Lung Cancer's Shifting Face: Two Specialists on Never-Smokers, the Screening Dilemma, and the Symptoms we Ignore
By Arunima Rajan
Should a healthy 38-year-old be scanned? Aster Whitefield's Dr Ashwin K R and Dr Shivaraj A L weigh awareness against over-screening and agree that a cough lasting more than a month deserves a closer look.
Smoking history influences probability, not whether we investigate
Dr Ashwin K R, Head of Department and Consultant, Surgical Oncology and Gynaecological Oncology, Aster Whitefield Hospital
Dr Ashwin K R on lung cancer in never-smokers, the case against scanning a healthy 38-year-old, and what a diagnosis does to a young family's finances
Lung cancer in people who have never smoked
One of the greatest misunderstandings about lung cancer is that only people who smoke get it. Smoking remains the major cause of lung cancer globally, but there is growing recognition that people who have never smoked also develop it. Lung adenocarcinoma is the clearest example. It is the form of lung cancer most frequently seen among never-smokers.
A lung cancer diagnosis in a never-smoker is often a complete shock to the patient and the family, because they have never considered themselves at risk. That lower level of awareness can also delay diagnosis.
Persistent cough, breathlessness, unexplained weight loss, chest pain, recurrent chest infections affecting the same area of the lung, or coughing up blood should not be dismissed simply because the patient has never smoked. Symptoms should always be evaluated on their own merit.
As clinicians, we must remember that smoking history influences probability, but it should never determine whether we investigate persistent symptoms.
Should healthy young never-smokers undergo CT screening?
For a healthy, asymptomatic 38-year-old who has never smoked and has no major additional risk factors, I would not recommend routine CT screening. The evidence supporting low-dose CT screening has been generated primarily in older individuals with significant smoking exposure, and current international guidelines are based on that evidence.
Screening and diagnosis are two completely different situations. A person without symptoms should not automatically undergo CT scanning simply for reassurance. Someone with persistent respiratory symptoms deserves careful clinical evaluation, regardless of smoking history.
If a member of my own family asked me the same question, my recommendation would remain evidence-based. I would not advise unnecessary investigations simply because they were related to me. What I would insist upon is that persistent or unexplained symptoms are never ignored.
One of the major downsides of indiscriminate CT screening is the detection of incidental lung nodules that are completely benign. These findings can lead to repeated imaging, invasive biopsies, unnecessary surgery, considerable anxiety and increased healthcare costs.
The simplest improvement we can make immediately is not widespread screening of everyone, but better clinical follow-up. A patient whose cough persists despite appropriate treatment should not repeatedly receive another prescription without reassessment.
In my opinion, the larger delay today is often not the absence of screening programmes but the delay in recognising when a persistent symptom deserves further investigation.
The impact of lung cancer on young families
When lung cancer is diagnosed in someone in their 30s or 40s, the consequences extend far beyond the individual. These are often people at the peak of their careers, with young children, ageing parents and significant financial responsibilities.
Cancer treatment affects household income in multiple ways. Patients may need prolonged leave from work, while family members frequently become caregivers and reduce their own employment. Medical expenses, travel, investigations, medications and supportive care create an additional financial burden.
Modern lung cancer treatment has advanced tremendously. Surgery, targeted therapy, immunotherapy, stereotactic radiotherapy and personalised treatment have significantly improved outcomes for many patients. However, availability does not always translate into accessibility.
Access depends on timely diagnosis, molecular testing, affordability, insurance coverage and geographical access to specialised cancer centres.
Insurance generally covers cancer treatment irrespective of smoking status. The real challenges are inadequate insurance limits, exclusions, co-payments, expensive targeted therapies, repeated imaging and the prolonged nature of cancer treatment.
Improving awareness, strengthening referral pathways and encouraging timely imaging in appropriate patients would probably have a greater impact than indiscriminate screening of low-risk individuals.
Is lung cancer in never-smokers being overstated?
This is an important scientific question. Some experts caution against describing lung cancer in never-smokers as an "epidemic" without carefully examining the available evidence.
Their strongest argument is that although the proportion of lung cancers occurring in never-smokers may appear to be increasing, this does not necessarily mean the absolute incidence is increasing at the same rate. As smoking-related lung cancer declines in many populations, never-smokers naturally account for a larger proportion of the remaining cases.
That is a valid epidemiological point and one that deserves careful consideration. At the same time, we are undoubtedly diagnosing more lung cancers in people who have never smoked than many clinicians expected a generation ago. Improvements in imaging, molecular diagnostics and greater recognition of adenocarcinoma have contributed to this observation.
Journalists sometimes oversimplify the issue by suggesting that smoking no longer matters, or that air pollution alone explains every case. Neither is correct.
Cigarette smoking remains the single most important modifiable cause of lung cancer worldwide. But other factors also cause lung cancer in never-smokers, including air pollution, passive smoking, occupational exposure, biomass fuels and inherited genetic mutations.
Another misconception is that every healthy young adult should undergo annual CT screening. Current evidence does not support that approach.
If I could change one thing in India today, it would be greater awareness among both healthcare providers and the general public that lung cancer can occur even in people who have never smoked. Persistent respiratory symptoms should trigger reassessment rather than repeated empirical treatment.
The message I would like the public to remember is simple. Never-smoking does not mean zero risk. Lung cancer can occur in never-smokers, but the answer is not indiscriminate screening. The answer is greater awareness, timely evaluation of persistent symptoms, accurate diagnosis and ensuring that every patient reaches appropriate specialist care without unnecessary delay.
When the cough does not go away
Dr Shivaraj A L, Lead Consultant and Head of Department, Pulmonology, Aster Whitefield Hospital
Dr Shivaraj A L on chronic cough in never-smokers, and why a month without improvement should trigger a scan
A 45-year-old woman with no history of smoking came to us with a chronic cough of almost two months. She had first gone to a clinic near her home, tried all the usual medication, and was then referred to us. Because the cough had already lasted two months, I went straight to a CT. It showed a mass lesion in the left lower part of the lung. We did a bronchoscopy and biopsy immediately, and it turned out to be an adenocarcinoma. By the time she reached me she also had weight loss and a little blood in the sputum. So nearly two months passed between her first symptom and the scan.
We referred her to medical oncology, chemotherapy was started, and she remains on regular follow-up.
When a cough lasts more than a month and does not subside with regular medication, I strongly recommend a CT to look for any abnormality, including malignancy. This is what I tell my colleagues. Any patient with a chronic cough needs to be evaluated, irrespective of smoking history. Ask about family history of lung cancer, exposure history, and passive smoking. That history matters, because a smoking history is often absent in patients who turn out to have cancer. A chronic cough should never be neglected. It needs a CT, and if the CT raises any doubt, the patient needs a biopsy without delay.
What a scan can show
If a patient wants their lungs scanned, a low-dose CT is the better option. In the lungs, what we are looking for is the solitary pulmonary nodule.
Solitary pulmonary nodules are classified by size: under 6 mm, 6 to 8 mm, and above 8 mm. Within that, we classify patients as low risk or high risk. For a low-risk patient with a nodule under 6 mm, we advise repeating the scan after 12 months so that there is some follow-up. If the patient is in the high-risk category, we ask for it within six months. For nodules above 8 mm, we recommend a repeat CT after three months in high-risk patients, and after six months if the patient is low risk.
Take a healthy 38-year-old who has never smoked and who asks for a CT scan. A low-dose CT is a reasonable option. It gives you a picture, and if something is there, you can follow it up.
The case for screening more
Can we do more on screening? We can. Lung cancer incidence is rising, and we are seeing patients with no comorbid conditions presenting at an advanced stage. Wherever the option exists, and particularly where there is a family history, screen them. A low-dose CT carries little risk, and repeating it once every two to three years could make a real difference. It would let us screen a much larger number of people and pick up disease at an earlier stage.
What patients should take away
Lung cancers are on a slightly rising trend, especially among non-smokers, so do not ignore your symptoms. A simple cough is one of the symptoms of lung malignancy. If a cough is not settling in the first few days, or with simple medication, do not wait for it to get worse. Get your lungs checked and consult a specialist, so that anything in the early stage can be evaluated and acted on. An occasional CT does not really harm the body, and a low-dose HRCT is the better option. It will at least give you an idea of where you stand.
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