Curbing the nation's deadliest cancer

photo of a woman breaking a cigarette in half while looking directly at the camera

About 50% more American women die from lung cancer each year than from breast cancer. Screening mammograms to detect the latter are considered routine for women over 40. So why haven't lung cancer screenings caught up?

If you weren't aware screening for lung cancer was even possible, that's part of the problem, Harvard experts say. Nearly a decade after national guidelines led to broad screening programs for the nation's deadliest cancer — which the American Cancer Society estimates will kill about 130,000 Americans in 2022, including 61,000 women — an "abysmal" 2% of those eligible for the testing get it, says Dr. Andrea McKee, founder of the CT lung cancer screening program at Harvard-affiliated Lahey Hospital and Medical Center.

But tens of thousands of lives each year could be saved if they did, Dr. McKee says. Fewer than 20% of lung cancers are diagnosed at an early stage, when they're most treatable with surgery or radiation.

"It's really sad that so few people considered at high risk for lung cancer get screened," says Dr. McKee, who developed the first nationally accredited lung cancer screening center, which remains one of the largest programs in the United States. "It's a really incredible, lifesaving tool. We've never had anything this effective to reduce lung cancer mortality."

But many people don't know that lung cancer has joined the list of malignancies detectable through standard screening, which also includes breast, cervical, and colorectal cancers. "How long does it take to become household knowledge? That's what we're struggling with — getting that message out," she says.

Who's eligible, and what's involved?

Far fewer people in the United States smoke tobacco products today than even 15 years ago, with the smoking rate dropping to 13% in 2020, according to the CDC. Yet smoking accounts for about 85% of all lung cancers. Quitting at any point is beneficial, but even if you quit long ago, that doesn't eliminate your risk.

Screening is meant for certain people who smoke or used to, but don't show signs of lung cancer — such as persistent cough, hoarseness, shortness of breath, or chest pain — which tend to hide until the disease is already advanced.

Recommendations vary by medical organization, but you're eligible for lung cancer screening if all of the following apply:

You're 50 to 80 years old.
You currently smoke, or you quit in the past 15 years.
You have a smoking history of at least 20 pack-years (meaning you smoked a pack a day for 20 years of your life, or two packs a day for 10 years, or the equivalent).

About 15 million Americans are considered at high risk for lung cancer, qualifying them for annual low-dose CT scans that can reveal tiny abnormalities in the lung that might be cancer, Dr. McKee says. If screening catches lung cancer at stage 1, the cure rate with surgery or radiation treatment can reach 90%.

Noninvasive and painless, low-dose CT involves far less radiation than conventional CT scans, says Dr. Carey Thomson, director of the Multidisciplinary Thoracic Oncology and Lung Cancer Screening Program at Harvard-affiliated Mount Auburn Hospital.

Lung cancer's shrinking gender gap

It's always been the case that more men than women die from lung cancer. But this gender gap is narrowing in worrisome ways.

According to the American Lung Association, lung cancer diagnoses have skyrocketed 84% in women over the past four decades, while dropping more than one-third in men. Moreover, about one in five women diagnosed with lung cancer today has never smoked (compared with one in 12 among men).

"We're definitely seeing that even nonsmoking women are getting lung cancer," says Dr. Andrea McKee, chief of the Division of Radiation Oncology at Harvard-affiliated Lahey Hospital and Medical Center. "We don't yet know why, though."

The news isn't all bad. Women appear to benefit more from lung cancer screening, Dr. McKee says, because their tumors tend to grow on the outer edges of the lungs, which are easier to view on CT scans. Also, women often respond better to lung cancer treatments. Part has to do with women being more likely to have non-tobacco-related lung cancers, which tend to have targetable gene mutations. Dr. McKee says. "We can use targeted therapies to treat those cancers, and we've seen incredible results."

Obstacles to screening

Despite its advantages, low-dose CT cannot find all early-stage lung cancers, and some lesions it reveals won't be cancer — which will only be known after repeated imaging or more extensive and possibly invasive tests. Worries over such false-positive results can significantly hamper people's willingness to undergo the screening and even some doctors' willingness to recommend it, Dr. McKee and Dr. Thomson say.

"We expect people to have lung nodules if they're over 50 and smoke," Dr. Thomson says. "But the vast majority are not cancer. We tell people they're like freckles on the skin until we prove otherwise."

Another obstacle to more widespread screening is a lingering bias attached to smoking. "Stigma is a big part of it," Dr. Thomson says. "Some people may not be honest with their doctors about their smoking history. The medical system needs to understand how much you smoked and when you quit."

Another reason to quit smoking — or never start

Beyond the threat of lung cancer, smoking's health risks are well documented. Cigarette smoking has consistently topped the list of causes of preventable deaths and disease in the United States, according to the CDC.

Now a new study suggests that cigarette smokers are also twice as likely as lifelong nonsmokers to develop heart failure, a weakness of the heart muscle that keeps it from pumping enough blood to meet the body's needs. The study, published online June 6, 2022, by the Journal of the American College of Cardiology, analyzed long-term records of about 9,300 people (ages 61 to 81) in four U.S. communities. None had heart failure at the study's start. Smokers were diagnosed with heart failure at twice the rate of never-smokers over the following 13 years. Plus, their risks of developing the condition grew with the number of daily cigarettes smoked and years of smoking.

Heart failure is typically a progressive condition, in which the heart's pumping ability diminishes over time. One of the top causes of death and disability, the condition affects more than six million Americans.

Key takeaways

If your age and smoking history make you eligible for lung cancer screening — or if you're concerned about your risks for the disease regardless of those factors — start a conversation with your primary care doctor. "Doctors are so time-pressed in their practices today that they often don't have time to wrap this information into a routine checkup," Dr. Thomson says.

Dr. Thomson and Dr. McKee offer this additional advice.

Don't be fooled. Just because your smoking years are long past, that doesn't necessarily negate your lung cancer risks. "We see a lot of lung cancers occurring years after someone quits," Dr. Thomson says.

Don't be fatalistic. "Many women tell us they don't want lung cancer screening because they think they'll die of it anyway if lung cancer is found," Dr. Thomson says. "But the point of screening is to find it when it's very small and not lethal. Lung cancer screening saves more lives than any other screening we have for cancer."

Be your own advocate. "Anyone who has lungs can get lung cancer, but rates are much lower in nonsmokers," Dr. McKee says. "But if you have symptoms suggestive of lung cancer, you need to advocate for yourself and ask about testing — because some doctors will think they don't need to look for it since you don't smoke."

Spread the word. Encourage your friends and loved ones to be screened if they smoke or did in the past.

"Screening is the tide that will raise all boats," Dr. McKee says. "We're learning so much about lung cancer — both tobacco-related and not tobacco-related — because of screening. And the more we know about it, the more we'll all benefit."