Short of breath: For Canadian women, COPD deaths surpass those from breast cancer

Text Size: Normal / Medium / Large
Printer-friendly versionPrinter-friendly version
Publication Date: 
Mon, 2014-05-12

By Ann Silversides

When Irene Donaldson became anxious about her persistent dry cough and the “terrible time” that she had breathing, her physician downplayed her concerns.

Donaldson had quit smoking 15 years earlier. Her doctor ordered a chest X-ray, which was clear.

“But I kept after her—and after her—and finally she referred me to a respirologist,” says Donaldson, 79, who lives in Rockland, a town of about 11,000 an hour’s drive east of Ottawa.

Donaldson, who was 75 at the time, waited six months for that appointment, at which she had a spirometry test and was diagnosed with chronic obstructive pulmonary disease (COPD), an umbrella term for emphysema and chronic bronchitis.

Spirometry is the standard test to confirm a COPD diagnosis (see video here); chest X-rays are “seldom diagnostic” for COPD, according to international guidelines.

Now the fourth leading cause of death worldwide, COPD is expected to climb to 3rd place by 2030, according to the World Health Organization.

Despite the burden that COPD places on sufferers—and on the health care system—researchers agree that this chronic disease is under-diagnosed and under-treated and, relative to other chronic conditions, underfunded and under-researched.

It will surprise many to learn that more Canadian women are expected to die from COPD this year than from breast cancer, continuing an existing trend. This underscores COPD’s low profile as a public health issue.

In fact, COPD overtook breast cancer as a cause of death for Canadian women in 2009, according to Statistics Canada figures, and since then COPD deaths have climbed while breast cancer deaths have fallen. (The latest figures, from 2011, show 5,342 deaths from COPD, 4,958 for breast cancer.)

Back in 2006, a Canadian Lung Association report pointed out that COPD was “becoming a crucial women’s health issue.”  Today it’s safe to say it is a women’s health issue. Taking Her Breath Away highlights the disturbing increase of COPD among women in the United States and was released just last year by the American Lung Association.

Getting a diagnosis

By the time that Donaldson was diagnosed with COPD, her condition was so severe that the specialist promptly arranged for her to be admitted to a 30-day in-patient pulmonary rehabilitation program in Ottawa. 

While COPD cannot be cured, deterioration can be slowed down or even halted, and early diagnosis significantly improves outcomes. Donaldson needed a walker to get around when she entered the program, but after three weeks in rehab she folded up her walker and put it away. 

With a (preferably early) early diagnosis of COPD, clinician scientist Pat Camp of the University of British Columbia advises that women should:
  • be strongly encouraged to quit smoking. If they don’t quit, their health will decline much more rapidly. 
  • treat any chest infections aggressively with antibiotics and oral steroids to reduce inflammation. With COPD, infections rapidly get into the chest and, if untreated, patients end up in hospital with a “lung attack”.
  • get the pneumonia vaccination and a flu shot.
  • maintain physical activity—improving muscle strength and function means you put less load on your lungs, you don’t need as much oxygen.

The difficulty that Donaldson had getting her family doctor to take her concerns seriously is not uncommon. A 2011 British report, Reconsidering sex-based stereotypes of COPD, notes that COPD has “historically been considered a disease of older, white, male smokers” and that women with COPD present with somewhat different symptoms than men—more breathlessness and coughing, but less phlegm. 

That report also cites an earlier (2001) study, in which researchers asked Canadian and American doctors to consider hypothetical cases of individuals—their gender was not revealed—with the symptoms of COPD.

The physicians diagnosed the female patients more often with asthma than with COPD. Only when shown the results of spirometry tests for the hypothetical patients did the doctors correctly diagnose the women—yet only 22 per cent of the doctors  “would have requested spirometry after the initial presentation,” the study reported.

Indeed, a recent study found that, when they do diagnose COPD, Ontario doctors typically do not bother to confirm their diagnosis. Only about 36 per cent of those diagnosed with COPD in the decade 2000 to 2010 had the confirmatory spirometry test.

COPD is not the only condition where gender bias may play a role in diagnosis and treatment. A study recently published in the CMAJ noted that women suffering from heart attacks are treated differently from male counterparts at emergency departments.

Spirometry should be “mandated as a quality improvement initiative” for patients at risk of COPD just like blood pressure screening for hypertension, says Dilshad Moosa, a respiratory therapist with the Ontario Lung Association who also manages education for health care providers for the Ontario Thoracic Society.

One way to help identify patients at risk of COPD is with a screening tool—a simple series of questions—developed by the Canadian Lung Association, she says.

Moosa has spent ten years educating Ontario doctors about lung health issues and says there is still a lack of knowledge among primary care providers about how to do quality spirometry tests and how to interpret them.

Meanwhile, the prevalence of COPD in Ontario (that is, the percentage of the population that is affected) increased by 64 per cent between 1996 and 2007, with more of the burden shifting from men to women, according to a recent Ontario study.

For both men and women between 35 and 80, the “lifetime risk” of a COPD diagnosis is double that of congestive heart failure and, for women, three or four times the risk of developing breast cancer, according to a 2011 a study by the Institute of Evaluative Sciences (ICES) published in the Lancet and based on Ontario data.

COPD accounts for the highest rate of hospital readmissions

The lack of attention to prevention and early diagnosis of COPD is particularly striking when costs to the health care system are considered.

For medical patients, COPD accounts for the highest rate of re-admissions to hospital in Canada. Almost one in five COPD patients was readmitted to hospital within 30 days, according to a Canadian Institute of Health Information study of the period 2010 to 2011. 

Research from Ontario shows that the 11.8 per cent of the population over 35 with a diagnosis of COPD had rates of hospital, emergency and ambulatory visits that were 63 per cent, 85 per cent and 48 per cent higher than the rest of the population over a three year period, according to a 2013 study from the Institute for Clinical Evaluative Sciences (ICES). Rates of long-term care and home care use were 58 per cent and 59 per cent higher.

Lead author Andrea Gershon explained the study did not provide a breakdown by gender of health care usage. “I think that would be a great topic for a future study,” she added.

Cigarette smoking accounts for about 90 per cent of cases of COPD—smoke inhalation damages upper airways and the lungs. The other 10 per cent of cases are caused by second hand smoke, air pollution, occupational exposure and a rare genetic disorder.

It’s true that smoking rates have fallen among women, from close to 40 per cent in 1965, to about 24 per cent in 2001 and 15 per cent in 2011. However, the rise in COPD diagnoses today represents the toll being paid today from the effects of the post WW2 rise in the number of women smokers.

People who smoke have two major respiratory risks—lung cancer and COPD—notes Dr. Anna Day, respirologist at Women’s College Hospital in Toronto. Lung cancer is the leading cause of death from cancer in Canada and, disturbingly, lung cancer diagnoses continue to climb among women even as they fall among men.

Having one does not preclude the other, but the risk of COPD is independent of that of lung cancer, says Dr. Day.

Among Canadian women, smoking rates are highest among those in the lowest income brackets. It is notable that for both men and women, COPD rates are higher among those who live in rural areas and those with lower incomes, according to research from the Institute of Clinical Evaluative Sciences in Ontario.

These facts, together with an element of ageism—the risk of COPD increases steeply at 60 years of age—could well contribute to the relative neglect that the disease has suffered in terms of research dollars and public profile.

Certainly, it is clear that the neglect of COPD as a chronic disease is related to the stigma attached to smoking, together with a degree of victim blaming. “Yeah, yeah, you hear that: ‘You smoked, you deserve it.’ I even got that from my family,” says Donaldson.

However, smoking is an addiction, notes Day, and unfortunately “many doctors think you can’t do much about it.” 

Day, whose rallying cry focuses on prevention and early diagnosis, says she has felt like “a sole voice in the wilderness” as she has tried for the past 15 years to raise the alarm about women’s risk of COPD.

Disturbingly, she says that people can lose up to 50 per cent of their lung function and still not show symptoms of COPD.  Day and her colleagues at WCH advocate that, at age 40 to 45, current smokers— or those with a history of smoking—should routinely be given a spirometry test.

The test, which is the only way to confirm a COPD diagnosis, can detect small airway obstruction, indicating COPD in early stages. Now, however, most people aren’t diagnosed until their COPD is moderate or severe.

Much attention has recently focused on screening tests like mammography, and the risk that they can lead to unnecessary and sometimes harmful invasive procedures. In contrast, the simple and relatively inexpensive spirometry test, when it confirms a diagnosis of COPD, paves the way for non-invasive steps that can improve health.

“A lot of doctors think they don’t need the test to diagnose COPD and then can just treat,” says Pat Camp, an assistant professor and clinician scientist in the department of physical therapy at the University of British Columbia. They would never think that about another chronic condition like hypertension, she adds.

Efforts at prevention and early diagnosis must, as Day argues, be stepped up. But for those who already have COPD, the merry-go-round of emergency ward visits and hospital admissions that are characteristic of a COPD diagnosis, can be significantly reduced with different approaches to caring for people with COPD. One example is the INSPIRED program in Halifax, Nova Scotia that stresses emotional and community-based support.

Donaldson, who smoked for 40 years before she quit, is in that respect typical of the patients for whom Camp provides pulmonary rehabilitation. COPD takes a long time to develop and most of her patients have smoked for 30 or 40 years, she says.

Camp, who has conducted research into women and COPD, nonetheless says such research is still “in its infancy.” Still, there is evidence that women are more vulnerable to the effects of smoking, likely due to factors such as their smaller size (and lung capacity) and the impact of hormones and inflammatory response. 

Internationally, women who regularly tend open fires for cooking food are vulnerable to developing COPD because of their exposure to the smoke, Camp points out.

Donaldson now travels twice a week to Ottawa to join 15 others for a group program of exercise and support for their COPD. “I can now do 20 minutes on a treadmill …and last summer I went outside for a 20 minute walk,” she enthuses. “It improves your life.”

Donaldson has also improved the lives of others. She says her condition “scared the living daylights” out of her family, and led her children and their spouses to quit smoking. “Now they’ve all quit except one grandson, who is 33 years old.”

Oh yes, and after that problem she had convincing her family physician to take her concerns seriously? A new clinic opened up in town and she switched doctors.

Ann Silversides is an independent journalist and author who specializes in health policy.

Additional resource:

Self-treatment results in lower overall health care costs for COPD sufferers,, May 17, 2009