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Lung cancer is the third most common cause of death among patients with cancer in Puerto Rico, according to researchers from that territory, with non-small cell lung cancer (NSCLC) the most prevalent. Unfortunately, patients in Puerto Rico were diagnosed at late stages (stages III/IV), and received platinum-based systemic therapy as their first-line treatment, even though there are other first-line therapies used stateside -- i.e., immunotherapy, radiotherapy, surgery, and tyrosine kinase inhibitors.

Karen J. Ortiz-Ortiz, DrPH, MPH, of the University of Puerto Rico in San Juan, and colleagues set out to determine the reasons for the disparities with the retrospective TREATLINES-ONCOLUNG cohort study that used data from a Puerto Rico health insurance registry.

As noted in the study in , the team looked at the years 2012-2016, and reviewed data on approximately 1,000 patients. About 57% were male, and >71% were diagnosed at stages III and IV, with more than 75% having non-squamous cell carcinoma (SCC). Of those, almost 62% received systemic therapy -- specifically, platinum-based chemotherapy combinations -- as the first line of treatment (almost 83%), while less than 25% received radiotherapy.

The researchers also noted that a significant percentage of the study patients were enrolled in Medicare or dual Medicare-Medicaid, and yet around 66% were diagnosed with advanced-stage disease. "Interestingly, nearly 80% of patients with NSCLC who were enrolled in Medicaid or had private insurance were also diagnosed at advanced stages. This suggests that there may be barriers to early detection and timely treatment initiation in Puerto Rico."

In addition, more men in the study had SCC (about 73%) -- which "may be related to their higher smoking prevalence," the team said.

While the study was not designed to compare data in Puerto Rico versus the mainland U.S., the researchers said the findings suggest that significant barriers to healthcare access in Puerto Rico may contribute to the higher proportion of metastatic disease at presentation. Factors such as limited access to specialized cancer care, challenges in the availability of healthcare resources, along with socioeconomic disparities and structural barriers may all play a role in hindering timely diagnosis and being able to start treatment.

Another issue that Puerto Rico, along with the entire globe, of course, is dealing with is climate change. Puerto Rico has warmed by more than 1°F since the mid-20th century, while carbon monoxide emissions have been on the rise, and greenhouse gases are getting more intensive, according to a 2017 report.

Leticia Nogueira, MD, of the American Cancer Society in Palm Harbor, Florida, and Felipe Roitberg, MD, of the Brazilian Hospital Services Company in Brasília, offered a blue-sky overview of the crossroads between climate change and lung cancer in a from the 2024 World Conference on Lung Cancer. Below are excerpts from their discussion.

What is the link between climate change and lung cancer?

Nogueira: Climate change impacts every step along the cancer control continuum, from prevention -- when it comes to exposure to pollution, we know that the same greenhouse gases that are driving climate change also increase lung cancer risk -- to treatment. We know that climate-driven disasters are going to end up disrupting access to cancer care and survivorship because cancer patients are a population vulnerable to the hazards of climate change.

What is the impact on a community level?

Nogueira: The communities that have been exposed to the most pollution, that have the worst barriers in access to care, that are living in places with a scarcity of resources, have historically been the communities identified as those suffering a disparity or those driving health inequities.

Roitberg: One of the things we are working with in Brazil is driving discussions and specific initiatives for research related to implementation science. So how can we acknowledge the inequalities and social demographic determinants and try to shape what we discuss in academia and try to translate it into outcomes?

What are some possible ways to manage and mitigate the climate change-lung cancer connection?

Nogueira: A lot of the solutions already exist, and we're all on the same planet. So, for example, in the same way that some hazards of climate change -- such as wildfire smoke from California traveling all the way to Iceland and Britain -- fossil fuels are generating greenhouse gases here and then impacting climate in the entire world.

Roitberg: A recent study in showed that some fogs and chemical materials that were found in Ukraine were also found in Milan, so the researchers found a way to detect these heavy metals that will surely also impact the health of those who are in Italy, in Milan, right now.

Nogueira: We already know that smoking cigarettes, using tobacco, is one of the main causes, or one of the main behaviors, that is associated with increased lung cancer risk, and it's been recognized worldwide, and it's been a great success story for lung cancer prevention. We have learned a lot about prevention from the tobacco perspective and we know what we can do to change behavior, to influence healthier behavior.

There is a parallel here with some of the other environmental causes of lung cancer, as the prevalence of smoking starts to decrease worldwide, then we start to pay attention to these other lung cancer risk factors, which include air pollution. If we are very committed to reducing the lung cancer burden, then we need to think beyond smoking.

Roitberg: Twenty percent of the current lung cancer patients have , so if you agree that radium and other environmental substances that we ignore and don't have an agenda for, it means as well that we are also ignoring the risk factors for 20% of lung cancers; so we have a call for action.

We have a call to discuss environmental health. We need now to take a look at those who are still waiting to see how we can shape a way to detect these patients with non-smoking-related lung cancer earlier, and to detect their risk factors, and then manage the environment to reduce the risk.

Read the study by Ortiz-Ortiz et al here.