Lung cancer symptom appraisal, help-seeking and diagnosis - rapid systematic review of differences between patients with and without a smoking history

A systematic review on the qualitative experiences of people living with lung cancer in rural areas

PURPOSE

To synthesize the qualitative literature exploring the experiences of people living with lung cancer in rural areas.

METHODS

Searches were performed in MEDLINE, CINAHL, and PsycINFO. Articles were screened independently by two reviewers against pre-determined eligibility criteria. Data were synthesized using Thomas and Harden's framework for the thematic synthesis of qualitative research. The CASP qualitative checklist was used for quality assessment and the review was reported in accordance with the ENTREQ and PRISMA checklists.

RESULTS

Nine articles were included, from which five themes were identified: (1) diagnosis and treatment pathways, (2) travel and financial burden, (3) communication and information, (4) experiences of interacting with healthcare professionals, (5) symptoms and health-seeking behaviors. Lung cancer diagnosis was unexpected for some with several reporting treatment delays and long wait times regarding diagnosis and treatment. Accessing treatment was perceived as challenging and time-consuming due to distance and financial stress. Inadequate communication of information from healthcare professionals was a common concern expressed by rural people living with lung cancer who also conveyed dissatisfaction with their healthcare professionals. Some were reluctant to seek help due to geographical distance and sociocultural factors whilst others found it challenging to identify symptoms due to comorbidities.

CONCLUSIONS

This review provides a deeper understanding of the challenges faced by people with lung cancer in rural settings, through which future researchers can begin to develop tailored support to address the existing disparities that affect this population.

The Role of Smoking Status in Making Risk-Informed Diagnostic Decisions in the Lung Cancer Pathway: A Qualitative Study of Health Care Professionals and Patients

BACKGROUND

Lung cancer clinical guidelines and risk tools often rely on smoking history as a significant risk factor. However, never-smokers make up 14% of the lung cancer population, and this proportion is rising. Consequently, they are often perceived as low-risk and may experience diagnostic delays. This study aimed to explore how clinicians make risk-informed diagnostic decisions for never-smokers.

METHODS

Qualitative interviews were conducted with 10 lung cancer diagnosticians, supported by data from interviews with 20 never-smoker lung cancer patients. The data were analyzed using a framework analysis based on the Model of Pathways to Treatment framework and data-driven interpretations.

RESULTS

Participants described 3 main strategies for making risk-informed decisions incorporating smoking status: guidelines, heuristics, and potential harms. Clinicians supplemented guidelines with their own heuristics for never-smokers, such as using higher thresholds for chest X-ray. Decisions were easier for patients with high-risk symptoms such as hemoptysis. Clinicians worried about overinvestigating never-smoker patients, particularly in terms of physical and psychological harms from invasive procedures or radiation. To minimize unnecessary anxiety about lung cancer risk, clinicians made efforts to downplay this. Conversely, some patients found that this caused process harms such as delays and miscommunications.

CONCLUSION

Improved guidance and methods of risk differentiation for never-smokers are needed to avoid diagnostic delays, overreassurance, and clinical pessimism. This requires an improved evidence base and initiatives to increase awareness among clinicians of the incidence of lung cancer in never-smokers. As the proportion of never-smoker patients increases, this issue will become more urgent.

HIGHLIGHTS

Smoking status is the most common risk factor used by clinicians to guide decision making, and guidelines often focus on this factor.Some clinicians also use their own heuristics for never-smokers, and this becomes particularly relevant for patients with lower risk symptoms.Clinicians are also concerned about the potential harms and risks associated with deploying resources on diagnostics for never-smokers.Some patients find it difficult to decide whether or not to go ahead with certain procedures due to efforts made by clinicians to downplay the risk of lung cancer.Overall, the study highlights the complex interplay between smoking history, clinical decision making, and patient anxiety in the context of lung cancer diagnosis and treatment.

Pathways to lung cancer diagnosis among individuals who did not receive lung cancer screening: a qualitative study

BACKGROUND

Although early detection of lung cancer through screening is associated with better prognosis, most lung cancers are diagnosed among unscreened individuals. We therefore sought to characterize pathways to lung cancer diagnosis among unscreened individuals.

METHODS

Participants were individuals with lung cancer who did not undergo asymptomatic lung cancer screening (n = 13) and healthcare providers who may be involved in the pathway to lung cancer diagnosis (n = 13). We conducted semi-structured interviews to identify themes in lung cancer patients' narratives of their cancer diagnoses and providers' personal and/or professional experiences of various pathways to lung cancer diagnoses, to identify delays in diagnosis. We audio-recorded, transcribed, and coded interviews in two stages. First, we conducted deductive coding using three time-period intervals from the Models of Pathways to Treatment framework: appraisal, help-seeking, and diagnostic (i.e., excluding pre-treatment). Second, we conducted inductive coding to identify themes within each time-period interval, and classified these themes as either barriers or facilitators to diagnosis. Coding and thematic summarization were completed independently by two separate analysts who discussed for consensus.

RESULTS

Eight of the patient participants had formerly smoked, and five had never smoked. We identified eight barrier/facilitator themes within the three time-period intervals. Within the appraisal interval, the barrier theme was (1) minimization or misattribution of symptoms, and the facilitator theme was (2) acknowledgment of symptoms. Within the help-seeking interval, the barrier theme was (3) hesitancy to seek care, and the facilitator theme was (4) routine care. Within the diagnosis interval, barrier themes were (5) health system challenges, and (6) social determinants of health; and facilitator themes were (7) severe symptoms and known risk factors, and (8) self-advocacy. Many themes were interrelated, including minimization or misattribution of symptoms and hesitancy to seek care, which may collectively contribute to care and imaging delays.

CONCLUSIONS

Interventions to reduce hesitancy to seek care may facilitate timely lung cancer diagnoses. More prompt referral to imaging-especially computed tomography (CT)-among symptomatic patients, along with patient self-advocacy for imaging, may reduce delays in diagnosis.

New insights into the biology and development of lung cancer in never smokers-implications for early detection and treatment

Lung cancer is the leading cause of cancer deaths worldwide. Despite never smokers comprising between 10 and 25% of all cases, lung cancer in never smokers (LCNS) is relatively under characterized from an etiological and biological perspective. The application of multi-omics techniques on large patient cohorts has significantly advanced the current understanding of LCNS tumor biology. By synthesizing the findings of multi-omics studies on LCNS from a clinical perspective, we can directly translate knowledge regarding tumor biology into implications for patient care. Primarily focused on never smokers with lung adenocarcinoma, this review details the predominance of driver mutations, particularly in East Asian patients, as well as the frequency and importance of germline variants in LCNS. The mutational patterns present in LCNS tumors are thoroughly explored, highlighting the high abundance of the APOBEC signature. Moreover, this review recognizes the spectrum of immune profiles present in LCNS tumors and posits how it can be translated to treatment selection. The recurring and novel insights from multi-omics studies on LCNS tumor biology have a wide range of clinical implications. Risk factors such as exposure to outdoor air pollution, second hand smoke, and potentially diet have a genomic imprint in LCNS at varying degrees, and although they do not encompass all LCNS cases, they can be leveraged to stratify risk. Germline variants similarly contribute to a notable proportion of LCNS, which warrants detailed documentation of family history of lung cancer among never smokers and demonstrates value in developing testing for pathogenic variants in never smokers for early detection in the future. Molecular driver subtypes and specific co-mutations and mutational signatures have prognostic value in LCNS and can guide treatment selection. LCNS tumors with no known driver alterations tend to be stem-like and genes contributing to this state may serve as potential therapeutic targets. Overall, the comprehensive findings of multi-omics studies exert a wide influence on clinical management and future research directions in the realm of LCNS.

Value of dual-source CT dual-energy parameters combined with serum detection of VEGF and CEA in the diagnosis of early lung cancer

To discuss the value of dual-source CT dual-energy parameters combined with serum detection of vascular endothelial growth factor (VEGF) and carcinoembryonic antigen (CEA) in the diagnosis of early lung cancer (LC). In total, 100 patients with lung lesions in our hospital from January 2020 to January 2022 were selected for retrospective study, and were divided into the lung cancer group (group A) and benign lung disease group (group B) according to the final results of pathological diagnosis, using dual-source CT dual-energy scanning combined with serum detection of VEGF and CEA to analyze the diagnostic values of single detection and combined detection. Among the 100 patients with lung lesions, there were 58 patients with LC and 42 patients with benign lung diseases after pathological examination, with no statistical difference in normalized iodine concentration (NIC) and the increased value of iodine at arterial phase between the two groups (P > 0.05). The NIC value of group A was higher than group B at venous phase (P < 0.05). The serum levels of VEGF and CEA in group A were higher than group B (P < 0.05). The area under the curve, specificity, sensitivity, Youden index and 95% CI of combined diagnosis were higher than single detection of NIC, VEGF and CEA at venous phase. The combined application of dual-source CT dual-energy parameters and serum detection of VEGF and CEA has higher diagnostic value in patients with early LC, which can provide effective reference for clinical diagnosis and treatment, with higher application value in clinic.

Associations between smoking status and involvement of personal and professional relations among individuals reporting symptoms related to a diagnosis of lung cancer: a population-based study

BACKGROUND

Smoking is the leading cause of lung cancer, but individuals who currently smoke seek healthcare less frequently. This study of individuals reporting symptoms related to diagnosis of lung cancer has the following aims: 1) to explore the involvement of personal and professional relations; 2) to analyse whether age, sex and smoking status are associated with involving personal and professional relations; and 3) to analyse whether involving a personal relation is associated with healthcare-seeking.

METHODS

Data was extracted from a Danish population-based survey from 2012 with 100,000 randomly selected invitees 20 years or older. We describe the involvement of personal and professional relations among individuals experiencing four predefined symptoms indicative of lung cancer: prolonged coughing, prolonged hoarseness, shortness of breath and haemoptysis, either alone or in combination. Using multivariate logistic regression, we analyse the associations between involving personal or professional relations and various covariates (sex, age, smoking status). Moreover, we analyse the association between involving a personal relation and healthcare-seeking.

RESULTS

A total of 35,958 individuals over 40 years old completed the questionnaire. Of these, 5,869 individuals reported at least one lung cancer symptom. A higher percentage of participants with prolonged hoarseness and prolonged coughing reported no involvement of personal and professional relations (27.6% and 22.7%, respectively) compared to shortness of breath (12.4%). The most involved personal and professional relations were the spouse (46.2-62.5%) and the general practitioner (GP) (31.3-54.5%), respectively. Women and individuals in the oldest age group had higher odds of involving personal and professional relations. Individuals who currently smoke involved all relations less frequently than individuals who formerly,- and never smoked. Odds of contacting the GP or another doctor were three to seven-fold higher when a personal relation was also involved.

CONCLUSION

Women and the oldest age group had higher odds of involving relations, whereas individuals who currently smoked tended to be less likely to contact any personal or professional relations. Involving a personal relation was associated with higher odds of healthcare-seeking. The findings could be useful for GPs in terms of identifying patients at risk of postponing relevant healthcare-seeking with potential lung cancer symptoms.

What are the similarities and differences in lung cancer symptom appraisal and help-seeking according to smoking status? A qualitative study with lung cancer patients

OBJECTIVE

Lung cancer in never-smokers represents a growing proportion of patients. The relationship between smoking status, symptom appraisal and help-seeking behaviour is complex. Little is known about cancer symptom-related health behaviours according to smoking status. The aim of the study was to explore lung cancer patients' experiences of a lung cancer diagnosis, identifying differences by smoking history.

METHOD

This was a qualitative study involving telephone interviews with 40 lung cancer patients (20 never smokers, 11 former smokers and 9 current smokers). We used framework analysis to analyse the data using the Common Sense Model of Illness Self-Regulation as a theoretical framework, developed after initial analysis.

RESULTS

All patients were likely to delay seeking help for symptoms in primary care regardless of smoking history, but for different reasons. Smoking history was instrumental to how individuals perceived and responded to early symptoms of lung cancer. Differences in interpretation and coping responses to new symptoms seemed to be caused by the higher presence of comorbidities due to smoking, and perceptions of the current state of health. Individuals with a smoking history reported acting with urgency in seeking help and follow up, whereas patients who experienced low levels of concern were more easily reassured by clinicians, resulting in delays.

CONCLUSIONS

Never and former smokers perceive, interpret, and respond to symptoms of lung cancer differently to smokers. However, few people attribute their lung symptoms to cancer initially, even with a smoking history. Interventions that drive increased urgency and vigilance in never smokers may be effective.

A population-based study on social inequality and barriers to healthcare-seeking with lung cancer symptoms

Healthcare-seeking with lung cancer symptoms is a prerequisite for improving timely diagnosis of lung cancer. In this study we aimed to explore barriers towards contacting the general practitioner (GP) with lung cancer symptoms, and to analyse the impact of social inequality. The study is based on a nationwide survey with 69,060 individuals aged ≥40 years, randomly selected from the Danish population. The survey included information on lung cancer symptoms, GP contacts, barriers to healthcare-seeking and smoking status. Information about socioeconomics was obtained by linkage to Danish Registers. Descriptive statistics and multivariate logistic regression model were used to analyse the data. “Being too busy” and “Being worried about wasting the doctor’s time” were the most frequent barriers to healthcare-seeking with lung cancer symptoms. Individuals out of workforce and individuals who smoked more often reported “Being worried about what the doctor might find” and “Being too embarrassed” about the symptoms. The social inequality in barriers to healthcare-seeking with lung cancer symptoms is noticeable, which emphasises the necessity of focus on vulnerable groups at risk of postponing relevant healthcare-seeking.