What Paul Auster's Story Can Help Us Understand About Lung Cancer

What was reported

Terry Gross opened NPR's Fresh Air on 3 May 2024 by remembering the writer Paul Auster. He had died the previous Tuesday, 30 April, of complications from lung cancer. He was 77.

Auster was best known for The New York Trilogy, along with Moon Palace, Leviathan and The Book of Illusions, and for screenplays including Smoke. NPR quoted his New York Times obituary describing him as the patron saint of literary Brooklyn.

That is the public record. Nothing here describes his treatment, his stage or his care.

Two lung cancers, not one

Lung cancer divides into two broad groups, and the division changes everything downstream.

Non-small cell lung cancer is by far the more common. It includes several subtypes and is the one most likely to be treated with surgery when it is caught early enough. Small cell lung cancer grows and spreads faster and is usually treated with chemotherapy and radiation rather than an operation.

NCI states plainly that smoking is the major risk factor for non-small cell lung cancer. It is not the only one, and lung cancer does occur in people who never smoked. This page makes no claim about what caused any individual case.

Why it is usually found late

NCI makes a blunt observation: sometimes lung cancer causes no signs or symptoms at all, and is found on a chest X-ray taken for something else.

When symptoms do appear, they are the ones smokers and older adults have learned to live with. NCI lists chest discomfort or pain; a cough that does not go away or gets worse; trouble breathing; wheezing; blood in sputum; hoarseness; loss of appetite; unexplained weight loss; fatigue; trouble swallowing; and swelling in the face or the veins of the neck.

The figures show the cost. American Cancer Society projections, which SEER reprints, put 2026 at an estimated 229,410 new US lung cancer cases and 124,990 deaths. Lung cancer is 10.8% of new cancer diagnoses and 20.0% of cancer deaths, more than any other cancer.

Fifty-one percent are found only after the cancer has spread to distant parts of the body. Just 24% are found while still confined to the lung.

Five-year relative survival, for people diagnosed between 2016 and 2022, is 65.5% when still confined, 38.2% once it has reached nearby lymph nodes, and 10.5% once it has spread further. Across all stages it is 29.5%. These are averages across a large group in past years and predict nothing for any individual.

Screening exists, for a specific group

Lung cancer is one of the few cancers with a screening test that reduces deaths, and the criteria are narrow.

The USPSTF recommends annual screening with low-dose CT for adults aged 50 to 80 who have a 20 pack-year smoking history and who currently smoke or have quit within the past 15 years. A pack-year means a pack a day for a year, so 20 pack-years is a pack a day for 20 years, or two packs a day for 10.

Screening stops once someone has not smoked for 15 years, or develops a health problem that substantially limits life expectancy or the ability to have curative lung surgery.

That last clause is the honest part of the recommendation. Screening is only useful if a positive finding can lead to treatment. Our page on lung cancer screening covers who qualifies and what the scan involves.

What determines treatment now

A lung cancer diagnosis is made by biopsy, and modern treatment turns on what the laboratory finds in that tissue.

NCI lists the factors that shape prognosis and options: the stage, the type of lung cancer, whether the tumor carries changes in certain genes such as EGFR or ALK, whether there are symptoms such as cough or breathlessness, and general health.

Those gene names matter. A tumor with an EGFR or ALK change can be treated with a targeted drug taken by mouth rather than intravenous chemotherapy, which was not possible twenty years ago. This is why biomarker testing on the biopsy sample is now standard.

NCI is also direct about the overall picture: for most people with non-small cell lung cancer, current treatments do not cure the cancer, and it points to clinical trials as an option at every stage. Our page on lung cancer treatment sets out the sequence.

When to get checked

See a doctor about:

• A cough lasting more than three weeks, or a long-standing cough that has changed
• Coughing up blood, even once
• Breathlessness that is new for you, or wheezing that is not asthma
• Chest, shoulder or back pain that does not settle
• Hoarseness lasting more than three weeks
• Repeated chest infections
• Weight loss, appetite loss or fatigue you cannot explain
• Swelling of the face or the veins in the neck

If you smoke or used to, ask separately whether you meet the low-dose CT criteria. That is a different conversation from a symptom, and it belongs at a routine appointment.

What this does not mean

• His family said the cause was complications from lung cancer. Nothing else about his illness was made public, and nothing here should be read as describing it.
• Lung cancer occurs in people who have never smoked. A diagnosis is not evidence about anyone's habits.
• A 29.5% all-stages survival figure reflects how late most lung cancers are found, not how untreatable they are.
• Low-dose CT screening is not recommended for everyone. Outside the criteria, the harms outweigh the benefits.
• Targeted drugs work only for tumors carrying the matching gene change, which is a minority.

Sources

• NPR Fresh Air, Remembering novelist, screenwriter and memoirist Paul Auster — https://www.npr.org/2024/05/03/1248686515/remembering-novelist-screenwriter-and-memoirist-paul-auster
• NCI PDQ, Non-Small Cell Lung Cancer Treatment (Patient Version) — https://www.cancer.gov/types/lung/patient/non-small-cell-lung-treatment-pdq
• U.S. Preventive Services Task Force, Lung Cancer: Screening — https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
• SEER Cancer Stat Facts, Lung and Bronchus Cancer — https://seer.cancer.gov/statfacts/html/lungb.html

How this article was prepared

An AI-assisted editorial system helped prepare this page. No named medical reviewer has reviewed it unless one is listed.

The National Cancer Information Foundation publishes Cancer Explained. This page is for learning. It is not medical advice and does not suggest a test or treatment.

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