Key points:
- A never-smoker is someone who has smoked less than 100 cigarettes in their lifetime
- 8th most common cause of cancer death – and rates are increasing
- Smoking status should not influence the decision to investigate persistent unexplained symptoms
- A normal chest X-ray does not exclude lung cancer
- Remember: If you have lungs, you can get lung cancer
Growing concern
Lung cancer has been conceptualised as a smoker’s disease: which it is not. In the UK, 6,000 people who have never smoked die of lung cancer every year. That’s greater than the numbers that die of cervical cancer (~900), lymphoma (~5200), leukaemia (~4500) and ovarian cancer (~4200) (Bhopal et al, 2019). Never-smoking lung cancer, if it was considered a separate entity, would be considered the eighth most common cause of cancer-related death in the UK.
Risk
Risk factors for never smokers in the UK:
| Second-hand smoke |
| Occupational carcinogen exposure |
| Air pollution |
| X-ray radiation |
| Radon exposure |
| Family history of lung cancer |
| Personal history of non-malignant respiratory illness |
| Personal history of non-lung related illness |
Genomics
Researchers have found differences between smoking-related and non-smoking-related lung cancers. For example, never smokers display distinct gene changes, including EGFR, ALK-EML4, ROS-1 and BRAF, and in some cases these gene changes can be used to guide treatment. Specific phenotypes increase the risk of never-smoker lung cancer – this is more commonly found in women and those of Asian descent (LoPiccolo et al, 2024).
Catching it early
Although there have been some recent advances in treatment with targeted therapy against genetic mutations, early diagnosis is still the most important route to improving outcomes.
Pitfall: Smoking status should not influence the decision to investigate persistent unexplained symptoms
If your patient has persistent chest symptoms (cough, breathlessness, chest pain) or changes in their existing symptoms for longer than 3 weeks then this warrants an investigation, regardless of their smoking status.
The first step is a chest X-ray, but a normal chest X-ray, with no visible nodules, tumours or masses, does not exclude lung cancer. It remains important to give safety netting advice to all patients – providing clear instruction on when to return if symptoms do not resolve.
Accurx Template – for normal CXR but advising further monitoring
Dear [Patient Name],
We are pleased to inform you that your recent chest X-ray did not show any concerning findings. However, it’s important to continue monitoring your health. Please remain vigilant for any persistent symptoms, including:
- Persistent cough
- Unexplained weight loss
- Ongoing chest pain
- Continual breathlessness
- Repeated episodes of haemoptysis (coughing up blood)
If any of these symptoms persist or worsen, please contact the practice and arrange a review.
Best regards, [Your GP’s Name]
