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. 2024 Nov 20;117(6):1104–1109. doi: 10.1093/jnci/djae299

Elevated risk of lung cancer among Asian American women who have never smoked: an emerging cancer disparity

Scarlett Lin Gomez 1,2,✉, Mindy DeRouen 3,4, Moon S Chen Jr 5, Heather Wakelee 6, Jeffrey B Velotta 7,8, Lori C Sakoda 9,10, Salma Shariff-Marco 11,12, Peggy Reynolds 13,14, Iona Cheng 15,16
PMCID: PMC13396256  PMID: 39565906

Abstract

Lung cancer is a leading cause of cancer mortality for most ethnic groups of Asian American women, including Chinese, Korean, Japanese, and Vietnamese Americans, a striking pattern given the exceedingly low prevalence of smoking among Asian American women in the general population. Recent research demonstrates that among Asian American women with a lung cancer diagnosis, the vast majority of patients have never smoked, a rate as high as 80% among Chinese and Asian Indian American women. Despite declining rates in lung cancer overall in the United States, rates among Asian American women who have never smoked appear to be increasing. This commentary articulates extant knowledge, based on studies in Asia, of a range of risk factors, such as a family history of lung cancer; a history of lung diseases, including tuberculosis and chronic obstructive pulmonary disease; exposure to cooking fumes and second-hand smoke; and various putative risk factors. Unique mutational profiles at the tumor level, including a higher prevalence of EGFR variations among Asian populations, highlight the importance of tumor genomic testing of newly diagnosed patients. Additional research is essential, given the high burden of disease among Asian American women who have never smoked and the limited knowledge regarding contributing risk factors specific to Asian American women, because the risk factors identified in Asian people living in Asia may not apply.

Descriptive epidemiology

Lung cancer ranks among the top 2 causes of cancer-related deaths across Asian American ethnic women. For Chinese, Vietnamese, Japanese, and Korean American women, lung cancer is the leading cause of cancer deaths.1 This high burden of lung cancer is particularly striking given the low prevalence of smoking in the general Asian American female at-risk population, with 6% of Chinese, 17% of Filipino, and 2% of Asian Indian females having ever smoked cigarettes.1 In Asia, the high incidence of lung cancer among women who have never smoked is well documented.2-4

Until recently, documenting incidence rates by smoking status at the population level in the United States has been constrained by the lack of smoking information in cancer registry and population denominator data. In the past 3 years, however, several published US reports from independent data sources have shown that among women who have never smoked, lung cancer incidence rates are highest among Asian Americans compared with other racial and ethnic groups. Using electronic health record data from 2 large health-care systems linked to population-based state cancer registry data from 2000 to 2013, our group found that all Asian American ethnic populations who had never smoked had 1.5-fold to 2-fold higher incidence rates of lung cancer than those of all women combined, except for Japanese American women, whose rate was approximately half of women overall.5,6 Incidence rates were highest among Chinese American women who had never smoked, making lung cancer in women who have never smoked the third-most common cancer overall in this group. Strikingly, more than 50% of Asian American women with a diagnosis of lung cancer had never smoked, with proportions as high as 80% among Chinese and Asian Indian American women. Capitalizing on the availability of relatively complete smoking information in the Florida cancer registry and a new approach to creating population estimates by smoking status, another study from 2014 to 2018 documented an incidence rate ratio of 1.15 (95% confidence interval [CI] = 1.00 to 1.32) for lung cancer when comparing Asian American and Pacific Islander to non-Hispanic White women who have never smoked.7 In Florida, lung cancer in Asian American and Pacific Islander women who have never smoked was the second-leading cause of cancer mortality. Finally, using data from electronic health records from Kaiser Permanente Northern California, we found increasing incidence trends of lung cancer among Asian American and Pacific Islander individuals aged 40 years and older (separate trends for men and women could not be estimated) from 2007-2009 to 2016-2018, with an average annual percentage increase of 2.0% (95% CI = 0.01% to 3.9%). This trend contrasts with the stable incidence trends observed in other racial and ethnic groups.8 In this study, incidence rates of lung cancer were approximately 2-fold higher in Asian American and Pacific Islander individuals who had never smoked than in non-Hispanic White individuals who had never smoked. Contemporary national lung cancer incidence data show stable incidence trends in Asian American and Pacific Islander women relative to declining trends in women of other racial and ethnic groups9; these statistics based on Surveillance, Epidemiology, and End Results (SEER) Program cancer registry data were not available by smoking status, masking an important emerging disparity among women who have never smoked. There is also evidence of a younger age at lung cancer diagnosis among Asian American women relative to men; in a study that examined multiple cohorts, the age at diagnosis was, on average, 11 years younger among Chinese American women than among Chinese American men.10 The incidence of other tobacco-associated cancer types, including bladder, esophageal, colorectal, and kidney cancers, is lowest among Asian American and Pacific Islander women relative to other racial and ethnic groups, further reinforcing that lung cancer among Asian American and Pacific Islander women has a unique etiology independent of smoking exposure.

We note here that many prior studies have aggregated Asian Americans or Asian Americans and Pacific Islanders into 1 group. There is well-documented heterogeneity in cultural and lifestyle factors, immigration patterns, and structural and social drivers of health across the more than 30 Asian American groups and more than 10 Pacific Islander ethnic groups. This heterogeneity is reflected in the differences in lung cancer incidence across Asian American and Pacific Islander women who have never smoked, for example, ranging from an age-adjusted incidence rate of 6.4 (95% CI = 3.6 to 10.0) per 100 000 person-years among Japanese individuals to 22.8 (95% CI = 17.3 to 29.1) among Chinese individuals in a cohort of adults from Northern California and Hawaii.6 Incidence rates for disaggregated Asian American and Pacific Islander ethnic groups are unfortunately not often available in information based on cancer registry data, given the lack of population denominators for disaggregated populations. Further methodological work is needed to overcome this denominator limitation to ensure that timely incidence rates for Asian American and Pacific Islander ethnic groups can be reported.

Risk factors and implications for primary prevention

The ongoing Female Asian Never Smokers Study (FANSS), funded by the National Institute on Minority Health and Health Disparities, led by the authors of this commentary, is the first and currently only study focused on identifying risk factors for lung cancer among Asian American women who have never smoked. Scattered evidence comes from studies of other racial and ethnic populations in the United States and from Asia that have explored several domains of risk factors. Established risk factors include second-hand smoke, air pollution, radon exposure, bacterial lung infections, some lung diseases, and cooking oil fumes. Other potential risk factors that have been examined include reproductive factors, body size, and genetic factors. This literature is briefly discussed below.

Second-hand smoke is an established risk factor, contributing to an estimated 27% increased risk of lung cancer among women who have never smoked.11 The proportion of lung cancer attributable to second-hand smoke among women who never smoked is unclear,12-16 however, with estimates ranging from 15% to 35%.3 Moreover, estimates for Asian American women who never smoked are not available. Air pollution and residential exposure to radon contribute to lung cancer among never-smoking individuals. Meta-analyses have found that long-term exposure to fine particulate matter 2.5 (ie, particles ≤2.5 µm in diameter) to be associated with increased lung cancer risk.17-20 For individuals who have never smoked, the estimated risk was 1.18 (95% CI = 1.00 to 1.39) per 10-μg/m3 increase in fine particulate matter 2.5.17-20 For radon, the excess relative risk of lung cancer per 100 Bq/m3 was recently estimated to be 15% (95% CI = 6% to 25%).21

A history of bacterial lung infections such as pneumonia and tuberculosis has been associated with lung cancer risk among individuals who have never smoked.22 A 2012 meta-analysis of 17 North American and European studies estimated a 35% (95% CI = 12% to 63%) increased risk of lung cancer among never smokers with a history of pneumonia compared with individuals without a history of pneumonia.22 A meta-analysis of 13 studies reported a positive association of tuberculosis with lung cancer risk among never smokers (odds ratio = 1.78, 95% CI = 1.42 to 2.23) among the study population, which was similar among Asian and non-Asian study populations.23 In the United States, the incidence of tuberculosis among Asian Americans is more than 25 per 100 000 persons, with 95% of these cases occurring among foreign-born Asian Americans.24 For comparison, the incidence of tuberculosis among White Americans is 1.1 per 100 000 persons.24 Thus, tuberculosis is a potentially relevant factor for lung cancer risk among Asian Americans who have never smoked. Meta-analyses of cohort and case-control studies have found elevated risk of lung cancer in never smokers with chronic obstructive pulmonary disease and emphysema, but chronic bronchitis22,25,26 and asthma27 were not linked with increased risk.

Assessing the risk of lung cancer from cooking oil fumes among Asian Americans, especially among foreign-born Asian Americans, is of particular interest, given results from Asian studies and occupational studies in the US restaurant industry.28-30 A 2018 meta-analysis of observational studies, mostly based in China, of cooking practices in restaurant and household settings reported double the odds of lung cancer for women who cooked vs women who did not cook (pooled odds ratio = 1.98, 95% CI = 1.54 to 2.54); contributing factors were poor ventilation and cooking method, with stir-frying conferring greater risk than other methods.29 A study of Chinese restaurant workers in Taiwan reported high oxidative DNA damage consistent with exposure to cooking oil fumes that was more pronounced among women than among men and among kitchen staff than among dining room staff.30

Given the higher risks observed among women, studies have investigated reproductive and body size as putative risk factors for lung cancer in women who have never smoked, but results have largely been inconclusive. Nulliparity or having fewer children has been associated with increased lung cancer risk among never smokers, particularly for studies in Asia.31,32 Studies in Asia for other factors, however, such as oral contraceptive use, hormone replacement therapy use, and menopausal factors, remain somewhat mixed.31-35 Body mass index results in never smokers are mixed, with most studies reporting no association with lung cancer.36-41

A 2020 systematic review and meta-analysis confirmed family history of lung cancer as a risk factor among never smokers, particularly for Asian women compared with European women42,43; no studies have been conducted in Asian American women. Ongoing efforts have been directed at developing polygenic risk scores to screen for higher risk among Chinese women who have never smoked.44,45 The extent to which shared household, occupational, and ambient environments contribute to associations of family history and genomic loci with lung cancer risk remains unclear, however.43

Screening

Despite the high and continued rise in the incidence of lung cancer among Asian American women who have never smoked, currently no recommended screening guidelines exist for this at-risk population. Some of the best data on the efficacy of screening for lung cancer in never smokers come from Taiwan, where computed tomography screening in individuals without a history of smoking but with a family history of lung cancer, second-hand smoke exposure, history of tuberculosis or chronic obstructive pulmonary disease, or exposure to cooking oil fumes was used to investigate lung cancer incidence in the Taiwan Lung Cancer Screening in Never Smoker Trial (TALENT).46 This study demonstrated a 2.6% detection rate of lung cancer, more than double the rate from the Nederlands-Leuvens Longkanker Screenings Onderzoek trial conducted in the Netherlands and Belgium and the National Lung Screening Trial.47,48 In addition, 77.4% of the diagnoses were at an early stage46 compared with the general population, where lung cancer is often diagnosed at higher stages with worse prognosis. There is controversy, however, over whether this represents overdiagnosis.49 Nonetheless, Taiwan has implemented the first national screening program for high-risk individuals who have never smoked following the results from the TALENT study. In the United States, few screening trials have been conducted in this population; 1 small program, the New York University FANSS, focuses on Asian American women without a smoking history. Preliminary data presented at the American Society of Clinical Oncology meeting in 2023 showed similar rates of lung cancer diagnosis as in the TALENT trial.50 There are now efforts to launch similar programs in other locations across the United States.

Diagnosis and treatment

Unfortunately, the misperception that lung cancer affects only people with a history of heavy smoking is especially detrimental for Asian American women who have never smoked and make up the majority of the Asian American female population diagnosed with lung cancer. That observation—that patients without a smoking history are not immediately considered for evaluation for lung cancer in the face of respiratory and other symptoms—and a lack of consensus on symptomology as well as the absence of symptoms of lung cancer in persons who have never smoked may lead to delayed diagnosis in Asian American women who have never smoked. As such, most Asian American women who do not smoke are often initially diagnosed with late-stage disease, once cancer has spread to other organs.51 Tremendous advances have been made in the past 2 decades in targeted treatment of lung cancer. Among Asian women without a smoking history who develop non-small cell lung cancer (NSCLC), 40% to 60% have been found to harbor a tumor with a variation in the EGFR gene, with other “driver mutations” frequently found in individuals without an EGFR variation. The Iressa Pan-Asia Study (iPASS)52 trial established the superiority of EGFR-targeted agents over chemotherapy in the first line for patients with metastatic (stage IV) NSCLC with tumors harboring an EGFR variation and the third-generation EGFR-targeted agent osimertinib is now the standard of care for patients with newly diagnosed metastatic NSCLC with EGFR variation either alone (AZD9291 Versus Gefitinib or Erlotinib in Patients With Locally Advanced or Metastatic Non-small Cell Lung Cancer [FLAURA])53 or in combination with chemotherapy (FLAURA 2).54 For patients with early-stage (IB-IIIA) NSCLC with EGFR variation that has been completely surgically resected, the AZD9291 Versus Placebo in Patients With Stage IB-IIIA Non-small Cell Lung Carcinoma, Following Complete Tumour Resection With or Without Adjuvant Chemotherapy (ADAURA) study demonstrated that adjuvant osimertinib improved both disease-free survival and overall survival, establishing osimertinib as the standard of care for early-stage NSCLC with EGFR variation after surgery.55 Most recently, in 2024, the A Global Study to Assess the Effects of Osimertinib Following Chemoradiation in Patients With Stage III Unresectable Non-small Cell Lung Cancer (LAURA) trial showed that consolidation osimertinib after concurrent chemotherapy and radiation therapy for patients with unresectable EGFR-mutated stage III NSCLC profoundly improved disease-free survival,56 establishing osimertinib as the standard approach in that setting as well. However, the proper therapy can be chosen only if molecular testing is performed to determine whether a tumor harbors an EGFR variation or other driver mutations. Though it is considered standard of care to conduct molecular testing, the rates of testing still vary widely, even in the United States.57 Thus, it is now more important than ever that clinicians understand the significance of testing all patients diagnosed with lung cancer, regardless of stage, using next-generation sequencing. Targeted treatment agents are now available for many specific driver mutations, offering improved outcomes over treatment with nontargeted agents.

Moving forward

Considerable efforts to advance our knowledge and detection of lung cancer in Asian American women who have never smoked have occurred since 2020 (Figure 1). Large-scale descriptive epidemiological studies have documented the high and increasing incidence rates of lung cancer Asian American women who have never smoked. The ongoing FANS Study, which will examine etiological risk factors for Asian American women who have never smoked, is expected to provide potential etiological clues that can inform prevention. The New York University FANSS and other, similar efforts will assess the effectiveness of screening methods for lung cancer in this population. To drive impactful changes in public health and clinical improvements, we must continue efforts to raise awareness of this high burden of disease among Asian American women and address unanswered questions (Figure 1). We are heartened by the increased public attention to this issue in the past year and inspired by the courage of Asian American women affected by this disease to share their stories.58-60 To continue to increase awareness among health-care professionals and patients, we encourage widespread educational events, seminars, and social and traditional media outreach to all segments of Asian American populations and their health-care professionals. Increased awareness will facilitate earlier diagnosis and molecular testing, allowing for optimal treatment. Finally, funding is needed to sustain and expand upon the current momentum in research to better understand the etiology and also to determine whether screening US populations who have never smoked at high risk is warranted. As we gain a better understanding of the etiology of this disease, we will be able to identify modifiable risks and implement effective prevention efforts to reduce the burden of lung cancer among Asian American women who have never smoked and eliminate the current disparities.

Figure 1.

Figure 1.

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Summary of the current state of knowledge and recommendations for moving forward. FANSS = Female Asian Never Smokers Study; NSCLC = non-small cell lung cancer.

Contributor Information

Scarlett Lin Gomez, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA 94158, United States; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94158, United States.

Mindy DeRouen, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA 94158, United States; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94158, United States.

Moon S Chen Jr, Department of Internal Medicine, Division of Hematology and Oncology, University of California, Davis School of Medicine, Sacramento, CA 95817, United States.

Heather Wakelee, Department of Medicine, Stanford University, Stanford, CA 94305, United States.

Jeffrey B Velotta, Department of Thoracic Surgery, Kaiser Permanente Northern California, Oakland, CA 94611, United States; Division of Research, Kaiser Permanente Northern California, Pleasanton, CA 94588, United States.

Lori C Sakoda, Division of Research, Kaiser Permanente Northern California, Pleasanton, CA 94588, United States; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, United States.

Salma Shariff-Marco, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA 94158, United States; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94158, United States.

Peggy Reynolds, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA 94158, United States; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94158, United States.

Iona Cheng, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA 94158, United States; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94158, United States.

Author contributions

Scarlett Lin Gomez, PhD (Conceptualization; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Writing—original draft), Mindy DeRouen, PhD (Writing—original draft; Writing—review & editing), Moon S Chen Jr, PhD (Funding acquisition; Writing—review & editing), Heather Wakelee, MD (Writing—original draft; Writing—review & editing), Jeffrey B. Velotta, MD (Writing—original draft; Writing—review & editing), Lori Sakoda, PhD (Writing—review & editing), Salma Shariff-Marco, PhD (Writing—review & editing), Peggy Reynolds, PhD (Writing—review & editing), Iona Cheng, PhD (Funding acquisition; Supervision; Writing—original draft; Writing—review & editing).

Funding

This work was funded by grant No. 1R01MD014859 (principal investigators Gomez, Chen, and Cheng) from the National Institute for Minority Health and Health Disparities.

Conflicts of interest

The authors declare no conflicts of interest.

Data availability

No empirical data were used in this commentary. All statistics reported are from published sources.

References

  • 1.American Cancer Society. Cancer Facts & Figures for Asian American, Native Hawaiian, & Other Pacific Islander People 2024-2026. American Cancer Society; 2024.
  • 2. Sun S, Schiller JH, Gazdar AF.  Lung cancer in never smokers—a different disease. Nat Rev Cancer. 2007-10 2007;7:778-790. 10.1038/nrc2190 [DOI] [PubMed] [Google Scholar]
  • 3. Wakelee HA, Lung cancer in never smokers. UpToDate 2015. 2015. Accessed May 13, 2015.
  • 4. Wakelee HA, Chang ET, Gomez SL, et al.  Lung cancer incidence in never-smokers. J Clin Oncol. 2007;25:472-478. 10.1200/JCO.2006.07.2983 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. DeRouen MC, Canchola AJ, Thompson CA, et al.  Incidence of lung cancer among never-smoking Asian American, native Hawaiian, and pacific islander females. J Natl Cancer Inst. 2022;114:78-86. 10.1093/jnci/djab143 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6. DeRouen MC, Thompson CA, Canchola AJ, et al.  Integrating Electronic Health Record, Cancer Registry, and geospatial data to study lung cancer in Asian American, native Hawaiian, and pacific islander ethnic groups. Cancer Epidemiol Biomarkers Prev. 2021;30:1506-1516. 10.1158/1055-9965.Epi-21-0019 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7. Pinheiro PS, Callahan KE, Medina HN, et al.  Lung cancer in never smokers: Distinct population-based patterns by age, sex, and race/ethnicity. Lung Cancer. 2022;174:50-56. 10.1016/j.lungcan.2022.10.009 [DOI] [PubMed] [Google Scholar]
  • 8. Sakoda LC, Alabaster A, Sumner ET, Gordon NP, Quesenberry CP Jr, Velotta JB.  Trends in smoking-specific lung cancer incidence rates within a US integrated health system, 2007-2018. Chest. 2023;164:785-795. 10.1016/j.chest.2023.03.016 [DOI] [PubMed] [Google Scholar]
  • 9. SEERExplorer: An interactive website for SEER cancer statistics. Surveillance Research Program, National Cancer Institute; 2024 Apr 17. [updated: 2024 Jun 27; cited 2024 Aug 28]. https://seer.cancer.gov/statistics-network/explorer/.
  • 10. Blechter B, Wong JYY, Chien LH, et al.  Age at lung cancer diagnosis in females versus males who never smoke by race and ethnicity. Br J Cancer. 2024;130:1286-1294. 10.1038/s41416-024-02592-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11. Taylor R, Najafi F, Dobson A.  Meta-analysis of studies of passive smoking and lung cancer: Effects of study type and continent. Int J Epidemiol. 2007;36:1048-1059. 10.1093/ije/dym158 [DOI] [PubMed] [Google Scholar]
  • 12. Brenner DR, Hung RJ, Tsao MS, et al.  Lung cancer risk in never-smokers: A population-based case-control study of epidemiologic risk factors. BMC Cancer. 2010;10:285. 10.1186/1471-2407-10-285 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Kurahashi N, Inoue M, Liu Y, et al. ; JPHC Study Group. Passive smoking and lung cancer in Japanese non-smoking women: a prospective study. Int J Cancer. 2008;122:653-657. 10.1002/ijc.23116 [DOI] [PubMed] [Google Scholar]
  • 14. Lee CH, Ko YC, Goggins W, et al.  Lifetime environmental exposure to tobacco smoke and primary lung cancer of non-smoking Taiwanese women. Int J Epidemiol. 2000;29:224-231. 10.1093/ije/29.2.224 [DOI] [PubMed] [Google Scholar]
  • 15. Wang A, Kubo J, Luo J, et al.  Active and passive smoking in relation to lung cancer incidence in the Women's Health Initiative Observational Study prospective cohort. Ann Oncol. 2015;26:221-230. 10.1093/annonc/mdu470 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16. Ni X, Xu N, Wang Q.  Meta-analysis and systematic review in environmental tobacco smoke risk of female lung cancer by research type. Int J Environ Res Public Health. 2018;15:1348. 10.3390/ijerph15071348 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17. Hamra GB, Guha N, Cohen A, et al.  Outdoor particulate matter exposure and lung cancer: a systematic review and meta-analysis. Environ Health Perspect. 2014. 2014;122:906-911., 10.1289/ehp/1408092 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18. Myers R, Brauer M, Dummer T, et al.  High-ambient air pollution exposure among never smokers versus ever smokers with lung cancer. J Thorac Oncol. 2021;16:1850-1858. 10.1016/j.jtho.2021.06.015 [DOI] [PubMed] [Google Scholar]
  • 19. Yang W-S, Zhao H, Wang X, Deng Q, Fan W-Y, Wang L.  An evidence-based assessment for the association between long-term exposure to outdoor air pollution and the risk of lung cancer. Eur J Cancer Prev. 2016;25:163-172. 10.1097/CEJ.0000000000000158 [DOI] [PubMed] [Google Scholar]
  • 20. Turner MC, Krewski D, Pope CA 3rd, Chen Y, Gapstur SM, Thun MJ.  Long-term ambient fine particulate matter air pollution and lung cancer in a large cohort of never-smokers. Am J Respir Crit Care Med. 2011;184:1374-1381. 10.1164/rccm.201106-1011OC [DOI] [PubMed] [Google Scholar]
  • 21. Cheng ES, Egger S, Hughes S, et al.  Systematic review and meta-analysis of residential radon and lung cancer in never-smokers. Eur Respir Rev. 2021;30:200230. 10.1183/16000617.0230-2020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Brenner DR, Boffetta P, Duell EJ, et al.  Previous lung diseases and lung cancer risk: a pooled analysis from the International Lung Cancer Consortium. Am J Epidemiol. 2012;176:573-585. 10.1093/aje/kws151 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Liang HY, Li XL, Yu XS, et al.  Facts and fiction of the relationship between preexisting tuberculosis and lung cancer risk: a systematic review. Int J Cancer. 2009;125:2936-2944. [DOI] [PubMed] [Google Scholar]
  • 24. American Lung Association. State of lung disease in diverse communities. 2010. https://action.lung.org/site/DocServer/state-of-lung-disease-in-diverse-communities-2010.pdf
  • 25. Park HY, Kang D, Shin SH, et al.  Chronic obstructive pulmonary disease and lung cancer incidence in never smokers: a cohort study. Thorax. 2020. 2020;75:506-509. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Zhang X, Jiang N, Wang L, Liu H, He R.  Chronic obstructive pulmonary disease and risk of lung cancer: a meta-analysis of prospective cohort studies. Oncotarget. 2017-8-18. 2017;8:78044-78056. 10.18632/oncotarget.20351 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Rosenberger A, Bickeböller H, McCormack V, et al.  Asthma and lung cancer risk: a systematic investigation by the International Lung Cancer Consortium. Carcinogenesis. 2012;33:587-597. 10.1093/carcin/bgr307 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28. Lee T, Gany F.  Cooking oil fumes and lung cancer: a review of the literature in the context of the US population. J Immigr Minority Health. 2013. 2013;15:646-652. [DOI] [PubMed] [Google Scholar]
  • 29. Jia PL, Zhang C, Yu JJ, Xu C, Tang L, Sun X.  The risk of lung cancer among cooking adults: a meta-analysis of 23 observational studies. J Cancer Res Clin Oncol. 2018;144:229-240. 10.1007/s00432-017-2547-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Pan CH, Chan CC, Wu KY.  Effects on Chinese restaurant workers of exposure to cooking oil fumes: a cautionary note on urinary 8-hydroxy-2'-deoxyguanosine. Cancer Epidemiol Biomarkers Prev. 2008;17:3351-3357. 10.1158/1055-9965.Epi-08-0075 [DOI] [PubMed] [Google Scholar]
  • 31. Yin X, Zhu Z, Hosgood HD, Lan Q, Seow WJ.  Reproductive factors and lung cancer risk: a comprehensive systematic review and meta-analysis. BMC Public Health. 2020;20:1458. 10.1186/s12889-020-09530-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. Yin X, Kishida R, Abe SK, et al.  Association between reproductive factors with lung cancer incidence and mortality: a pooled analysis of over 308,000 females in the Asia cohort consortium. Int J Cancer. 2024;154:2090-2105. 10.1002/ijc.34866 [DOI] [PubMed] [Google Scholar]
  • 33. Elbasheer MMA, Bohrmann B, Chen Y, et al.  Reproductive factors and risk of lung cancer among 300,000 Chinese female never-smokers: evidence from the China Kadoorie Biobank study. BMC Cancer. 2024;24:384. 10.1186/s12885-024-12133-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34. Bae J-M, Kim EH.  Hormonal replacement therapy and the risk of lung cancer in women: An adaptive meta-analysis of cohort studies. J Prev Med Public Health. 2015. 2015;48:280-286. 10.3961/jpmph.15.054 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Wilunda C, Sawada N, Yamaji T, Iwasaki M, Inoue M, Tsugane S.  Reproductive factors and lung cancer risk among never-smoking Japanese women with 21 years of follow-up: a cohort study. Cancer Epidemiol Biomarkers Prev. 2021;30:1185-1192. 10.1158/1055-9965.Epi-20-1399 [DOI] [PubMed] [Google Scholar]
  • 36. Goodman MT, Wilkens LR.  Relation of body size and the risk of lung cancer. Nutr Cancer. 1993;20:179-186. 10.1080/01635589309514284 [DOI] [PubMed] [Google Scholar]
  • 37. Drinkard CR, Sellers TA, Potter JD, et al.  Association of body mass index and body fat distribution with risk of lung cancer in older women. Am J Epidemiol. 1995;142:600-607. [DOI] [PubMed] [Google Scholar]
  • 38. Henley SJ, Flanders WD, Manatunga A, Thun MJ.  Leanness and lung cancer risk: fact or artifact?  Epidemiology. 2002;13:268-276. [DOI] [PubMed] [Google Scholar]
  • 39. Rauscher GH, Mayne ST, Janerich DT.  Relation between body mass index and lung cancer risk in men and women never and former smokers. Am J Epidemiol. 2000;152:506-513. [DOI] [PubMed] [Google Scholar]
  • 40. Zhu H, Zhang S.  Body mass index and lung cancer risk in never smokers: a meta-analysis. BMC Cancer. 2018;18:635-610. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41. Kabat GC, Miller AB, Rohan TE.  Body mass index and lung cancer risk in women. Epidemiology. 2007;18:607-612. 10.1097/ede.0b013e31812713d1 [DOI] [PubMed] [Google Scholar]
  • 42. Wu AH, Fontham ET, Reynolds P, et al.  Family history of cancer and risk of lung cancer among lifetime nonsmoking women in the United States. Am J Epidemiol. 1996;143:535-542. [DOI] [PubMed] [Google Scholar]
  • 43. Ang L, Chan CPY, Yau WP, Seow WJ.  Association between family history of lung cancer and lung cancer risk: a systematic review and meta-analysis. Lung Cancer. 2020;148:129-137. 10.1016/j.lungcan.2020.08.012 [DOI] [PubMed] [Google Scholar]
  • 44. Dai J, Lv J, Zhu M, et al.  Identification of risk loci and a polygenic risk score for lung cancer: a large-scale prospective cohort study in Chinese populations. Lancet Respir Med. 2019;7:881-891. 10.1016/s2213-2600(19)30144-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45. Wei X, Sun D, Gao J, et al.  Development and evaluation of a polygenic risk score for lung cancer in never-smoking women: a large-scale prospective Chinese cohort study. Int J Cancer. 2024;154:807-815. 10.1002/ijc.34765 [DOI] [PubMed] [Google Scholar]
  • 46. Chang GC, Chiu CH, Yu CJ, et al. ; TALENT Investigators. Low-dose CT screening among never-smokers with or without a family history of lung cancer in Taiwan: a prospective cohort study. Lancet Respir Med. 2024;12:141-152. 10.1016/s2213-2600(23)00338-7 [DOI] [PubMed] [Google Scholar]
  • 47. de Koning HJ, van der Aalst CM, de Jong PA, et al.  Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020;382:503-513. 10.1056/NEJMoa1911793 [DOI] [PubMed] [Google Scholar]
  • 48. Aberle DR, Adams AM, Berg CD, et al. ; National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365:395-409. 10.1056/NEJMoa1102873 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49. Silvestri GA, Young RP, Tanner NT, Mazzone P.  Screening low-risk individuals for lung cancer: the need may be present, but the evidence of benefit is not. J Thorac Oncol. 2024;19:1155-1163. 10.1016/j.jtho.2024.05.001 [DOI] [PubMed] [Google Scholar]
  • 50. Elaine Shum WL, Lecia V, Sequist S-HI, et al. Preliminary results from the Female Never Nonsmoker Screening Study (FANSS). 2023.
  • 51. Banks KC, Sumner ET, Alabaster A, et al.  Sociodemographic and clinical characteristics associated with never-smoking status in patients with lung cancer: findings from a large integrated health system. Transl Cancer Res. 2022;11:3522-3534. 10.21037/tcr-22-1438 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52. Fukuoka M, Wu YL, Thongprasert S, et al.  Biomarker analyses and final overall survival results from a phase III, randomized, open-label, first-line study of gefitinib versus carboplatin/paclitaxel in clinically selected patients with advanced non-small-cell lung cancer in Asia (IPASS). J Clin Oncol. 2011;29:2866-2874. 10.1200/jco.2010.33.4235 [DOI] [PubMed] [Google Scholar]
  • 53. Soria JC, Ohe Y, Vansteenkiste J, et al. ; FLAURA Investigators. Osimertinib in untreated EGFR-mutated advanced non-small-cell lung cancer. N Engl J Med. 2018;378:113-125. 10.1056/NEJMoa1713137 [DOI] [PubMed] [Google Scholar]
  • 54. Planchard D, Jänne PA, Cheng Y, et al. ; FLAURA2 Investigators. Osimertinib with or without chemotherapy in EGFR-mutated advanced NSCLC. N Engl J Med. 2023;389:1935-1948. 10.1056/NEJMoa2306434 [DOI] [PubMed] [Google Scholar]
  • 55. Tsuboi M, Herbst RS, John T, et al. ; ADAURA Investigators. Overall survival with osimertinib in resected EGFR-mutated NSCLC. N Engl J Med. 2023;389:137-147. 10.1056/NEJMoa2304594 [DOI] [PubMed] [Google Scholar]
  • 56. Lu S, Kato T, Dong X, et al.  Osimertinib after chemoradiotherapy in stage III EGFR-mutated NSCLC. N Engl J Med. 2024;391:1555-1556. 10.1056/NEJMoa2402614 [DOI] [PubMed] [Google Scholar]
  • 57. Smeltzer MP, Wynes MW, Lantuejoul S, et al.  The international association for the study of lung cancer global survey on molecular testing in lung cancer. J Thorac Oncol. 2020;15:1434-1448. 10.1016/j.jtho.2020.05.002 [DOI] [PubMed] [Google Scholar]
  • 58. Bijaj S. What we're learning from lung cancer patients who never smoked. National Geographic. 2024. https://www.nationalgeographic.com/science/article/lung-cancer-air-pollution-never-smoked
  • 59. Bijaj S. Asian American women are getting lung cancer despite never smoking. It's baffling scientists and leading to more research. NBC News. 2024. https://www.nbcnews.com/news/us-news/asian-american-women-lung-cancer-rcna138895
  • 60. Cook E. Lung cancer mystery: Why are healthy, non-smoking, Asian women contracting the disease? CBS News Bay Area. 2024. https://www.cbsnews.com/sanfrancisco/news/why-do-non-smoking-asian-women-have-high-rates-of-lung-cancer-a-ucsf-study-hopes-to-find-out/

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Data Availability Statement

No empirical data were used in this commentary. All statistics reported are from published sources.

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