By Karen Blum
Women are challenged by a lung cancer diagnosis on multiple levels, which makes their treatment more complex, but the issues often go unaddressed (Clin Lung Cancer 2024;25[1]:1-8).
Lung cancer is the leading cause of cancer-related death for women in many countries including the United States, the experts noted in a review about women and lung cancer. Even if they have no history of smoking, women are exposed to unique risk factors such as indoor pollution and secondhand smoke that are largely understudied, yet they continue to lack representation in lung cancer clinical trials, they said.
“Clinicians should understand the unique factors and consequences associated with lung cancer in women; thus, a holistic approach that acknowledges environmental and societal factors is necessary,” they wrote.
Lead study author Narjust Florez, MD, the associate director of the cancer care equity program at the Dana-Farber Cancer Institute and an assistant professor of medicine at Harvard Medical School, both in Boston, said she has met female patients who were surprised to be diagnosed with lung cancer because the disease is not commonly thought to affect women.
“I slowly learned that because of gender bias, many women face delays in diagnosis,” Dr. Florez said. “Subsequently, I started learning about their unique needs that were embarrassingly underaddressed. A lot of the treatments for lung cancer have been tested and approved in a majority male population, and then we use these data and extrapolate it to treat everybody. In the era of precision oncology, we forget one of the most basic differences, which is biological sex.”
The work noted several key differences, including:
- Environmental risk factors. Although cigarette smoking is a well-known risk factor for lung cancer, people forget that nearly 20% of all U.S. women smoke (Environ Health Prevent Med 2021;26:1-13). Other prominent risk factors for women include air pollution, secondhand smoke, radon and asbestos. Diet and radiation exposure also may be confounding factors.
- Lack of representation of women in lung cancer clinical trials. Numerous studies have demonstrated a sex disparity in lung cancer clinical trial enrollment from 2000 to 2019 (e.g., Cancer 2022;128:770-777). A meta-analysis of 269 trials found that only 39% of 124,357 participants were women. As women tend to have increased familial responsibilities, sex-specific barriers to trial participation include increased time or opportunity costs in visiting clinics. Meanwhile, researchers may have misperceptions that women are less willing to participate in these studies (ESMO Open 2020;5:e000773).
- Sex differences in tolerability and responses to therapy. Women overall are 25% more likely to experience severe adverse events than men (J Clin Oncol 2022;40:1474). Men treated with immune checkpoint inhibitors have a significantly reduced risk for death and higher benefit compared with women (Lancet Oncol 2018;17:737-746). Outcomes could differ based on sex differences in innate and adaptive immune responses (ESMO Open 2018;3:3000344), but “there is lack of prospective validation on the dose-regimen and efficacy for women with lung cancer, which could impact the ability of healthcare teams to be fully informed when choosing medications and treatment protocols,” the authors wrote.
- Survivorship. Lung cancer has been associated with high rates of depression, anxiety and poorer quality of life, particularly for women. Treatments for the disease also have been commonly associated with sexual dysfunction. Men frequently are encouraged to preserve sperm, but women are not always given fertility conservation options (Br J Obstet Gynecol 2012;119:1049-1057).
- Family consequences. Women diagnosed with cancer report difficulties in the home with performing domestic chores, managing personal care and caring for dependents (Br J Cancer 2002;87:1099-1104).
The article “is a great summary of the risk factors that are specific to [lung cancer] patients who are women,” commented Lisa Holle, PharmD, BCOP, FHOPA, FISOPP, a clinical professor of pharmacy practice at the University of Connecticut School of Pharmacy, in Storrs, who was not directly involved in the research. “Additionally, this article describes that not all studies evaluating lung cancer treatments have a good representation of women, and this is an important point to consider in treatment selection.”
Lung cancer screening needs to be recommended to all eligible patients regardless of sex, race or socioeconomic status, and participation in clinical trials should be encouraged, added Dr. Holle, who practices at the Carole and Ray Neag Comprehensive Cancer Center, part of the University of Connecticut Health Center, in Farmington. Dr. Holle is also a member of the Pharmacy Practice News editorial advisory board.
“Pharmacists can play a role in both of those things,” she said. “Even though we can’t offer lung cancer screening because it’s a diagnostic test, we can certainly make people aware of the fact that if they have the criteria to be screened for lung cancer, they should have it done on an annual basis.”
Additionally, she said, people who are prescribed or who pick up smoking cessation products at pharmacies should be counseled about lung cancer screening.
Dr. Florez reported a consultant/advisor role to AstraZeneca, Bristol Myers Squibb, DSI, Merck, NeoGenomics, Pfizer and Regeneron Janssen. Dr. Holle reported no relevant financial disclosures.
