2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Research and Standard Care: Lung Cancer
in China
By Tony S. Mok, MD, Qing Zhou, MD, and Yi-Long Wu, MD
Overview: China has an enormous burden from rising tobacco
consumption and lung cancer incidence. Governmental
intervention on lung cancer prevention is insufficient, and both
incidence and mortality related to lung cancer are still on the
rise. Treatment guidelines are available, but heterogeneity in
the quality of care between centers, especially the disparity
between urban and rural areas, have resulted in inconsistent
care to patients with lung cancer. Despite knowledge on
molecular-targeted therapy, only a small fraction of patients
CHINA, A COUNTRY in rapid development, is confronted
with a major health hazard. Success of her
development comes with the price of pollution, change in
dietary habits, and increase in tobacco consumption. Cancer
has become the leading cause of death in China. According to
the Ministry of Health in China, mortality related to cancer
has risen by 80% during the last 30 years to an alarming
number of 1.8 million cancer deaths in 2010. Cancer incidence
rose from 74.2/100,000 in 1970 to 135.9/100,000 in
2004. 1 Among the death tolls, a substantial proportion is
attributed to lung cancer. Similar to other developed countries,
majority of patients with lung cancer are diagnosed at
advanced stage, and only a small proportion of patients have
curable disease at presentation. During the last three decades,
deaths related to lung cancer have increased by 465%.
But different from other developed countries, the quality of
health care in this most populated country is highly heterogeneous.
The tremendous success in economic development
brings wealth to a small sector of society, whereas a large
proportion of residents are still living close to poverty line.
With the lack of universal health care system, many suffer
from inadequate treatment as well as from disease itself. In
this review, we summarize the disease burden of lung cancer
in China, the current treatment standard across the country,
and the impressive development in clinical/translational
research on this dreadful illness.
The Burden
The burden starts with tobacco consumption. Being the
world largest tobacco-producing country, China also consumes
majority of her own production. The World Health
Organization (WHO) estimated China to have 320 million
smokers in 2008, and this may indirectly cause environmental
tobacco exposure to an estimate of more than 500 million
nonsmokers. With the lung cancer risk being six to 10 times
higher in smokers and 30% to 60% higher in nonsmokers
with exposure to second-hand smoke, the incidence of lung
cancer in China is expected to increase. To date, there is
still an absence in reversing the trend in the number of
smokers in China. This country generates over US$21 billion
in tobacco tax annually, and some provinces such as
Yunnan are basically dependent on this tax revenue. 2 It is
unlikely that there will be dramatic control of tobacco
production or consumption.
China has signed the WHO Framework Convention on
Tobacco Control in 2003. The scale of the health care burden
is being recognized, but the total budget spent on tobacco
432
have access to routine EGFR mutation analysis. Platinumbased
doublet chemotherapy remains the most commonly
used regimen irrespective of mutation status. On a positive
note, both clinical and translational research on lung cancer
are in rapid progress. The Chinese Thoracic Oncology Group
(CTONG) has already contributed substantially to the care of
patients with lung cancer and is expected to continue in the
trend.
control was estimated to be less than US$1 million, which is
a very small fraction compared with the revenue generated
by tobacco. In 2002, it was estimated in a national survey in
30 provinces in China that smoking prevalence rate was
35.8% (66% in men and 3.1% in women). 3 The greatest
concern is the increasing number of young smokers. It was
estimated that about 15 million young people between the
ages of 13 and 18 years are regular smokers, and another 40
million in this age group are occasional smokers. The median
age of starting smoking is 19 years. 4 The smoking rate
in men (60%) is much higher than that in women (� 5%), but
the incidence of women smokers is rapidly rising.
Given the grim situation in tobacco consumption, it is not
surprising that lung cancer incidence has increased. More
than 400,000 cancer deaths were attributed to tobacco
consumption in 2005, among which lung cancer accounted
for more than 240,000. 5 In 2004, the mortality rate of lung
cancer was 41/100,000 in urban areas and 26/100,000 in
rural areas. WHO estimated that total number of new cases
of lung cancer may reach 1 million every year by 2025; thus
the death toll will increase proportionally. 6
The only logical way to reduce lung cancer incidence and
related death is tobacco control. The China National Office
for Cancer Prevention is responsible for reduction of cancer
incidence and mortality, and their primary targets are lung,
liver, and gastric cancers. Tobacco control is on the top of
their agenda, but investment in the program was relatively
small comparing to the magnitude of the problem. Joining
other countries, the WHO Framework Convention on Tobacco
Control was signed in 2003 and ratified in 2005. The
government had invested 10 million RMB on the project.
The objective is to promote a smoke-free environment, build
an antismoking network, and provide assistance in smoking
cessation. But for the 320 million current smokers in China,
this amount is highly insufficient. To date there is legislation
against smoking in public places but lack of effort in
execution of the law. Cigarette cost and taxes are still
relatively low. Although there is a law against sales of
From the Department of Clinical Oncology, State Key Laboratory of South China, Hong
Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong; Guangdong Lung
Cancer Institute, Guangdong General Hospital and Guangdong Academy of Medical
Sciences, Guangzhou, China.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Tony S. Mok, MD; email: tony@clo.cuhk.edu.hk.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10