A quiet killer

CHICAGO — Quick — what’s the biggest cancer killer of women?

If you said, “breast cancer,” you’d be in good company. But you’d be wrong.

Lung cancer kills more women in the U.S. than breast cancer and all other gynecologic cancers combined. According to the American Cancer Society, nearly 70,000 American women are expected to die of lung cancer this year, compared with about 40,000 who will succumb to breast cancer.

“Women don’t have this on their radar screen,” said Dr. Kathy Albain, professor of medicine at Loyola University Chicago, “and it’s a travesty.”

Lee Ann Gaal, 50, one of Albain’s patients at Loyola’s Cardinal Bernardin Cancer Center in Maywood, Ill., learned the hard way.

Gaal, a longtime Chicago Public Schools teacher, started having mammograms while she was still in her 30s. An aunt had died of breast cancer, making Gaal well aware of the danger from that quarter. But even though her father had died of lung cancer, Gaal smoked at least a pack of cigarettes a day from the age of 13.

“I guess I thought lung cancer was just for men,” she said.

(That was true in the past, because far more men smoked cigarettes, and smoking causes nearly 90 percent of lung cancer cases. In recent decades, however, women have just about caught up: 21 percent of U.S. women and 25 percent of men now smoke.)

About six years ago, Gaal noticed that her ankles were swollen. Her primary-care doctor sent her to an arthritis specialist, who poked and prodded and eventually pronounced, “I’m not positive, but I’m pretty sure you have lung cancer.”

It was a bolt from the blue. Gaal turned out to have an 8-centimeter tumor on her lung that eventually spread to her brain. But after surgery, radiation and chemotherapy, she’s alive to tell her story.

The majority of lung cancer patients are dead within two years of diagnosis, but Albain stresses that increasing numbers of patients are beating those odds, thanks to new and improved forms of treatment.

“I need to say, ‘thank you, Jesus’ every day,” Gaal said. “It’s only by a miracle that I’m alive.”

Her biggest regret is that she put her family through hell. “My (then) 15-year-old son had to hold his mother on the couch while she was having a seizure” from the cancer in her brain, she said tearfully.

“Women who smoke need to know they’re risking their lives,” Gaal said. “But what they do to their families is so much worse.”

Gaal would like to help spread the word about women and the risk of lung cancer. “I’m not minimizing those who die of breast cancer,” she said, “but for pity’s sake, we just had the very first lung cancer walk in November! People just don’t want to hear about it.”

Albain, who specializes in both breast and lung cancer, is trying to do something about that. Three years ago she helped found Women Against Lung Cancer, which brings women oncologists and other health-care professionals together with leaders of women’s advocacy groups to advance education and research.

This year she and other researchers are launching a large clinical trial that will attempt to establish why some people get lung cancer while others don’t, and why some patients do better once they get it.

Being female may have something to do with it, Albain believes. Some studies (but not all) have suggested that women who smoke are more susceptible than male smokers to the carcinogens in cigarettes. There are also many more women than men among lung cancer patients who never smoked. It’s unclear, though, whether that’s because women are more susceptible to lung cancer.

Different type of cancer

Dr. Michael Thun, who heads epidemiological research for the American Cancer Society, said it could be simply because there are more older women than men in America who have never smoked.

Women also tend to get different types of lung cancer, to be younger when they get it and to have a close relative with the disease. In addition, lung cancer behaves differently in women than in men: Women are more likely than men to respond to certain types of treatment, and they live longer once diagnosed.

“Lung cancer appears to be a different disease in women,” said Dr. Jyoti Patel, an oncologist at Northwestern Memorial Hospital and author of a recent paper in the Journal of the American Medical Association calling for gender-specific studies to address those differences.

Patel said that lung cancer is not a priority for agencies that fund medical research. HIV/AIDS research gets almost $30,000 per patient death, and breast cancer gets about $13,000, she said. But lung cancer gets only about $1,500 per patient death.

“There are no pink ribbons for lung cancer,” Patel said. “So it’s a double blow – you have a horrible illness and no one seems to care.”

Albain agrees more research needs to be done. And, like Patel, she believes it’s imperative that scientists include more women in lung cancer treatment and prevention trials so they can discover what differences might be linked to sex – which could yield important clues for treatment and detection of the deadly disease in both men and women.

Looking for answers

Some of the angles she expects to examine in her study are whether women metabolize certain carcinogens differently, whether their DNA is less efficient at repairing itself when it’s damaged, whether they have more or different gene mutations that promote cancer (“oncogenes”), and how hormones affect their risk of getting lung cancer. Some studies have suggested, for example, that women who take oral contraceptives or hormone replacement therapy are more likely to get lung cancer.

“We know that smoking causes lung cancer,” Albain said. “But only 1 in 10 smokers gets the disease. Why is that?” The answer probably lies in the complex interactions between smoking and other factors, both environmental and biological.

So Albain’s study of 740 lung cancer patients will collect information on smoking, exposure to secondhand smoke and other environmental carcinogens in addition to tissue and blood samples. “We need to find out if there’s an environmental exposure profile that puts you at higher risk” for lung cancer, Albain said.

The study, which is expected to start enrolling patients nationwide in the fall, will include equal numbers of men and women, both smokers and nonsmokers. Researchers in several large cancer research cooperatives will participate.

First, stop smoking

Once your consciousness has been raised, what can you actually do to protect yourself against lung cancer?

If you smoke, stop. Nearly 90 percent of lung cancer cases are caused by smoking, and the terrifying increase in the incidence of lung cancer among women in the last century tracked the increasing popularity of cigarette smoking.

Be aware that, if you’ve smoked in the past, you have an increased risk for many years – perhaps forever. So don’t ignore possible symptoms, such as a persistent cough, coughing up blood, hoarseness, persistent chest or shoulder pain, weight loss, unusual fatigue or loss of appetite. Dr. Kathy Albain of Loyola University Chicago says lung cancer sometimes goes undetected because people are afraid to acknowledge the early symptoms. “You shouldn’t be scared,” she added. “We can cure more and more early-stage lung cancer.”

If you have recently been diagnosed with lung cancer, says Albain, get to a major medical center where you’ll have access to state-of-the-art treatments. Also consider enrolling in a nationwide study that is due to open in the fall. That study, to be conducted by Albain and others, could yield important clues about why some people are more susceptible to lung cancer than others.

And what about having a screening test for early detection of lung cancer – something like the mammograms used to detect breast cancer?

The U.S. Preventive Services Task Force says there isn’t enough evidence to recommend for or against lung cancer screening of people with no symptoms. Early studies of lung cancer screening (mostly with chest X-rays) showed that screening detected many more cases of lung cancer but failed to reduce deaths from the disease. The conclusion was that the tests were probably detecting lung cancers that would never have become life-threatening. However, more recent studies using CT scans to screen high-risk men and women have raised questions.

Research is currently under way to determine whether screening with low-dose CT is more effective than old-fashioned X-rays. The results won’t be known for several years, but in the meantime some doctors are recommending CT scans for patients at high risk, including longtime smokers and those with a strong family history of lung cancer.

One of the problems with CT screening is that the test is too sensitive: About 1 in 4 people who get screened will be found to have an abnormality that needs further work-up, but only 1 in 10 of those will turn out to be cancer.

“We’re not recommending lung cancer screening outside of a good clinical trial,” said Albain, “except perhaps for someone in a high-risk family, or a longtime smoker. But I will always recommend a diagnostic CT for someone whose symptoms won’t go away – even if she’s not a smoker.”