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Each year, in the UK, it is estimated that nearly 6000 never-smokers die of lung cancer. This is more than those who die of cervical cancer, non-Hodgkin’s lymphoma, leukaemia or ovarian cancer. Incidence of lung cancer in never-smokers rises with age but it is important to be aware that younger patients are also affected.

If never-smoker lung cancer was considered a separate entity to smoking induced lung cancers then it would still be around the eighth to eleventh most common cause of cancer-related death in the UK.

A never-smoker refers to someone who has smoked the equivalent of less than 100 cigarettes in their lifetime.

Persistent respiratory symptoms in never-smokers should be investigated. Healthcare professionals should not be reassured by the individual’s never-smoker status.

GatewayC GP Lead, Dr Sarah Taylor, talks to Matt Evison about how the incidence of lung cancer in never-smokers is increasing, the groups it is more prevalent in, and what primary care professionals can do to help.

Key points:

  • Rates of lung cancer in never-smokers are increasing
  • If a patient has persistent chest symptoms longer than 3 weeks (cough, breathlessness, chest pain) then it warrants an investigation. The first step is a chest X-ray (CXR), but a normal CXR does not exclude lung cancer
  • Smoking status should not influence the decision about whether to investigate persistent unexplained symptoms.

Lung cancers in never-smokers are often different from those that occur in smokers. Lung cancers in never smokers are almost exclusively non-small-cell whereas small-cell lung cancer is strongly associated with smoking and is rare in never-smokers. There is widespread evidence that adenocarcinomas are the most commonly diagnosed subtype. 

Genetic changes found in lung cancers associated with never-smokers are different from those associated with cancers in those who have smoked. In some cases, these gene changes can be used to guide treatment. An EGFR mutation is the most common mutation for which there are treatments available. There are specific phenotypes that increases the risk of never-smoker lung cancer; this mutation is more common in women and those of Asian descent.

Risk factors for never-smokers in the UK include:

  • 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 malignancies

Below are four stories of patients who have been diagnosed with non-smoking lung cancer.

All of these patients had persistent non-specific respiratory symptoms and a low suspicion of lung cancer which made diagnosis difficult. It is important to give safety-netting advice to all patients, giving them clear instructions on when to return if symptoms don’t resolve.


Diagnosed age 34

I had a severe and persistent cough to the point of wetting myself and being sick, whilst also constantly needing to clear my throat. I received antibiotics for this. 3 weeks later I called my GP back as it hadn’t gotten better. I was referred for a chest X-ray which showed pneumonia and was given more antibiotics. I was sent for a repeat chest X-ray 6 weeks later and the results still showed pneumonia. I was given further antibiotics whilst waiting for a CT scan. This scan lead to my diagnosis.


Diagnosed age 56

I had a minor cough in late August 2020 and a few pains in my calf muscles which I put down to cycling. During the first few weeks of September, the cough worsened, so I went to my GP and was prescribed antibiotics. Over the last 2 weeks of September the cough worsened, I became  breathless with mild exertions, and I had some swelling on my upper calf. I awoke one day with severe breathlessness so went back to my GP. I was sent to hospital where I had chest X-rays, CT and ultra scans. Later that week, I was diagnosed with stage 4 non-smoking lung cancer.


Diagnosed age 44

I had severe shoulder pain and back ache for around 18 months. I later suffered a cold and cough. The cold went but the cough remained which prompted me to visit my GP. I was referred for a chest X-ray that showed an area on my lung. The cough then got worse, so I decided to go to A&E. I had a CT scan there and was then diagnosed through emergency presentation.


Diagnosed age 49

I contacted my GP in early 2020 with increased coughing, congestion in my chest and wheezing. I returned to my GP in August 2020 with a dull chest pain and back pain and was referred for a chest X-ray. My GP was initially reluctant to send me for an X-ray as I had on in June 2019 which hadn’t revealed a problem. The new chest X-ray revealed a large mass in my lung, and I was subsequently diagnosed with stage 4 lung cancer that had spread to my liver and spine.

Additional resources

Link: Lung cancer in never-smokers: a hidden disease, Journal of the Royal Society of Medicine Vol 112:7 (2019)
Link: Science Surgery: ‘Why do never-smokers get lung cancer?’, Cancer Research UK (2018)
Link: Lung Cancer in Non-Smokers, Missouri Medicine Vol 117:4 (2020)
Link: Time trends in never smokers in the relative frequency of the different histological types of lung cancer, in particular adenocarcinoma, Regulatory Toxicology and Pharmacology Vol 74 (2016)
Link: Lung cancer in never smokers – A review, European Journal of Cancer Vol 48:9 (2012)
Link: Lung cancer in never smokers in the UK Million Women Study, International Journal of Cancer Vol 139:2 (2016)

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