What is the current incidence of lung cancer in the United States?

176,000 people will be diagnosed with lung cancer this year in the U.S. It is the second most common cause of cancer in men and women, but the number one cancer killer. 158,000 people per year die of lung cancer in this country. Than means that every two years we have lost the same number of people to lung cancer as we lost soldiers in World War II. It is also equivalent to one 747 jet, crashing daily in this country. While the use of tobacco products and the incidence of lung cancer appear to be dropping in the U.S., worldwide lung cancer is increasing at one half percent per year. We believe that's because of the increased use of tobacco products across the globe.

Do you think that there are still large numbers of people who don't believe smoking is a serious risk for lung cancer?

I think there are some people who don't want to believe that smoking is a serious risk for lung cancer; but I think it is quite rare in this country today. I think the majority of people do believe there is an association. Every physician and scientist I know believes there is an association. It's one of the few cancer-causing agents where we can clearly delineate that the more you smoke, the higher your chance of developing lung cancer. When we look at the people diagnosed with lung cancer, we find that nine out of ten of them are smokers. It doesn't mean that lung cancer can't happen in non-smokers. It certainly does. But if you smoke, the chances are much greater that you will develop lung cancer.

What about second-hand smoke? I would think it would be difficult to prove cause and effect between second-hand smoke and lung cancer. Yet, the American Cancer Society is advertising heavily to draw attention to the risk of second hand smoke.

There is more and more data linking second-hand smoke to cancer. Remember, it initially took many years to prove what we now think of as obvious - that smoking causes lung cancer in those who smoke. Linking increased incidence of lung cancer in people exposed to second hand smoke is a much more complex issue. It's much more difficult to get patient histories that clearly document how much exposure someone has had. Was the exposure recent or many years ago? Were people exposed in the office place or at home? Today, I think people feel there is pretty good data showing that people who live with smokers die of lung cancer at a higher incidence than people who don't.

One alarming fact is that for every carcinogen, every cancer causing agent, we know that the people most vulnerable are children and the very young. Children exposed to second hand smoke are at risk for a number of health problems. Certainly, one may be an increased risk of lung cancer, but others include asthma and other respiratory diseases.

What are the other risk factors for lung cancer?

One other risk factor for lung cancer is asbestos exposure for people who work with asbestos or who are, or have been, involved with asbestos removal. Intact asbestos is not a risk factor. It's when it is removed from a building that the fibers can scatter and be inhaled. Being in a room with asbestos in the ceilings, for example, is not dangerous, if the asbestos is well contained in the ceiling.

Coal tar fumes are also very dangerous. We know that miners who mined coal and smoked have very high risks of developing lung cancer. Other risk factors for lung cancer include exposure to nickel, chromium, arsenic, radiation and radon. Radon is a natural radioactive gas emitted from the earth. It is not a significant problem in California. In fact, it's quite rare. But, in pockets of the Northeast, there can be a steady production and excretion of radon into people's basements. This is often tested for in these areas. Since radon is not present in all areas of the country, not everybody should go out and test their home. The first question is whether or not you are in an area of risk. If you are, you should test for radon. Radon test kits are available for purchase. The good news is that, if you do have radon present but at low levels, the situation can be very easily remedied by just ventilating the basement. This pulls out the emission and can reverse the detectable emission of radon.

What causes certain geographic areas to have radon?

It's based on geology and the natural composition of the bedrock and soil. It is not related to anything man-made.

What about pollution?

Pollution is a man-made problem. We do believe, although again it's been hard to prove, that pollution puts people at risk for lung cancer and other cancers. While the data is a little bit harder to document, in my opinion, there is no reason not to believe that car exhaust and other chemicals are not carcinogenic.

If you are a smoker, how effective is stopping smoking from a standpoint of actually preventing lung cancer?

It's actually very effective. We know that the more you smoke, or have smoked, directly correlates with the incidence of lung cancer. So if you smoked two packs per day for 20 years and then stopped, that's much better than two packs per day for 40 years. But stopping smoking doesn't completely negate the chance of being diagnosed with cancer. This is unfortunate because I think more people would quit if they believed their risk of developing lung cancer would completely go away once they stopped.

Which brings me to the next question. If somebody does know that they are at a high risk for cancer, either because of their work environment or smoking, is there some type of screening they can do to detect the cancer early?

No. Unfortunately one of the tough things about lung cancer is there is no early detection mechanism. This actually has been tested with chest x-rays to see if early detection of lung cancer could be achieved through routine chest x-rays. Today, no effective test exists. However, there are ongoing investigations that are looking for some type of radiographic test that may prove to be beneficial in terms of early detection. Researchers are also looking at molecular tests and genetic tests to see if we can diagnose lung cancer earlier using these methods.

This brings up the very important point that lung cancer is often incurable. If we could improve the cure rate through early detection, even small gains, for example an increase in survival rate of 1 or 2 percent, could save thousands of people a year. As I mentioned, 158,000 people die of lung cancer each year in this country alone. A one percent improvement represents almost 1,600 more people surviving.

What limits the research in this area?

Unfortunately the funding for lung cancer research has been limited. People often blame smokers for causing their own lung cancer. As a result, there has been less empathy for people who are diagnosed. I think that's wrong. I don't believe anybody's ever smoked so they could get lung cancer. It's a habit people start, and it's very, very difficult to break. There is also a lot of competition today for dollars to fund research in general.

What are the main treatments for lung cancer?

The number one treatment for lung cancer is surgery. It is also the best treatment to cure lung cancer. Surgery may be accompanied by radiation therapy and sometimes chemotherapy. Today, the trend is towards using less aggressive surgery, with some radiation and some chemotherapy, to try to minimize side effects. One of the problems we often have with treating lung cancer is that people who have smoked may already have lung injury and may not be able to tolerate a major operation. Sometimes, either because of somebody's health or because of the location of the lung cancer, surgery may be too risky. For instance, if the cancer has invaded a major blood vessel, then we will often do radiation with chemotherapy or radiation alone, sometimes in the hopes that we can later proceed to surgery.

What percent of people with lung cancer are effectively treated?

The good news is that the cure rate for lung cancer has increased over the past ten years. It had been 8 percent and has climbed to 14 percent. Of course, what most of us would rather see is a decrease in the incidence, but we do need to keep looking for a better cure rate.

How would you define "Cure Rate"?

Someone is considered cured if they live for five years or more after their diagnosis without any evidence of disease.

Are there any new treatments for lung cancer?

The mainstay of treatment in lung cancer is the combination of surgery, chemotherapy and radiation therapy. Probably the most exciting new area has been in the use of chemotherapy and radiation therapy to make lung cancers that would have been unacceptable for surgery, acceptable. This is the main area where we have seen some advancement.

If you or someone you cared for were diagnosed with lung cancer, what would be your recommendations for identifying a place for treatment? What steps should someone take after learning of the diagnosis?

A pulmonologist is the most common specialist to diagnose a person with lung cancer. That's an internal medicine physician who specializes in lung diseases. Pulmonologists will often do what's called a bronchoscopy to look down the breathing tubes and take a tissue sample or a biopsy in order to make a diagnosis. The pulmonologist is often very good at assessing whether or not somebody could tolerate surgery from a medical standpoint. If surgery is an option, the first step should be a referral to a qualified thoracic surgeon or a general surgeon with an expertise in lung cancer. These referrals are usually best made by the patient's primary care physician or the pulmonologist. Either of these physicians will know who the qualified surgeons are in the community.

If surgery can't be done, the next step would be to go ahead and see a radiation oncologist and a medical oncologist to see whether or not radiation and/or chemotherapy would be indicated. In most communities, there are enough lung cancer cases to keep surgeons, radiation oncologists and medical oncologists all skilled in treatment.

Nevertheless, it is always important to make sure you feel comfortable with the person treating you. I would suggest you do a little bit of personal research. Make sure you go to your doctor's appointment prepared to ask questions. If you have any level of discomfort or feel, for any reason, that you might want a second opinion, you should obtain one. Remember, you don't need to have a particular reason for a second opinion. You just need to ask for it. If you do pursue a second opinion, a University Medical Center or any kind of Comprehensive Cancer Center would be a good place to go. These organizations often have a panel of specialists and health professionals that meet regularly to review and discuss second opinion cases.