May is AANHPI Heritage Month so it’s a good time to share again my journey from nonsmoker to lung cancer survivor. It is such an important issue to bring awareness to this little-known and potentially deadly health disparity because, according to the 2020 census, 6.2 percent or 20.6 million people identify as AANHPI (Asian American Native Hawaiian Pacific Islander).

Wait. How can you have lung cancer? You’re not a smoker.

That’s what I said when I got a call from my PCP back in 2021 with the results of a chest X-ray she ordered when I went to her with a persistent chronic cough which I had developed after starting Lisinopril. Annoying, persistent coughing is a known side effect of ACE inhibitors. We both agreed and I was switched to an ARB, and my cough went away as expected.

Completely unexpectedly, however, my PCP called a couple of weeks later and told me I had a “suspicious” lung nodule. As an experienced emergency physician myself, I know that “suspicious nodule” is one of those phrases you hate to see in a radiology report. Here, ironically, it is being used to describe a finding on my own X-ray.

Despite being in the medical field for more than 35 years, this was the first time I’d heard about this cohort of lung cancer patients into which I fit exactly: the female Asian American never-smoker. The term “Asian American” encompasses a wide heterogeneous swath of the U.S. population simply categorized as part of AANHPI (Asian American Native Hawaiian Pacific Islander.). Even though the number one risk for lung cancer in the U.S. and worldwide is smoking, 10 to 20 percent of lung cancers in the U.S. are in nonsmokers. So, while 20 percent of all women with lung cancer in the U.S. are nonsmokers, a whopping  57 percent of Asian American females with lung cancer are nonsmokers. Even more peculiar is that approximately 95 percent of Chinese American females with lung cancer have never smoked. I am one of these women.

Lung cancer is the leading cause of cancer-related deaths worldwide as well as in the U.S.  Every year, more than two million people around the world are diagnosed with the disease. According to the American Cancer Society, about 234,580 will be diagnosed with lung cancer in the U.S. in 2024. Lung cancer in nonsmokers occurs more frequently in women and at an earlier age than lung cancer in smokers. Most lung cancers are of the non-small cell histological type (NCSLC) and adenocarcinoma is the most common subtype in nonsmoker lung cancers.

Most NCSLC, when discovered, is already in stage III or IV. The USPSTF (U.S. Preventative Services and Task Force) currently recommends routine screening for lung cancer in smokers between the ages of 50 to 80. There is no such recommendation for nonsmokers. Asian American female nonsmokers, therefore, are at increased risk for late diagnosis because we don’t think we can get lung cancer. There is much we still do not understand regarding this disease. What causes this disparity? Why is the nonsmoker in the Asian American female at higher risk for lung cancer than the non-AANHPI female smoker? Shouldn’t routine screening be a USPSTF recommendation for this population?

There are currently two ongoing studies recruiting Asian American female never-smokers. The New York Female Asian Nonsmoker Screening Study (NY FANSS) is led by Dr. Elaine Shum. This study is offering up to three annual free low-dose CT scans (LDCT) to screen for lung cancer. In June of 2023, Dr. Shum et al., published preliminary results of the NY FANSS supporting the feasibility of screening female nonsmokers of AANHPI descent. The second study is out of UCSF similarly called FANS Study. This study is led by Scarlett Lin Gomez, PhD. This study will look at possible causes of lung cancer in this population. Here is a quick YouTube post explaining this study and how to enroll.

There are sadly multiple stories of Asian American female nonsmokers who were diagnosed with lung cancer too late and succumbed including two female physicians noted on the UCSF FANS study website. We live in a melting pot society and I am positive you know a female AANHPI nonsmoker. Please spread the word about these FANS studies and/or consider enrolling in them yourself.

As for me, I was very fortunate. I had a right upper lobe lobectomy deemed “curative” in May 2021. It was an early stage of diagnosis. I was 59 and healthy at the time of my surgery and did well. I am taking Tagrisso, a targeted therapy specific for EGFR mutation-positive NSCLC identified on genetic testing of my lung nodule. I feel tremendously blessed to have had my cancer discovered early. Let’s spread the word and sound the alarm! Let’s help future generations of AANHPI female nonsmokers detect lung cancer early before it’s too late.

Alice S. Y. Lee is an emergency physician.