the incidence of lung cancer is constantly increasing , and this is a phenomenology that has raised concerns since decades , mostly important , because the disease has changed its manifesting modalities , and even the histological profile has undergone modifications [ 13 ] . on the other hand ,
if previously the age - specific parameter regarded mainly older patients , actually the trend of having more and more younger patients with lung cancer and with females suffering increasingly from the latter , is unrelenting .
tobacco smoking habits have been accused to play a direct role in the fact that females are manifesting increasingly a higher incidence of lung cancer , although conclusions hardly converge [ 57 ] .  
albeit that numerous professional settings have been related to higher incidence of lung cancer , tobacco smoking still remains the mostly discussed factor .
it seems nevertheless that several years of exposure to active or passive smoking are necessary before modifications of the bronchial mucosa can be detected .
furthermore , correlating the manifestation of the adenocarcinoma of the lung with tobacco smoking has been continuously an issue of controversy , although recent and more large studies have still found a relation , but rather a smaller one , when compared with other histological types of lung cancer [ 8 , 9 ] . in the present study
, the authors have tried to describe the behaviour of a sample group of 54 albanian females suffering from lung cancer and recruited for a diagnostic and therapeutic followup at the university hospital of pulmonary diseases ( uhpd ) in tirana , during the period from january to june 2011 .
several factors are discussed , such as the age of the patients , smoking habits , karnofsky score , histological type , and treatment modalities . aiming to profile the actual trend of lung cancer in albanian women
other studies have been sketched on the same issue but focusing on other parameters , such as pain and other oncologic variables .
also , models of studying smoking behaviour in this setting and group of patients have been proposed , mainly in regard to disease perception and behavioural changes related to the latter .
in a retrospective study , we have evaluated the behaviour of female patients diagnosed and treated for lung cancer .
all patients were admitted in a university facility ( uhpd ) of tirana , and cases were grossly divided in 
primary  and  secondary  lung cancer . the female patients diagnosed with lung cancer during the period january 
june 2011 and treated with the previously mentioned facility were all recruited consequentially to the present study , with a sample group having a total of 54 cases .
the majority of the cases were diagnosed through thoracic computerized tomography ( ct ) , namely , 28 from the total of 54 females that formed the present sample of study .
karnofsky performance status ( kps ) was used as a standard score of measuring the ability of cancer patients to perform ordinary tasks of the everyday life activities .
kps is a scale ranging from 0 to 100 , with a higher score meaning the patient to be more able to carry out everyday activities ; such a scale has been proposed more than sixty years from now and yet has never lost its validity and utility .
the stadification of the lung cancer has been done according to the system tnm ( tumor , node , and metastasis ) of the year 2009 , seventh update .
self - reporting of the number cigarettes per day was used as a measure to consider the presence of smoking as a risk factor . for the purpose of the study ,
female patients were divided in smokers and nonsmokers , with the latter group never smoking or smoking occasionally ( less than two cigarettes per day in an irregular basis ) ; strong smokers ( consuming 1 pack per year , equivalent of smoking twenty cigarettes daily for at least one year ) formed a minority of the sample ( see results later ) .
30 of them suffered from primary lung cancer ( 57% ) , and the rest of 24 female patients manifested a secondary lung cancer ( 43% ) .
although the majority of cases were above 51 years of age ( 28/54 , i.e. , more than half of the total ) , worth mentioning is the fact that we had 17 cancer patients ( 31% ) aging from 31 to 40 years old .   from the sample group we had 6 patients self - referring as smokers ;
 heavy smokers  that exceeded their smoke consumption by more than twenty cigarettes per day were a minority ( two from six  smokers  ) . surprisingly , 48 female patients diagnosed with lung cancer self - referred as being nonsmokers ; thus we had a large majority ( 89% ) of nonsmoking patients , forming part of a group diagnosed and treated for lung cancer .
regarding the distribution of histological types of the primary lung cancer , we had a majority of adenocarcinomas ( 20 from a total of 30 cases with primary lung cancer ) ; the overall histological data are included in the table 2 . from the other subgroup with secondary lung cancer ( 24 cases in total ) we had one case of metastasizing melanoma , one tumor of the thoracic wall extending per contiguity , one metastasizing cerebral tumour , one ovary - originated , and another one from colorectal origin ; two cases had originated from trachea and another two from mediastinal structures .
breast metastasis and mesotheliomas formed the majority of the secondary lung cancer cases , respectively , with six and nine cases ( see figure 1 for the histological distribution of secondary lung cancer diagnosed in the sample group ) .   in the following table ( table 3 )
we summarize the distribution of cases regarding the tnm staging , performance status ( kps ) , and the main modality of treatment the patients received . from the data we gathered , we had the majority of cases presenting to a medical facility already in their fourth stage ( tnm ) , although their performance status was generally good , which might comply with the surreptitious character of lung cancer , especially in nonsmoking women .  
the main modality of treatment offered was chemotherapy ( 45 out of a total of 54 patients ) ; eight patients were operated and eventually half of them received thereafter chemotherapeutic treatment as well .
we had no data regarding one case , which was treated in another facility , after the diagnosis was made .
this is a descriptive and retrospective study , performed in a university facility , which is the only tertiary hospital dedicated to pulmonology in albania .
the data of the present study have a limited validity , since the number of patients ( 54 in total ) and the time length of their recruitment ( six months ) are both parameters of a controversial significance , from the epidemiological point of view .   in order to avoid confusions regarding the role of risk factors , we dichotomized the sample group merely in  smokers  and  nonsmokers  , without entering in details regarding the severity of tobacco smoking as a phenomenon .
such a severity must , for sure , play an important role in the genesis of the lung cancer ; therefore it can not be underemphasized .
in fact , the definition of  nonsmokers  ,  light smokers  , and 
heavy smokers  are another subject of controversy ; nonprofessional sources consider a light smoker as a person smoking less than five cigarettes per day , in confront to a  heavy 
there are authors that have made much more meticulous separations of smokers in subgroups , such as  nonsmokers  ,  heavy smokers  ,  3-month quitters  ,  6-month quitters  ,  12-month quitters  , and  long - term quitters  .
heavy smoker index  has been proposed and applied in different studies . obviously , the scope of our study was more limited , and we merely divided patients into smokers and nonsmokers .   from the data we gathered and
the results presented herein , it is an impressive finding of a majority of  nonsmokers  suffering from lung cancer ( 48 out of 54 patients in the present sample , i.e. , 89% ) .
the question of secondary , second hand , or passive smoking will come out surely under these circumstances , and several sources have detailed the issue [ 18 , 19 ] . in an obvious desperate attempt to control smoking in public environments ,
albanian government passed an ad hoc bill , on november 2006 , which forecasted severe fines applied to smokers ; such fines in fact were never collected .
the law was stigmatized as the  forgotten law  from the media ; but it is not excluded that other legislative or judicial acts might follow in the next future , since the era of litigation aiming to restrict tobacco exposure is surely arrived . hereby passive smokers and claims of liabilities related to health damages provoked to them are continuously upheld , especially in particular settings such as working places and so forth .
such a good performance should have played some role in delaying the diagnosis , for we had on the other side , a very important number of cases staging at the fourth stage ( tnm ) , with exactly 66% of the patients at the most advanced stage in the moment of diagnosis . regarding the kps we grouped the scores under the denominations of  low  when such a score was 1040 ;  medium  when the score was 5070 and  high  for the scores 80100 , such a grouping of scores has been applied from other sources as well [ 23 , 24 ] .
the present study , while confirming the general medical concern regarding a possible increasing trend of lung cancer among albanian women , raises two important issues .
first , the fact that second - hand smoking role has to be scrutinized seriously and measured to be applied , when dealing with a majority of female lung cancer patients that self - referred as  nonsmokers  .
second , the fact that a large number of newly diagnosed lung cancer patients were already in advanced tnm stages albeit the performance status ( kps ) was generally high requires a thorough revision of preventive medical policies and diagnostic procedures at the primary level of medical care that are obviously lacking the ability to early diagnose a potentially lethal disease .  
since the initial clinical signs of this malignant disease are far from being specific or pathognomonic , guidelines for early referral and investigation are proposed and applied , with meaningful results .
this study tries to clarify some of the factors that have concerned albanian clinicians recently regarding the trend of lung cancer among females .
albeit the sample is relatively small and the time length of the study is short , it is worth mentioning that parallel studies are difficult to find ; paucity of sources has made comparative international conclusions , with albania mentioned , rarely , if ever .
 lung cancer is a potentially lethal disease , whose prevalence in albania is constantly increasing , especially in women . 
 early diagnosis is extremely important with regard to life expectancy and quality . 
 the authors conducted a survey on the behaviour in a sample group of albanian women diagnosed with primary and secondary lung cancers . a discussion upon diagnostic methods , smoking habits , histological type , karnofsky performance status ( kps ) , and treatment modalities is made . 
 the data collected by the authors suggest that nonsmokers formed the main group of lung cancer female patients . 
 the most frequent histological type was adenocarcinoma . 
 mesothelioma was the most frequent of the secondary pulmonary lung cancers , followed from metastasizing breast cancer . despite a generally good performance of the cases , 
 the diagnosis of pulmonary cancer is delayed . 
 the data collected could not find a convincing etiological role of tobacco smoking , but caution is needed , regarding the short time length of the study and the sustained number of participants . 