk factor for lung cancer such as a family history, Chronic Obstructive Pulmonary Disease (COPD), or exposure to radon.  Given the close link between COPD and lung cancer, the Network’s screening criteria could potentially find more cases of lung cancer than the 30-pack criteria. (For more on COPD, read: Chronic Obstructive Lung Disease and Lung Cancer). The American College of Chest Physicians and the American Society of Clinical Oncology also have guidelines.  Only time will tell which guidelines work best, but any of these guidelines make it more likely that insurance companies will pay for screening. As a result of the National Lung Cancer Screening Trial, the U.S. Department of Veterans Affairs is starting to implement a screening program using CT scans for veterans at high risk.  However, most government health programs, such as Medicare and Medicaid, do not usually reimburse for lung cancer screening and might not do so until a public health agency has issued guidelines.

In the past, the lung cancer screening debate focused on the lack of evidence that screening reduced lung cancer deaths. Since the NLST trial, the debate is focusing on the benefits, risks, and cost of low-dose CT scans. Some of the risks include radiation exposure, a high rate of false-positive test results, and over-diagnosis (diagnosis of tumors that are not cancerous or not threatening to the patient).

False Positives

Chest x-rays report fewer false positives than low-dose CT scans, but they usually find large, aggressive tumors that are typical of later stages of lung cancer when treatment is usually not effective. When the men and women who had abnormal findings on either low-dose CT scans or x-rays underwent biopsies, approximately 96% did not have lung cancer. Biopsies can cause serious complications for patients. Since the low-dose CT scans found three times as many abnormal findings compared to x-rays, it resulted in many more false positives, biopsies, and complications. The approximately 1% of smokers screened with the CT scan who were found to have lung cancer would have an improved chance of survival. In contrast, the approximately one in four people screened who had false positive results would be at risk for complications, and those numbers would increase the more often people were screened.18
Computer-aided detection (CAD) methods may enhance the accuracy of CT screening and are being investigated. A European study which incorporated CAD into CT screening found a sensitivity of 95% in accurately detecting lung cancer. This means that out of 100 people at high risk for lung cancer with detected abnormalities, 95 really have lung cancer and 5 people have false-positive results. This same screening method was found to have a specificity of 99% in accurately ruling out disease in patients at high risk for lung cancer, which means that out of 100 people determined not to have lung cancer, only 1 person really does (a “false negative”).23

Over-Diagnosis

Over-diagnosis is the identification of a disease in a person who would never have any symptoms or be harmed by the disease. Over-diagnosis can result in the treatment of pre-cancerous lesions with radiation therapy, hormone therapy, or surgery even though the lesions will never develop into lung cancer.

There are numerous reasons to be concerned about over-diagnosis of lung cancer. Those most likely to be screened are elderly, current or former smokers who may have co-existing medical conditions such as heart disease or emphysema. Scarring in the lungs from years of smoking and related respiratory illnesses can lead to a misdiagnosis of lung cancer, which will require further evaluation.

The testing can itself cause health problems. Radiologic imaging examinations, such as chest x-rays, chest CTs, and FDG-PET scans (fluorodeoxyglucose positron emission tomography), are the most common follow-up measures that are used to determine if additional invasive diagnostic procedures are needed. Radiologic imaging has little short-term risk, but it exposes patients to unnecessary radiation that can be harmful later in life. Invasive procedures, such as needle biopsies, are inserted into the lung to remove tissue samples and determine if there is cancer. This procedure can puncture the lung and cause it to collapse. Bleeding can also occur in the tumor or at the site of the needle insertion. Although very serious complications are rare (less than one in 1,000), they can occur.

Surgery may be necessary for diagnostic evaluation. It is also the preferred treatment for early-stage lung cancer. As with any invasive procedure, there are risks. Age and co-existing medical conditions increase the risk of death or complications from surgery. If a section of the lung is removed to reduce the chance of cancer spreading outside of the lung, then the patient will have reduced respiratory function. This could make breathing more difficult, especially for current and former smokers who already have respiratory issues.

Unnecessary treatment can also lead to pain, lost time at work, increased medical costs, and a reduction in the quality of life.

Radiation Exposure

Low-dose CT scans might result in earlier diagnosis of lung cancer, but radiation exposure from the screening test might actually increase a person’s risk of lung cancer, especially with repeated screenings. Although low-dose CT releases one tenth of the radiation of standard diagnostic CTs, the radiation that is released may act together with smoking to increase the risk of lung cancer. More research is needed to accurately measure the potential risk from exposure to radiation.

The frequency and dose of radiation exposure could affect risk, in addition to smoking history and age. The impact of frequency, dose, and age are still being determined, but risk modeling suggests that the risk of cancer caused by annual low-dose CT screening decreases with age.

Dr. David J. Brenner of Columbia University suggests that there is up to a 5.5% increase in the risk for lung cancer between the ages of 50 and 75 from annual low-dose CT screening of smokers or others at high risk for lung cancer during those 25 years. That risk would be reduced by half if screening was done every 2 years instead. He concludes that the screening method chosen for lung cancer must reduce lung cancer deaths by more than 5.5% to compensate for the potential risk of cancer caused by the CT radiation.24

Costs, Benefits, and Insurance Coverage

On average, low-dose CT scans cost about $300 per screening, making them more expensive than mammograms for breast cancer ($80-$150) and pap smears for cervical cancer ($25-$75). No private insurance agencies (except for WellPoint) cover lung cancer screening with CT scans because it is not currently recommended by the U.S. Preventive Services Task Force. Medicare will cover low-dose CT scans for individuals who meet the following criteria:

  • Age 55-77 years
  • Has a tobacco smoking history of at least 30-pack years
  • Is a current smoker or quit within the past 15 years
  • Receives a written order for a low-dose CT scan from a qualified individual such as a doctor

A 2012 study conducted by actuaries (people trained to calculate the cost of risk and uncertainty) and published in Health Affairs, concluded that CT screening for lung cancer could save thousands of lives at a relatively low cost if it were covered by insurance companies.25 The study examined the costs and benefits of providing high-risk individuals—smokers and long-term former smokers ages 50 to 64—with lung cancer screening using low-dose CT. Most private insurers do not currently cover the screening because evidence of the screening’s cost effectiveness has been scarce or conflicting until now. The researchers found that the screening would cost insurance companies about $247 per member screened annually, and when the total expense of screening was spread over the commercially insured population, the cost was under $1 per insured member per month. According to the study if the screening had been in place for the last 15 years, 130,000 more people under the age of 65 would be alive today, and the cost per life-year saved would be lower than screening for both cervical and breast cancers. The authors acknowledged that actual costs could be higher and the benefits lower if the screenings are not conducted according to best practice guidelines for pricing and follow-up of patients. The study is the first to show that low-dose CT screening is potentially cost-effective and could actually save insurance companies money since lung cancer would often be detected earlier and therefore require less expensive treatment. More importantly, detecting lung cancer early could save lives and improve the quality of life for people diagnosed with lung cancer.

Biomarker Tests for Diagnosis

Biomarker tests, which examine urine, blood, sputum (spit), tissue samples, and even exhaled air, for abnormal levels of certain proteins, antibodies or other substances, are being investigated as another type of diagnostic tool for detecting lung cancer.26  Used together with low-dose CT scans, biomarker tests could potentially result in fewer misdiagnoses and less unnecessary treatment.

What We Still Need to Know and Change

The latest research suggests that lung cancer deaths can be reduced with low-dose CT screening in people who are at increased risk for lung cancer due to heavy smoking, and that annual chest x-rays are not effective regardless of smoking history. Questions remain about who else would benefit from screening (such as non-smokers who live with smokers or have had substantial radon exposure), at what age different groups should begin screening, and how often they should get screened. For now, low-dose CT appears to be the screening method with the most favorable ratio of benefit to harm, but the number of people harmed is quite large compared to the number of people who would benefit. Researchers will continue to search for other less risky and more accurate methods for lung cancer screening.

Funding and Legislation

Lung cancer research has not been a priority at the National Cancer Institute. Research dollars for lung cancer investigations continue to lag far behind other cancers that are less fatal. In fiscal year 2010, the National Cancer Institute spent $631 million for breast cancer research and $300 million for prostate cancer research. Lung cancer, the #1 cancer killer for women and men, received only $282 million. In fact in 2009, lung cancer research funding at NCI was actually reduced from the previous year, while breast and prostate cancer research funding continued to grow. Breast and prostate cancers have benefited from vigorous federal funding, and as a result, have made great strides in the early detection and treatment of the cancers.27

Increased funding is needed to understand gender and racial differences in lung cancer and to continue research at the cellular and molecular levels for targeted, individualized, and less invasive detection and treatment of lung cancer. For more on lung cancer treatments, read here (Lung Cancer is a Women’s Health Issue).

In a 2010 report, the Institute of Medicine recommended that the NCI increase reimbursement from $2000 to $6000 per patient in their studies to encourage investigators in large cooperative groups to increase their involvement in lung cancer research. This reimbursement level has remained unchanged for over 10 years and the IOM report found that investigators limit their involvement in cancer research based on reimbursement concerns. Study participants would also benefit from increased funds. Patients in under-represented groups such as racial and ethnic minorities may be more likely to participate in trials that include reimbursement costs for patient care during the duration of the trial.28

As policy-makers continue to debate about federal research funding, some are proposing that the tobacco industry help underwrite the costs of screening smokers. Most of the state funding for lung cancer prevention activities comes from the 1998 tobacco industry lawsuit. States will collect $25.3 billion this year from the tobacco lawsuit and state taxes from the sale and distribution of tobacco products. However, only about 2% of that revenue will go toward smoking cessation programs. The distribution of settlement money from the lawsuit is at the discretion of states, most of which are using the funding for unrelated state projects because of economic problems that they face. Unfortunately, most states have now reduced funding for prevention and smoking cessation programs to 1999 levels. Although the lawsuit did not stipulate that the settlement money go towards lung cancer prevention, treatment, or early detection programs, progress in finding more effective screening is less likely unless funding from the law suit is used to improve lung cancer screening, diagnosis, and treatment activities.29

There is some pending legislation that may help persuade the federal government to fund more lung cancer research. The Lung Cancer Mortality Reduction Act of 2011 is a bipartisan bill currently in Congress which aims to reduce lung cancer mortality by 50% by 2020.30 The bill, first introduced in 2008, calls on the cooperation of the Department of Health and Human Services, the Department of Defense, and Veterans Affairs to meet that goal and develop a coordinated plan that addresses the prevention, early detection, and treatment of lung cancer. It would require the National Cancer Institute to review and prioritize research grants related to lung cancer, the Food and Drug Administration to establish quality standards and guidelines for facilities that screen for lung cancer using low-dose CT scans, and the Centers for Disease Control and Prevention to establish a Lung Cancer Early Detection Program which would provide low-income, uninsured, and underserved populations at high risk for lung cancer with access to early detection services. For more information and to support this important legislation in the fight against lung cancer, visit http://www.opencongress.org/bill/112-h1394/show.

As lung cancer continues to take lives, increased funding for lung cancer research will be critical for ensuring better screening, earlier diagnosis, more effective treatment, longer survival, and an overall lower mortality for patients diagnosed with the disease. New research will not only benefit smokers and former smokers, but nonsmokers as well who make up 15% of lung cancer cases.

Screening for lung cancer: do risks outweigh benefits?

By Diana Zuckerman, PhD
2015

Medicare and U.S. insurance companies will pay for lung cancer screening with low-dose CT scans (LDCT) for former heavy smokers. However, a careful review of the research indicates that this screening is unlikely to save the lives of Medicare patients. It may help save the lives of some patients ages 55-65, but may also harm some.

A major study called the National Lung Cancer Screening Trial (NLST) found fewer deaths from lung cancer in patients ages 55-74 who had smoked for at least 30 pack-years (1 pack of cigarettes per day for 30 years, or 2 packs a day for 15 years, etc) and were screened with LDCT rather than chest x-ray (CXR). Patients were 20% less likely to have died within 6.5 years of screening and 16% less likely within 7.5 years. However, the decrease in deaths from all causes (not just lung cancer) was not as impressive: 6.7% after 6.5 years. That means that these former and current smokers were dying from other diseases, some of which might also have been related to their smoking, such as emphysema, breast cancer, and COPD.

Most Medicare patients are over 65 and many are over 74, so the study above can’t predict what is likely to happen to older patients. What evidence is there that Medicare patients with a 30-pack-year habit would benefit from LDCT screening? The major issues are:

1) Would screening heavy smoker and former smokers over 65 detect cancers early enough to save lives or extend lives?
2) Would the screened patients who are diagnosed with lung cancer be healthy enough to undergo lung surgery and benefit from it?
3) Would the screened patients who are diagnosed with lung cancer be likely to die from something other than lung cancer, making lung cancer screening irrelevant to their survival?

The US Preventive Services Task Force recommended LDCT screening for people ages 55-80 who currently smoke or had quit within the last 15 years and who have a history of at least 30 pack-years of smoking. However, those experts warn that “screening cannot prevent most lung cancer deaths.” In fact, even if men and women who are screened with LDCT are diagnosed earlier and live longer with the diagnosis, they may die at the same age they would have without screening. In other words, a patient diagnosed after screening at age 65 might live to be 68 and if they were not screened they might have been diagnosed at 67 but still died at the age of 68. Even patients diagnosed with the earliest (stage 1) lung cancer will not necessarily be treated successfully.

The answer to #2 above is also difficult to know. The patients studied in the NLST were half as likely to have emphysema, diabetes, or heart disease as most smokers of the same age. Since typical Medicare patients eligible for LDCT screening would have more health problems, they would be less likely to be healthy enough to undergo surgery or other cancer treatment. And, even fewer than 6.7% would be likely to benefit by living longer.
Another major concern is that screening has health risks. LDCT screening is very inaccurate: 96% of the patients who are told their results show they may have lung cancer, do not actually have lung cancer. That is called a false positive result. Those patients will need more tests to find out whether or not they have lung cancer. Some of those additional tests, such as lung biopsies, can be dangerous or even deadly.

In addition, using LDCT every year to screen for lung cancer will expose patients to radiation that can increase their risk of lung cancer.

The Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), made up of experts from across the country, recommended that Medicare not pay for LDCT screening, saying they were not confident that the benefits would outweigh the risks.
After heavy lobbying, Medicare decided to pay for LDCT screening anyway. Only time will tell how many lives will be saved – or lost – as a result.

For more information, see: D. Zuckerman, Screening for Lung Cancer: To Be or Not to Be Covered by Medicare? Thoracic Imaging, Vol 30, No. 1, 2015.

Lung cancer is a women’s health issue

By Susan Dudley, PhD, Renee Y. Carter, MD, Tiffanie Hammond, and Amrita Ford, MA

Risk Factors for Lung Cancer
Non-Smokers and the Possible Role of Estrogen
Surviving Lung Cancer
Racial and Ethnic Differences in Lung Cancer
Symptoms of Lung Cancer
Lung Cancer Detection and Treatment
Advances in Treatment but They are High-Cost and Only for Some Patients
Funding for Lung Cancer Research

Lung cancer is the #1 cause of cancer death among women in the United States. Lung cancer used to be thought of as a man’s disease, but women now account for almost half of new cases and deaths from lung cancer. In 2014, 48% of the almost 216,000 people diagnosed with lung cancer were women, and 45% of the 155,526 who died from lung cancer were women.31

Lung cancer deaths in women began quickly rising in 1960, and by 1987, the number of female deaths from lung cancer exceeded the number of deaths from breast cancer. Today the number of deaths in women from lung cancer surpasses those from all gynecological cancers combined.32 While the rate of lung cancer deaths among men has been steadily decreasing since the 1990s, the lung cancer death rate among women did not start to go down until a decade later (2003-2007).33 The decline of lung cancer deaths among women, however, may not be as rapid as it has been in men: women born around 1960 with a high rate of smoking are just now entering the age when lung cancer diagnosis is most common.

Risk Factors for Lung Cancer

Everyone knows that smoking is the leading cause of lung cancer. It is responsible for 90% of lung cancer deaths in men and 80% in women. Beginning in the 1940’s during World War II, smoking became more acceptable for American women.34 As more women began to smoke, the number of deaths from lung cancer increased very dramatically among women — by more than 600% between 1950 and 1997. When a woman stops smoking, her risk of developing lung cancer decreases, but not as much as many women may think. Twenty years after stopping, the risk of developing lung cancer drops only by half. In addition, exposure to second-hand smoke at home, work, or other environments—including childhood exposures—can cause lung cancer in women who have never smoked themselves.35

Additionally, exposure to radon, arsenic, asbestos, radiation, air pollution, some organic chemicals, such as benzene, and tuberculosis, also increase the risk of developing lung cancer.

Non-Smokers and the Possible Role of Estrogen

Although smoking increases the risk of lung cancer dramatically, 1 in 5 women diagnosed with lung cancer have never smoked, whereas among men who develop lung cancer, only 1 in 12 have never smoked.436 Of all the types of lung cancer, women are more likely to develop adenocarcinoma, a type of non-small cell lung cancer (NSCLC), which is also the type of lung cancer more commonly found in non-smokers.

It is unclear why non-smoking women are at greater risk for developing lung cancer than non-smoking men. Studies indicate that biological and genetic differences between men and women play a role in susceptibility to lung cancer and the risk of dying from it. Some research shows that estrogen, a hormone found in both men and women but much higher in women, may help certain lung cancer cells to grow and spread throughout the lungs. For example, a 2009 study based on the Women’s Health Initiative showed that post-menopausal women who took estrogen and progesterone combined hormone therapy had an increased risk of dying from lung cancer, regardless of whether they had never smoked, stopped smoking, or were currently smoking (although current and former smokers were at the highest risk for death).37 A 2010 study indicated that post-menopausal women who took hormone therapy for more than 10 years were at an increased risk of developing lungcancer.38  In 2011, a study showed that women who take estrogen-blocking medication like tamoxifen to prevent a recurrence of breast cancer also reduce their risk of dying from lung cancer.39 For both the 2010 and 2011 studies, the link between hormones and lung cancer were maintained regardless of the person’s smoking status. For more information about hormone therapy and lung cancer, read Lung Cancer and Hormone Therapy: Bad News for Former and Current Smokers.

Surviving Lung Cancer

Women are nearly as likely as men to be diagnosed with lung cancer, but on a more positive note, they tend to survive longer than men with the disease. Women generally live longer than men at every stage of lung cancer, regardless of when they were diagnosed, the type of lung cancer they had, or how they were treated.4041 Studies have shown that women with non-small cell lung cancer (NSCLC) have a greater 5-year survival following partial removal of the lung (resection) than men.424344 Women with NSCLC who are treated with chemotherapy prior to removal of the tumor also have better survival rates than men.45 Furthermore, women with advanced lung cancer of any type who undergo chemotherapy survive longer than their male counterparts.46

Why do women with lung cancer live longer than men? No one is really certain. One reason may be that women tend to notice symptoms and go to the doctor earlier than men, allowing the disease to be caught at an earlier stage when the cancer is local (still in the lung) and can be completely removed.47 However, even when researchers control for this and other differences between men and women, women still live longer following surgery.13 For both women and men with lung cancer, complete removal of an entire lobe of the lung (lobectomy) results in higher survival rates than only partial removal of the lung. Younger patients and patients with smaller tumors are more likely to survive lung cancer than those who are older or have larger tumors, regardless of sex.14

Racial and Ethnic Differences in Lung Cancer

The incidence of lung cancer among African American women is about the same as white women yet smoking rates among African American women are lower.48 In 2007, about 16% of African American women smoked, while the rate for white women was about 20%.49 Similarly, African-American men smoke less than white men yet have higher rates of lung cancer. Is there a genetic difference that places African Americans at higher risk? Or are African-Americans exposed to other lung cancer causing bacteria and chemicals that increase their risk?

No one knows the answer yet but there are several explanations for why African Americans—men and women—are more likely to die from lung cancer than white men and women. Even African American women who have never smoked have higher death rates from lung cancer than white women who have never smoked.50 Most experts believe African Americans with lung cancer don’t live as long because they don’t have the same access to health care. For instance, they are less likely to have insurance coverage which could impact diagnosis and treatment options.51 They are less likely to receive timely care and may not receive the most effective treatment for their type of lung cancer.52 One study found that African American patients underwent partial surgical removal of the lung less frequently than white patients. 53 Other factors that may contribute to the lower survival rates of African American lung cancer patients include differences in lung function,20 provider biases,54 inadequate physician-patient communication,55 distrust of physicians and the health care system,56 and a greater likelihood of refusing surgery.57 For more on African Americans and lung cancer, read here.

After African American and white women, native Hawaiian women have the highest incidence of lung cancer, while Hispanic and Japanese women have the lowest rates.20 Unlike other racial and ethnic groups where the incidence of lung cancer in women has increased over time, rates have actually declined among Hispanic women (who are more likely to be non-smokers than African Americans, whites or native Hawaiians): they decreased by 1.5% every year from 1994 to 2003.58 Despite the decline of lung cancer in both men and women, lung cancer remains the leading cause of cancer death among Hispanic men and the second leading cause of cancer death among Hispanic women.

Symptoms of Lung Cancer

The most commonly recognized symptoms of lung cancer include:

  • persistent cough, coughing that wakes you up at night, and/or coughing up blood
  • wheezing and/or shortness of breath
  • chest pain
  • hoarseness
  • swelling of the face and neck
  • loss of appetite and/or unexplained weight loss
  • unusual tiredness
  • recurring pneumonia or bronchitis

Lung Cancer Detection and Treatment

While survival rates for many cancers have improved substantially over the last 30 years, little progress has been made in the survival rate for lung cancer. For example, between 1974 and 2007, the 5-year survival rate for breast cancer increased from 75% to 89% and the 5-year survival rate for prostate cancer increased from 67% to 99%. In contrast, the 5-year survival rate for lung cancer increased from 13% to just under 16% during the same time period.

What would be needed in order for the survival rates for lung cancer patients to parallel that of breast, prostate or cervical cancers? The main problem is that by the time most women are diagnosed with lung cancer, it has already spread to other organs, making a cure extremely unlikely. Pap smears and colonoscopies, for instance, make it possible to diagnose and remove pre-cancerous cells on the cervix or polyps in the colon before they can develop into cervical cancer or colon cancer or spread elsewhere in the body. And while better survival rates for women with breast cancer are mostly attributed to improvements in treatment, mammogram screenings have helped some women by detecting their breast cancer at earlier stages than before, when surgery, radiation, or chemotherapy have an even better chance of eliminating the disease. Earlier diagnosis and more effective treatments, therefore, will be necessary to improve the survival rate of lung cancer.

The National Lung Screening Trial, which started in 2002, evaluated the use of chest x-rays and low-dose computed tomography (low-dose CT scans) for early detection of lung cancer in men and women who were heavy smokers. Each randomized group was screened annually for 3 years. Researchers found that using low-dose CT scans reduced lung cancer deaths by 20% in the high-risk population. Compared to standard x-rays, CT scans may be more effective in detecting nodules and tumors. Based on a 2011 report of the trial, low-dose CT screening could potentially increase the 5-year lung cancer survival rate to 70% if it allowed lung cancer to be detected in its earliest stage (stage 1A), when the tumor is still relatively small, still in the lung, and can be removed easily through surgery.59606162

Although no U.S. public health agency has recommended screening for lung cancer, in January 2013 the American Cancer Society (ACS) did so for the first time, saying that annual screening with low dose CT scans “could save many lives.”63 ACS has recommended that people at highest risk for lung cancer, as defined by the National Lung Cancer Trial, have a discussion with their doctor about the benefits and risks of annual screening. They advised doctors to have this conversation only with patients who match the profile of the people who were enrolled in the National Lung Cancer Screening Trial: current and former smokers who are 55 to 74 years old and have a 30-pack-year history of smoking (20 cigarettes a day for 30 years, 40 cigarettes a day for 15 years, and so on. To calculate your pack years, visit http://smokingpackyears.com/). If the patients are former smokers, they should have quit within the last 15 years.  Doctors should discuss screening with patients only if low dose CT scans and high quality treatment are available in their area, and only if the patient seems healthy and able to undergo treatment in the event that cancer is found.  For all other patients, “there is too much uncertainty regarding the balance of benefits and harms …”

Three other organizations have issued their own slightly different guidelines.  The National Comprehensive Cancer Network has two definitions of high risk: the one used by the American Cancer Society and one that includes people as young as 50 and as old as 79 with only a 20-pack-year history—provided they have one other risk factor for lung cancer such as a family history, Chronic Obstructive Pulmonary Disease (COPD), or exposure to radon.  Given the close link between COPD and lung cancer, the Network’s screening criteria could potentially find more cases of lung cancer than the 30-pack criteria. (For more info on COPD, see Chronic Obstructive Pulmonary Disease and Lung Cancer.) The American College of Chest Physicians and the American Society of Clinical Oncology also have guidelines.  Only time will tell which guidelines work best, but any of these guidelines make it more likely that insurance companies will pay for screening. As a result of the National Lung Cancer Screening Trial, the U.S. Department of Veterans Affairs is starting to implement a screening program using CT scans for veterans at high risk.  However, most government health programs, such as Medicare and Medicaid, do not usually reimburse for lung cancer screening and might not do so until a public health agency has issued guidelines.

Unfortunately, CT scans are not a great solution for finding and diagnosing lung cancer in people who don’t have symptoms and aren’t at high risk. Low-dose CT scans have been shown to produce a high percentage of false positive results (people who the scan says have an abnormality when they don’t have cancer), which can lead to unnecessary lung biopsies. Since lung biopsies can be harmful, low-dose CT as a screening method isn’t useful for the general population. This is unfortunate because women who didn’t smoke are at higher risk than men who didn’t smoke, as are men and women exposed to years of second-hand smoke, but no screening has been found to be appropriate for them. For more information about screening, read Lung Cancer: Who Is at Risk and Can They be Screened?

Advances in Treatment but They are High-Cost and Only for Some Patients

Historically, lung cancer treatments have not been very effective. For instance, erlotinib (trade name Tarceva), which is taken as a pill, extends survival in patients with non-small cell lung cancer by only about 2 months on average and costs anywhere from $2,000 to $5,000 a month.646566 Patients usually take Tarceva after having already undergone chemotherapy, and many use it as a maintenance therapy to prevent further cancer progression and to shrink tumors that are already present. Patients stay on Tarceva for as long as it appears to be having an effect (developing a rash is considered a good sign) and scans show that the cancer is stable. Not only is Tarceva expensive but it doesn’t benefit everyone with lung cancer: it works best in patients who have never smoked or who have a specific gene mutation (EGFR mutation).36[67 Tarceva acts by inactivating the signal in the mutated EGFR gene that makes lung cancer grow.

New targeted treatments that interfere with specific molecules involved in tumor growth and progression and which promote cancer cell death are showing promise in the fight against lung cancer. In August of 2011, the Food and Drug Administration fast-tracked approval for crizotinib (trade name Xalkori) for use in a small subset of lung cancer patients with late-stage, non-small cell lung cancer (NSCLC) who express a rearrangement of the anaplastic lymphoma kinase (ALK) gene. Rearrangement of this gene leads to cancer growth and occurs in 1-7% of NSCLC patients. Xalkori was approved with an accompanying diagnostic test to determine if a patient has the abnormal ALKgene rearrangement.68 Based on an October 2011 study published in Lancet Oncology, the overall survival rate for Xalkori after 1 and 2 years was 74% and 54%, respectively. The recommended dose for Xalkori is 250mg twice daily and the drug costs about $9,600 per month or about $115,000 a year.69 Targeted treatments tend to be very expensive because they are usually taken by a very small number of patients who have limited treatment choices.

Funding for Lung Cancer Research

Far too many women and men are dying of lung cancer every year. Could an increase in research funding result in better screening, earlier diagnosis, more effective treatments, longer survival, and overall lower mortality for patients diagnosed with lung cancer? We believe the answer is “yes.”

The National Cancer Institute is the major source of cancer research funding in the U.S. Comparisons of NCI funding for various types of cancer in 2010 are shown below and clearly show that lung cancer research is under-funded in proportion to how deadly it is for so many people.170 Between 2003 and 2007, NCI funding for lung cancer actually decreased while funding for breast cancer increased.71 The same inequities are seen in funding for prevention. In the Centers for Disease Control and Prevention (CDC) 2008 budget, about $201M was allocated for breast cancer while $104M was allocated for smoking cessation programs (and not lung cancer specifically).72

Total NCI Funding (in millions)

New Cases Diagnosed
(male & female)

Funding per New Case

Overall Deaths

Funding per Patient Death

Lung Cancer

$282.0

221,130

$1,275

156,940

$1,797

Breast Cancer

$631.2

232,620

$2,713

39,970

$15,792

ColonCancer

$270.4

101,340

$2,668

49,380

$5,476

Prostate Cancer

$300.5

240,890

$1,247

33,720

$8,912

 

Many researchers and advocates point to the stigma associated with lung cancer as a reason for why the disease is under-funded.73 Since smoking is associated with the majority of lung cancer cases, many people believe lung cancer patients are responsible for their health problems and therefore not deserving of the same sympathy and research investments that patients of other deadly diseases receive. This attitude may also extend to clinicians who care for lung cancer patients. One study found that physicians were less likely to send their lung cancer patients with advanced stages of the disease to an oncologist than their breast cancer patients.74 Breast cancer patients were also more likely to be referred for further therapy where lung cancer patients were referred for only symptom control. We know now that more complex factors other than cigarette smoking contribute to lung cancer and the lack of funding over the years has hindered researchers from fully understanding why and how this disease progresses in different populations.

So how can we persuade the federal government to fund more lung cancer research? Some think legislation is needed.

In 2008, Congress approved the Peer Reviewed Lung Cancer Research Program which was the first time in history that federal funding was allocated specifically for the study of lung cancer. However, the program is funded by the Department of Defense to study early detection and disease management specifically in military men and women at high risk for lung cancer.

The Lung Cancer Mortality Reduction Act of 2011 is a bipartisan bill currently in Congress which aims to reduce lung cancer mortality by 50% by 2020.75 The bill, first introduced in 2008, calls on the cooperation of the Department of Health and Human Services, Department of Defense, and Veterans Affairs to meet that goal and develop a coordinated plan that addresses the prevention, early detection, and treatment of lung cancer. It would require the National Cancer Institute to review and prioritize research grants related to lung cancer, the Food and Drug Administration to establish quality standards and guidelines for facilities that conduct computed tomography screening for lung cancer, and the Centers for Disease Control and Prevention to establish a Lung Cancer Early Detection Program which would provide low-income, uninsured, and underserved populations at high risk for lung cancer with access to early detection services. For more information and to support this important legislation in the fight against lung cancer, visit http://www.opencongress.org/bill/112-h1394/show.

Smoking cessation products

It’s hard to quit smoking, but there are products that can help you quit.  No matter how long you have smoked, stopping can decrease your risk of lung cancer and possibly lower your risk of breast cancer.  Here are some important points to remember:

Types of smoking cessation products:

There are two types of smoking cessation products:

  1. Those that contain nicotine to help you reduce your addiction by lowering the levels
  2. Those that do not contain nicotine that are intended to ease withdrawal symptoms

If you use a nicotine replacement product, only use one kind. Do not use gum and a patch on the same day, for example.  Call your health care professional if you experience nausea, dizziness, weakness, vomiting, fast or irregular heartbeat, mouth problems with the lozenge or gum, or redness or swelling of the skin around the patch that does not go away.

Risks

Talk to your health care professional before using these products if you have

  • diabetes, heart disease, asthma, or stomach ulcers
  • had a recent heart attack
  • high blood pressure that is not controlled with medicine
  • a history of irregular heartbeat
  • been prescribed medication to help you quit smoking

Women who are pregnant or breast-feeding should use these products only with approval from their health care professional.

If you take prescription medication for depression or asthma, let your health care professional know if you are quitting smoking; your prescription dose may need to be adjusted.

Products not containing nicotine

Two medicines that do not contain nicotine have FDA’s approval as smoking cessation products. They are Chantix (varenicline tartrate) and Zyban (buproprion). Both are available in tablet form on a prescription-only basis.  Neither of these drugs is recommended for people under 18 years of age.

Both products have serious risks, and can cause changes in behavior, depressed mood, hostility, and suicidal thoughts or actions.  Since quitting smoking is already difficult, does it make sense to take a drug that can make you feel depressed and suicidal. A recent study found that Chantix is especially likely to cause an increase in reported depression, suicide, and self-injury.  Chantix has other risks as well, and we agree with the researchers who called it “unsuitable” for smoking cessation, unless nothing else has worked.[end Moore, T, et. al. Suicidal Behavior and Depression in Smoking Cessation Treatments. PLoS One. Vol 6. November 2011. <http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0027016>]

Before taking either of these products, read the product’s patient medication guide in its entirety if you use or plan to use either Chantix or Zyban. These guides offer important warnings that you need to know before making a decision.

This article is based on an article on the FDA web site.  For more information, click here.

Quitting smoking: women and men may do it differently

By Anna E. Mazzucco, Ph.D

Quitting  smoking is hard to do, and new studies suggest that what works for men may not always work for women, and vice versa.  Scientists believe that nicotine is more important for men, while other aspects of smoking seem to be more important for women.  If you are trying to quit, there’s new research that may help you choose the strategy that is most likely to work for you.

Many counselors, quit lines, and other experts recommend talking with your doctor about your interest in quitting or cutting back on the number of cigarettes you smoke. Your doctor will discuss different tools and medications, some of which require a prescription.  Nicotine patches and gum, for instance, can be purchased without a prescription.  These are often used to “step down” nicotine levels (see this article for more information),  but studies have suggested that these medications may work better for men than women, especially when it comes to quitting for good. 76  Other types of medication to help you quit smoking, such as prescription drugs Chantix and Zyban, do not replace nicotine, but instead try to reduce the craving for it.  But these drugs are riskier and have more side effects than nicotine replacements (see this article for more information).

So, what are the other options, especially for women who may not be helped as much by nicotine patches or gum, and who don’t want to use prescription medicines with serious side effects?  Most experts suggest the following:

  1. Plan for success.  Start by picking a good time to quit.  Experts recommend choosing a time of year that is not particularly stressful, since quitting can take a lot of energy.  You might try setting a goal like a “smoke-free” date that is personally meaningful to you—maybe your or a loved one’s birthday, or a holiday.  Some people decide to save the money they would have spent on cigarettes for something special.  If watching your savings accumulate is helpful, consider putting a glass jar somewhere where you can easily see it and get re-inspired daily!  Interestingly, one study showed that women who try to quit during the first half of their monthly cycle (right after menstruation) are more likely to succeed.77
  2. Know yourself.  Quitting can be more successful if you try to identify the situations where you tend to smoke.  Do you have a particular time of day, or group of people that you enjoy smoking with? Anticipate these situations and come up with plans for how to handle them ahead of time.
  3. Find healthier replacements.   Some people find mint gum, lozenges, sunflower seeds or shelled nuts can help reduce their craving for a cigarette.   This may be especially important for women, who often need to replace the hand-to-mouth aspects of smoking as much or more than the nicotine itself.  Research suggests that certain foods might make cigarettes less appealing, such as healthy fruits and vegetables and spicy foods, which might curb the craving for a strong taste.78  Even brushing your teeth can help keep cravings at bay!
  4. Be good to your body.  Regular exercise, such as brisk walking, jogging, yoga or tai chi, can help reduce stress and increase a sense of well-being.  Research suggests that these feel-good replacements may be especially useful for those who smoke to cope with stress. 79  Lungs can quickly begin to heal once you quit smoking.  So breathe deeply and enjoy!
  5. Call in reinforcements.  Next time you feel a craving, try calling a friend, or consider joining a support group.  There are also online quitting tools such as TheExPlan, SmokeFree Women Quit Plan, QuitNet, and Freedom From Smoking Online.  And, you guessed it, there are now many “quitting apps” such as Smoke Out, tweetsmoking, Butt Out, Livestrong MyQuit Coach, and Smoke Break.   Apps can help you count the days since your last cigarette, calculate money saved, show your decreasing risks for diseases, and share your progress with others– and many of them are free. (For a detailed review, see this site). There are also many websites with useful information and links, compiled here by the Center for Disease Control.

Chronic Obstructive Pulmonary Disease (COPD) and Lung Cancer

Tiffanie Hammond, Amrita Ford, MA, Brandel France de Bravo, MPH, and Jessica Cote, Cancer Prevention and Treatment Fund

What is COPD, and What Causes It?
Gender Differences in COPD
How is COPD Diagnosed?
Not Everyone Defines COPD the Same Way
The Controversy Surrounding COPD Screening
Treatment Options and Prognosis
What Does This Have To Do with Lung Cancer?
How are COPD and Lung Cancer Linked?
Could COPD Patients be the Best Candidates for Lung Cancer Screening?
You Think You Might Be at Risk for COPD and/or Lung Cancer. Now what?

 

Did you know that more than half of all people with lung cancer have chronic obstructive pulmonary disease (COPD)? In fact, depending on the way COPD is diagnosed, 50-90% of lung cancer patients suffer from COPD.[1] Some people with lung cancer don’t find out that they have COPD until they’ve already been diagnosed with cancer. Could testing for COPD be a way of catching lung cancer earlier? We know that smokers with COPD are much more likely to develop lung cancer than smokers without it, but what about people who don’t smoke—can they get COPD, and if so, are they also at increased risk of developing lung cancer?

If you’ve never touched a cigarette in your life and have lung cancer, there is a chance it’s because you have COPD. A 2008 study published in the Archives of Internal Medicine estimated that COPD was responsible for 10% of lung cancer cases among people who don’t smoke.[2] COPD is the third leading cause of death in the U.S., and there are over 12 million people currently diagnosed with the disease.[3] Experts believe that the real number of people with COPD is twice that.[4]

While cigarette smoking is the leading cause of COPD, people who have never smoked make up 20% or more of all COPD cases[5] Interestingly, 4 out of 5 non-smokers with COPD are women. People who never smoked make up approximately 15% of diagnosed cases of lung cancer, and as with COPD, the majority of lung cancer patients who never smoked are women.  One out of 5 women diagnosed with lung cancer have never smoked whereas in men who develop lung cancer, only 1 out of 12 have never smoked.[6,7]

What is COPD, and What Causes It?

COPD is a progressive disease that causes airflow obstruction, making it more difficult for a person to breathe. COPD can take the form of chronic bronchitis or emphysema. Chronic bronchitis is the inflammation and scarring of the lung’s bronchial tubes, or air passages, which results in frequent coughing and the formation of thick mucus in the airways.  In emphysema, the walls of the tiny air sacs in the lungs are damaged and destroyed over time which leads to reduced gas exchange in the lungs.  Most people with COPD have a combination of both chronic bronchitis and emphysema.

COPD can’t be cured but its symptoms can be managed and controlled through various treatments, including medicines and pulmonary rehabilitation. Pulmonary rehabilitation includes exercise training, counseling, breathing strategies, and energy conservation techniques.

The leading cause of COPD is smoking;[8] smokers’ risk for the disease ranges from 35% to as high as 50%.[9] Second-hand smoke is also a major risk factor. A 2012 Norwegian study suggests that childhood exposure to tobacco smoke doubles the risk of girls developing COPD as adults.[10] Men exposed to tobacco smoke as children did not share the same heightened risk as women, but early exposure to tobacco smoke increases the risk of certain COPD symptoms in men, such as chronic cough. Other COPD risk factors include age, environmental and occupational exposures to pollution, dust and chemical fumes, a family history of COPD, a prior diagnosis of asthma, cooking with fire without proper ventilation, and in rare cases, having a genetic condition called alpha-1-antitrypsin (AAT) deficiency. AAT is a naturally occurring protein that protects the lungs from damage. People who don’t have enough of the protein are more likely to develop emphysema.[11]

Gender Differences in COPD

From 1998-2009, more women were diagnosed with COPD than men. Although overall death rates from COPD were lower in women than men, death rates in men decreased during this time period while death rates among women stayed the same.[12] No one is certain why this is, but there are differences in the way men and women are diagnosed and treated for COPD that may contribute to the disparity.

Even when they have the same symptoms, women with COPD are often misdiagnosed initially as having asthma, are less likely to be referred to specialists, and are therefore less likely to be treated quickly, accurately, and effectively for COPD compared to men. Women with COPD also report more severe symptoms and experience a lower quality of life. Women who are dependent on oxygen have a 50% increased risk of death from COPD as opposed to men on oxygen.[13]

How is COPD Diagnosed?

COPD is estimated to be undiagnosed or misdiagnosed in about 50% of the 24 million men and women estimated to have COPD in the U.S. Many people are not aware they have it until symptoms such as coughing, shortness of breath (dyspnea), increased mucus production, and wheezing develop slowly over time. Many patients fail to report symptoms to their doctors because they assume these symptoms are a normal part of aging and are unaware of the symptoms of COPD. Many smokers just assume that the symptoms they are experiencing are due to smoking and not to something more serious.[14] However, diagnosing patients with COPD from symptoms alone leads to errors of overdiagnosis. Studies have shown that the best method for diagnosing COPD is spirometry, which is a common and inexpensive office test that measures lung capacity. Spirometry can detect COPD even before symptoms become apparent and can be used to track the progression of COPD and determine if a treatment is working. Other methods used to diagnose COPD include chest x-rays, computed tomography (CT) scans, listening to the lungs with a stethoscope, and arterial blood gas tests that determine oxygen and carbon dioxide levels in the blood. In general, spirometry is used to detect airflow obstruction and low-dose CT is used to diagnose emphysema. Spirometry is usually used for standard COPD screening because it’s safe and inexpensive, but CT screening is sometimes necessary to diagnose people with emphysema who don’t also have airflow obstruction.

Over the years, various evidence-based guidelines for the prevention, diagnosis and management of COPD have been developed to assist healthcare professionals in their management of the disease. In 2001, the Global Initiative for Chronic Obstructive Lung Disease (GOLD), in conjunction with experts from the National Heart, Lung, and Blood Institute and the World Health Organization, published guidelines for physicians based on the latest research and recommendations.[15] The GOLD guidelines were updated in 2006 and again in 2011. Professional societies like the American Thoracic Society, the European Respiratory Society, and others have also published their own COPD guidelines, all with the same goal of educating healthcare professionals and improving COPD outcomes.[16]

Despite the availability of these guidelines for COPD, one of the most significant barriers to diagnosing COPD is a lack of knowledge among primary care professionals. A survey conducted in 2008 by Barbara Yawn and Peter Wollan at Olmsted Medical Center found that fewer than half of primary care professionals (family physicians, nurse practitioners and physicians assistants) knew about or used accepted guidelines for diagnosing COPD. A little over 20% reported using no COPD guidelines, 10% were unaware of what the current COPD guidelines are, 11% admitted using guidelines for asthma to diagnose and treat COPD, and only 7% tested for alpha-1-antitrypsin deficiency regularly. Even when these primary care physicians had spirometry in their offices, only 31% used it on suspected cases of COPD. Furthermore, only 1 in 5 primary care professionals referred all or most of their COPD patients to lung specialists.[17] This is alarming because lung specialists tend to follow the established COPD guidelines more closely than primary care physicians, and without their seeing COPD patients, the opportunity for early diagnosis and treatment may be lost.[18]

Too many primary care providers are unable to distinguish asthma from COPD and don’t recognize that women are at higher risk for COPD than men. Over a third (38%) of primary care physicians felt it was difficult to distinguish COPD from asthma, and 78% thought COPD was primarily a disease that affects men. When COPD symptoms are misdiagnosed as asthma, women receive the wrong treatment, and the correct COPD treatment is delayed.

Perhaps one of the biggest barriers to diagnosis, though, is the failure of patients to report symptoms to their doctor. People who feel guilty about smoking may decide not to tell their doctor about symptoms, or like non-smokers with COPD who think their symptoms are due to getting older, they may simply cut back on physical activity.4 When patients adapt to their increasing breathlessness and don’t mention it to their doctors, an opportunity to educate primary care providers about COPD—how widespread it is and whom it affects—is lost. This hurts people suffering from COPD and medical professionals alike.

Not Everyone Defines COPD the Same Way

There is no single standard for defining COPD with spirometry, which may account for some of the misdiagnosis of the disease. The GOLD definition of COPD is widely accepted: a FEV1/FVC of less than 0.70, which is the ratio of how much air a patient is able to exhale in 1 second (FEV1) to the total volume of air a patient can exhale in one breath (FVC).[19] The GOLD guidelines also classify COPD into 4 stages from mild to very severe based on other calculations.

The GOLD definition tends to over-diagnose COPD in the elderly since one value in the FEV1/FVC ratio decreases with age more rapidly than the other. An alternative definition is the lower limit of normal (LLN) definition of COPD, which takes age into consideration and compares the FEV1/FVC ratio of a patient to that of a healthy person who is the same age. Researchers found that while the GOLD definition tended to over-diagnose COPD, the LLN definition under-diagnosed COPD in some symptomatic patients.[20] Collecting more information during spirometry readings, such as total lung capacity (TLC), reduced the number of misdiagnoses. Another study found that sex differences in diagnoses are influenced by the COPD definition used.[21] When the GOLD definition of COPD was used, men had a higher risk of COPD, but among smokers, women were more likely to be diagnosed with COPD due to their increased susceptibility to cigarette smoke. However, when the LLN definition was used, there was no significant difference between male and female risk for COPD and no evidence of increased susceptibility to COPD among female smokers. Without an agreed upon standard for defining COPD, it is difficult to diagnose COPD definitively or to understand the different risk factors.

The Controversy Surrounding COPD Screening

In 2000, the National Lung Health Education Program (NLHEP) recommended that all smokers age 45 and older be screened using lung function tests, like spirometry, to identify undiagnosed COPD.[22] This led to widespread screening and spirometers in doctors’ offices everywhere. However in 2007, the American College of Physicians recommended that only patients with respiratory symptoms be screened with spirometry and not asymptomatic individuals, regardless of smoking history or age.[23]  In 2008, the U.S. Preventive Services Task Force followed suit and recommended against screening healthy adults without any respiratory symptoms for COPD using spirometry, stating that it had no overall benefit. The recommendation does not apply to individuals who have symptoms such as wheezing and chronic cough or people with a family history of alpha-1-antitrypsin deficiency who should be screened. (Few people are aware of whether they or their relatives have alpha-1-antitrypsin deficiency, but the test to screen for it is very inexpensive.)

The Task Force determined that the harms of spirometry screening, which include misdiagnoses and adverse effects from unnecessary treatment, outweighed the possible benefits of treatment and pulmonary rehabilitation. Spirometry can result in substantial over-diagnosis of COPD in never-smokers aged 70 and older, but there are fewer false-positives in other healthy adults who are screened. The Task Force found that although treatments can prevent COPD from worsening, patients with severe COPD die at the same rate whether or not they receive treatment. COPD treatments have also been associated with negative side effects in some patients, such as elevated heart rate and infections. Unfortunately, the Task Force found that providing smokers with their spirometry results did not necessarily result in more smokers quitting, and a favorable spirometry reading could actually discourage smokers from quitting.

According to the Task Force recommendation, patients with severe or very severe COPD who would stand to gain the most from screening make up less than 10% of those identified as having COPD using current diagnostic criteria. This means that hundreds of smokers would have to be screened to identify one person who would benefit. The Task Force concluded that widespread spirometry screening is likely to identify many patients with mild to moderate COPD who would not experience any substantial benefits from being diagnosed and treated. However, no one really knows if that is true: patients with mild or moderate COPD and patients without symptoms are rarely included in drug trials for COPD treatments, and without studies there is no evidence one way or the other.[24]

While the USPSTF has weighed in against widespread screening, there is no evidence that spirometry itself causes any significant adverse effects. Spirometry is noninvasive, low cost, and a fast way to determine lung function. Current or former smokers should speak with their physicians about the risks and benefits of being screened and see if their insurance will cover it.

Spirometry in combination with other clinical methods has been shown to be an effective COPD screening in some studies. In 2008, the National Heart Lung and Blood Institute and the COPD Foundation developed a 3-part approach to screening the general population for COPD.[25] First, a patient would answer a brief questionnaire about exposure to COPD risk factors and possible symptoms. Peak expiratory flow (the maximum amount of air that a person can forcibly exhale) would then be measured in the patient. If the peak expiratory flow was less than 70% of the predicted value, only then would spirometry be performed. The study found that the 3-step approach was useful for ruling out COPD in the general population and preventing false-positive results. However, the approach was not as accurate at detecting COPD in patients who had it. Another study looked at a validated COPD assessment test (CAT), which is a questionnaire asking about symptoms in their daily lives, on a random sample of the population.[26] The researchers found that smoking history, age (55 and older), and the presence of breathlessness were all key factors in identifying individuals at risk for COPD who would benefit from spirometry screening.

Treatment Options and Prognosis

There is no cure for COPD but symptoms can be managed through several treatment options, none of which have been shown to make people with COPD live longer.  Medications, such as bronchodilators which relax the airway muscles to make breathing easier, are administered using an inhaler.

  • Bronchodilators. There are two types of bronchodilators: B2 agonists and anticholinergics. Each type can be short-acting (taken only when needed and not more than every 4-6 hours) or long-acting (taken every 12 hours or more, everyday), and some people use both types. Both B2 agonists and anticholinergics improve symptoms and lung function, but neither extends patients’ life span. Anticholinergics have been shown to be more effective in preventing symptoms from getting worse compared to long-acting B2 agonists (LABAs). LABAs appear to cause more side effects than anticholinergics, but some people find that LABAs offer them more relief than anticholinergics.[27]
  • Inhaled Glucocorticosteroid. These reduce the body’s immune response and so, decrease inflammation. People who have moderate or severe COPD or are experiencing flare ups or worsening symptoms may be prescribed an inhaled glucocorticosteroid. A patient taking one of these will continue to have a declining quality of life but a slower decline than without the inhaled steroid. A patient’s breathing capacity will continue to deteriorate but the glucocorticosteroids allow the patient to be less bothered or limited by the decline. Side effects of glucocorticosteroids include hoarseness and “thrush,” a mucosal infection from yeast (oropharyngeal candidiasis).[28]
  • Pill or Intravenous Steroids.  Whether inhaled or taken some other way, steroids can be very effective in the short term but have many serious side effects over the long term, including increased blood pressure, an increased risk of type 2 diabetes, weakened bones, and cataracts.[29]

In addition to controlling symptoms with medication, patients are encouraged to be vaccinated against pneumonia and the flu, both of which can worsen COPD symptoms.

Another treatment option is pulmonary rehabilitation, which can improve the health and quality of life of those who suffer from COPD. Rehab programs include exercise to maintain muscle strength, disease management training, nutritional counseling to prevent muscle wasting and maintain a healthy weight, and psychological counseling to deal with depression. Oxygen therapy is another option but is usually reserved for patients with severe COPD. It can improve quality of life by allowing patients to perform certain tasks or engage in physical activity that they otherwise couldn’t do. Oxygen therapy also helps to reduce symptoms, improve sleep, and increase overall survival in some patients.

In a small study in Japan, researchers found that acupuncture improved shortness of breath in COPD patients taking medications.[30] Patients were better able to tolerate exercise and experienced less shortness of breath during exercise, which is usually a debilitating problem for COPD sufferers. Acupuncture has previously been shown to improve shortness of breath in cancer patients. Although this alternative approach seems promising, larger studies are needed to demonstrate the efficacy of acupuncture and determine if it’s a reasonable treatment option for COPD patients.

Although rare, surgery is a last resort for cases of severe COPD where medications, pulmonary rehabilitation, oxygen therapy, and alternative medicines don’t work. Surgery can range from removing parts of the diseased lung to a complete lung transplant.

Just as there are barriers to diagnosing COPD, there are barriers to treating it, too.  According to a study of knowledge and attitudes among primary care providers, only 15% believed COPD treatment was useful for improving symptoms. Among those with access to pulmonary rehabilitation, 3% believed it was useful and 16% were neutral about its benefits.

How quickly COPD progresses varies with each patient and therefore it is hard to predict how long someone with COPD will live. One study, however, showed that inflammation measured by testing urine, blood, sputum (spit), tissue samples, and even exhaled air may help predict death in COPD patients within the next three years.[31] In the 3-year ECLIPSE study, inflammation was associated with an increased risk of death from COPD.

What Does This Have To Do With Lung Cancer?

COPD is a lung disease that often co-exists with lung cancer and is estimated to affect 40-70% of lung cancer patients (depending on the diagnostic criteria used). Similarly, the Lung Health Study Research Group found that the most common cause of death among patients with airflow obstruction was lung cancer. [32,33] One study which looked at the prevalence of COPD in lung cancer patients, independent of age, sex, or smoking history, concluded that the prevalence of COPD in newly diagnosed lung cancer cases was six-times greater than in smokers without lung cancer: 50% of newly diagnosed lung cancer patients had COPD whereas only 8% of smokers without lung cancer had COPD. Lung cancer is much more likely in smokers with previously diagnosed COPD and poor lung function compared to smokers with normal or near normal lung function. It is estimated that 20% of all long-term smokers will eventually develop COPD over the course of a lifetime. The results suggest that impaired lung function may be more important than age or even smoking history as a predictor of lung cancer.

The findings of Victor Kiri and colleagues at PAREXEL International (a pharmaceutical clinical research firm) suggest that while lung cancer survival in general is very low, survival is even lower among patients with a previous diagnosis of COPD.[34] In the study, 26% of lung cancer patients without COPD were still alive 3 years after their diagnosis compared to just 15% of lung cancer patients with COPD. A 2005 meta-analysis, which is a combined analysis of several different but comparable studies, concluded that even a small reduction in airflow significantly predicted lung cancer.[35] Another study demonstrated that just a 10% reduction in lung function (as measured by a spirometer using forced expiratory volume in 1 second or FEV1%) was associated with an almost 3-times greater lung cancer risk.[36]

The link between emphysema and lung cancer has been illustrated in several studies. Lifelong non-smokers with a history of emphysema were more likely to be diagnosed with lung cancer and died earlier than other lifelong non-smokers.[37] In another study, current and former smokers whose CT scans showed emphysema were more likely to develop lung cancer than current and former smokers whose CT scans showed no evidence of emphysema. This was true regardless of whether spirometry testing indicated airflow obstruction among the smokers, which is also a predictor of lung cancer.[38] Lung cancer occurred most frequently in patients with both airflow obstruction and emphysema—regardless of how much tobacco exposure they had. On the other hand, the more severe the case of emphysema a patient had (severity increases with the number of cigarettes smoked per day), the greater the risk of lung cancer.

How are COPD and Lung Cancer Linked?

Genetic link

The above findings strongly suggest that COPD may be an important, independent risk factor for lung cancer. Some researchers believe that COPD and lung cancer have common origins in inflammation and also share some of the same genetic predispositions and environmental risk factors, with exposure to tobacco smoke being the primary risk factor.[39] It is well known that tobacco smoke can cause inflammation leading to chronic bronchitis and COPD. It is possible that chronic inflammation of the airways and lungs could result in repeat injury and repair of cells, uncontrolled cell growth, and eventually the development of lung cancer.[40] Chronic inflammation among people with COPD may activate the proteins that help cancer grow.[41] At the same time, the proteins needed to repair DNA in some of the lung’s cells are deactivated when COPD is present. COPD may also reduce the expression of key genes, preventing them from being involved in the detoxification of cigarette smoke. This can make cigarette smoke even more toxic and lead to the spread of malignant tumors beyond the lungs to other parts of the body. No one understands exactly how or why this happens, but studies reveal that genetic or biological changes could be responsible.

Sex hormones

Female sex hormones affect lung cancer, COPD, and asthma, which are the three most common lung diseases in women. The role of female hormones may explain why women (smokers and non-smokers) are more likely to develop lung cancer and COPD than men (smokers and non-smokers) (see Lung Cancer is a Women’s Health Issue).

Some studies suggest that female sex hormones, such as estradiol, inflame a smoker’s airways which could lead to lung cancer. Estradiol is the type of estrogen found in pre-menopausal women who are not pregnant. Its levels are low during menstruation and high during ovulation, and it causes an increase of certain proteins in the lungs which make the lungs more susceptible to damage from cigarette smoke.[42] This could be the reason why women smokers are more likely to develop COPD than male smokers—even when they smoke fewer cigarettes and for fewer years (called “pack-years” of smoking). Other studies suggest that estrogen may speed up the metabolism of cigarette smoke, which would increase cellular stress and damage in the lungs and ultimately lead to a higher chance of getting lung disease and COPD for women smokers.[43]

In addition to estrogen produced by the body, estrogen taken as hormone therapy also affects lung function. Research suggests that estrogen may help certain lung cancer cells spread throughout the lungs. A 2009 study based on the Women’s Health Initiative showed that post-menopausal women who took estrogen and progesterone combined hormone therapy had an increased risk of dying from lung cancer, regardless of whether or not they were smokers (although smokers had a higher risk of death than non-smokers).[44] A study published in 2010 showed that post-menopausal women who took estrogen hormone therapy for more than 10 years had a higher risk of developing lung cancer than women who didn’t take estrogen.[45] The use of hormone treatment after menopause does not appear to independently increase the risk of COPD, however.[46]

In terms of asthma, boys are more likely to be diagnosed with asthma than girls until the age of 15; after that, more women than men are diagnosed with asthma until women’s hormones decrease during the early stages of menopause. About a third of women with asthma find that symptoms worsen (and peak flow declines) in the period immediately before their menstrual cycle, presumably due to sudden changes in hormone levels.[47] Some studies suggest that a drop in estrogen levels is the problem while other studies indicate an increased risk of developing asthma when postmenopausal women take hormone therapy, which contains estrogen.[48] Despite the confusion, one thing is clear: dramatic changes in hormone levels trigger asthma and asthma symptoms in women, and asthma increases the risk for developing COPD.

Could COPD Patients be the Best Candidates for Lung Cancer Screening?

The relationship between smoking, airflow obstruction, and lung cancer is well recognized. Diseases characterized by airflow obstruction, like COPD, are associated with an increased risk of lung cancer and screening smokers for COPD as a risk factor for lung cancer could be worthwhile.

While low-dose CT screening for lung cancer has gained support in recent years, its value is still being debated (see Lung Cancer: Who is at Risk and Can They be Screened?). Most experts agree that current and former smokers are at the highest risk for lung cancer, yet not everyone agrees that they should all be screened. Smokers who have COPD could be the best candidates for lung cancer screening because they are most likely to benefit from it. Prioritizing high-risk smokers could also increase the accuracy and cost-effectiveness of CT screening. Since emphysema is usually detected with low-dose CT, it would be efficient and cost-effective to screen smokers and former heavy smokers for both emphysema and lung cancer at the same time.

The combined use of spirometry to diagnose COPD and CT to diagnose emphysema could help identify those at greatest risk for lung cancer and who would benefit the most from lung cancer screening. A diagnosis of COPD could alert patients to their elevated risk of lung cancer, just as high blood pressure does for the risk of stroke.

You Think you Might be at Risk for COPD and/or Lung Cancer. Now What?

  1. If you are currently smoking, stop or at least start cutting back. 1-800-QUITNOW and Smokefree.gov are free resources you can use to help you quit. Women have a harder time quitting than men and it takes years to reverse the damage of cigarette smoke. Even then some lung damage cannot be undone. However, women who do quit recover faster from the effects of cigarette smoke than men.
  2. If you have risk factors for COPD or lung cancer, discuss the risks and benefits of screening with spirometry or low-dose CT with your doctor. If you are experiencing any symptoms associated with COPD and/or lung cancer, see your doctor immediately.
  3. If you are diagnosed with COPD, lung cancer or both, consider participating in clinical trials for new treatments and therapies.
  4. Advocate for additional federal funding for research to investigate the link between COPD and lung cancer and discover new treatments for both diseases.

Related Content:
Screening for lung cancer: do risks outweigh benefits?
Lung cancer: who is at risk and can they be screened?
Lung cancer and African Americans

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