According to the American Cancer Society; there were 215,020 new cases of lung cancer and 161,840 deaths expected due to lung cancer in the United States in 2008. I know how lethal this cancer can be. I was 15 years old when the Surgeon General, Luther Terry, in 1964 announced that cigarette smoking could cause lung cancer.13 I came from a family of smokers, my parents as well as my grandmother who lived with us smoked. Everyone I knew smoked including most of my classsmates. By 16 I was smoking to be “sophisticated and adult”. In my early 20s, I developed asthma which forced me to quit. It was a blessing in disguise. My father was not so lucky. He quit smoking in the early 90s due to a heart attack and did quite well until he developed a nagging pain in his side. It was a shock to learn he had small cell lung cancer that had metastasized to the liver. The oncologist advised with chemotherapy he could prolong his life, with quality of life – for about seven months. Without it, he would be dead in two. Although he sailed through chemotherapy, two months afterwards he had a stroke. The cancer had spread to his brain. Treated then with radiation, he lived another four months. My father became another lung cancer statistic.
There was hardly any reference to lung cancer prior to the nineteenth century. The use of tobacco in the 1800s was primarily cigar use by wealthy gentlemen; cigarettes were made of the leftover cigar scrapings and smoked by the poor. 19 It wasn’t until World War I when cigarettes were mass produced and given away free to millions of soldiers by tobacco companies that cigarettes became popular. Because of the time lag of about 20 to 30 years between starting to smoke and lung cancer development, it wasn’t until the 1930s that suddenly there was an increase in the cases of lung cancers. 19
In the 1950s studies in the United States and in England proved the association between smoking and lung cancer. 10 However, cigarette smoking was, by then, a way of life. The rich and famous, the sophisticated and attractive, all smoked. Macho men such as The Marlboro Man, John Wayne, Yul Brynner, Jason Robards, Paul Newman and a huge number of Hollywood actors, entertainers such as Nat King Cole, TV broadcasters such as Edward R. Murrow, and even Walt Disney, all smoked. Old movies from the 40s and 50s almost always showed actors smoking. Women started smoking as well during World War II in part to huge marketing campaigns by the tobacco companies. Lung cancer went from hardly been heard of, to the number one cancer killer in the Western world by the 1970s.19
By the 1990s the public was made aware of the methods that some tobacco companies used to making cigarettes even more addicting. 9 Of the above mentioned actors (including three who appeared in the Marlboro commercials as the Marlboro Man), all died of lung cancer. 10, 7, 20, 11, 14 Yul Brynner made a very profound commercial against smoking which aired in the 1980s shortly after his death.
Lung cancer begins in the tissues of the lungs and is primarily caused by cigarette smoking. It is responsible for about 85-95% of all lung cancer deaths and is primarily a disease of the elderly usually over the age of 65. 9, 16 There are over 4,000 chemical compounds in tobacco smoke. There are two primary carcinogens, nitrosamines and polycyclic aromatic hydrocarbons, as well as many other carcinogenic compounds. Smoking one pack of cigarettes a day increases the risk of developing lung cancer that is 25 times that of a nonsmoker and the risk increases by the number of years smoked. Cigar and pipe smoking can also cause lung cancer and the risk of developing cancer is about 5 times that of a non tobacco user. 16
Radon gas is a natural radioactive gas that is the second leading cause of lung cancer among non-smokers and is responsible for about 21,000 lung cancer deaths each year. Radon gas can travel through pipes, foundation gaps, or other openings into homes. It is invisible, and undetectable by smell or taste. One out of every 15 homes can contain lethal levels of radon gas per the Environmental Protection Agency. This gas can be detected with simple testing kits. 13
Secondhand smoke, inhaling the smoke from tobacco users, is another cause of lung cancer. There is a 24% increased risk for developing lung cancer in a nonsmoker who resides with a smoker. 16
Occupational hazards, such as asbestos exposure, can cause cancer although the use of asbestos today has been banned or very limited. Asbestos fibers can last permanently in the lungs after exposure, and smoking vastly increases the risk of lung cancer to as much as 50 to 90 times that of nonsmokers. 16
Environmental causes, the smallest percent of lung cancer deaths at 1%, can be attributed to air pollution. Whether industrial, vehicle, power plants, etc, the prolonged exposure to air pollution can carry a risk similar to that of secondhand smoke. 16
Genetically there is also a predisposition in some people to the development of lung cancer as well, those people with a relative who has had lung cancer are more likely to develop lung cancer, regardless of whether they smoke or not. There is also recent research that has determined a chromosome that likely contains a gene that increases the chance for development of lung cancer in smokers. 16
The symptoms of lung cancer often are similar to other respiratory disorders and can make early detection very difficult in a smoker. A chronic cough, shortness of breath, coughing up blood, chest pain or back pain, a new cough, wheezing, decrease in exercise capacity, pneumonia or repeated respiratory infections all can be signs of lung cancer. These symptoms are caused by the effects of the tumor or possible disturbances of blood or hormones. 17
There can be other symptoms that can be caused by the tumor’s effect due to metastasis to other organs in the body. Some of the more common symptoms can be bone pain, joint pain, vision problems, hoarseness, seizures, weakness, fatigue, chills, clubbing, atrophy, loss of appetite and weight loss. It is estimated that 1/4 of people with lung cancer will not have any symptoms until the cancer has been diagnosed by other means, such as a chest x-ray. 22
Lung cancer is a disease of uncontrolled cell growth in the lung tissues. It is divided into two classes and further divided by histological appearance, non small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). The classifications determine the treatment and the prognostic factors. 6
The most common type of lung cancer is NSCLC. It makes up approximately 80% of all lung cancer cases. It is divided into three main categories. The two most common types of non-small cell lung cancer are adenocarcinoma (ADC) and squamous cell carcinoma (SCC). ADC originates in the cells that are in the lining of the lungs and is the most common type in non-smokers. It can be histologically sub classified further into bronchioloalverolar (BAC), papillary, acinar, mixed and solid with mucin carcinomas.4 SCC originates in the cells that line the passages of the respiratory tract. There is an additional third type called large-cell carcinoma (LCC) or large-cell undifferentiated carcinoma which makes up a group of cancers which have variants including clear cell carcinoma, giant cell carcinoma, and large cell neuroendocrine carcinoma (LCNEC). 4, 14 These cancers are somewhat slow growing as opposed to the SCLC. NSCLC usually starts in the bronchi/lung lining but it can also start in other parts of the lungs, and commonly spreads to the mediastinum and the lymph nodes. It can take years sometimes, for NSCLC to develop to the point where it is symptomatic.
SCLC, on the other hand, is the most aggressive of the lung cancers, making up about 20% of all lung cancer cases. 15 The statistics for survival are low – only a 5-year survival rate. SCLC is considered a neuroendocrine tumor and is subdivided into three classes which are small cell carcinoma (oat cell cancer) the most common, mixed small cell/large cell carcinoma, and combined small cell carcinoma. It usually originates in the central airways; the lobar or main bronchi and lymph nodes are involved very early in the disease process. 5 This is a particularly lethal cancer that grows extremely rapidly. Usually no symptoms are ever indicated until there is already metastasis to another organ site. The course, treatment and prognosis are much different from LSCLC as it is considered a systemic disease. 5
Last to mention are the carcinoid tumors, which recently have been discovered to be a form of bronchopulmonary neuroendocrine tumors which include SCLC but not as lethal. These are fairly uncommon pulmonary neoplasms; typical carcinoid tumors grow slowly and metastasis is rare, atypical carcinoid tumors are much more aggressive. Approximately 1 to 6% of lung carcinomas are carcinoid. 5
There are several additional rare forms of cancer that can occur in the lung such as adenoid cystic carcinoma and mucoepidermoid carcinoma, but these are primarily salivary gland tumors. 6
Early detection of lung cancer is crucial since approximately 16% is diagnosed at the earliest and potentially curable stage. Most lung cancers are not diagnosed until symptomatic and most patients will die within one year because they are diagnosed too late.16 Diagnostic testing for lung cancer starts with a physical exam including history and symptoms, then likely a chest x-ray, blood tests including CBC and liver functions, sputum cytology and lung function tests. Other tests may include a bronchoscopy with lung biopsy, needle biopsy or possibly a mediastinoscopy. The diagnosis for SCLC is always based on tissue samplings. 5 Once the diagnosis has been established, further testing will be made for staging NSCLC which can include a CT scan, MRI, abdominal ultrasound, PET scan (or CT/PET fusion imaging), bone scan, brain scan or bone marrow scanning. 2 There may be additional blood tests to look for lung cancer markers, such as PTH (parathyroid hormone), CEA (carcinogenic antigen), or CYFRA21-1 (cytokeratine fragment 19). 18
Cancer staging can indicate whether the cancer is limited or has metastasized, the appropriate treatment and the prognosis. The TNM system (T = tumor size, N = node involvement, and M = metastasis status) is used for NSCLC, but not used for SCLC. SCLC is usually grouped as limited or extensive. Limited-stage means the cancer is still just in the chest, the mediastinum and the supraclavicular nodes, and extensive-stage the tumor has spread beyond the lungs.18 Once the diagnosis has been established, the treatment is very different between NSCLC and SCLC. The primary factor that will influence the type of treatment for NSCLC will be whether or not the cancer has spread to the lymph nodes in the chest. Most likely SCLC has already spread to other parts of the body before it is detected although in rare instances it may be detected early enough for surgical treatment. Metastasis to the brain is common in SCLC as well as metastasis to the liver, bones, and adrenal gland. 5
It is beyond the scope of this article to go into any great depth regarding the various types of treatment, because there are so many factors that determine how each patient will be treated. Much depends upon the type of lung cancer and the staging in NSCLC and whether limited or extensive in SCLC. The patient’s physical condition also determines the type of treatment as some medical concerns will compromise the usual treatment that would be provided. Both types of cancer respond differently to various kinds of treatment.
NSCLC can be treated with surgery if the tumor is stage I or II without evidence of any mediastinal disease and has not spread to the lymph nodes of the chest.5 Techniques used may include a thoracotomy, median sternotomy, anterior limited thoractomy, anterioraxillary thoracotomy or a posterolateral thoracotomy. Newer, less invasive surgeries include video-assisted thoracoscopy or video-assisted thoracic surgery (VATS). Partial removal of the tumor along with a lung lobe is called a lobectomy. A wedge resection, also called a segmentectomy is a sublobar resection used for those patients with poor pulmonary reserve. 5 If the entire side of the lung is removed, it is called a pneumonectomy. 4, 5
Radiotherapy may also be used and in some cases may be curative for those stage I and II cancers that are not amenable to surgical resection.5, 6 It can kill the cancer cells, shrink the tumor and/or relieve pain. There is external beam radiation that targets specific sites, brachytherapy which can be implanted near or in a tumor, and intensity modulation radiation therapy which attempts to match the shape of the tumor. 15 The side effects may include vomiting, anorexia, hair loss, pain, swelling, erythema, atrophy and infection risk with leukopenia. 4
Stereotactic radiosurgery is another treatment that can be used to treat lung cancers that are inoperable. There are three different kinds of SRS that operate three different ways using difference machines and radiation source. It is not a surgical procedure but is usually a single dose of radiation that treats the tumor directly although some machines can be used over time. 5, 15
Chemotherapy and concurrent radiotherapy may be used together for cure or partial remission as well as alternating chemo-radiotherapy. There are several commonly used chemotherapy agents, but the standard for NSCLC chemotherapy is usually a combination of two or more drugs including paclitaxel (Taxol) and carboplatin (Paraplatin), cisplatin (Platinol) and vinorelbine tartrate (Navelbine), cisplatin and etoposide (VP-16), and carboplatin plus VP-16. For combination chemo-radiotherapy, the drugs are etoposide and cisplatin, chest radiation and surgery if the tumor is operable. The side effects from these drugs are not as significant as they once were in the past, but still include anemia, neutropenia, thrombocytopenia, leukopenia and vomiting. Other drugs that may be used include gemcitabine (Gemzar), ifosfamide (Ifex), vincristine sulfate (Oncovin), doxorubicin (Adriamycin), and docetaxel (Taxotere). 18
SCLC responds very favorably to both chemotherapy and radiotherapy although it is a very aggressive systemic disease process and tumor recurrence is common.3 Surgery in most cases is not performed as the tumor has usually spread to other sites before detection. 3 There are studies that find up to 60-70% of patients already have metastasis by the initial diagnosis. 5
The standard for limited SCLC is etoposide (VP-16, VePesid) with cisplatin with 4000-4500 cGy radiation to the chest, or etoposide, cisplatin and vincristine sulfate with radiation to the chest. These may be followed by cranial radiation for prophylactic purposes. In a small percentage of patients, this treatment may be curative although most patients with SCLC usually relapse.
For extensive disease, the treatment is a combination chemotherapy of several different drugs which may include cyclophosphamide (Neosar), doxorubicin, vincristine sulfate, cisplatin, etoposide, carboplatin or ifosfamide possibly also with prophylactic cranial radiation. Metastatic areas may receive radiotherapy, typically the brain, bones, and spinal column. Neither chemotherapy, radiotherapy nor a combination of both is usually curative due to the rapid tumor cell growth of SCLC, but they can be used for partial remission and to extend and improve the quality of life. Without any treatment the average survival rate is about two to four months. With treatment life can be extended to usually about six months to one year. 18
Lung cancer is the number one preventable cancer, and is the number one cause of all cancer deaths for both men and women of every ethnic group in the United States. 13 On average, about 439 people a day will die from lung cancer. In 2005 per the CDC, it was attributed to more deaths than a combination of prostate, breast or colon cancer. The American Cancer Society projected 215,020 new lung cancer cases and 161,840 deaths in 2008. 16 Most people diagnosed are 65 years of age or older, and of new cases diagnosed, only 16% are being discovered at a curable stage. 15 The survival rate of a patient with lung cancer after five years is less than 10%; with Stage 4 is less than one year. 15
The financial costs are staggering; with a study 2004 that indicated about $9.6 billion was spent per year in treatment in the United States. 12 However, for a disease that is the leading cause of cancer deaths, out of breast, prostate and colon, it is the lowest in total research funding. In 2007 lung cancer research was less than 5% of the National Cancer Institute’s budget and it was $0 for the Center for Disease Control. 15
There is a difference in the trend of lung cancer by state as well, those primarily southern to mid-western states which are dependent upon tobacco growing, and the tobacco excise tax is lower, have the highest incidence of lung cancer. 12 In the long-term trend from 1975 to 2005, Kentucky appeared to be the state with the highest number of lung cancers, and Utah appeared to be the lowest (this is primarily due to the high Mormon population whose religious beliefs prohibit smoking). 9 Other factors that appear to affect the difference in state trends are public awareness, education, tobacco industry lobbyists and local and state tobacco control activities including public smoking. 12
It appears that the lung cancer death for men has been slowly decreasing; however, the lung cancer death for women is increasing. Part of this can be attributed to the fact that men began smoking earlier in the 1900s but many stopped smoking after the 1980s, where women did not begin cigarette smoking until during and after World War II. Since this is a disease primarily of those over 65, it may be another decade before this hopefully levels off and begins to decline. 9
Pulmonary nodules have been included in this article since they are fairly common and can be very concerning in the underwriting process. Approximately one out of 500 chest x-rays will show pulmonary nodules.21 Those with a diameter of 3 cm or less are called nodules and larger than 3 cm are called a mass. Most lung nodules are benign and are very common. Benign nodules have very little growth or change. The cause can include scarring from granulomatous disease, lung cysts, TB, histoplasmosis, or vascular abnormalities. However, some are early stage lung cancer and these nodules tend to grow fairly quickly, doubling in size every four months but sometimes as fast as 25 days. 21
Most nodules are discovered by accident on a chest x-ray or a CT scan. Stability is the best way to determine benign versus malignant without a biopsy since benign nodules grow very slowly if they grow at all. Another way is to evaluate the surface and shape. Malignant nodules are irregular shaped, spiculated, ill-defined, rough surfaced, abnormal margins, ground glass appearance and speckled or color variated. Benign nodules are smooth, even colored, more regularly shaped, round and usually less than 2 cm. If evaluation is difficult, then a biopsy may be performed or sputum may be analyzed for malignant cells. 21
It wasn’t too long after the 1964 Surgeon General’s report that State Mutual Insurance Company first offered a policy for non-smokers. After favorable mortality and the 1979 Surgeon General’s report, many other life companies offered non-smoking policies starting in 1980. 1 Now we have smoker-non smoker, tobacco-non-tobacco and other variations per company actuarial standards.
As underwriters, we see very rare lung cancer cases which may be due to the low survival statistics, after 5 years it’s usually less than 10%. One of the most common problems we as underwriters do usually face, however, is lung nodules. Determining benign versus a possible malignancy is always challenging, with current/past use of tobacco, client age, size and shape of nodule, and stability primary factors. Another problem is that many people still smoke, or have previously smoked for many years and quit, but the damage has been done. It may be difficult to distinguish a respiratory disorder in a client from that of an early malignancy because the symptoms may be so similar. The cancers that do appear to be insurable after a reasonable length of time are early stage carcinoid tumors. These rare neuroendocrine tumors can be cured by surgery if they have not spread. 17
Lung cancer is a killer which is not only caused by smoking, but many other factors including second-hand smoke, radon, environmental, occupational and genetics. This article was not written with the intention of being an anti-smoking campaign, but because the two, lung cancer and smoking, are so closely related to each other, that it is difficult to discuss one without the other. It is a cancer that in so many cases could be prevented. Each state’s public health department funds tobacco prevention programs in which 46 states also have funds provided from the Master Settlement Agreement of 1998 (this was an agreement dated November 1998 between the four largest US tobacco companies and the Attorneys General of 46 states). 6 There are also various organizations that are dedicated to the prevention and education of lung cancer including the American Lung Association, the CDC, the National Cancer Institute, the American Cancer Society, the Mayo Clinic, the WHO, and many, many sources on the Internet.
With continued public awareness, education, continued research as well as the increasing cost of cigarettes it is possible not only will adults, but our youth, decide not to start, or will choose to quit. Per the American Lung Association, smoking rates among high school students has declined by 45% since 1997 and overall consumption of cigarettes has declined by over 100 billion cigarettes over the last 10 years. 8 In the future, it is possible that lung cancer will someday lose it’s distinction as the number one cancer killer.
