In 2019, medical staff at David Grant USAF Medical Center perform thoracoscopic surgery to remove the upper left lobe in a lung cancer patient at the heart, lung and vascular center, Travis Air Force Base, California. Because of its partnership with the VA Northern California Health Care System, the HLVC provides one-stop care for patients with diseases of the heart, lungs and circulation. U.S. Air Force photo by Heide Couch
OMAHA, NE—Lung cancer kills as many people in the United States as the next three most deadly cancers combined. This year, about 236,000 people will be diagnosed with the disease, and nearly 132,000 will die from it.
As common as it is in the general population, lung cancer occurs more often in servicemembers and veterans, with the incidence up to 76% higher in veterans than in those who never served. An estimated 7,700 veterans are diagnosed with lung cancer every year, and another 900,000 face elevated risk of developing lung cancer as a result of smoking, environmental exposures and older age, according to the VA.
About 85% of lung cancer diagnoses occur in individuals who currently smoke or have a history of smoking. The U.S. Centers for Disease Control and Prevention estimate that smoking increases the risk of lung cancer and lung cancer mortality 15 to 30-fold with risk rising with duration of smoking history.
Smoking remains more common among current and former military personnel than the general population. According to the DoD, 24% and 38% of servicemembers smoke, compared to 14% of civilians. Deployments increase smoking rates by about 50%, as a response to stress, peer influence, boredom, the need to stay awake and other factors. The higher rate of smoking persists after separation as well. Thirty percent of veterans report current tobacco use, with nearly two-thirds of those currently smoking cigarettes.
The association between environmental factors, military service and lung cancer has been long established. Lung cancer is a presumptive condition for Agent Orange exposure for Vietnam era veterans, and multiple bills have been introduced in Congress to include it as a presumptive condition for veterans who served in the Gulf War or the War on Terror based on exposure to burn pits and other toxins. Asbestos, exposure to carbon monoxide from diesel fuel, radiation, pesticides, heavy metals and chemical weapons also increase the risk of developing lung cancer.
NSCLC Accounts for Most
Nonsmall cell lung cancer (NSCLC) accounts for 85% of all lung malignancies. NSCLC has three main subtypes. The most common is adenocarcinoma, which is the type most likely to arise in individuals who never smoked. Squamous cell carcinoma represents about 30% of NSCLC cases and typically occurs in smokers or former smokers and is more common in women. Less than 10% of people with NSCLC have the large cell carcinoma subtype, which is a good thing, as it tends to be quite aggressive.
At diagnosis, the average age of a patient with NSCLC is 70 years. For younger patients, the disease is associated with female gender, the adenocarcinoma subtype, and being Asian or a Pacific Islander.
Nationally, the incidence of NSCLC declined overall from 2010 to 2017, dropping from 46.4 to 40.9 per 100,000 person years, researchers found in a study published in JAMA Oncology in October. The incidence of Stage 1 cancers rose from 10.8 to 13.2, however. “The findings of this cross-sectional epidemiological analysis suggest that the increased incidence of stage 1 NSCLC at diagnosis likely reflected improved evaluation of incidental nodules,” wrote the researchers, who were led by Apar Kishor Ganti, MD, of the VA Nebraska Western Iowa Health Care System in Omaha.1
The incidence by age puts the association between rising age and lung cancer in sharp relief. Among those under 65 years of age, the incidence dropped from 15.5 to 13.5, while for those 65 and over, it declined from 29.9 to 23.0 per 100,000 person years. Eighty-six percent of patients with NSCLC in 2015 were 60 years of age or older.
Even as the incidence of NSCLC declined, its prevalence in the U.S. rose from 2010 to 2016 from 175.3 to 198.3 overall, reflecting longer survival associated with improved treatment options, particularly among younger patients.
For all stages of NSCLC, the JAMA Oncology study reported a five-year survival rate of 26.4% for the U.S. The DoD’s Congressionally Directed Medical Research Programs note, however, that for veterans the “five-year survival rate remains extremely poor at 20%.”
For the general population, five-year survival is boosted significantly by relatively high survival rates among patients diagnosed with localized cancer, 63%, the National Cancer Institute’s Surveillance, Epidemiology and End Results database showed. The survival rate drops markedly for patients diagnosed once the cancer has spread to the lymph nodes or chest, to 35%. For those with distant metastases at diagnosis, five-year survival remains a grim 7%.
While therapies have been approved for all stages of NSCLC, the JAMA Oncology researchers found that 38.3% of older patients with metastatic cancer received no treatment, and they concluded that “patients aged 65 years or older with stage IV NSCLC may be undertreated.”
Nationally, only 16% of lung cancers are diagnosed with localized disease. In another 40%, the cancer has spread to the lymph nodes or other tissues in the chest. As a result of late diagnosis, the American Lung Association reports that more than half of patients with lung cancer die within a year of diagnosis.
At the VA, in contrast, 21% of diagnoses were Stage I, 8.2% were Stage II, 20% Stage III, and 38% Stage IV, an analysis showed before the VA implemented its lung cancer screening program. Another 12.86% were not staged in the VA database. That compared to 55% of lung cancer patients in the SEER database at the time.2
- Ganti AK, Klein AB, Cotarla I, Seal B, Chou E. Update of Incidence, Prevalence, Survival, and Initial Treatment in Patients With Non-Small Cell Lung Cancer in the US. JAMA Oncol. Published online Oct.21, 2021. doi:10.1001/jamaoncol.2021.4932
- Zullig LL, Sims KJ, McNeil R, Williams CD, Jackson GL, Provenzale D, Kelley MJ. Cancer Incidence Among Patients of the U.S. Veterans Affairs Health Care System: 2010 Update. Mil Med. 2017 Jul;182(7):e1883-e1891. doi: 10.7205/MILMED-D-16-00371. PMID: 28810986; PMCID: PMC5650119.