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‘Health Chatter’: Research Department of Behavioural Science and Health Blog



Smokers’ interest in a national lung cancer screening programme

By Jo Waller, on 4 May 2018

By Samantha Quaife and Maria Kazazis

Lung cancer is typically diagnosed too late; a major reason why it remains the leading cause of cancer death both in the UK and globally. Catching lung cancer early drastically improves survival, but often there are no symptoms in the early stages, or at least no symptoms that initially cause alarm.

Therefore, a national lung cancer screening programme is being considered in the UK. This would use a special type of CT scan with a lower dose of radiation (a LDCT scan) to screen for nodules in the lungs which could be early cancers. There is evidence from a large US trial that this decreases deaths from lung cancer among current smokers and former smokers aged 55-74 who have a significant smoking history. However, there are risks as well as benefits to screening and the UK are waiting for further European evidence.

One potential problem our research is trying to address is low uptake. For screening to work best, those taking part should be at high risk of developing lung cancer (usually due to a long history of tobacco smoking among other factors). Smoking is more common within socioeconomically deprived communities meaning that a greater proportion of adults are at high risk when compared with more affluent communities. However, in both Europe and the US, fewer smokers and individuals of a lower socioeconomic position, have taken part in screening when offered by research trials. But trial participation is different. What we don’t know is to what extent this problem might exist in the context of a national NHS programme.

In our newly published paper, funded by Cancer Research UK and the Medical Research Council, we surveyed 1464 adults aged 50-70 years as part of our Attitudes Behaviour and Cancer-UK Survey (ABACUS). We asked participants how likely they were to take part in screening following three hypothetical screening invitation scenarios. We also asked participants how much they worried about lung cancer, whether they thought the chances of surviving early stage lung cancer were good and whether they thought (again hypothetically) they would have surgery if screening found an early stage cancer. We compared current smokers with non-smokers on all these beliefs.

Most participants (97%) thought screening was a good idea and intended to be screened, regardless of their smoking status (>89% of current and former smokers). This is encouraging in principle, but intentions are not always the most accurate way of predicting actual screening behaviour. Indeed, we also found that smokers reported worrying more about lung cancer, and were less likely to think the chances of surviving lung cancer (when detected early) are good, or think they would opt for surgery (the most effective treatment for early stage lung cancer). It’s possible that these negative perceptions may deter smokers from screening. Importantly though, beliefs are modifiable. To optimise participation among those at high risk, we should communicate the screening offer in a way that minimises excessive worry, clearly explains the improvement in survival for early disease and dispels any misconceptions about surgical treatment.

Reference: Quaife, S. L., Vrinten, C., Ruparel, M., Janes, S. M., Beeken, R. J., Waller, J., McEwen, A. (2018). Smokers’ interest in a lung cancer screening programme: a national survey in England. https://doi.org/10.1186/s12885-018-4430-6

Delays in the diagnosis of cancer: an issue on both sides of the Atlantic

By rmjlmko, on 18 September 2015

By Monica Koo and Yoryos Lyratzopoulos

In recent years, there has been a lot of attention on the delays in the diagnosis of cancer in England. Evidence from the International Cancer Benchmarking Partnership (ICBP) has indicated that delays in diagnosis were contributing to poorer cancer survival in England compared to other countries. However, it would be wrong to assume that delays in diagnosis of cancer were unique to countries with a strong primary care system such as England.

We recently wrote an editorial in Cancer Epidemiology on this very topic, commenting on a new population-based study looking at delays in the diagnosis (and treatment) of lung cancer in elderly patients in the US. The study was based on linked routine healthcare data (SEER-Medicare to be specific) collected on nearly 50,000 US patients. There are a few key findings that we highlight in the editorial:

  • The median diagnostic interval (the time between when a patient first presents with symptoms and diagnosis) was around 180 days (almost 6 months). This means that more than half of the patients in this study had a diagnostic interval of longer than 6 months, which is a pretty alarming finding. Similar findings have been published in England recently, showing how difficult it can be to detect and diagnose lung cancer.
  • Older patients had longer median diagnostic intervals than younger patients, and women had longer diagnostic intervals than men. Again, similar patterns have been described before in the UK, but the inequalities found by this study were particularly large and clearly further research is needed in this area.
  • There were also delays from diagnosis to treatment, which were much shorter than the diagnostic interval (27 and 18 days for patients with non-small cell and small cell lung cancer respectively). Patient characteristics didn’t have much effect on the length of the treatment interval, compared to the diagnostic interval. In other words, once a diagnosis of lung cancer was made, the patient’s age, sex, race, and comorbidity status (whether they had other health conditions) didn’t influence their time to treatment much.

Relatedly, specialist investigations are increasingly being used to inform treatment options, including PET-CT imaging and biomarker profiling. Unfortunately such advances in personalising cancer care also have the potential to delay the start of treatment. Although challenging, this may be seen as an opportunity to streamline and integrate cancer care pathways and services.

Overall, the findings of the US study add to the growing body of evidence on diagnostic delays in cancer from the UK and other countries, clearly indicating that this is a global problem that transcends countries and healthcare systems. Building on the shared learning generated by the ICBP, future international efforts in cancer outcomes research should aim to include US patients in order to bring further insights into the cause of such delays. By first asking “why” the delays occur, we can then turn to the “how” and “what” we can do about these universal problems.

Our editorial is open access (freely available online) and is available at: http://dx.doi.org/10.1016/j.canep.2015.08.008

The lowdown on lung cancer stigma

By Laura Marlow, on 17 February 2015

Lung cancer is the second most common cancer in the UK with over 40,000 people diagnosed each year.  Smoking accounts for around 86% of lung cancer cases and studies have shown that most people are now well aware of the link between smoking and lung cancer risk.

While public health campaigns have successfully portrayed smoking as an undesirable behaviour, stigmatising lung cancer seems to have been a by-product of this success. Studies suggest that many lung cancer patients feel stigmatised and the link with smoking is often offered as an explanation for this.  In a study published online last week, we show that lung cancer patients’ perceptions of stigma are reflected in the general population, with greater stigma attributed to lung cancer than to other cancer types.

In our study, 1205 men and women answered questions about lung, skin, breast, bowel or cervical cancer.  The questions used were taken from the recently developed Cancer Stigma Scale  which assesses six dimensions of cancer-related stigma: Awkwardness, Severity, Avoidance, Policy Opposition, Personal Responsibility and Financial Discrimination.

Participants  who answered questions about lung cancer generally gave higher ratings on the stigma scale than those who were asked about other cancers.  They rated lung cancer patients as more responsible for their illness and reported being more likely to avoid people with lung cancer.  They said they would feel more awkward around people with lung cancer, and were more tolerant of financial discrimination and lower levels of support for patients with the disease.  They also considered lung cancer to have more severe consequences than other cancers, which is consistent with the poor survival rates among lung cancer patients.

There were some exceptions, for example personal responsibility was judged to be similar for skin and lung cancer patients, probably because of the role of sun exposure in skin cancer risk.  Perceived awkwardness scores were similar for bowel and lung cancer patients.

Negative perceptions of lung cancer can have a negative impact on patient experience and funding contributions.  They may also have an impact on preventive behaviours among smokers, such as seeking medical help for cancer symptoms or participation in lung screening if this is introduced.  We need to find ways of limiting cancer stigma for patients, health professionals and the community, while still promoting public health messages about lifestyle based cancer prevention – perhaps a difficult balance to achieve.

Article reference: Marlow LAV, Waller J, Wardle J. Does Lung cancer attract greater stigma than other cancer types? Lung Cancer, http://dx.doi.org/10.1016/j.lungcan.2015.01.024