# Lung Cancer in Never-Smokers: Risk Factors, Driver Mutations, and Therapeutic Advances

## TL;DR

Lung cancer in never-smokers is influenced by environmental factors and specific genetic mutations, with new therapies improving outcomes.

## Contribution

The paper identifies distinct driver mutations and environmental risk factors specific to lung cancer in never-smokers.

## Key findings

- Environmental factors like cooking oil fumes and PM2.5 are strongly linked to lung cancer in never-smokers.
- EGFR, PIK3CA, and MET mutations are characteristic of never-smokers, while TP53 mutations are more common in smokers.
- Targeted therapies and immunotherapy have improved survival and quality of life for patients with lung cancer in never-smokers.

## Abstract

Background and Objectives: Lung cancer in never-smokers (LCINS) has become a major global health concern, ranking as the fifth leading cause of cancer-related mortality. Unlike smoking-related lung cancer, LCINS arises from complex interactions between environmental carcinogens and distinct genomic alterations. This review summarizes current evidence on environmental risks, molecular features, and therapeutic progress shaping lung cancer management. Methods: A narrative review was conducted to examine risk factors for lung cancer in non-smokers. Studies reporting driver mutations in never-smokers and smokers were identified across major lung cancer histological subtypes, including small-cell lung cancer (SCLC), lung adenocarcinoma (LUAD), squamous cell carcinoma (SCC), and large-cell carcinoma (LCC). In addition, PubMed was searched for phase III trials and studies on targeted therapies related to driver mutations published between 2016 and 2025. Results: Environmental factors such as cooking oil fumes, radon, asbestos, arsenic, and fine particulate matter (PM2.5) are strongly associated with LCINS through oxidative stress, DNA damage, and chronic inflammation. EGFR, PIK3CA, OS9, MET, and STK11 mutations are characteristic of never-smokers, in contrast to TP53 mutations, which are more common in smokers. Recent advances in targeted therapy and immunotherapy have improved survival and quality of life, emphasizing the importance of molecular profiling for treatment selection. Conclusions: LCINS represents a distinct clinical and molecular entity shaped by complex interactions between environmental exposures and genetic susceptibility. Genetic alterations promote tumor immune evasion, facilitating cancer development and progression. Continued advances in air quality control, molecular diagnostics, and precision therapies are essential for prevention, early detection, and reduction of the global disease burden.