Lung cancer poses a potential smoke screen for today’s pulmonologists. Overall, incidence rates continue to decline in the US as other cancers are on the rise, yet a growing number of patients are being diagnosed with lung cancer without any history of smoking. While this could partly be attributed to airborne pollutants, making a lung cancer diagnosis as early as possible is essential in reducing the rate of fatalities.
According to the American Lung Association (ALA), many lung cancer diagnoses are not happening early enough for many of today’s patients. Recent ALA findings claim that only 27.4% of patients are being diagnosed at a point when their chances of 5-year survival are optimal. “We are making progress against lung cancer, but there’s still tremendous opportunity for improvement,” said Peter Olivieri III, MD, director of interventional pulmonary at the University of Maryland (UM) Baltimore Washington Medical Center, Glen Burnie, Maryland. “Early diagnosis is key, but most studies that have been done suggest that screening is vastly underutilized.”
Although insurance does not usually cover routine lung screenings among never smokers, Olivieri and other providers believe there are strategies that can help identify lung cancer early and help treat comorbid infections in patients with lung cancer.
The Pulmonologist’s Place Supporting Patients
With stage I lung cancer being asymptomatic, improving outcomes hinges on the detection of “incidental” pulmonary nodules, said Olivieri. “The majority of pulmonary nodules that are actually detected today are not found through lung cancer screenings — they’re found on CT scans that are done for other reasons,” he said. “For instance, patients who come into the ED [emergency department] after a trauma or with chest pain.”
Although the majority of these nodules are found to be noncancerous, there are enough early-stage cancer nodules found this way to make an impact. “We need to develop an infrastructure to identify those patients who are found incidentally and get them care quickly because many of them actually would not have qualified to undergo screening, and it represents an opportunity to detect cancer early,” said Olivieri.
At UM Baltimore Washington Medical Center, an incidental lung nodule program launched in 2024 by interventional pulmonary and thoracic surgery specialists associated with the Lung Center and Tate Cancer Center reviews ED scans to better identify nodules. Olivieri encourages others to consider a similar approach. “There should be some process for how to identify these nodules, whether it’s in the ED, the hospital, or your local outpatient radiology center where primary care doctors may be ordering scans for various reasons,” he said. “It’s a big logistical and resource endeavor, but we think it’s worth the investment if you can make that a priority and then funnel patients into a clinic where they can be evaluated.”
At the University of Iowa, a group of pulmonologists in the Holden Comprehensive Cancer Center’s Lung Cancer Clinic perform same-day lung function testing, point-of-care ultrasound, and bronchoscopy to assist in patient management, according to Thomas J. Gross, MD, professor of internal medicine-pulmonary, critical care, and occupational medicine. “We stay involved with and perform procedural interventions in cases that may need physical tumor debulking or airway stenting, or patients who suffer from bleeding complications related to tumor invasion,” he said.
Iowa’s pulmonologists are also involved in advanced bronchoscopic biopsy techniques, including robotic-guided navigation to the lung periphery that allows for a safe biopsy of small peripheral nodules to assist in curative surgical resection planning. “We also perform measurements of pulmonary function and cardiopulmonary fitness to assess risk for lung resection,” said Gross.
Adapting Disease Treatments With Cancer
Pulmonary disease treatments often need to be modified when lung cancer is present, especially for chronic conditions such as chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), asthma, or pulmonary hypertension, said Amina Pervaiz, MD, pulmonologist, thoracic oncologist, and member of the thoracic oncology multidisciplinary team at Karmanos Cancer Institute, Detroit. According to Pervaiz, COPD complicates surgery and standard cancer treatments, limiting surgical options, such as lobectomy; increasing postoperative risks, such as failure of extubation; and increasing respiratory infections, especially with the forced expiratory volume in 1 second < 50%.
“As an alternative, stereotactic body radiation therapycan offer similar outcomes to surgery in early-stage patients with poor lung function,” said Pervaiz. “ILD patients face higher risks of lung toxicity from chemo- and radiotherapy. Regimens like carboplatin and paclitaxel are preferred. Antifibrotic drugs, such as pirfenidone and nintedanib, added to chemotherapy can reduce postoperative exacerbations and improve outcomes.”
With asthma, systemic steroids can interfere with immune checkpoint inhibitors, necessitating careful balancing of control and immunotherapy risks, while pulmonary hypertension or reduced diffusing capacity of the lungs for carbon monoxide (DLCO) can affect candidacy for curative-intent surgery or radiotherapy, Pervaiz said.
According to Kathleen McAvoy, MD, assistant professor at Yale School of Medicine, New Haven, Connecticut, “it is incredibly important for any newly diagnosed patient who’s scheduled to undergo lung cancer treatment to have other pulmonary conditions defined and under good control.”
New or worsening respiratory symptoms often lead to treatment interruptions in lung cancer, said McAvoy. “Controlling underlying lung diseases can help streamline a patient’s treatments,” she said.
All medications should be reviewed with a pharmacist due to the possibility of interactions with cancer treatments, McAvoy advises. “For those with underlying pulmonary disease who are at higher risk for cancer treatment-related complications, frequent monitoring of symptoms, lung function, and pulse oximetry, including with ambulation, is also strongly encouraged,” she said.
Jeffrey D. Marshall, MD, a pulmonologist and critical care medicine physician at UM Baltimore Washington Medical Center, agrees that pulmonary diseases change certain approaches to lung cancer care. “Management of infectious processes may be different given concerns around resistance or more opportunistic infections in the face of chemotherapy or other immunomodulating therapies used to treat lung cancer,” he said. “And though we already consider patients with structural lung disease or COPD to be at risk for pseudomonas aeruginosa, patients on chemotherapy are at risk of other gram-negative organisms, invasive aspergillosis, and less common organisms such as nocardia, necessitating a lower threshold for thorough diagnostic workup.”
Other considerations include the use of steroids for management of COPD, asthma exacerbations, or community-acquired pneumonia. “Though steroids are the backbone for the treatment of reactive airway disease flares or exacerbations, when patients are on immunomodulatory therapies their use is controversial,” said Marshall. “Many of our newest treatments for all cancers work by revving up the immune system to use our own mechanisms for defense against the cancer cells. The use of steroids necessarily inhibits this immune response. We know from laboratory experiments and clinical trials that the use of steroids can dramatically impair the ability of checkpoint inhibitors to fight cancer.”
Immunotherapy or small molecule-targeted therapies can cause pneumonitis and secondary infections related to impaired immunity. “And we manage medications to palliate symptoms,” said Gross.
At the same time, determining whether a patient has infectious pneumonia vs pneumonitis secondary to therapy can prove diagnostically challenging and make it difficult to determine the need for steroids vs antibiotics, said Marshall.
Current Research and Best Practices
Earlier diagnosis of lung cancer could be on the horizon. At UM Baltimore Washington Medical Center, Olivieri and colleagues are involved in a study conducting a blood-based test to look at the epigenome to assist lung cancer diagnosis. “We would envision this test being administered in a primary care office as routinely and be available to everyone to predict cancer or at least identify early,” Olivieri said.
Lisa Paul, MD, assistant professor of medicine – pulmonology at New York Medical College, is optimistic about research efforts targeting early detection by using liquid biopsy to look at DNA biomarkers. “Those with strong family history of lung cancer and nonsmokers with environmental exposures are now being looked at closely,” she said. Paul also serves as a director of the lung cancer screening program at affiliated Westchester Medical Center, Valhalla, New York.
According to Pervaiz, research also supports personalized screening using artificial intelligence and nodule risk models, expanded molecular profiling, and biomarker-driven prehabilitation. “Trials are evaluating how spirometry, DLCO, and frailty scores can guide treatment intensity,” he said.
Gross, Olivieri, McAvoy, Paul, and Pervaiz had no relevant financial conflicts to report.