Non-Smokers vs Smokers Lung Cancer - Differences and Unity

Non-Smokers and Smokers Unite as a Lung Cancer Community

man holding a cigarette and looking upwards as if questioning something
Should there be a distinction between smokers and non-smokers lung cancer?. Istockphoto.com/Stock Photo©Siphotographys

It's not uncommon to hear a particular adjective preceding a diagnosis of lung cancer. You've likely heard it spoken this way: "I have non-smoker's lung cancer."

I have a love-hate relationship with this distinction between "non-smoker's lung cancer" and "smoker's lung cancer." In one way, I'm pleased these words are sometimes spoken. Every time someone hears the words "non-smokers lung cancer" it's a reminder that lung cancer can, and does, occur in never smokers.

On the other side, my heart goes out to those who have lived with "smoker's lung cancer" and the horrible stigma of lung cancer they have had to cope with since the day of their diagnosis.

I'd like to say that if I developed lung cancer I would not make this distinction. But that wouldn't be honest. I'm guessing I would be someone who would say I have "non-smokers lung cancer." It pains me to put that out there, but it's true.

How do I know?

Instead of lung cancer, I was dealt the pretty-pink-ribbon cancer. And even having a cancer with minimal stigma, there's still a sense of being blamed for the disease. To be brutally honest I know that I've shared with more than one person that I nursed all 4 of my children, and only for the reason of escaping that sense of blame. Breastfeeding lowers the risk of developing breast cancer. In other words, the only reason I wasted a precious moment of someone's time was to assert that I didn't intentionally not do something I could have done to lower my risk.

Looking back it saddens me to realize this.

But back to the distinction - as it affects many people. After all, lung cancer in never-smokers is now the 7th leading cause of cancer deaths in the United States. Should we ever distinguish between smokers and non-smokers lung cancer? Does it matter?

Bare with me as I break a rule and give important arguments for both answers to this question.

Smokers vs Non-Smoker's Lung Cancer - A Conversation

Let's start by talking about when and where the distinction between smoking status in people with cancer appears, and when and where it should appear. As we'll talk about later, it can be important in the oncologist's office. Outside of the office, however, is another story. Distinguishing with the office door open interferes with the sense of community which is so important for people with lung cancer: smokers and non-smokers alike.

Though I hear comments about "non-smokers lung cancer" frequently, it hit me from another angle last week. A neighbor in her 40's was diagnosed with lung cancer and was furious that her doctor had labeled her as having "smoker's lung cancer." It broke my heart what occurred next. To understand why, think about what ordinarily occurs next in a conversation when someone tells you that they've been diagnosed with breast cancer. Perhaps the discussion would revolve around what her treatment choices may be - at least, that happens often when people know I'm a physician.

For those who aren't physicians in my shoes, the conversation may instead turn to special needs. What can they do to help? Should they bring meals? Does she need a ride to appointments?

Instead, this conversation went another way. My neighbor couldn't focus her thoughts on getting the best treatments, or how she was going to balance her life and work during those treatments. Instead, she needed to vent, and vent she did. Yes, she had smoked she told me. She smoked for a total of 6 months back in college 25 years ago. Yet since this added up to over 100 cigarettes total she was placed in the "smoker's category." She felt as if she was being punished and being given a life sentence for a moment of rebellion when she was 20. 

What came next? Again, instead of being able to talk about treatments and what she needed help with, she was thrown back to her college days. Why did she smoke way back when? And worse. Maybe if she'd had a different roommate - one who didn't offer her the first cigarette - she wouldn't be in the place she is now. She started to think of ways in which her life could have been different 25 years ago.

Where does that direction in a conversation lead? Think about it. Does it help her make any of the big decisions now placed in front of her regarding her health care? No. (And even worse, it made her feel just a tad less worthy of those treatments.) Does it help her figure out how she is going to feed her kids while she is having those treatments that she still has to figure out how she is going to get to - when she can get around to thinking about them in the first place?

What Would You Do?

Thinking that this conversation was being anything but constructive - I didn't want her to dwell on her past and seriously wanted to find out what she needed so I could get to work rounding up others to make her life as easy as possible through a difficult diagnosis—I tried re-directing the conversation. But she wasn't finished. The comment about having "smoker's lung cancer" had reached to her very soul. The stigma of lung cancer was eating her alive.

That's when I realized how most of us would feel the stigma just as she was. Our first remarks would be to clarify our non-smoking status, or go where she did.

I'm guessing some people would just tell her not to let it bother her. "Don't let what you think others might think hurt you." But what is that doing? It places yet another burden on her shoulders.  Now she not only has to cope with her feelings about her disease, her feelings about her past smoking, the treatments she needs to consider, and what she's going to do with her kids, but we've tacked the burden of fixing the stigma on top of that list. How unfair. We're already victimizing the victims with lung cancer enough without asking them to fix the problem.

Which is why I'm writing these words. We need to address the stigma of lung cancer so people like Sharon (I changed her name for her privacy) don't have to suffer so much, and part of that effort means looking at when it is right—and when it is not—to preface the term lung cancer with non-smoker or smoker.

So let's talk about exactly when it's okay and when it's not, to make the distinction.

When Should We Make the Distinction?

There are important reasons to separate out lung cancers in people who have never smoked and those who have smoked. Those reasons, however, are ones that should remain behind an exam room door. My neighbor's doctor was making the distinction because lung cancers in non-smokers and smokers are different in many important ways—and those differences can guide treatments (although I still believe that smoking for 6 months in college places her medically in the non-smokers group more than smokers and let her know that.)

Let's put a name on those differences—spell them out—and then get back to why, for non-smokers and smokers alike, making a distinction will harm progress in treatments that will negatively affect both groups.

Smoker’s vs Non-Smoker’s Lung Cancer – From the Medical Side

Lung cancer is different in non-smokers and smokers in several important medical ways. These can include:

Symptoms before diagnosis - You may have heard recently that heart disease symptoms in women often differ from those in men—enough that women are more likely to die from the disease as the diagnosis is frequently missed until it's too late. Unfortunately, a similar phenomenon occurs in non-smokers with lung cancer. 

The symptoms of lung cancer in non-smokers often differ from the symptoms most common in people who smoke - and the ones most people know. Lung cancer in non-smokers is often diagnosed at a later stage - when it is more advanced - than in people who smoke. Part of this may be that the symptoms differ, and part may simply be that lung cancer in non-smokers is low on most doctor's radar screen.

Lung cancer screening - If you've smoked, make sure you know about lung cancer screening. In one sense people who have smoked have an advantage - there is a screening test available. Otherwise, your best bet is still being aware of the early symptoms of lung cancer.

early symptoms of lung cancer

Types of cancer - One type of non-small cell lung cancer called lung adenocarcinoma is much more frequent than other types in people who have never smoked. While people who smoke also get adenocarcinoma, cancers such as squamous cell carcinoma of the lungs and small cell lung cancer occur far more frequently than in people who don't smoke. This is important as these types of lung cancer may be treated very differently.

Molecular profile of tumors - It's now recommended that everyone with non-small cell lung cancer have gene profiling (molecular profiling) done on their tumors, and it turns out that this is extra important for never smokers. In never smokers, and in young people who develop lung cancer, the chance that a treatable mutation or genetic change is present is higher than in people who smoked. In other words, this testing can detect not only a unique signature to the tumor, but there are specific treatments available to treat those unique characteristics. So - while everyone should be tested, knowing that someone has never smoked should alert oncologists to make extra sure this is done.

Surgery - Lung cancer surgery for people who smoke can be riskier for those who smoke (or have smoked) than never smokers since smoking is also associated with conditions such as coronary artery disease.  People who smoke may also have other smoking-related cancers.

Immunotherapy - It may surprise some people, but immunotherapy - the "new" treatments which harness the body's own ability to fight cancer via the immune system - may work better in people who have smoked than in those who haven't. It seems that the more mutations present in a tumor, the better some of these treatments work. And lung cancer cells in people who have smoked tend to have many more mutations than those of people who haven't smoked.

Predicting survival - It's been found that non-smokers with lung cancer have better survival rates at each stage of the disease, so knowing whether or not someone has smoked may help your doctor discuss your prognosis. There's a caveat to this, though. Many new treatments have been approved for lung cancer, even in the past year, so statistics we look at to predict survival may not mean as much as they did in the past. In fact, at best they can only tell us what your statistical survival rate would be if you were treated with treatments that are no longer the best treatments available for the disease.

Smokers vs Non-Smokers Lung Cancer in Community

If you haven't heard about the "lung cancer community" you will. Lung cancer is no longer the wallflower, Not only is the face of lung cancer changing, but its voice is becoming louder.

What this community lacks in numbers - after all, with the differences in survival rates between lung cancer and breast cancer there are simply fewer survivors - it makes up for in-depth. A depth we don't want to see threatened by divisions caused by the smokers vs non-smokers lung cancer distinction. Could that happen?

We don't have to look far to see our answer. Let's look to the pink ribbon and a community most of us know well: the breast cancer community. Have divisions caused a problem? Just ask someone with metastatic breast cancer, for example, another of my neighbors who was kicked out of her breast cancer support group for having metastatic breast cancer. The others in her group - women who had non-metastatic cancer - found it too "depressing" to hear about her struggles with complications, and, well, worries about death. In creating this division, however, there is less support and ultimately less strength in fighting for a cure.

I haven't seen this with the lung cancer community and don't want to see this change. It doesn't seem to matter if someone is stage IA or stage IV. It doesn't seem to matter if someone has a cancer which is localized or one which is widely metastatic. Since there has been so much unity in this regard, let's not allow a distinction based on smoking. There is strength in unity. The kind of strength that benefits everyone with the disease.

Smokers and Non-Smokers With Lung Cancer Uniting 

Instead of making a distinction between non-smokers and smokers lung cancer, let's remain united as a lung cancer community. Discrimination ends here. I once shared ways in which it is harder to cope with breast cancer than with lung cancer. Let's make unity be one of the reasons it may be easier to cope with lung cancer than with breast cancer. The white ribbon of lung cancer represents hope for everyone with the disease alike.

Sources:

American Cancer Society. Why Non-Smokers Sometimes Get Lung Cancer. 10/15/15. http://www.cancer.org/cancer/news/features/why-lung-cancer-strikes-nonsmokers

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