Lung Cancer in Never Smoking Asian Populations

Abstract

Introduction: Lung cancer incidence is disproportionately higher in Asian individuals who have never smoked compared with non-Asian counterparts. While epidemiologic determinants remain unclear, risk factors appear to include environmental exposures, oncogenic drivers, and sex-specific patterns. Understanding these factors may lead to effective screening and treatment. This narrative review synthesizes the current state of research on lung cancer in never-smoking Asian populations, comparing disease characteristics between persons from Asia and the Asian diaspora.

Methods: Literature related to lung cancer in never smoking-Asian populations living in and out of Asia and published during January 1, 2018–August 17, 2024, were included. PubMed was searched for observational studies, interventional studies, and existing systematic reviews for articles published in English. Independent reviewers screened and conducted full text review and then synthesized insights from the articles by consensus.

Results: Studies published during 2018–2024 indicated that lung cancer among Asians who have never smoked is influenced by genetic, environmental, and lifestyle factors, with a higher incidence of adenocarcinoma and younger age of diagnosis among Asian and Asian American women. Increased lung cancer incidence was observed among populations who have never smoked, especially within Asian populations. Targeted therapies, in addition to standard surgical resection, have improved survival in patients with epidermal growth factor receptor, anaplastic lymphoma kinase-positive, and other actionable mutations, which are common in this population. However, treatment resistance and limited benefit from immunotherapy constrain longterm outcomes. Future strategies, such as novel targeted agents, combination regimens, and biomarker-driven monitoring, were found to extend progression-free survival and personalize care.

Conclusions: Lung cancer among Asian populations who have never smoked represents a biologically distinct, often targetable disease entity that necessitates rethinking of screening eligibility and treatment paradigms. Limitations of smoking-based risk models, emerging resistance to therapies, and geographic disparities in diagnostic and treatment access, both within Asian and across communities of the Asian diaspora, highlight the urgent need for more inclusive screening criteria, improved resistance management strategies, and equity in precision oncology deployment across Asian subpopulations. Improvements for screening programs should aim to maximize accurate detection while minimizing overdiagnosis.