Women & lung conditions.

It started as a "fluttering" in Jacquie Bossert's chest about eight years ago, a strange feeling that would wake her up at night. But there were other symptoms, too.

Climbing the stairs in her house left the 64-year-old San Diego woman so out of breath and shaking so badly she'd have to sit down and rest. Walking from the chair in the den to the refrigerator in the kitchen made her gasp for breath. She showered every other day instead of daily because holding her arms up to wash her hair left her breathless. She had stopped going certain places because they required too much walking.

Finally she broke down and saw her doctor. He put her through a series of heart rests, none of which showed any problem with her heart. Then he tested her lung capacity with a spirometer, a small, handheld instrument that measures the volume of inhaled and exhaled air. It showed she had less than half of her total lung capacity remaining. The diagnosis: chronic obstructive pulmonary disorder, or COPD.

The condition, which used to be called emphysema or chronic bronchitis, results when airways in the lungs no longer move air through the lungs normally. It's usually associated with an abnormal inflammatory response of the lungs to noxious particles or gases. This makes breathing more difficult, often leading to shortness of breath, a chronic cough and mucus production. The mucus can block airways, making breathing even more difficult. And worse, COPD symptoms are usually progressive and not fully reversible. With the diagnosis, Ms. Bossert knew the two packs of cigarettes she'd smoked every day for 50 years had finally caught up to her.

Those cigarettes are catching up to a lot of women these days. Today, COPD is the fourth leading cause of death in the United States, with 125,000 deaths in 2002. (1) It is also the only chronic disease in North America whose rate continues to increase. (2)

For decades, COPD was considered a disease of men. But that gender disparity ended in 2000 when for the first time more women than men in the U.S. died from the disease. (3) In fact, deaths from COPD have doubled in white and African-American females over the past decade while remaining stable in men. (1)

The changing gender picture of COPD is likely related to the growing numbers of women who took up smoking in the past 50 years, since smoking is the primary risk factor for COPD. (4) Data suggest that women are more susceptible to developing airway obstruction compared to men for the same number of cigarettes smoked.

The new gender reality of COPD has yet to catch up to many health care professionals, however. Because COPD has traditionally been considered a disease of older men, many women never receive the diagnosis they need to begin proper treatment. Just ask Ann Zahniser, 68, of Wilmore, KY. It took years of doctor visits before she received the correct diagnosis, a diagnosis made more difficult because she'd never smoked. Just as many doctors don't think to look for the disease in women, they also don't look for it in nonsmokers. They don't realize that as many as one in six people with COPD never smoked, and that there is a strong genetic component to the disease. (5)

Kenneth R. Chapman, MD, who directs the Asthma & Airway Centre at the University of Toronto, wasn't surprised by Ms. Zahniser's misdiagnosis. In 2001, he published the results of a seminal study that found primary care doctors have significant gender bias when it comes to diagnosing COPD in women.

He and his colleagues sent a hypothetical summary of a patient with the characteristic symptoms of COPD (chronic cough, mucus production and shortness of breath) to 192 primary care physicians in the United States and Canada (154 men and 38 women). They told half the doctors that the patient was male and half that the patient was female. Although just 57 percent of all the doctors suggested a diagnosis of COPD at all, they were much more likely to diagnose COPD in men than women. (6)

"I think that's one of the more important studies I've done," says Dr. Chapman. "It points out how a prevalent and lethal disease is being overlooked in half the population by primary care physicians. I think there's an appalling ignorance by physicians of just how common this disease is overall, and how much more common it's becoming in women."

The problem with missing a COPD diagnosis is that the disease, while not curable, is treatable. And although the damage to the lungs can't be fully reversed, treatment can reverse some of the damage and greatly improve a person's quality of life. Simply quitting smoking is the first step. That, at least, ensures that lung function won't get any worse.

One reason doctors and other health care professionals often miss COPD is that they don't use the most reliable test for the condition: a lung function test conducted with a spirometer. You blow into the instrument as hard as possible to get a baseline measurement. Then you take a puff of a bronchodilator, a drug that opens up the airways in the lungs, and take the test again.

If you had a low score to begin with and you improve, you probably have asthma. If you don't, you probably have COPD. Despite recommendations from every major national and international pulmonary medical organization for spirometry testing on patients who have smoked or still smoke, however, few primary care physicians conduct the tests. In one survey of 57 primary care offices, 66 percent of responding offices owned their own spirometer yet didn't perform the test because they didn't know how to use it or didn't know what its impact would be. (7)

Yet by the time COPD symptoms become significant--shortness of breath, coughing and mucus--many patients have lost half their lung function, says Dr. Chapman. "The thing about COPD is that what you've lost with tobacco damage you've lost for good," he says. "We want to find people when their damage is relatively minor."

Ms. Bossert's damage wasn't minor, but she is doing much better than in the days when she couldn't make it up the stairs without getting out of breath. When she received her diagnosis, she and her husband immediately quit smoking (for more on smoking cessation, see Smoking Cessation & Women on page 5). They also began attending a pulmonary rehabilitation program, where they learned about the lungs and COPD, and began monitored exercises to strengthen the muscles that help with breathing.

Today, Ms. Bossert, 72, uses two daily medications: Spiriva (tiotropium bromide), and Advair (a combination inhaled steroid, fluticasone, and a long-acting bronchodilator). She uses supplemental oxygen during her daily exercise sessions and says her lung capacity has actually increased since her diagnosis. "I'm feeling great," she says.

Lung Cancer: Epidemic in Women

Colleen Cayton calls herself "one of the very few lucky ladies," and she's made it her mission to extend that luck to other women. Ms. Cayton, 65, of Stevensville, MD, quit smoking seven years ago. But because she'd smoked for more than 40 years, her doctor recommended an annual spiral CT scan of her lungs to screen for early signs of cancer.

Ms. Cayton went for a few years, but became involved with a home remodeling project and forgot her regular screening. Then came news of Peter Jennings's and Dana Reeves's lung cancer diagnoses. Ms. Cayton scheduled her 2005 screening and, sure enough, that one showed a pea-sized tumor.

"It was very small, but at the time you don't hear that," says Ms. Cayton. "You just flip out. Your life is flashing before your eyes, and you feel that it's over."

Lung cancer is the deadliest cancer around. Not only because it's more difficult to treat and more invasive than many cancers, but also because the majority of lung cancers are found in the very late stages, when the five-year survival rate is less than five percent. If found at the earliest stage, the five-year survival rate is more than 50 percent. (8)

Lung cancer is the leading cause of cancer death in women, killing more women each year than breast, ovarian and uterine cancers combined, and accounting for nearly a third of all cancer deaths in women in the United States. The number of women diagnosed with lung cancer has risen steadily in the past 20 years--a 60 percent increase between 1990 and 2003--compared to a significant decline in men, leading some researchers to call the disease an "epidemic" in women's health. (9)

The rise is directly related to the increased rates of women who took up smoking after World War II, says Jyoti D. Patel, MD, a lung cancer specialist at Northwestern University in Chicago. Even though many have since quit, the damage to their lungs couldn't be reversed.

Yet studies on lung cancer in women have typically been few and far between, she notes. "When I was doing my fellowship, I imagined patients with lung cancer would look like the Marlboro Man," she recalled. Instead, she found that more than half her patients were women. But most of the studies on lung cancer had been done in men. "I couldn't tell women enough about their disease or what to expect," she said, which is why she's made it her specialty to study and treat the disease in women.

As with many health conditions, it turns out that women and men are not the same when it comes to lung cancer. Specifically, women who never smoked are 2.5 times more likely to develop lung cancer than men who never smoked. (9) This may be due to the fact that women are often exposed to more secondhand smoke than men, either from their jobs (such as waitress and airline attendant, before smoking was banned on planes and in some restaurants) or from living with men who smoke, says Dr. Patel. Data suggests that women may be more susceptible to smoking and environmental damage to lungs than men and are not able to repair DNA damage as well.

About 20 percent of women who develop lung cancer never smoked compared to less than 10 percent of men, according to a recent study of the incidence of lung cancer in people who never smoked. (10)

Women are also more likely to be diagnosed with the adenocarcinoma subtype of lung cancer, while men are more likely to be diagnosed with squamous cell carcinoma. The difference is likely related to many hormonal, genetic and even behavioral reasons. Researchers have found that estrogen receptors are found on lung cancer cells, and that circulating estrogen could affect cancer growth. Researchers have also identified certain genetic differences between men and women that affect women's risk of lung cancer.

Ms. Cayton, however, was one of the lucky ones. Because her cancer was found at a very early stage, her surgeon was able to remove it all. She underwent six months of chemotherapy because the cancer was found in one of 14 surrounding lymph nodes, and today is cancer free. But she's angry--angry because although millions of people quit smoking each year, few get the advice she did from their doctors: to undergo an annual CT scan, the best way to catch the disease early. (11)

"I'm so angry because there's no focus on the fact that millions of people are walking around right now without a clue that they're at such high risk of having lung cancer," she says.

A major study published in the New England Journal of Medicine (NEJM) in October 2006 found that 85 percent of lung cancers detected by annual spiral CT screening were found in the early stage. In that study, the 10-year survival rate was 92 percent for patients who immediately underwent surgery. (10)

When the findings were published, pulmonologists called it a "major, major finding." (12) The scans typically cost less than $200, although most insurance companies won't cover them for screening purposes.

However, some researchers urge caution when it comes to interpreting the results of this study, noting that it was carried out at numerous centers by many investigators who may have had different interpretations of who was a "high-risk" patient. The benefits of screening high-risk patients came under additional scrutiny in February with the publication of another major study finding that CT screening did not increase survival times in lung cancer patients, even though the cancers were found at an early stage. (13)

A National Lung Cancer Study Trial that will compare annual chest x-rays with spiral CT scans as screening tools in high-risk patients has finished enrolling participants, and researchers hope it will provide more substantial information when it is completed in 2010.

"If you have a good relationship with your physician and can have a discussion about the risk of having a false positive test, I think it makes sense to consider screening," says Dr. Patel. That's because any positive finding on the test requires follow-up in three months to see if a biopsy is required. And lung biopsies are much more invasive than a breast biopsy.

In the NEJM trial, 43 of the 535 participants with a positive result on the CT scan had no evidence of disease, a rate of about 8 percent, similar to the false positive rate of screening mammograms. So, says Dr. Patel, talk to your doctor about your own risk. "If you smoked for five years when you were 18 you have a much lower risk than someone who smoked 50 years," she said.

Colleen Cayton has made it her mission to get more people talking with their doctors about lung cancer screening. When she learned that a local hospital was offering spiral CTs for $75, she gave a brochure to every person in her real estate office. Of the 15 people who were screened, two had suspicious nodules that are being watched.

She's also angry about the relatively low levels of funding for lung cancer compared to breast and other cancers. For instance, in 2007, the National Cancer Institute will spend an estimated $551 million on breast cancer research, more than twice as much as will be spent on lung cancer research. (14)

Ms. Cayton knows why lung cancer is the stepchild of cancer. "People think you did this to yourself," she says. Her message: Even if you did, you still deserve the best treatment and care possible.

Resources

American Lung Association 

800-586-4872

www.lungusa.org

COPD: Learn More, Breathe Easier

www.nhlbi.nih.gov

Joan's Legacy

212-627-7594

www.joanslegacy.org

National Cancer Institute

Lung Cancer

800-422-6237

www.cancer.gov

National Heart, Lung and Blood Institute

301-592-8573

www.nhlbi.nih.gov

National Lung Cancer Partnership (formerly Women Against Lung Cancer)

608-233-7905

www.nationallungcancerpartnership.org

Office on Smoking and Health, U.S. Centers for Disease Control and Prevention 

800-232-4636

www.cdc.gov/tobacco

References

1 National Heart Lung and Blood Institute, Bethesda, MD, US Department of Health and Human Services. Morbidity and Mortality: 2004 Chartbook on Cardiovascular, Lung, and Blood Diseases. Available at: http://www.nhlbi.nih.gov/resources/docs/cht-book.htm. Accessed Oct 3, 2006.

2 Chapman KR. Chronic obstractive pulmonary disease: are women more susceptible than men? Clinics in Chest Medicine. 2004;25(2):331.

3 Mannino DM, Homa DM, Akinbami U, Ford ES, Redd SC. Chronic obstructive pulmonary disease surveillance--United States, 1971-2000. MMWR Surveill Summ. Aug 2 2002;51(6):1-16.

4 Varkey AB. Chronic obstructive pulmonary disease in women: exploring gender differences. Curr Opin Pulm Med. Mar 2004;10(2):98-103.

5 COPD: Learn More, Breathe Better. National Heart, Lung and Blood Institute. Available at: http://www.nhlbi.nih.gov. Accessed Feb 19, 2006.

6 Chapman KR, Tashkin DP, Pye DJ. Gender Bias in the Diagnosis of COPD. Chest, 2001;119(6):1691-1695.

7 Kaminsky DA, Marcy TW, Bachand M, Irvin CG. Knowledge and use of office spirometry for the detection of chronic obstructive pulmonary disease by primary care physicians. Respir Care. Dec 2005;50(12):1639-1648.

8 Fast Stats: Lung and Bronchus Cancer. National Cancer Institute. http://seer.cancer.gov. Accessed Feb 19, 2007.

9 Patel JD. Lung cancer in women. J Clin Oncol. 2005 May 10;23(14):3212-8.

10 Wakelee HA, Chang ET. Gomez Sl. et al. Lung Cancer Incidence in Never Smokers. J Clin Oncol Vol 25 (5):472-478, 2007.

11 International Early Lung Cancer Action Program Investigators; Henschke CI, Yankelevitz DF, Libby DM, Pasmantier MW, Smith JP, Miettinen OS. Survival of patients with stage I lung cancer detected on CT screening. N Engl J Med. 2006 Oct 26;355(17):1763-71.

12 Gardner, A. CT Scans Catch Lung Cancer at Earliest Stage. HealthDay News. Oct 25, 2007.

13 Bach PB, Jett JR, Pastorino U. Tockman MS, Swensen SJ, Begg CB, Computed tomography screening and lung cancer outcomes. JAMA. 2007 Mar 7;297(9):953-61.

14 Cancer Research Funding. National Cancer Institute. www.cancer.gov. Accessed Feb 19, 2007.