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Join us in this episode as we hear the inspiring story of Alice S. Y. Lee, an emergency physician diagnosed with lung cancer despite being a never-smoker. Discover the unique challenges faced by Asian American female nonsmokers, the importance of early detection, and ongoing studies addressing late diagnoses. Gain valuable insights into treatment options and raising awareness about lung cancer risks. Don’t miss this conversation with Alice S. Y. Lee, an advocate for early diagnosis and a symbol of hope for others.

Alice S. Y. Lee is an emergency physician.

She discusses her KevinMD article, “The rising threat of lung cancer in Asian American female nonsmokers.”

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Transcript

Kevin Pho: Hi and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Alice Lee. She’s an emergency physician. Her KevinMD article is titled “The rising threat of lung cancer in Asian American female nonsmokers.” Alice, welcome to the show.

Alice S. Y. Lee: Thank you, Kevin. I’m so honored to be here.

Kevin Pho: So I think your article talks about your story, so let’s start there. Share your story and journey to where you are today.

Alice S. Y. Lee: Sure. So back two years ago, in 2021, I had a cough during COVID, and I decided it was a lisinopril cough, because I had just started lisinopril and developed the cough. So I went to my primary physician, and we talked about it. She agreed with me. She said, “Let’s get a chest X-ray just in case, because, you know, we live in Arizona. Maybe it’s valley fever.” So I didn’t really think much of it, changed my medicine to olmesartan, and my cough went away after a few weeks.

But then I get a call after my chest X-ray, and my doctor says, “There’s this spot that’s suspicious.” And I’m like, “Oh, really?” So we go through the whole process, including a needle biopsy, and when I was calling, the voice on the other side said, “It’s adenocarcinoma.” I was so shocked. I mean, I was completely not expecting it, because I didn’t think it could be lung cancer. I’ve never, ever smoked. I didn’t really grow up in a smoking family. My dad did smoke earlier, when I was a child, but he quit when I was a child. So it was a completely shocking diagnosis, and I thought there’s just no way I could have lung cancer.

So I dived into it, and it turns out there’s this small, very unknown, peculiar cohort of lung cancer patients, which are never-smoking or never-smoker Asian American females, and that’s me.

So then, long story short, I did have a right upper lobectomy back in 2021, in fact almost exactly two years ago, Memorial Day weekend. And I was really fortunate. I only had the right upper lobe resected, and all the lymph nodes intraop were negative. And I discovered there’s a unique genetic mutation that’s commonly found in the nonsmoker lung cancers. So my oncologist recommended I send my lesion for genetic testing, and it turned out to be one of the more common EGFR mutations, genetic mutations that actually had targeted therapy. In fact, in 2020, the FDA had just approved Tagrisso for early-stage non-small cell lung cancer, and the data was very good at the time, and it continues to be very good with the updates, that it will prevent recurrence of that specific mutation. So I’ve been on Tagrisso for two years, and I’m doing well. All my checkups thus far have been good.

Kevin Pho: So let’s go back to that whole diagnostic journey. I just want to be sure: The only clinical symptom that you had, essentially, was this cough? You didn’t have any other associated symptoms, is that correct?

Alice S. Y. Lee: Correct. I’m a very healthy person, and in fact, that cough had nothing to do with my lesion. Both my thoracic surgeon and the pulmonologist said that it had nothing to do with my cough. First of all, my cough went away after we switched from lisinopril to an ARB. Second of all, it was nowhere near the wall of a bronchus or something where it would cause some irritation. It was a tiny little spot, 1.4.

So my opinion is that it was divine intervention. I’m a Christian, and so I feel that very strongly. But also, if you look at the statistics, most non-small cell lung cancers in nonsmokers actually are discovered incidentally. So for me, it was really exactly what happened. It was an incidental cough. We had agreed it was a lisinopril cough, and then because my primary doctor was thorough, she wanted to get a chest X-ray in case it was valley fever, since I live in Arizona, and that’s how we discovered it.

Kevin Pho: Now, if you didn’t have this incidental chest imaging that found the cancer, what’s the natural disease progression of this?

Alice S. Y. Lee: So naturally, unfortunately, most of the nonsmoker or non-small cell lung cancers are detected at stage 3 or 4. In my article, I linked two studies that are occurring currently to study the etiology of these peculiar cancers in nonsmoking Asian American females. And one of the links will also highlight a very tragic story of a very potentially successful OB/GYN resident who was diagnosed at a late stage. Very tragic.

Kevin Pho: Now, what are the current recommendations when it comes to lung cancer screening, and are there any specific recommendations for screening this particular Asian American cohort that you talk about?

Alice S. Y. Lee: Yeah, that’s a great question, and this is where we really have to get better at it. The U.S. Preventive Services Task Force does recommend regular screening for smokers. These are low-dose radiation CTs. But for the nonsmokers, it’s a very small percentage of the total numbers of lung cancers per year, and there is no such recommendation. And so people like myself, patients like myself, are at very high risk of late detection, and that’s what happened with that one particular person I referenced in my article, that physician.

So it is a tough thing right now. We really need to get more information, more data, through different studies in order to garner the argument to also recommend nonsmokers get screened for lung cancer, especially in the AANHPI population, because we have such a high percentage of nonsmokers in our population who get lung cancer.

Kevin Pho: Tell us about the genetic predisposition of something like this. For instance, in your family history, any history of any lung issues, lung cancer?

Alice S. Y. Lee: So no. And there’s very little knowledge about genetic predisposition. There are some theories of what would increase your chance as an AANHPI person to have lung cancer, but there’s very little knowledge about exactly what’s going on. We think maybe radon, we think maybe long-term exposure to, let’s say, cooking oils, but there’s really very little data to confirm what the causes are for nonsmoker cancers.

Kevin Pho: Now, in your case, it was your cough that precipitated this chest X-ray. Tell us what other symptoms people should look out for that would bring them to a doctor’s office, perhaps for some chest imaging.

Alice S. Y. Lee: So typically, the symptoms of a possible lung cancer in a smoker, or in a nonsmoker actually, because most lung cancers are in smokers, are a persistent cough and some chest pain in the lung, especially if it’s sharp and stabbing, and especially if the pain is more noticeable when you take a deep breath or when coughing. Shortness of breath, or noticeably worsening shortness of breath more than the normal, can be a symptom of a possible lung cancer.

Kevin Pho: Now, you’re an emergency physician. Tell us about this journey, from the surprising diagnosis all the way to remission. How has that changed you?

Alice S. Y. Lee: I think that’s a great question, Kevin. One of the first things I actually really learned was that we can be even kinder. I’ve always felt that I’ve been a very nice doctor, you know, a very kind doctor, but when you’re on this side of things, when you’re on the receiving side of services from health care workers, you sense the little things that make a difference, the kind gestures that are made by the staff. I had a tremendous amount of pain, but they were very kind, and every step along the way, they tried to minimize the amount of pain I was suffering. I had a chest tube, I had the catheter and all this stuff, and they were just really helpful.

So I’ve always been very, very independent, and I always feel like I can do everything myself, right? There are lots of female physicians who feel that way about themselves, very, very strong and independent. But I think that we’ve missed along the way the little kindnesses that cushion our suffering, if you will. So with the little kindnesses that I noticed, I thought, “Wow, I can actually be even more kind and even nicer,” just little things, you know. And I thought that was a great lesson for me personally.

I also felt through the whole experience that my faith in God carried me through the whole thing, and that’s, for me, the only way really I could be carried through all the anxiety and fear that comes with it. But that’s also another point: I really sympathize, through this experience, with what fear in a patient really feels like, and anxiety, because so many of us, especially women that are high-achieving, are just strong women and tough-minded, you know, and you don’t tend to be easily subject to anxiety or fear, right? For me, that sense of uncertainty and fear was more real, and I thought, “Wow, this is how my patients really feel.”

And for me, the way I handled it may be different from other people’s, but the way I handled all the fear and anxiety was my faith in the Lord. So I thought that was a great lesson for me as a physician, to really understand the subjective side of the patient when going through a cancer struggle.

Kevin Pho: So you mentioned that your cancer is in remission. You’re taking Tagrisso, which is a targeted therapy for patients in your cohort. What’s the long-term outlook? Do you have to have periodic imaging of your chest? Are you going to be on this medication lifelong? Tell us in terms of what the treatment course is currently for you.

Alice S. Y. Lee: The study was performed on patients for three years, meaning that they took Tagrisso for three years. These patients had early-stage non-small cell cancer with the EGFR mutation. So the data comes from that, and I will need to be on Tagrisso for three years, mostly because that’s what the study protocol was. So I’ll be on it for three years. I’m two years into it. And the data is very good. The disease-free survival and overall survival is high, in the 90s or more, I believe. I think that was the latest data that just came out. So after my three years, you’d expect, theoretically, not to have a recurrence.

But I do have to say, anybody with a cancer diagnosis, especially as a physician, I think you’re just aware of it, which is you just never lose that sense in the back of your head that it might come back, regardless of what, you know, modern science says. And cancer therapy has gone through a revolution, right, Kevin? You probably are aware that cancer therapy has gone leaps and bounds in the past 10 years, with immunotherapy, targeted therapy, or CAR T therapy. So despite all of that advancement, I still have this little thought in my head: Well, you just don’t know, right?

So anyway, that’s the anticipated course: Finish Tagrisso, and then, no, there’s no ongoing treatment. I have been getting CT scans every four to six months, and I would imagine that’ll be less frequent after the Tagrisso.

Kevin Pho: So as you reflect on your journey, is there anything that you wish you could have done differently?

Alice S. Y. Lee: It was really an incidental finding, so I’m grateful. I’m very, very grateful that it turned out the way it did.

Kevin Pho: And how are you doing today? Are you back practicing in the emergency department?

Alice S. Y. Lee: Yeah. So one of your possible topics is what am I passionate about these days. So I am really getting into international medicine. I went part-time in terms of my clinical work, but I’m just really interested in giving back, if you will, paying it forward. I’ve been an emergency physician for 30 years in a high-acuity geriatrics ER, so I feel like I have a trove of experience and knowledge and wisdom. It would be just a shame to let it go and not give it back to people. So I’ve been teaching at the medical school for about six years. I had a video blog, an educational blog, with Emergency Medicine News for about four years, until my cancer.

And so I am participating in a couple of international trips. I went to Mexico just this weekend with medical students, and we served at a couple of low-resource clinics for the poor. And then last year, I went with the Christian Medical and Dental Associations, CMDA National. They have a medical education section, and I went with six other physicians to Romania to form a relationship with the emergency department of one of the main hospitals in Oradea.

And then I also went to Dubai in January this year. You should go to Dubai, Kevin. It was so fun. Anyway, I have a friend who lives in Abu Dhabi in the UAE, and she invited me to a conference in Dubai, so I was able to give a lecture to some of the emergency physicians at a big, big conference there.

So I’m really, really interested in doing more international medicine, mostly because I am interested in international medicine, but also I want to give back. So I’m going to Malawi. Actually, I’m going to Malawi in September with a missionary group, and it’ll be a big group. There are like 30 of us, dental, medical, OBs. So it’s just a big group to go over there, and we’re going to just see what we can do and help serve the people there. So I’m really into international medicine right now.

Kevin Pho: We’re talking to Alice Lee. She’s an emergency physician. Her KevinMD article is titled “The rising threat of lung cancer in Asian American female nonsmokers.” Alice, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Alice S. Y. Lee: Well, good, I’m glad you asked, because I jotted them down. Number one message: Even though this is a very scary situation, unexpectedly having cancer as a nonsmoker when you never think you would, I do want to point out, don’t be frightened, because statistically, only half a percent, that’s 0.5 percent, of all lung cancers are in Asian American, Native Hawaiian, and Pacific Islanders. OK, so only half a percent of all lung cancers. Now, if you look at the female lung cancers who are nonsmokers, 3.6 percent are in the Asian American, Native Hawaiian, and Pacific Islander population. So even though it’s scary, I want you to put it in perspective. That is really a small percentage of the overall number of cancers we have in this country, lung cancers in this country.

Number two, I do have a lot of educational material. I have a YouTube channel, youtube.com/@AliceLeeMD. Very easy, @AliceLeeMD. I have all my lectures and all of my previous video screencasts, called I Cubed, on there.

And number three, for those who are believers, Romans 8:28 carried me through this entire very scary journey. And I thank you so much, Kevin, for letting me spend some time with you.

Kevin Pho: Alice, thank you so much for sharing your story, time, and insight. Thanks again for coming on the show.

Alice S. Y. Lee: Very good.