What The Bucket List Can Teach Us About Lung Cancer

The film, and the diagnosis at its center

"The Bucket List," released by Warner Bros. on December 25, 2007, puts two terminally ill men in the same hospital room and sends them off to finish a list before they die. Edward, played by Jack Nicholson, has lung cancer.

The film is about friendship and regret, not oncology, and it does not pretend otherwise. But lung cancer is the leading cause of cancer death in the United States. The version of it most people carry in their heads is about fifteen years out of date.

Two diseases, not one

The National Cancer Institute divides lung cancer into non-small cell lung cancer, or NSCLC, and small cell lung cancer. They behave differently and are treated differently, so the type is the first thing that gets established.

Within NSCLC, where the tumor starts predicts what it looks like. NCI notes that squamous cell carcinoma usually begins near a central airway, while adenocarcinoma and bronchioloalveolar carcinoma usually start in the outer lung tissue.

NCI also describes the path a smoking-related lung cancer takes before it is cancer at all. The airway lining passes through hyperplasia, metaplasia, dysplasia, and carcinoma in situ. NCI calls the last two the principal premalignant lesions. They are the ones most likely to progress and least likely to fade on their own.

What raises the risk

NCI states the headline directly: the single most important risk factor for lung cancer is smoking. For a smoker, the risk is on average tenfold higher than for a lifetime nonsmoker, defined as someone who has smoked fewer than 100 cigarettes. Risk rises with the number of cigarettes, the duration, and how young a person started.

Quitting works. NCI reports that stopping smoking reduces precancerous lesions and lowers lung cancer risk, while noting that former smokers keep an elevated risk for years afterward.

The rest of NCI's list matters, because lung cancer is not only a smoker's disease:

• Secondhand smoke.
• Occupational exposure to asbestos, arsenic, chromium, beryllium, and nickel.
• Radon in the home or workplace.
• Radiation to the breast or chest, and radiation from medical imaging.
• Air pollution.
• A family history of lung cancer.
• HIV infection.
• Beta carotene supplements in heavy smokers.

NCI adds that asbestos and cigarettes together do more damage than either alone.

When to get checked

NCI is clear that lung cancer sometimes causes no symptoms at all, and is found on a chest x-ray done for something else. When there are signs, it says to check with a doctor about:

• Chest discomfort or pain.
• A cough that does not go away or gets worse over time.
• Trouble breathing, or wheezing.
• Blood in sputum, meaning mucus coughed up from the lungs.
• Hoarseness.
• Loss of appetite, or weight loss for no known reason.
• Fatigue.
• Trouble swallowing.
• Swelling in the face, or in the veins of the neck.

Thresholds that make that list usable:

• A cough lasting more than three weeks that is new, or a long-standing smoker's cough that has changed in character.
• Any amount of blood coughed up, once, at any age. That earns a same-week appointment.
• Hoarseness lasting more than three weeks with no cold to explain it.
• Breathlessness on exertion that is worse than it was a few months ago.

The screening test that exists, and who qualifies

Lung cancer now has a screening test with proven mortality benefit, which was not true when the film came out.

The U.S. Preventive Services Task Force recommendation, issued March 9, 2021, is a grade B: annual screening for lung cancer with low-dose computed tomography, or LDCT, in adults aged 50 to 80 years who have a 20 pack-year smoking history and who currently smoke or have quit within the past 15 years.

A pack-year is one pack a day for a year. Two packs a day for ten years is 20 pack-years, and so is one pack a day for twenty years. If you are in that band, this is a specific thing to ask a primary care clinician about by name.

Why the tumor gets genetically tested

This is the biggest change since 2007, and it is why an old film cannot serve as a guide.

NCI states that identifying genetic variants in lung cancer has led to molecularly targeted therapies that improve survival for subsets of patients with metastatic disease. It lists genomic alterations that can be targeted with approved therapies or ones in development: EGFR, ALK, BRAF, ROS1, RET, NTRK1, NTRK2, NTRK3, MET, KRAS, and HER2.

The pattern is not random. NCI reports that EGFR and ALK changes predominate in adenocarcinomas arising in nonsmokers, while KRAS and BRAF changes are more common in smokers and former smokers. In one series of 2,142 lung adenocarcinoma specimens, the relevant EGFR changes appeared in 52% of tumors from never-smokers, 15% from former smokers, and 6% from current smokers.

The practical consequence: for advanced non-small cell lung cancer, molecular testing of the tumor is not optional extra detail. It determines which treatments exist for that person.

What the numbers show

These are population figures. They describe groups and predict nothing for an individual.

SEER, the National Cancer Institute's surveillance program, publishes an American Cancer Society projection of 229,410 new lung and bronchus cancers in the United States in 2026, about 10.8% of all new cancer diagnoses, and 124,990 deaths, about 20.0% of all cancer deaths. SEER's own measurement puts five-year relative survival across all stages at 29.5% for people diagnosed from 2016 to 2022. Lung cancer is diagnosed most often between ages 65 and 74.

Stage drives the difference. Within that 2016–2022 group, SEER records five-year relative survival of 65.5% for localized disease, 38.2% for regional disease, and 10.5% once the cancer has reached distant organs. Only about 24% of cases are found while localized. About 51% are already distant at diagnosis.

One more figure is worth knowing for anyone who has been treated. NCI reports that after a lung cancer is removed, there is a 1% to 2% risk per patient per year that a second lung cancer will occur. That is why surveillance continues after successful surgery.

What the film gets right, and what it cannot

The emotional core of "The Bucket List" is sound: a late-stage diagnosis reorders what matters, and how someone spends that time is their own business.

What the film cannot show, because it predates it, is that lung cancer treatment now begins with a question about the tumor's genes. That single change is why a story from 2007 should be watched as a story, and not read as a description of what a lung cancer diagnosis means today.

Sources

• NCI: Non-Small Cell Lung Cancer Treatment (PDQ) — Health Professional Version
• NCI: Non-Small Cell Lung Cancer Treatment (PDQ) — Patient Version
• SEER Cancer Stat Facts: Lung and Bronchus Cancer
• USPSTF: Lung Cancer Screening, final recommendation, March 9, 2021
• Warner Bros.: The Bucket List (2007)