A hidden epidemic: the rise of lung cancer among women and the need for equity

 

Lung cancer is the most diagnosed cancer and the leading cause of cancer-related deaths globally. While incidence rates among men have generally declined over the past 30 to 40 years, however, rates among women have continued to rise in many countries, narrowing the historical gender gap. Over 600,000 women lost their lives to lung cancer in 2022, surpassing those lost to breast, ovarian, and cervical cancers combined.  

This trend is influenced not only by changes in tobacco use patterns, but also by increased exposure to ambient air pollution, which has a well-established link to lung adenocarcinoma, the most common type of lung cancer, increasing the incidence of disease among non-smokers. In the US now, about 10% to 20% of lung cancers, or 20,000 to 40,000 lung cancers each year, happen in people who have never smoked or have smoked fewer than 100 cigarettes in their lifetime. 

The rise in the number of lung cancer cases is particularly noticeable among younger women, adding to urgent questions about overlooked risk factors and persistent inequities in detection and treatment. 

Dr Narjust Florez is the Co-Director of the Young Lung Cancer Program at the Dana-Farber Cancer Institute, a UICC member organisation, and Assistant Professor at Harvard Medical School. She has also worked on The Lancet Commission for Women, Power, and Cancer. Her work in lung cancer encompasses thoracic oncology and the systemic barriers that shape outcomes for women and historically excluded populations.  

In a conversation with UICC, Dr Florez discusses the rise of lung cancer in women, from genetic and environmental factors to the stigma surrounding diagnosis, and what must change to build more equitable care systems.  

What do we know about the rise in lung cancer cases among women? 

Lung cancer kills more women than breast, ovarian and cervical cancers combined, yet we still talk about it as though it’s mainly a men’s disease. In women under 65, we’re seeing a consistent rise in incidence, surpassing that of men in 2021 – and a growing number of them have never smoked.  

I am seeing this in my professional work. Just last week, a 22-year-old medical student presented with metastatic lung cancer so extensive that I could feel skin lesions during the exam. She had never used tobacco. Before that, I saw a 19-year-old who tested EGFR-positive, which means the tumour has a mutation in the EGFR gene, which drives cancer growth. This can be targeted with specific therapies – but she’s 19! 

It’s not just in Boston or the US. When I was practicing in Wisconsin, I saw the same thing, and next week, I have a 28-year-old woman coming from Mexico for treatment. I have colleagues in Spain, France, India, China, Australia, Brazil, Mexico – all reporting the same trend: More young women, often never tobacco users, being diagnosed with lung cancer.  

This is important. This is a real, documented epidemiologic shift that has been going on since 2018 at least, and it’s not anecdotal anymore. I’m the same doctor, in the same clinic, but the patients are getting younger. And it’s important to note that this rise is in large part attributable to factors unrelated to lifestyle, though in any case we avoid placing any blame on smokers for a consumption that is driven by nicotine, an addictive substance.  

What factors do you think are driving this trend? 

It’s not one thing. For decades, people assumed it only happened because of tobacco exposure, or at least the research was only considering smoking, and we weren’t looking closely at family history. Basically, we are missing cases in young women and people who never used tobacco because we are still not really looking for them. And we’re not looking for them because we think we already know who gets lung cancer. Until we change that, we’re going to keep being surprised. 

When we started using genomic testing more widely, we began to uncover germline mutations such as EGFR T790M. This mutation is more prevalent in women, particularly those of Asian descent and some Jewish populations. It’s associated with increased lung cancer risk, even in never-smokers. So that’s one factor. 

And sometimes, even when we can’t pinpoint a specific mutation, we still see strong family patterns. The TALENT study in Taiwan found that daughters of people with EGFR-mutant lung cancer had a significantly higher risk themselves of developping the disease – equivalent to smoking a pack a day for 20 years. That’s huge. This kind of data really changes how we think about risk and who should be getting screened. 

Finally, there are also rare inherited conditions such as Li-Fraumeni, that can make someone much more likely to develop cancer at a young age.  

You’ve also spoken about environmental factors. What should we know? 

There is air pollution, of course, and particularly for women, indoor or household air pollution. This is a major factor in many low-income settings globally, where women are still cooking with wood or coal in poorly ventilated spaces, which produces toxic smoke that they breathe every day. Even though they’ve never smoked, they’re still at high risk, as I noted in a section on lung cancer in the report by The Lancet Commission on Women and Cancer. It’s estimated that emissions from cooking fuels may account for over 20% of lung cancer deaths in women. This exposure to indoor air pollution is tied to poverty and traditional gender roles. 

Radon is another preventable cause of lung cancer, a radioactive gas that comes from the soil and accumulates in buildings, especially basements. In the US, it’s the leading risk factor for non-smokers. Women, again particularly those in low-income households, are more likely to be exposed because they spend more time indoors. And yet, in the US, radon testing is not routine. 

Another area that we are looking into is hormonal exposure. Lab studies support the idea that estrogen could play a role in how some lung cancers grow. In the US, oral contraceptives were introduced very early in some populations – in girls as young as 11 in the 1980s. That’s not common in many other countries. We’re studying whether this kind of early hormonal exposure could also be contributing to the rise in lung cancer among women. 

Beyond risk factors and exposure, are women also affected differently in terms of diagnosis and treatment? 

Yes, and this ties in very closely with stigma and bias, and a lack of awareness about how lung cancer presents in women. Because lung cancer is still seen as a ‘smoker’s disease’, and because smoking is still far more common among men, women – especially those who never used tobacco – are often dismissed when they report symptoms.  

Their cough is labelled as asthma or pneumonia, or women are told they have anxiety. Many don’t even get basic imaging like a chest X-ray. I’ve had patients who were sent for mammograms for chest pressure before anyone thought to scan their lungs. That’s how strong the assumption is that women get breast cancer, not lung cancer. 

As I showed in an article on lung cancer in women, younger women take three times as long to be diagnosed compared with younger men – even when you match for age, risk factors, and geography. That delay has consequences. I had a patient who told her doctor she was worried about lung cancer. He told her, “That’s not possible.” Two months later, she had a seizure: it turned out to be a brain metastasis from undiagnosed lung cancer. 

And it’s not just diagnosis. Women of color compared to white men are also six times less likely to be offered lung cancer screening than men, even when they meet the same criteria. That’s a huge equity gap. And when women finally do get diagnosed, many of them feel ashamed or blamed, even if they’ve never used tobacco a day in their life. That sense of stigma doesn’t just come from society – it comes from the health system too. 

What about stigma with regard to tobacco users? 

Changing the perception that people smoke by choice is crucial. When I talk about tobacco and cessation, I emphasise that tobacco use is an addiction – just a legal one. This is supported by animal and human studies. There are many socioeconomic factors that lead people to smoke: social environment and norms, targeted tobacco industry marketing, education levels, financial stress, psychological distress, and occupational factors. 

There is also a lack of adequate tobacco cessation counselling, even for people living with cancer, which leads to increased lung cancer risk, for instance we see women who have had breast cancer developing lung cancer due to radiation and continued smoking.  

Doctors often lack training in providing this support, so I go to community sites to train nurse practitioners and nurses in tobacco cessation. Providing proper cessation counselling is essential to break the cycle of addiction and improve outcomes. 

Smoking rates for women have been rising – what might be the reason for that? 

Yes, in some countries, smoking rates among women are going up – and that’s not an accident. Tobacco companies have deliberately and aggressively targeted women for decades. Starting in the 1960s, tobacco companies saw that women weren’t smoking as much as men, so they designed entire campaigns to change that. They tapped into women’s insecurities – about weight, about societal roles – and marketed cigarettes as tools of empowerment. They would advertise smoking as a means to lose weight, for instance. 

How do you see these broader inequities – across gender, income, geography – playing out in real life?  

Lung cancer doesn’t happen in a vacuum. It’s shaped by structural inequities at every level – who gets screened, who’s believed, who gets access to treatment, who can afford it. You see it in how long it takes women to get diagnosed. You see it in how people of colour are less likely to be offered biomarker testing. These aren’t coincidences. They’re patterns, and they have real-life consequences. 

Even being a lung cancer doctor didn’t protect my own family. My mother, a non-smoker, was misdiagnosed several times. She didn’t tell me at first – she’s incredibly independent – but by the time it was properly investigated, the cancer had already spread. I was already a Harvard professor when this happened, and still, the system failed her. That’s why I push so hard for better diagnosis, better communication, and an end to the assumptions about who lung cancer ‘belongs’ to. It belongs to all of us.  

What does this mean for global health systems, especially in lower-resourced settings? 

The Lancet Commission on Women and Cancer showed that in low- and middle-income countries, up to 72% of cancer deaths among women occur before age 70. That’s twice the rate in high-income countries. These women often don’t have the knowledge, power or resources to access care early. 

Even when they do, the systems aren’t designed for them. There’s limited access to screening. There’s no biomarker testing. Drugs are either unavailable or unaffordable. And the gender dynamics make it worse – women may not be able to make decisions about their own health, or may delay seeking care because of family responsibilities. 

What can cancer control organisations and advocates do to help shift the narrative? 

We need to start by listening to women living with lung cancer. Their experiences should shape national cancer plans, research priorities, and public awareness campaigns. We also need to fund research into non-smoking-related lung cancer, ensure equitable access to radon testing and screening, and address stigma at every level. 

Again, we’re not just talking about biology, we’re talking about structural inequities: who gets screened, who gets believed, who gets access to treatment. That’s all shaped by bias. And that’s what we need to change. 

How does your work at Dana-Farber try to address these issues? 

We focus on three things: outreach, trial design, and education. We’re building partnerships in communities that are underrepresented – Black and Latina women, for example – to improve access to screening and to make sure they’re offered biomarker testing when appropriate. 

We’re also advocating for changes in how trials are designed. Inclusion criteria are often too narrow. We’re pushing to design trials that reflect real-world populations, not just the ‘ideal’ patient who fits a narrow profile. 

Finally, we’re training clinicians to recognise their own biases and better support diverse patients. Equity isn’t just a box to tick – it has to be embedded throughout the system. 

What impact are the recent cancer research funding cuts in the US having on this kind of work? 

The recent reduction of USD 800 million in federal cancer research funding is likely to slow down important progress, particularly in areas such as early detection and studies focused on populations that have historically been underrepresented in research. We were beginning to see real momentum around lung cancer in women and never-smokers – gaps that have long been overlooked – and there’s a risk that some of that progress could be lost or delayed.