All Mo Rolfe was trying to do was indulge her husband.
Two siblings had recently suffered strokes, causing him some alarm, and now he wanted a full body scan for his own peace of mind. And he didn’t want to do it alone.
Rolfe, a 49-year-old high school teacher from Arcadia, California, felt perfectly fine. No symptoms of any kind. “I never felt anything was wrong with me,” she insisted.
To support her spouse, Rolfe agreed to have the procedure with him. They drove to San Diego together and paid for their tests at a private company.
“Out of the blue,” she recalled, “they saw something — a shadow, a nodule” in one lung.
Further tests over the next several months, including several computed tomography (CT) scans and a biopsy, confirmed Rolfe had early-stage lung cancer.
“It was shocking.”

Rolfe had never smoked. She is one of a growing number of 40- and 50-something nonsmoking Asian women (born in China, Rolfe came to the U.S. when she was 25) who develop lung cancer.
Their stories may vary a bit, but the overall narrative is the same: no symptoms, not a clue that anything’s wrong, then utter shock when told. “I have been living an active, healthy life,” remarked a 50-year-old patient who preferred anonymity. “Never smoked, eating healthy, running, hiking, swimming, finishing a few marathons, including the Boston Marathon. I would have never suspected anything, but I was diagnosed with bilateral lung cancers.”
Lung Cancer Rising Among Young Asians
It’s a phenomenon that has puzzled clinicians and researchers for decades: While overall lung cancer rates have been steadily dropping — likely due to a decrease in smoking — this unique population of young Asians is registering a 2% increase in cancer cases each year. And half of them have never picked up a cigarette.
City of Hope thoracic surgeon Jae Y. Kim, M.D., has researched this oddity for many years. While he says no one has pinpointed a cause, a few things stand out, most notably a genetic component.

“Two-thirds of these cancers in Asian women display the EGFR mutation,” said Dr. Kim, who is chief and associate professor in the Division of Thoracic Surgery, Department of Surgery. Epidermal growth factor receptor, or EGFR, controls the rate of cell growth. When it’s damaged, uncontrolled growth — cancer — occurs. Other mutations, in the ALK, ROS-1, KRAS and RET genes, may also play a role.
The EGFR mutation is not inherited. It develops in tumors later in life, most likely the result of exposure to environmental toxins, such air pollution, secondhand smoke, and perhaps even cooking fumes and the accompanying high heat — as in stir-frying — in a room lacking proper ventilation. More than a few patients born in China and Taiwan speak about encountering some or all of those conditions. “Cigarette smoke was all around me,” one said.
Lung cancer driven by the EGFR mutation behaves differently than the variety caused by smoking, says Dr. Kim. “At least in the beginning, it can be more indolent, and it can start with a precursor: a precancerous, pre-invasive lesion.” But don’t be fooled by the early slow pace. “Once it becomes invasive, it’s hard to predict how aggressive it will be.”
Caught early, this cancer is very treatable. Small masses can be surgically removed. Also, doctors can deploy targeted therapies known as EGFR inhibitors — drugs like Tagresso (osimertinib) and Tarceva (erlotinib) — that block the signal from EGFR that tells cancer cells to grow.
However, this form of lung cancer is not always caught early because the people it tends to strike never see it coming, they’ve never been encouraged to get screened for the disease, and the best early detection tool — a low-dose computed tomography (LDCT) scan — is not made available to them. So far in this country, regular LDCT screenings are reserved for older patients with a history of smoking.
The result is sadly predictable. Too many patients do nothing until symptoms develop, only to be shocked by a Stage 4 diagnosis.
The Benefits of Low-Dose CT Scans
It’s a different story in China and Taiwan, where lung cancer among nonsmoking women has reached crisis levels. It is far easier in China, for example, to receive an LDCT during a routine exam, as Kelly Pai of Fullerton, California, found out. The 53-year-old veterinarian, born in Taiwan but living in the U.S. since age 18, spent a decade in China doing missionary work. During one of her regular physicals, she was offered an LDCT at an affordable cost. She was having no symptoms and had no family history of lung cancer. Nevertheless, “I figured, why not?” she recalled. The scan detected a mass in her upper right lung.
“China saved me,” she says emphatically. “Because early detection is key.” Pai returned to California and contacted City of Hope for follow-up tests and a biopsy. Ultimately, Dr. Kim performed a robotic procedure to remove the tumor.

Taiwan is also the site of one of the largest studies of this problem. Twelve thousand nonsmoking and light ex-smoking patients, mostly women, with an additional risk factor, such as family history or frequent cooking involving pan frying, from 17 institutions received multiple LDCT scans over a five-year period. Those scans discovered hundreds of cases of lung cancer, 96% of them in the early stages. The so-called TALENT (Taiwan Lung Cancer Screening for Never Smoker Trial) study “confirmed the effectiveness of LDCT screening in a pre-defined, never-smoker high-risk population.”
So why, then, has LDCT not yet become the standard of care for this clearly at-risk population in the U.S.? Several reasons.
“The TALENT study didn’t show a survival benefit,” said Dr. Kim. In other words, detection of early lung cancer may just mean more of those precursor, indolent, not-yet-dangerous lesions are being detected. “People are waiting for the data that shows those screenings lead to better survival, and they’re waiting to see that data in the U.S.”
Efforts are underway to do that in several places, including New York University and in a study called FANS (Female Asian Never Smokers) tracking women in Southern California and the San Francisco Bay area.
Dr. Kim hopes those studies lead to changes.
“I’d like to see the U.S. expand screening to patients who’ve never smoked but have other risk factors,” he said, though he realizes “the guidelines will not change until data is available here in the U.S.”
His patients agree.
Screening in the U.S. “is not fair,” asserted Rolfe, who had surgery for her Stage 1B cancer and is now taking the EGFR inhibitor Tagresso. She wants screening made available to people in their 40s and 50s, and as commonplace as colonoscopies.
“More people getting screened would save a lot of lives,” added Pai, who’s doing well four years after her surgery.
“I feel lucky,” she said.
Main image: Mo Rolfe