Slides last updated: October 2013
Lung cancer incidence and mortality
Lung cancer is one of
the most common
cancers, with 1.6 million
new cases per year
worldwide1
Lung cancer is the most
common cause of death
from cancer, responsible
for 18.2% of all cancer
deaths1
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and
Mortality Worldwide: IARC Cancer Base No.10 [Internet]. Lyon, France: International Agency for Research on
Cancer; 2010. Available from: http://globocan.iarc.fr, accessed on 15/09/2013.
Rates of lung cancer incidence and mortality differ worldwide1
Northern America
Central and Eastern Europe
More developed regions
55% of new lung cancer cases
occur in developing countries
Eastern Asia
Micronesia
Western Europe
Polynesia
Highest lung cancer rates are
found in Northern America
Lung cancer is the most common
cancer in men and the second
most common in women
Northern Europe
Southern Europe
Australia/New Zealand
World
South-Eastern Asia
Less developed regions
Caribbean
Southern Africa
Western Asia
South America
Lowest lung cancer rates are
found in Middle Africa
Lung cancer is the 15th most
common cancer
Central America
Incidence
Melanesia
Mortality
Northern Africa
South-Central Asia
Eastern Africa
Western Africa
Male
Female
Middle Africa
80
60
40
20
0
20
40
60
80
Estimated age-standardized rates (World) per 100,000
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and
Mortality Worldwide: IARC Cancer Base No.10 [Internet]. Lyon, France: International Agency for Research on Cancer;
2010. Available from: http://globocan.iarc.fr, accessed on 15/09/2013.
Rates of lung cancer incidence differ between men and women1
Lung
Breast
Prostate
Cervix uteri
Lung
Colorectum
Colorectum
1092056
948993
Stomach
Lung
Liver
Stomach
Lung
Corpus uteri
Oesophagus
515999
427586
Bladder
Ovary
Non-Hodgkin lymphoma
Liver
Leukaemia
Thyroid
Lip, oral cavity
Leukaemia
Kidney
Non-Hodgkin lymphoma
Pancreas
Oesophagus
Larynx
Pancreas
Brain, nervous system
Brain, nervous system
Other pharynx
40
30
Kidney
20
10
ASR (W) rate per 100,00
0 0
10
20
30
ASR (W) rate per 100,00
40
Incidence
Mortality
Ferlay J, Shin HR, Bray F, Forman D, Mathers C and Parkin DM. GLOBOCAN 2008 v2.0, Cancer Incidence and Mortality
Worldwide: IARC Cancer Base No.10 [Internet]. Lyon, France: International Agency for Research on Cancer; 2010. Available
from: http://globocan.iarc.fr, accessed on 15/09/2013.
Survival rates for lung cancer are generally low1
Five-year survival trend
PERCENTAGE (%)
100
Breast
cancer
80
Colorectal
cancer
60
40
High unmet medical need
Prostate
cancer
20
Lung
cancer
0
1975
Survival rates vary
depending on stage
at diagnosis. The
later the stage of
diagnosis the
lower the survival
rates tend to be.
2004
1. SEER. Fast Stats Online. 5 year survival by diagnosis. 1975-2004. All races. All ages. Male and Female. Available online:
seer.cancer.gov/faststats/selections.php, accessed on 15/09/2013.
NSCLC makes up approximately 85% of lung cancer1
Large cell carcinoma
(2.6% of lung cancer)
Lung Cancer
(100%)
Other NSCLC
(20.2% of lung cancer)
Squamous cell
carcinoma
(21.4% of lung
cancer)
NSCLC
(85.3% of lung cancer)
Adenocarcinoma
(40.1% of lung
cancer)
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER
web site, April 2013, accessed on 15/09/2013.
The distribution of NSCLC subtypes is changing1
Since the 1980’s,
squamous cell
carcinomas have
become relatively
less common
Meanwhile,
adenocarcinomas
have become
relatively more
common
The reasons for these changes are unclear,
but may be due to changes in the
composition and filtering of cigarettes
1. Devasa S, Bray F, Vizcaino A, et al. Int. J. Cancer 2005: 117, 294–299
Slides last updated: October 2013
There are two main types of lung cancer1
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER
web site, April 2013, accessed on 15/09/2013.
NSCLC can be further divided into different sub-types1
Large cell carcinoma
(2.6% of lung cancer)
Lung Cancer
(100%)
Other NSCLC
(20.2% of lung cancer)
Squamous cell
carcinoma
(21.4% of lung
cancer)
NSCLC
(85.3% of lung cancer)
Adenocarcinoma
(40.1% of lung
cancer)
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER
web site, April 2013, accessed on 15/09/2013.
NSCLC: Adenocarcinoma
40.1%1
Adenocarcinoma
Adenocarcinoma lesions are
usually peripherally located2
Most frequent in women and
non-smokers2
Some patients have EGFR/ErbB1
mutations; these patients require
a specific diagnosis and
treatment approach3
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER web
site, April 2013, accessed on 15/09/2013. 2. Heighway J & Betticher DC. Atlas Genet Cytogenet Oncol Haematol. February 2004.
3. Vijayalakshmi R, et al. Indian J Surg Oncol 2011;2:178‒188.
NSCLC: Squamous cell carcinoma
21.4%1
Squamous Cell Carcinoma2
Squamous Cell Carcinoma
lesions are generally centrally
located, near bronchi
Tends to spread locally
Closely correlated with
smoking
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the
SEER web site, April 2013, accessed on 15/09/2013. 2. Heighway J & Betticher DC. Atlas Genet Cytogenet Oncol
Haematol. February 2004.
NSCLC: Large cell carcinoma
2.6%1
Large Cell Carcinoma
Comprised of
undifferentiated cells 2
Lesions are usually
peripherally located but can
occur anywhere 2
High tendency to
metastasize 2
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the
SEER web site, April 2013, accessed on 15/09/2013. 2. Heighway J & Betticher DC. Atlas Genet Cytogenet Oncol
Haematol. February 2004.
NSCLC: Other
20.2%1
Other, including Not Otherwise
Specified (NOS) or Unknown
A classification of NOS or
unknown is usually due to
ineffective sampling and
examination2
This classification is expected
to decline in use due to more
accurate biopsies and
advances in
immunohistochemistry and
biomarker testing2
1. Howlader N, Noone AM, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the
SEER web site, April 2013, accessed on 15/09/2013. 2. Righi L, Graziano P, Fornari A, et al. Cancer 2011;117:3416‒3423.
Slides last updated: October 2013
Relative contribution of risk factors to lung cancer burden
9-15%
Occupational
exposure to
carcinogens1-3
2%
Outdoor air
pollution1
85%
Cigarette
smoking1-3
8%
Asbestos3
8-10%
Radon exposure2,3
Population
attributable risk
Impact
of
exposure
= likelihood
of
exposure
1. Alberg AJ & Samet JM, Epidemiology of Lung Cancer. Chest 2003; 123:21s-49s
2. American Lung Association. Lung Cancer Fact Sheet. Available online: www.lung.org/lung-disease/lung- cancer/resources/facts-figures/lung-cancer-factsheet.html#Other_Causes, accessed on 15/09/2013
3. Cancer Research UK. Lung Cancer Risk Factors. Available online: www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/riskfactors/lung-cancer-risk-factors,
accessed on 15/09/2013
Tobacco use is the most important risk factor1
Higher rates of
smoking are
associated with
higher rates of lung
cancer. A decrease
in the prevalence of
smoking in many
countries since the
1950s has led to
lower rates of lung
cancer incidence
and mortality, albeit
with a lag of several
decades.
Trends in Tobacco Use and Lung Cancer Death Rates* in the US
1. American Cancer Society. Cancer Statistics 2013. Atlanta: American Cancer Society, Inc.
Tobacco blend/filtering may affect distribution of NSCLC subtypes1
The advent and increased popularity of filtered cigarettes has also
led to a change in the distribution of lung cancer subtypes.
Filters, along with newer tobacco blends, give rise to:
lower levels of polynuclear
aromatic hydrocarbons…
…and potentially to decreasing
incidence of squamous cell
carcinoma…
higher levels of tobaccospecific N-nitrosamines…
…and potentially to
increasing incidence of
adenocarcinoma
Filters also tend to lead smokers to inhale smoke more deeply
and retain smoke in the lungs longer, delivering higher doses of
carcinogens to the peripheries of the lungs
1. Hoffmann D, Djordjevic MV, & Hoffman I. Preventative Medicine 1997:26, 427–434
Radon and asbestos exposure are also important risk factors
• Radon exposure, especially when combined with
tobacco smoking, can lead to increased risk of lung
cancer1
• Studies in Europe and USA have found that the
risk of lung cancer increased by 8.9% and 11%
respectively per 100Bq/m3 increase in radon gas1,3
• Exposure to asbestos increases the risk of
developing lung cancer, mesothelioma and
other non-malignant lung disorders2
• Exposure to asbestos coupled with smoking
increases the risk to a greater extent than the
separate components added together2
1. Darby S, Hill D Auvinen A et al. BMJ 2005;330:223
2. Erren TC, Jacobsen M & Piekarski C. Epidemiology 1999;10:405–411
3. Krewski D, Lubin JH, Zielinski JM et al. Epidemiology 2005;16:137-145
Other risk factors include indoor air pollution and alcohol
Indoor air pollution is a known lung cancer risk factor1,2
• Wood burning
• Coal burning
• Cooking oil fumes
A diet high in fresh, beta-carotene-rich fruit and vegetables
shows some evidence of decreasing lung cancer risk. However,
beta carotene given as a supplement was shown to
increase lung cancer risk and mortality3
There is evidence that those who consume alcohol in high
amounts (more than three drinks per day) have increased
lung cancer risks, although it is difficult to control for the
confounding effect of smoking in studies4
1. Hosgood HD, Boffetta P, Greenland S, et al. Environ Health Perspect 2010; 118:1743–1747
2. Lam WK, White NW & Chan-Yeung MM. Int J Tuberc Lung Dis 2004;8:1045–1057
3. Omenn GS, Goodman GE, Thornquist MD, et al. NEJM 1996;334:1150-1155.
4. Bandera EV, Freudenheim JL & Vena JE. Cancer Epidemiol Biomarkers Prev 2001;10:813-821
Hereditary factors can play a role
Having a first-degree relative with lung cancer can be a
risk factor for developing the disease1
There are several genes that are potentially implicated in
familial lung cancer, one of which codes for nicotinic
acetylcholine receptors2
• Mutations to this receptor could increase lung cancer
risk from 14% in smokers overall to 20-23% in smokers
with the mutation2
1. Coté ML, Liu M, Bonassi S, et al. European Journal of Cancer 2012;48:1957-1968
2. Pray L. Nature Education 2008;1(1)
Slides last updated: October 2013
NSCLC is most often diagnosed at an advanced stage
Early lung cancer may not cause any symptoms.1 25% of
people with lung cancer have no symptoms when lung cancer
is diagnosed; the remaining 75% develop some symptoms2
Many of the symptoms that do appear with more advanced
disease can be mistaken for other illnesses3
 Bronchitis
 Pneumonia
 Consequences of cigarette smoking
1. MedlinePlus Medical Encyclopedia. Lung cancer - non-small cell. Available from
http://www.nlm.nih.gov/medlineplus/ency/article/007194.htm, accessed on 15/09/2013.
2. WebMD. Lung Cancer Health Center: Lung Cancer Symptoms. Available from: www.webmd.com/lung-cancer/lung-cancersymptoms, accessed on 15/09/2013.
3. Thomas K. Patient information: Lung cancer risks, symptoms, and diagnosis
(Beyond the Basics). Available from www.uptodate.com/contents/lung-cancer-risks-symptoms-and-diagnosis-beyond-the-basics,
accessed on 15/09/2013.
Some common NSCLC symptoms1,2
Mortality is greatly
improved when lung
cancer is diagnosed early.
It is very important to discuss any
potential lung cancer symptoms with
a health care provider
Worsening Long-Term Cough
Chronic Cough
Wheezing
Loss of appetite
Recurrent Pneumonia
Hoarseness
Shortness of Breath
Constant Chest Pain
Weight Loss
Haemoptysis
Fatigue
Recurrent Bronchitis
1. MedlinePlus Medical Encyclopedia. Lung cancer - non-small cell. Available from
http://www.nlm.nih.gov/medlineplus/ency/article/007194.htm, accessed on 15/09/2013.
2. Thomas K. Patient information: Lung cancer risks, symptoms, and diagnosis
(Beyond the Basics). Available from www.uptodate.com/contents/lung-cancer-risks-symptoms-and-diagnosis-beyond-the-basics,
accessed on 15/09/2013.
Symptoms of metastatic NSCLC may vary widely
Symptoms of metastatic lung cancer may vary widely and often
coincide with the site of tumour metastasis1
Seizures
Dizziness
Jaundice
Lumps near the surface of the
Headaches
body, (lymph nodes) often in the
neck or above the collarbone
Bone pain
Weakness or numbness
Bleeding or blood clots
of the arms or legs
Clusters of symptoms or paraneoplastic syndromes can point to
a possible lung cancer1
1. WebMD. Lung Cancer Health Center: Lung Cancer Symptoms. Available from: www.webmd.com/lung-cancer/lung-cancersymptoms, accessed on 15/09/2013.