Lung cancer: Not just a smoker’s disease

Here’s what primary care and community pharmacists need to know about lung cancer in people who have never smoked, says Krishma Patel, clinical pharmacist at the Manor View Practice in Borehamwood

As part of my job as a clinical pharmacist at a GP practice in Hertfordshire, I hold asthma and COPD clinics with patients. As well as going through patients’ medication, checking inhaler technique and discussing any concerns patients might have, I am also looking out for flare-ups in symptoms.

These might indicate a short-term exacerbation of a patient’s disease, infection, or disease progression. Since COPD is also a risk factor for lung cancer – around 1% of COPD patients develop lung cancer each year¹– malignancy is on the radar.

There is a strong association between smoking and both COPD and lung cancer. Approximately 90% of cases of COPD²and 72% of lung cancers³are thought to be caused by smoking.

However, more than a quarter (28%) of lung cancers are not caused by smoking³, and these non-smoking lung cancers are on the rise – so much so that it is the eighth most common cause of cancer-related death in the UK.⁴ A stark reality is that lung cancer in people who have never smoked is usually not picked up until it’s terminal.

With November being Lung Cancer Awareness Month, several charities are using the opportunity to spread awareness of the disease in never-smokers. Primary care healthcare professionals have a duty to know about non-smoking lung cancer, because earlier diagnosis can contribute to improved outcomes for patients.

What causes lung cancer in non-smokers?

Comparatively little is known about non-smoking lung cancer, but research is ongoing. Studies have identified several possible causes⁵, including second-hand tobacco smoke, exposure to workplace carcinogens, and outdoor pollution. Certain lung conditions – tuberculosis (TB), human papillomavirus (HPV) and pneumonia – may increase an individual’s risk.⁶

Most cases of non-smoking lung cancers are non-small cell carcinoma, of which one major sub-type is adenocarcinoma. Adenocarcinoma is the most common type of lung cancer that non-smokers develop⁷, and it is likely to be caused by a non-hereditary genetic mutation.

Around twice as many women as men develop non-smoking lung cancer, and women are more likely to have mutations in genes called epidermal growth factor receptor (EFGR-positive cancer) and anaplastic lymphoma kinase (ALK-positive cancer).

In recent years, targeted therapies have become available that can effectively treat these cancers and, although not curative, can improve patients’ quality of life. Despite these advancements, only one in 20 patients survive for 10 years or more.⁸

The Ruth Strauss Foundation funds research into non-smoking lung cancer, with hopes of improving those statistics. Together with charities ALK-Positive UK and EGFR-Positive UK, they also work to boost the profile of non-smoking lung cancer so that patients are encouraged to seek medical advice when they suspect something isn’t right, and healthcare professionals take them seriously.

Identifying people with symptoms

Lung cancer screening programmes do not capture most individuals with non-smoking lung cancer, because typically they are too young and have no smoking history. Symptoms are similar in smokers and non-smokers and include persistent cough, fatigue, breathlessness, hoarseness, recurrent chest infection, weight and appetite loss, and enlarged lymph nodes.⁹

But often when non-smoking patients see their GP, their symptoms are vague or not perceived to be serious. Many go back time and time again and face protracted pathways to diagnostic tests. In fact, it is not uncommon for patients to visit other healthcare professionals in the first instance. Another symptom is neck, back or shoulder pain, which might prompt people to suspect a musculoskeletal problem and seek advice from a physiotherapist.

Similarly, individuals may present to pharmacies. A patient returning a few times over the course of several months with, for example, a cough that won’t shift, complaining of relentless fatigue, or querying whether they should go to their GP because of swollen lymph nodes should raise concern.

Of course, these vague symptoms could also be signs of many other common illnesses, and much more likely than not to be nothing to worry about. But our threshold for referring patients to their GP and advising them to have symptoms investigated should be lower than it currently is.

We should keep in mind not to overlook potentially important symptoms on the basis of having no smoking history.

You can find out more at:

See Through the Symptoms – https://www.seethroughthesymptoms.uk/

The Ruth Strauss Foundation – https://ruthstraussfoundation.com/

ALK-Positive UK – https://www.alkpositive.org.uk/

EGFR-Positive UK – https://www.egfrpositive.org.uk/