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Join Alice S. Y. Lee, an emergency physician and lung cancer survivor. Alice shares her journey from a nonsmoker to a lung cancer survivor, shedding light on the health disparities faced by Asian American female nonsmokers. Discover how her diagnosis came about, the misconceptions surrounding lung cancer in nonsmokers, and the importance of early detection. We’ll also discuss the significance of ongoing studies and the need for increased awareness and routine screening.

Alice S. Y. Lee is an emergency physician.

She discusses the KevinMD article, “Lung cancer in Asian American women: Don’t be a statistic (never smoked)”

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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 back Alice Lee. She’s an emergency physician, and today’s KevinMD article is “Lung cancer in Asian American women: Don’t be a statistic.” Alice, welcome back to the show.

Alice Lee: Well, thank you, Kevin. Such an honor to be back on your show.

Kevin Pho: So Alice has been on in the past. Go to KevinMD.com/podcast, search her name to hear her story and prior episode. But today let’s jump right into your most recent article, “Lung cancer in Asian American women: Don’t be a statistic.” So tell us what this one is about.

Alice Lee: Well, this one actually is to present very exciting preliminary results for one of the FANS studies. So just as a brief background, in 2021 I was diagnosed with non-small cell lung cancer, which was entirely a shock for me, as I’ve never smoked. And I talk about my history very briefly in this new article.

But what I wanted to do this year for the AA and NHPI Heritage Month was to make people aware, especially the medical community, of some very exciting preliminary results from the FANS study. The primary investigator is Dr. Elaine Shum out of NYU Langone, and last year at the American Society of Clinical Oncology she presented preliminary data and results from her study.

Now, again, with a little bit of background, I think that’ll be important so that you understand the significance of this. Two major studies that are important to talk about, just briefly. Currently the US Preventive Services Task Force only recommends low-dose CT scan screening for smokers or previous smokers between the age of maybe 50 to 80. Now, this recommendation is really based on one study that was conducted nearly 20 years ago. Actually it was published in 2011, but the study subject enrollment was 2002 through 2004.

It’s a pretty big study, it was maybe 54,000 smokers or so and ex-smokers, and what they found with that study was that they had a detection rate of cancer of 1.1 percent with a screening low-dose CT. OK, so based on that study, the US Preventive Services Task Force recommends the screening for the smokers.

Now, another study that’s really pertinent here is that there’s a study out of Taiwan called TALENT, and it’s basically a Taiwan lung cancer screening for never smoker trial. Now this was conducted just recently, February 2015 through July of 2019, so very recent. Their enrollees were about 12,000 nonsmokers between the age of 55 to 75, and their invasive adenocarcinoma lung cancer detection was 1.52 percent.

The pertinence is this. Dr. Elaine Shum and her team enrolled 200 Asian American female nonsmokers between the age of 40 to 70 in her study, which is a female Asian nonsmoker study out of NYU Langone. Their adenocarcinoma detection rate was 1.52 percent. So pretty much the same as the TALENT study out of Taiwan, but even better than the National Lung Screening Trial that the US Preventive Services Task Force recommendation is based on.

So the FANS study preliminary results, the author’s conclusion was that the low-dose CT screening for Asian American female nonsmokers is quite feasible. So that is very, very exciting, because we all want to practice evidence-based medicine, right? I mean, that is just really what we’re chasing after. And Dr. Elaine Shum and her team, to their credit, are really chasing down data and support to change recommendations.

Because right now, if you’re a nonsmoker and you’re worried about cancer, you have a cough or you have some pleuritic chest pain, that screening is not going to get paid for. So that’s a disincentive for women at risk.

And as I’ve talked about multiple times, including a previous podcast with you, Kevin, I wasn’t even aware, I’m a physician, and when I was diagnosed with lung cancer I was shocked. I wasn’t aware that 10 to 20 percent of lung cancers are in nonsmokers. And what’s very peculiar, very pertinent to us Asian American Native Hawaiian Pacific Islanders, is that more than 50 percent of us that have lung cancer are nonsmokers.

What’s really peculiar is that the Chinese American female nonsmoker with lung cancer, which is me, 90 percent of us are nonsmokers. Studies are going on in Asia as well as here. We still don’t know why, but it’s a very peculiar cohort of patients that have lung cancer, and so I’ve been trying to make people more and more aware of that.

In any event, this preliminary study result is very exciting, because we’re pushing towards justification, if you will, or the feasibility of the US Preventive Services Task Force recommending screening routinely for the nonsmokers.

Kevin Pho: Right. Tell us what kind of studies we have in terms of this cohort, and we talked about this in your last podcast when you told your story, but in terms of this being an increasing risk factor, the Asian American female nonsmokers for lung cancer, just summarize the data that we have revealing that this could be a demographic that is going to be more prone to lung cancer.

Alice Lee: Right. So there’s a lot of questions that are not answered. We don’t really know. We just know that there are more and more lung cancers being discovered in nonsmokers, and I don’t really know if that’s because we’re paying attention to it, or is there some environmental factor or other factors that is contributing to this sort of increasing, if you will, incidence of nonsmokers, Asian nonsmokers, having lung cancer.

So the data is mostly from Asia. We have some studies where you’re looking at major health systems in California. That is the basis of some of the statistics I cite, such as, if you look at all lung cancers in Asia, 60 to 80 percent are actually nonsmokers. If you look at all lung cancers here in the United States, 10 to 20 percent are nonsmokers.

But the studies that we’re getting out of California, these are statistical evaluations, if you will. If you look at some of the major, like Sutter Health and Kaiser, the data shows that the AA and NHPI population has a disproportionate number, or percentage, of nonsmokers that have lung cancer.

So like I said earlier, the Chinese American nonsmoker female, 90 percent are nonsmokers. But if you look at, let’s say, Korean or Japanese Americans, they’re lower, more in the 20, 30, or 40 range in terms of nonsmokers. So we don’t know, again, whether it’s genetic, whether it’s the environment, whether it’s exposures, cooking smoke. So that’s why the studies are ongoing.

Now, I do want to highlight two studies that are ongoing currently. I’ve talked about Elaine Shum’s study at NYU. There’s another study that’s prominent, ongoing, it’s also called FANS, female Asian nonsmoker study, now that’s out of UCSF. Dr. Gomez is the primary investigator there. That study has just extended to include Sacramento, so I would strongly encourage any of you living in Northern California to look into that study. It’s the FANS out of UCSF.

That reminds me, actually I was in touch with Dr. Shum, and she is involved currently with trying to increase screening of nonsmokers to all ethnicities, not just female Asians, but to all ethnicities. And that is a process of getting grants and funding and all that, but she’s working collaboratively with others trying to push that agenda through, so that we can be more and more aware, or pick up nonsmokers with lung cancer earlier on.

It’s important, because most lung cancers in nonsmokers are picked up in late stage. I was so blessed, because I was picked up at stage one, no spreading into lymph nodes, I didn’t have to go through chemotherapy. What I had was a curative right upper lobe resection, and then I’ve been taking a targeted therapy, Tagrisso, and I should be finishing that up this summer, which is three full years. Yay.

And so if we can get authorization or official recommendation for early screening for lung cancer in those nonsmokers, then we can pick up the lung cancer early on, like it happened with me, and then have a much higher chance of survival from such a devastating disease. I am reminded all the time of the devastation I was spared, because I see patients with lung cancer, different stages, and on social media. So I’m extremely, extremely grateful.

Kevin Pho: So for those listening to you now, and if they’re concerned about potential lung cancer and they’re a nonsmoker, what kind of symptoms should they be on the lookout for? And I know the whole point of screening is that you don’t necessarily have to have symptoms, but if they’re going to their primary care doctor, is there anything that they should be on the lookout for that may tip them off to say, hey, I need a chest X-ray or a low-dose CT scan potentially for lung cancer, after hearing your story?

Alice Lee: Oh yeah, that’s a fantastic question. So patients that are having persistent coughs. Now, there’s different reasons for a persistent cough. For me, I had a cough for eight months, and just like any other doctor, I’m kind of the worst patient in the world, but I just kind of blew it off, thinking it was nothing serious.

But if you have a persistent cough, you or your patient have a persistent cough, if you have pleuritic pain, something that hurts with breathing, and it’s persistent, constant for weeks of it, if you are having more and more shortness of breath compared to normal, sort of unexplained shortness of breath, if you become very, very weak unexpectedly, all of a sudden you have lost your appetite, so these are some concerning symptoms that your primary care doctor, it might trigger them to think about, well, this could be something serious.

Now, other things such as family history of lung cancer, either first degree family or more distant, that could possibly increase your chance of having lung cancer. If you look at the TALENT study, they had listed as one of the criteria for enrollees in the TALENT study out of Taiwan, was if you had a family history of lung cancer. So if you personally have a family history of lung cancer, I think that would also increase your primary care’s concern over the possibility of your symptom being related to lung cancer. So I think that those are the primary symptoms I would worry about, I think.

Kevin Pho: Now, you’ve been such a passionate advocate to screen for lung cancer in nonsmokers. Do you experience any pushback? And maybe talk about some of the obstacles that you see to widen the population for lung screening.

Alice Lee: I think that’s a very good question. Now, I have been passionate in trying to bring awareness to different avenues, one of which is through you, and I appreciate you, when I suggested my story, to bring people’s attention to that.

So one of the things I have done to bring awareness is to speak at the APAMSA chapter at the University of Arizona College of Medicine, where I am an assistant clinical professor. So the APAMSA chapter at UA has usually an event at the end of the year typically, so I’ve given a lecture to the students there, the medical students, that’s usually MS1s and MS2s, to bring awareness to them with regard to this particular issue. And I bring my own story to it, and I think people really appreciate it.

I have put my lectures on my YouTube educational website, which is easy to find, if you go to YouTube and it’s AliceLeeMD, YouTube AliceLeeMD, and I put my lectures on there. And then I’ve been in touch with some people to see if I can get a little TV spot locally that I can bring attention to the local community.

I live in Arizona, we have a very small percentage of AA and NHPI population, it’s really only about 4 percent. It’s hard to connect with people. Some of the medical students are thinking of some projects we can work on. But so far, I have really not had any pushback. It’s just difficulty connecting with resources, as we still are a small percentage of the country’s population, and this is a very small, unique health disparity, if you will. So I’m doing my best to try to bring awareness.

Kevin Pho: We’re talking to Alice Lee. She’s an emergency physician. Today’s KevinMD article is “Lung cancer in Asian American women: Don’t be a statistic.” As always, Alice, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Alice Lee: Kevin, I do have just really two simple take-home messages. Number one, as physicians, providers, as the public, we have to completely forget the whole idea that you can’t get lung cancer if you’re not a smoker. OK? That’s just out the door. We have to realize that if you’re a nonsmoker you are still at risk for lung cancer. So especially AA and NHPI, right now for me personally, it’s a very, very high-risk group.

Number two, please, please do what you can to bring awareness. I am absolutely sure you know somebody in the AA and NHPI group. It could be in your family, it could be your fellow students, it could be friends you party with. I’m 100 percent sure you have friends in the AA and NHPI. So please make them aware, without scaring them, obviously, but be aware, make them aware.

And help Dr. Shum and Dr. Gomez with their FANS studies, one out of NYU Langone, one out of UCSF. And please, please help Dr. Shum, she is the lead investigator for the FANS study out of NYU Langone. Dr. Gomez is the lead investigator out of the FANS study out of UCSF. Please, that’s my second take-home point, please try and encourage others to enroll in these studies, therefore we can bring more and more evidence and data to support routine screening, especially in the AA and NHPI population.

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

Alice Lee: Thank you so much.