Bryant Lin’s persistent, hacking cough had lasted for six weeks, with no sign of improvement. As a clinical professor and primary care physician at Stanford University, he tried the usual treatments for allergies, asthma and reflux before finally going to his doctor for an X-ray.
Only days later, and less than a month before his 50th birthday, he learned he had Stage 4 lung cancer — a disease considered incurable, if not terminal. Lin had never smoked a cigarette in his life.
“Definitely a shock,” he recounted this month. At the time of his diagnosis in spring 2024, the cancer had already spread to his liver, bones and brain. Ironically, he had recently co-founded the Stanford Center for Asian Health Research and Education (CARE), devoted to diseases that disproportionately affect Asian communities. Among them: never-smoker lung cancer.
“I was diagnosed with the same disease that our center was supporting,” he said.
While cigarette smoking is still the primary risk factor for lung cancer, a growing proportion of patients with the disease are nonsmokers like Lin. Last week, Pope Leo had part of his right lung removed because of adenocarcinoma, the most common type of lung cancer. He is not known to have ever lit up.
The drop in smoking rates in the United States and other countries has unexpectedly shed light on this as an emerging health issue. Never-smoker lung cancer is now the eighth leading cause of cancer-related death in the U.S. and the fifth most common cause of cancer-related deaths worldwide.
“Because I’m a physician, most people make the assumption I’ve never smoked, and they ask, ‘Why did you get lung cancer?’” Lin said. “Then I explain to them that roughly one out of five people with lung cancer in the United States have never smoked.”
A growing body of research is identifying the disease’s unique clinical characteristics. In September, a study described a rare mutation concentrated in the southeastern U.S. that puts never-smokers at 60 times higher risk of developing lung cancer. The demographics of patients are also distinct — for instance, women who have never smoked are more than twice as likely to get lung cancer as men who have never smoked.
“Two-thirds of nonsmoking-related lung cancer happens in women, so there’s certainly an association with female sex,” said Jaclyn LoPiccolo, a medical oncologist at the Dana-Farber Cancer Institute and author of the mutation study. “Nonsmoking-related lung cancer is also more common in people of East Asian descent, but whether that’s a genetic or environmental association, we don’t yet know.”
Regardless of gender or ethnicity, risk factors include exposure to secondhand smoke, radon, air pollution and asbestos. A family history of any cancer diagnosed before age 50 in a first-degree relative is associated with increased lung cancer risk in nonsmokers.
At the beginning of the 20th century, lung cancer was considered rare in the United States, accounting for fewer than 140 cases per year. “The overwhelming majority of medical practitioners rarely, if ever, think of a diagnosis of tumor of the lungs,” physician Isaac Adler wrote in a 1912 review.
Fast forward a century, with the disease now the leading cause of death from cancer worldwide. Every year in the U.S., it claims more people than colon, breast and prostate cancers combined.
But smokers and never-smokers alike continue to face lung cancer stigma, which can mean delayed diagnosis and treatment, as well as limited public support for research and care.
“A cancer diagnosis should never become a judgment about a patient,” said Haiying Cheng, a medical oncologist at Montefiore Einstein Medical Center in New York.
Never-smokers typically are diagnosed at more advanced stages of disease, in part because both they and physicians don’t consider them vulnerable. “I feel we need to move beyond the old idea of who gets lung cancer,” Cheng added, “and just look at a person’s actual risk and biology of the tumor.”
The U.S. Preventive Services Task Force recommends lung cancer screening only for smokers or former smokers between 50 and 80 years old. As the landscape of lung cancer patients shifts to more nonsmokers — defined as people who have smoked fewer than 100 cigarettes in their lifetime — screening guidelines based on risk rather than smoking history could save more lives. Taiwan has a national lung cancer early-detection program that offers low-dose computed tomography (CT) scans to nonsmokers with a family history of lung cancer.
“I’ve got two sons, and I told them, ‘When you hit 45 or even 40, think about getting screened,’” Lin said. “By that time, maybe there will be different types of screening available, including blood-based testing. Hopefully, we’ll have made a lot of progress by then.”
Since his diagnosis, Lin has pushed to raise awareness. He taught a course based on his experience at Stanford Medical School called “From Diagnosis to Dialog: A Doctor’s Real-Time Battle with Cancer” and continued to advance the Stanford CARE Lung Cancer Initiative in Asian populations.
Today he works with the Susan Wojcicki Foundation to support efforts for screening and early detection. He even started a company focused on accelerating lung cancer therapeutics — all while still undergoing treatment himself. Though Stage 4 lung cancer carries a five-year survival rate of just 13 percent, Lin is hopeful. He has been taking an antibody therapy that targets a specific cancer-driving mutation, one that appears more often in never-smokers.
“The treatment has done wonders for me,” he said. “When I was a medical student or resident, I would have never thought a Stage 4 lung cancer patient could be very productive and have a high quality of life almost two-and-a-half years after diagnosis.”
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