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poor for all the series. Stage was the main prognostic found a relationship between histology and gender as
factor for survival. squamous and small cell cancers prevailed in males
and ADC in females. In our series as in most series,
The predominance of lung cancer men in our series [26]
has been reported yet in Spain. [17-20] The current Stage IV remained the most common stage. However,
male-to-female ratio in the USA is close to one. [21,22] Our our series distribution by stage has changed through
ratio of males to females with lung cancer is still the years, with a decrease in Stage IV and increase in
high, [23-25] similar to other spainish rural areas. In any Stage III. We have not implemented yet the lung cancer
case, the male-to-female ratio is still substantially screening. We can not explain this tendency change on
higher in Spain (8.5 in 2003) [26,27] than in other Western stage across years.
countries, where it varies between 1.3 and 4.5 likely due OS for our entire series remained low. Overall 5-year
to the much more rare habit of smoking in women than survival rate for all stages of lung cancer, is 17%
in men. [2,4,28] It is known that over 95% of Spanish male worldwide. Our 5-year OS for all series was 15% and
[27]
lung cancer patients smoke. Anti-tobacco policies had the only factor related to survival was stage. For Stage
[3]
been introduced in Spain only in recent years. [20,28] So, IV, a median increase of 2 months was seen through
the reason for the predominance of male patients in our years with a better prognosis in the latest years. When
area could be explained by tobacco use. We have not we analyzed Stage IV patients, we found a double
specifi ed tobacco habits of our series, but almost 90% distribution. Those who did not survive more than
were likely current or former smokers. [29] There is a 12 months had a median OS of only 5 months. Although
popular type of manufactured cigar, named “caliqueño,” long survival in lung cancer has been described and is a
without fi lter, and not low-tar so that smokers maintained matter of interest, shorter survival patients are still more
the profi le of tobacco users (not inhaling deeper, so common and should be a matter of study to know why
generating central tumors, as squamous and small cell there are so many patients with this discouraging OS.
cancers). For long survival at our database, the main factor was a

In our rural area, in the non-smoking population, the molecular prognostic factor (EGFR mutation). There was
incidence of lung cancer is higher among women. [30] For an interaction between female gender, ADC histology
lung cancer women, those elderly, always non-smokers, and EGFR mutation, as women with ADC were nearly
developed ADC. The younger female patients, usually all mutated. Our series had a low percentage of patients
smokers, developed lung cancer related to smoke, such with EGFR activating mutations. However, most patients
as SCLC. Recent fi ndings also suggest that women had not been tested for EGFR status. Probably, the low
may be somewhat more susceptible to the carcinogenic rate of men with ADC EGFR mutations (only 1.7%)
effect of tobacco, [6,31] although this remains a matter of could be explained by the high rate of smoking habit in
debate. this population.
Respect to histology, in our area we found a Our work has some weak points. Despite the
predominance of squamous and small cell cancer importance of a long follow-up time, our work is
through the years. This distribution is different from not as accurate as it could have been. In fact, first
those worldwide. Worldwide, the trend is toward an we presented a hospital-based cancer registry of
increase in the proportion of adeno- and a decrease in outpatient service; therefore a selection bias could
squamous cell carcinomas, although the rate of change not be excluded. Population-based cancer registries
varies across different geographical areas. [18] This change should be preferred. However, in Spain, in spite of
has mainly been attributed to the decline in the number many efforts [17-20] not more than 26% of the Spanish
of smokers and the more widespread consumption of population (28% in the case of childhood cancer)
fi ltered cigarettes in USA. In spite of the proportional is covered by cancer registries and the distribution
decline over the last 20-30 years, squamous cell of them is not random. [22] Second, we have not
carcinoma is still the most common histological subtype considered other prognostic factors, such as
among males in several European countries (37% in performance status or treatment. Thus, we must be
France, 44% in Poland and 45% in Holland). In Spain, cautious with conclusions. Treatment could be one
[5]
squamous cell carcinoma is the most common subtype of the explanations of why women with ADC had no
with percentages varying between 24% and 50% in differences on survival depending on EGFR status.
local and regional registries and SCLC still accounts In our country, lung cancer patients have access to
for some 20% of cases in most Spanish registries. EGFR TKI on the second and third line, regardless on
In United States, ADC (40%) is the most common EGFR status. [33] and most of these patients may have
subtype, followed by squamous cell carcinoma (25%) received EGFR TKI. Despite this bias and weaknesses,
and large cell carcinoma (10%). [26] Incorporation of we believe on the value of having own clinical real
women into tobacco use worldwide and smoking date if all admit that cancer is an individual disease,
fi ltered cigarettes that are low in nicotine could partially and probably, lung cancer is different according to
explain the rise in the rate of ADC worldwide. [28,32] We epidemiology characteristics.

Journal of Cancer Metastasis and Treatment ¦ Volume 1 ¦ Issue 3 ¦ October 15, 2015 ¦ 205