Development and Preliminary Psychometric Evaluation of a Patient-Reported Outcome Measure for Lung Cancer Stigma: The Lung Cancer Stigma Inventory (LCSI)

Interventions to Reduce Lung Cancer and COPD-Related Stigma: A Systematic Review

BACKGROUND

Many individuals with lung cancer and chronic obstructive pulmonary disease (COPD) experience high levels of stigma, which is associated with psychological distress and delayed help-seeking.

PURPOSE

To identify interventions aimed at reducing the stigma of lung cancer or COPD and to synthesize evidence on their efficacy.

METHODS

A systematic review was conducted by searching PubMed, Scopus, PsycINFO, and CINAHL for relevant records until March 1, 2024. Studies were eligible if they described an intervention designed to reduce internalized or external stigma associated with COPD or lung cancer and excluded if they did not report empirical findings.

RESULTS

We identified 476 papers, 11 of which were eligible for inclusion. Interventions included educational materials, guided behavior change programs, and psychotherapeutic approaches. Interventions targeted people diagnosed with, or at high risk of developing COPD or lung cancer or clinical staff. No interventions that aimed to reduce stigma associated with lung cancer or COPD in the general community were identified. Most interventions yielded a statistically significant reduction in at least one measure of stigma or a decrease in qualitatively reported stigma.

CONCLUSIONS

The emerging literature on interventions to reduce stigma associated with lung cancer and COPD suggests that such interventions can reduce internalized stigma, but larger evaluations using randomized controlled trials are needed. Most studies were in the pilot stage and required further evaluation. Research is needed on campaigns and interventions to reduce stigma at the societal level to reduce exposure to external stigma amongst those with COPD and lung cancer.

Cancer stigma: the need for policy and programmatic action

Cancer is a stigmatized disease in many countries that impacts the quality of life and mental health of people affected by cancer. This commentary examines some dimensions of cancer stigma and has been developed based on insights from participants in a Union for International Cancer Control program dedicated to cancer patient organizations in low- and middle-income countries. Aimed at program managers and policy makers, this commentary highlights the importance of developing strategies to reduce cancer stigma in cancer control programs in different contexts, working closely with community-based civil society organizations and those with lived experience of cancer to understand, evaluate, and take action regarding the impact of cancer stigma on health-seeking behavior and patients' quality of life.

Sleep Disturbance as a Mediator of Lung Cancer Stigma on Psychological Distress and Physical Symptom Burden

OBJECTIVE

This study tested sleep disturbance as a mediator through which stigma and discrimination predict psychological distress and physical symptom burden in adults with lung cancer.

METHODS

Lung cancer patients on active oncological treatment ( N = 108; 74.1% stage IV) completed questionnaires on lung cancer stigma, sleep, distress, and physical symptoms at study entry and at 6- and 12-week follow-up. Mediation analyses were conducted to investigate whether stigma and discrimination predicted distress and physical symptoms at study entry and across 12 weeks through disrupted sleep.

RESULTS

Higher discrimination ( b = 5.52, 95% confidence interval [CI] = 2.10-8.94) and constrained disclosure ( b = 0.45, 95% CI = 0.05-0.85) were associated significantly with higher sleep disruption at study entry. Sleep disruption, in turn, was associated with higher distress ( b = 0.19, 95% CI = 0.09-0.29) and physical symptoms ( b = 0.28, 95% CI = 0.17-0.40) at study entry. Sleep disruption significantly mediated relationships between higher discrimination and the outcomes of distress (indirect effect = 1.04, 95% CI = 0.13-1.96) and physical symptoms (indirect effect = 1.58, 95% CI = 0.37-2.79) at study entry. Sleep disruption also mediated relationships between constrained disclosure and the outcomes of distress (indirect effect = 0.85, 95% CI = < 0.01-0.17) and physical symptoms (indirect effect = 0.13, 95% CI = 0.01-0.25).

CONCLUSIONS

Lung cancer patients evidenced pronounced sleep disruption, which mediated relationships between indicators of lung cancer stigma and distress and physical symptoms at study entry. Research is needed to test additional mechanisms through which lung cancer stigma predicts these outcomes longitudinally.

Supportive Care Needs in Chinese, Vietnamese, and Korean Americans With Metastatic Cancer: Mixed Methods Protocol for the DAWN Study

BACKGROUND

Asian Americans with metastatic cancer are an understudied population. The Describing Asian American Well-Being and Needs in Cancer (DAWN) Study was designed to understand the supportive care needs of Chinese-, Vietnamese-, and Korean-descent (CVK) patients with metastatic cancer.

OBJECTIVE

This study aims to present the DAWN Study protocol involving a primarily qualitative, convergent, mixed methods study from multiple perspectives (patients or survivors, caregivers, and health care professionals).

METHODS

CVK Americans diagnosed with solid-tumor metastatic cancer and their caregivers were recruited nationwide through various means (registries, community outreach newsletters, newspapers, radio advertisements, etc). Potentially eligible individuals were screened and consented on the web or through a phone interview. The study survey and interview for patients or survivors and caregivers were provided in English, traditional/simplified Chinese and Cantonese/Mandarin, Vietnamese, and Korean, and examined factors related to facing metastatic cancer, including quality of life, cultural values, coping, and cancer-related symptoms. Community-based organizations assisted in recruiting participants, developing and translating study materials, and connecting the team to individuals for conducting interviews in Asian languages. Health care professionals who have experience working with CVK patients or survivors with metastatic solid cancer were recruited through referrals from the DAWN Study community advisory board and were interviewed to understand unmet supportive care needs.

RESULTS

Recruitment began in November 2020; data collection was completed in October 2022. A total of 66 patients or survivors, 13 caregivers, and 15 health care professionals completed all portions of the study. We completed data management in December 2023 and will submit results for patients or survivors and caregivers to publication outlets in 2024.

CONCLUSIONS

Future findings related to this protocol will describe and understand the supportive care needs of CVK patients or survivors with metastatic cancer and will help develop culturally appropriate psychosocial interventions that target known predictors of unmet supportive care needs in Chinese, Vietnamese, and Korean Americans with metastatic cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50032.

"Pathways": A hope-enhancing intervention for patients undergoing treatment for advanced lung cancer

OBJECTIVE

Observational data suggest hope is associated with the quality of life and survival of people with cancer. This trial examined the feasibility, acceptability, and preliminary outcomes of "Pathways," a hope intervention for people in treatment for advanced lung cancer.

METHODS

Between 2020 and 2022, we conducted a single-arm trial of Pathways among participants who were 3-12 weeks into systemic treatment. Pathways consisted of two individual sessions delivered during infusions and three phone calls in which participants discussed their values, goals, and goal strategies with a nurse or occupational therapist. Participants completed standardized measures of hope and goal interference pre- and post-intervention. Feasibility was defined as ≥60% of eligible patients enrolling, ≥70% of participants completing three or more sessions, ≥70% of participants completing post-assessments, and mean acceptability ratings ≥7 out of 10 on intervention relevance, helpfulness, and convenience. Linear regression fixed effects models with covariates modeled pre-post changes in complete case analysis and multiple imputation models.

RESULTS

Fifty two participants enrolled: female (59.6%), non-Hispanic White (84.6%), rural (75.0%), and with low educational attainment (51.9% high school degree or less). Except for enrollment (54%), feasibility and acceptability markers were surpassed (77% adherence, 77% retention, acceptability ratings ≥8/10). There was moderate improvement in hope and goal interference from pre-to post-intervention (d = 0.51, p < 0.05 for hope; d = -0.70, p < 0.005 for goal interference).

CONCLUSIONS

Strong feasibility, acceptability, and patient-reported outcome data suggest Pathways is a promising intervention to increase hope and reduce cancer-related goal interference during advanced lung cancer treatment.

Real-world analysis of the relationships between smoking, lung cancer stigma, and emotional functioning

INTRODUCTION

People diagnosed with lung cancer experience high rates of distress, which can be compounded by the stigma of the disease. This study assessed a real-world population to understand patient-reported emotional functioning, types of stigma experienced, and relationship with smoking history.

METHODS

Questionnaires using validated survey tools assessing demographics, smoking history, stigma, and quality of life (EORTC QLQ-C30 Emotional Functioning Scale) were analyzed from 539 global participants in the Lung Cancer Registry between November 2019 and July 2022. The associations between smoking history and self-reported internalized and perceived stigma and constrained disclosure of lung cancer diagnosis, as well as the potential impact of stigma on emotional functioning, were examined using multivariable logistic regression models.

RESULTS

Among the broad geographic mix of study participants, all types of lung cancer stigma were associated with decreased emotional functioning due to a combination of factors including depression, anxiety, stress, and irritability. Participants who reported a history of current or former smoking experienced higher levels of internalized stigma and perceived stigma. Constrained disclosure about a diagnosis was common, associated with decreased emotional functioning, and not related to a history of smoking. Smoking status itself was not associated with reduced emotional functioning, implicating the role of stigma in distress.

CONCLUSIONS

In this study, all types of lung cancer stigma were associated with clinically important decreases in emotional functioning. This impact was not dependent on smoking history. Internalized and perceived stigma were associated with the presence of a smoking history. These findings have implications for proper psychosocial care of people diagnosed with lung cancer.

Cigarette and Alternative Tobacco Product Use among Adult Cancer Survivors Enrolled in 9 ECOG-ACRIN Clinical Trials

BACKGROUND

While cigarette smoking has declined among the U.S. general population, sale and use of non-cigarette alternative tobacco products (ATP; e.g., e-cigarettes, cigars) and dual use of cigarettes/ATPs are rising. Little is known about ATP use patterns in cancer survivors enrolled in clinical trials. We investigated prevalence of tobacco product use, and factors associated with past 30-day use, among patients with cancer in national trials.

METHODS

Cancer survivors (N = 756) enrolled in 9 ECOG-ACRIN clinical trials (2017-2021) completed a modified Cancer Patient Tobacco Use Questionnaire (C-TUQ) which assessed baseline cigarette and ATP use since cancer diagnosis and in the past 30 days.

RESULTS

Patients were on average 59 years old, 70% male, and the mean time since cancer diagnosis was 26 months. Since diagnosis, cigarettes (21%) were the most common tobacco product used, followed by smokeless tobacco use (5%), cigars (4%), and e-cigarettes (2%). In the past 30 days, 12% of patients reported smoking cigarettes, 4% cigars, 4% using smokeless tobacco, and 2% e-cigarettes. Since cancer diagnosis, 5.5% of the sample reported multiple tobacco product use, and 3.0% reported multiple product use in the past 30 days. Males (vs. females; OR 4.33; P = 0 < 0.01) and individuals not living with another person who smokes (vs. living with; OR, 8.07; P = 0 < 0.01) were more likely to use ATPs only versus cigarettes only in the past 30 days.

CONCLUSIONS

Among patients with cancer, cigarettes were the most prevalent tobacco product reported.

IMPACT

Regardless, ATPs and multiple tobacco product use should be routinely assessed in cancer care settings.

Culturally-informed adaptation and psychometric properties of the Cataldo Cancer Stigma Scale in Northern Tanzania

BACKGROUND

Cancer-related stigma impacts patients' emotional health, care engagement, and cancer outcomes, but few measures of cancer stigma exist. We culturally adapted and assessed psychometric properties of the Cataldo Cancer Stigma Scale (CCSS) in Tanzania.

METHODS

We administered the CCSS short version (21 items), plus 12 locally-derived items, to 146 adult cancer patients. We conducted exploratory factor analysis, examined internal consistency/reliability, and assessed convergent validity with relevant measures.

RESULTS

We identified a 17-item cancer stigma scale with strong psychometric properties and four subscales: enacted stigma, shame and blame, internalized stigma, and disclosure concerns. Stigma was rare except for disclosure concerns. Stigma was positively associated with depression and anxiety and negatively associated with social support, quality of life, and illness acceptance.

CONCLUSIONS

The scale provides valid, culturally-informed measurement of cancer stigma in Tanzania. Future studies should assess associations with care engagement, which will inform interventions to reduce stigma and improve outcomes.

Preliminary validation of the Chinese version of the Shame and Stigma Scale among patients with facial disfigurement from nasopharyngeal carcinoma

OBJECTIVE

This study examined the reliability and validity of a Shame and Stigma Scale (SSS) and assessed shame and stigma among patients with facial disfigurement from nasopharyngeal carcinoma (NPC).

METHODS

Data were collected from 218 patients with NPC through a cross-sectional survey between January 14, 2020, and December 1, 2020. The original SSS is a 20-item scale with four dimensions (i.e., shame with appearance, sense of stigma, regret, and social/speech concern). We used Cronbach's alpha and McDonald's omega to assess reliability and exploratory factor analysis (EFA) to assess the factor structure. We also used Pearson correlation analysis to examine the relationship between each item and total score of scale items and convergent validity.

RESULTS

The final 18-item SSS had a Cronbach's alpha coefficient of .89. The EFA revealed that the SSS has a four-factor structure: sense of stigma, social/speech concern, shame with appearance, and regret. These factors showed satisfactory reliability, with McDonald's omega coefficients of .87, .77, .86, and .79, respectively. The scale showed significant relationship between each item and total score of scale items with respect to item-total correlations, item-subscale correlations, and item-other-subscale correlations. Convergent validity was supported by the significant positively correlated with the total scores for depression and anxiety.

CONCLUSION

The SSS is valid and reliable in assessing shame and stigma and monitoring treatment compliance among patients with NPC.

The Muscularity Bias Internalization Scale: Development and initial validation in Chinese adult men

The present study developed the Muscularity Bias Internalization Scale (MBIS), a measure of muscularity bias internalization, which assesses the extent to which an individual endorses muscularity-based stereotypes and engages in negative self-evaluations due to muscularity. In Study 1, a pool of candidate items was developed. By using exploratory factor analysis (EFA) on a sample of 300 Chinese adult men (M_age = 29.98 years, SD = 7.81), 14 items from the item pool were retained. The 14-item MBIS contained three factors. In Study 2, a second sample of 300 Chinese adult men (M_age = 29.50 years, SD = 7.50) was used to confirm the factor structure of the MBIS, as well as to examine its reliability and validity. Confirmatory factor analysis (CFA) further confirmed the three-factor structure of the MBIS with a good model fit. The MBIS showed high internal consistency reliability and high two-week test-retest reliability. The MBIS also showed good construct validity with measures of drive for muscularity, muscularity-oriented disordered eating, and muscle dysmorphia symptoms. The newly developed MBIS may help understand the role of muscularity bias internalization in the development and maintenance of muscularity-oriented body image and muscularity-oriented disordered eating.

Validation of the Malay Version of the Shame and Stigma Scale among Cancer Patients in Malaysia

The assessment of stigma among cancer patients is of the utmost importance as stigma may lead to various psychological sequelae and a lower quality of life. This study aimed to translate the English version of the Shame and Stigma Scale (SSS) into Malay and validate the Malay version of the SSS (SSS-M) to assess the degree of stigma among cancer patients in Malaysia. Initially, the concurrent translation and back translation of the SSS-M were performed, and the face and content validity were assessed. Subsequently, the SSS-M was administered to a total of 234 patients with mixed types of cancer to assess its reliability (internal consistency and test-retest reliability), construct validity (convergent and discriminant validity), and conduct an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA). The SSS-M total score registered a good internal consistency (a Cronbach's α of 0.881) and test-retest reliability (an intraclass correlation coefficient of 0.876, p < 0.001). The EFA and CFA confirmed that the SSS-M consisted of 16 items in 3 domains. Its convergent and discriminant validity were achieved. Hence, the SSS-M demonstrated good psychometric properties and is available for use to assess stigma among cancer patients in Malaysia.

Identifying Barriers to Advocacy Among Patients With Lung Cancer: The Role of Stigma-Related Interpersonal Constraint

OBJECTIVES

To examine whether aspects of disease-specific stigma are barriers to advocacy among individuals with lung cancer.

SAMPLE & SETTING

266 patients with lung cancer treated at two National Cancer Institute-designated comprehensive cancer centers in the United States.

METHODS & VARIABLES

Patients completed a cross-sectional survey. Demographic, clinical, and stigma-related correlates of advocacy were also explored.

RESULTS

In multivariable analyses, lower levels of patient advocacy were reported by older patients and those with higher levels of constrained disclosure (i.e., avoidance of or discomfort in disclosing one's lung cancer status).

IMPLICATIONS FOR NURSING

Avoidance of discussing lung cancer (constrained disclosure) may be a barrier to patient involvement in advocacy. Additional research is needed to examine this relationship, reduce stigma, and promote inclusivity for individuals with lung cancer.

Study protocol for a hybrid type 1 effectiveness-implementation trial testing virtual tobacco treatment in oncology practices [Smokefree Support Study 2.0]

BACKGROUND

Persistent smoking among patients diagnosed with cancer is associated with adverse clinical outcomes, yet an evidence-based tobacco use intervention has not been well-integrated into cancer care in community oncology settings. This paper describes the protocol of a nation-wide clinical trial conducted by the ECOG-ACRIN National Cancer Institute (NCI) Community Oncology Research Program (NCORP) Research Base to assess the effectiveness of a virtual tobacco treatment intervention and the process of implementing tobacco treatment in NCORP community oncology settings.

METHODS/DESIGN

This two-arm, multisite (n: 49 NCORP sites) hybrid type 1 effectiveness-implementation randomized controlled trial compares the effectiveness of a Virtual Intervention Treatment (VIT) versus an Enhanced Usual Control (EUC) among English and Spanish speaking patients recently diagnosed with cancer, reporting current smoking and receiving care at a participating NCORP Community or Minority/Underserved Site. The VIT includes up to 11 virtual counseling sessions with a tobacco treatment specialist and up to 12 weeks of nicotine replacement therapy (NRT). The EUC arm receives a referral to the NCI Quitline. The primary study outcome is biochemically confirmed 7-day point prevalence smoking abstinence. Moderators of treatment effect will be assessed. The study evaluates implementation processes from participating NCORP site staff via survey, administrative, and focus group data, including reach, acceptability, appropriateness, fidelity, feasibility, adoption, cost and sustainability outcomes.

DISCUSSION

This trial will generate findings about the effectiveness of an evidence-based virtual tobacco treatment intervention targeting patients diagnosed with cancer and illuminate barriers and facilitators that influence implementing tobacco treatment into community oncology settings nationally. In the era of COVID-19, virtual care solutions are vital for maximizing access and utilization of tobacco treatment delivery.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03808818) on January 18th, 2019; Last update posted: May 21st, 2020.

Stigma in Early-Stage Lung Cancer

BACKGROUND

The phenomenon of lung cancer stigma has been firmly established in the literature. However, studies have predominantly focused on patients with advanced disease, whose experiences may differ from patients with earlier stage, surgically resectable lung cancer and an improved prognosis.

PURPOSE

The objective of the study was to examine the stigma experienced in a Canadian population with early-stage, resectable lung cancer.

METHODS

Patients with newly diagnosed lung cancer were enrolled at a tertiary thoracic surgery clinic. The 25-item Lung Cancer Stigma Inventory (LCSI) was self-administered by patients to quantitatively measure experiences of lung cancer stigma. LCSI results informed the development of a semi-structured focus group and individual interviews.

RESULTS

Of the 53 participants completing the survey, 38 (72%) met established LCSI score threshold, indicating a clinically meaningful level of stigma. No significant relationship was found between total LCSI scores and any demographic variable. Analysis of qualitative data revealed multiple themes related to experiences of lung cancer stigma. The major themes were classified into four categories: impact of the association between lung cancer and smoking, societal attitudes and assumptions, personal choices in relation to diagnosis, and experiences related to care.

CONCLUSIONS

A surgical population of patients with predominantly early-stage lung cancer experienced lung cancer stigma at a high incidence and a level similar to previously studied populations with more advanced disease. The qualitative results support the quantitative findings that respondents experienced more internal stigma than either perceived stigma from others or constrained disclosure related to their diagnosis.

Patient reported outcomes in oncology: changing perspectives-a systematic review

In public health context, oncology is associated with severe negative impact on patients and on their relatives’ quality of life. Over the last decades, survival has remained at 50% worldwide for some tumor locations. Patient reported outcomes (PROs) assessment and, the corresponding use in clinical practice, help establishing patient individualized profiling involving caregivers. The purpose of this systematic review was to examine critical success factors for PROs assessment in daily clinical oncology practice. Additionally, we investigated how PROs collection can change oncology perspectives for patients and caregivers. According to PRISMA guidelines, 83 studies were included in this systematic review, whether related with implementation in daily clinical practice or associated with its use in oncology. PROs assessment gathers multi-professional teams, biomedical and clinical expertise, patients, families and caregivers. Institutional involvement, first line for caregiver’s adherence, team continuous formation, encompassing training and support, design of clear workflows, continuous monitoring, and data analysis are crucial for implementation. PROs measures are decisive in oncology. Several items were improved, including caregiver–patient–physician communication, patient risk groups identification, unmet problems and needs detection, disease course and treatment tracking, prognostic markers, cost-effectiveness measurement and comfort/support provision for both patients and caregivers. Routine assessment and implementation of PROs in clinical practice are a major challenge and a paradigm transformation for future.

Stigmatizing attitudes about lung cancer among individuals who smoke cigarettes

INTRODUCTION

Many individuals with lung cancer report experiencing stigma associated with their diagnosis. The objective of this study was to explore how different factors, including smoking status, lung cancer concern, and thoughts on smoking behaviors, were associated with increased stigmatizing attitudes towards people with lung cancer.

METHODS

In 2015, a Web-based survey was completed by people who currently smoked. Participants (n=1419) aged 18–65 years were randomly assigned to one of three scenarios in which the character who was diagnosed with lung cancer currently, formerly, or never smoked cigarettes. Two aspects of stigma were assessed: blaming the victim and negative attributions about people with lung cancer.

RESULTS

For blaming the victim and negative attributions, lung cancer stigma differed by scenario (described smoking status, p<0.0001), when adjusting for race, sex, education level, age, income, nicotine dependence, quit intentions, and quit attempts. Higher levels of lung cancer concern were associated with greater blaming the victim (p=0.001), when adjusting for scenario and other significant correlates.

CONCLUSIONS

The findings suggest that stigmatizing attitudes from people who smoke towards people with lung cancer may be reflective of how they feel about their own smoking habits. We suggest that specific messaging guidelines that avoid an over emphasis on an individual’s smoking status, cessation interventions that address stigma, and screening messages tailored to smoking status, may help to lessen the burden of lung cancer stigma.

Facets of stigma, self-compassion, and health-related adjustment to lung cancer: A longitudinal study

OBJECTIVE

The aim of this study was to investigate whether three facets of lung cancer stigma (internalized stigma, constrained disclosure, and perceived subtle discrimination) uniquely predicted psychological and physical health-related adjustment to lung cancer across 12 weeks. Additionally, self-compassion was tested as a moderator of the stigma-health relationship.

METHOD

Adults receiving oncologic treatment for lung cancer (N = 108) completed measures of lung cancer stigma, self-compassion, depressive symptoms, cancer-related stress, and physical symptom bother. Multivariable linear regression models were used to investigate cross-sectional and longitudinal relationships (at 6- and 12-week follow-up) between indicators of stigma and health-related outcomes, controlling for covariates. Self-compassion was tested as a moderator of these relationships.

RESULTS

At study entry, higher internalized stigma, constrained disclosure, and perceived subtle discrimination were associated significantly and uniquely with higher depressive symptoms (all p < .05). Constrained disclosure and perceived subtle discrimination were also associated significantly with higher cancer-related stress and higher physical symptom bother at study entry (all p < .05). Furthermore, higher internalized stigma predicted significant increases in depressive symptoms across 12 weeks and in cancer-related stress across 6 and 12 weeks (all p < .05). Higher self-compassion significantly moderated relationships between perceived discrimination and psychological health outcomes at study entry as well as between internalized stigma and increasing depressive symptoms across 12 weeks (all p < .05).

CONCLUSIONS

Results indicated robust relationships between distinct facets of stigma and health-related adjustment to lung cancer. Supportive care programs that bolster self-compassion may be useful for reducing lung cancer stigma. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of stigma and stigma-focused interventions on screening and treatment outcomes in cancer patients

Background

Stigma is known to negatively influence cancer patients’ psychosocial behaviour and treatment outcomes. The aim of this study was to systematically review the current data on cancer-related stigma across different populations and identify effective interventions used to address it.

Methodology

The protocol, search, appraisal, synthesis, analysis and reporting framework was used for conducting this systematic literature review. CINAHL, PubMed, PsycINFO and Google Scholar databases were searched using the different combination of keywords that include ‘cancer stigma’. Articles publication period was set for 2010–2020. A total of 54 articles (31 quantitative, 19 qualitative, 2 mixed methods and 2 scoping reviews) that met inclusion criteria were reviewed out of the 958 articles initially identified. Quality assessment of included studies revealed the studies had varying levels of methodological quality. Extracted data were organised and narratively analysed.

Results

Cancer stigma was expressed across different segments of the society including amongst the elites and healthcare providers. Developing countries had higher rates of stigma reported and experience of stigma varied by cancer type. Cancer was consistently associated with imminent death in all studies reviewed. Cancer patients experiencing stigma were more inclined to conceal their diagnosis and to seek medical help later. Whilst cancer stigma majorly resulted in negative psychosocial outcomes in patients, there were also instances of posttraumatic growth emanating from the stigma experienced. Literature on cancer-related stigma interventions was scant.

Conclusion

Cancer related stigma remains high in both clinical settings and amongst the general public. There is need for more interventions to combat cancer stigma and its effect in both patient and non-patient population. Anti-cancer public enlightenment campaigns should be sensitively designed to not further fuel stigma against patients with certain types of cancers.

Internalized stigma among cancer patients enrolled in a smoking cessation trial: The role of cancer type and associations with psychological distress

PURPOSE

Cancer patients who smoke may experience significant stigma due both to their disease, and negative attitudes and beliefs regarding smoking. We investigated whether internalized stigma differed between currently smoking cancer patients diagnosed with lung or head and neck cancers, other smoking related cancers, and non smoking-related cancers, and whether internalized stigma was associated with psychological distress.

METHODS

This cross-sectional analysis used baseline data on 293 participants enrolled in a multi-site randomized smoking cessation intervention trial of patients with recently diagnosed cancer. Internalized stigma was assessed using five Internalized Shame items from the Social Impact of Disease Scale. Smoking-related cancers included lung, head and neck, esophageal, bladder, kidney, liver, pancreatic, colorectal, anal, small intestinal, gastric, and cervical. We used multivariable linear regression to examine whether mean internalized stigma levels differed between individuals with lung and head and neck cancers, other smoking-related cancers, and non smoking-related cancers, adjusting for potential confounders. We further examined the association of internalized stigma with depression, anxiety, and perceived stress, overall and among cancer type groups.

RESULTS

Thirty-nine percent of participants were diagnosed with lung or head and neck cancer, 21% with another smoking-related cancer, and 40% with a non smoking-related cancer. In multivariable-adjusted models, participants with lung or head and neck cancers (11.6, 95% confidence intervals (CI) = 10.8-12.2; p < 0.0001) or other smoking-related cancers (10.7, 95% CI = 9.8-11.7; p = 0.03) had higher mean internalized stigma scores compared to those non-smoking-related cancers (9.3, 95% CI = 8.6-10.0). We observed similar positive associations between internalized stigma and depressive symptoms, anxiety, and perceived stress among participants with smoking-related and non smoking-related cancers.

CONCLUSIONS

Among smokers, those with smoking-related cancers experienced the highest levels of internalized stigma, and greater internalized stigma was associated with greater psychological distress across cancer types. Providers should assess patients for internalized and other forms of stigma, refer patients for appropriate psychosocial support services, and address stigma in smoking cessation programs.

Lung Cancer Stigma: Does Smoking History Matter?

BACKGROUND

Lung cancer patients commonly report stigma, often attributing it to the well-established association of smoking as the leading preventable cause. Theory and research suggest that patients' smoking history may differentiate patients' experience of lung cancer stigma. However, there is inconsistent evidence whether lung cancer stigma varies by patients' smoking history, owing to limitations in the literature.

PURPOSE

This study examined differences in lung cancer patients' reported experience of lung cancer stigma by smoking history.

METHOD

Participants (N = 266, 63.9% female) were men and women with lung cancer who completed a validated, multidimensional questionnaire measuring lung cancer stigma. Multivariable regression models characterized relationships between smoking history (currently, formerly, and never smoked) and lung cancer stigma, controlling for psychological and sociodemographic covariates.

RESULTS

Participants who currently smoked reported significantly higher total, internalized, and perceived lung cancer stigma compared to those who formerly or never smoked (all p < .05). Participants who formerly smoked reported significantly higher total and internalized stigma compared to those who never smoked (p < .001). Participants reported similar levels of constrained disclosure, regardless of smoking history (p = .630).

CONCLUSIONS

Total, internalized, and perceived stigma vary meaningfully by lung cancer patients' smoking history. Patients who smoke at diagnosis are at risk for experiencing high levels of stigma and could benefit from psychosocial support. Regardless of smoking history, patients reported similar levels of discomfort in sharing information about their lung cancer diagnosis with others. Future studies should test relationships between health-related stigma and associated health behaviors in other stigmatized groups.

Developing pathways, a hope-enhancing intervention for metastatic lung cancer patients receiving cancer treatment

OBJECTIVE

Between 40% and 65% of lung cancer patients report concern about maintaining valued activities and roles, yet few interventions address this concern. Hope, a patient's perceived ability to generate goals and identify ways to pursue them, may be a promising intervention target to support function among lung cancer patients. The goal of this study was to assess metastatic non-small cell lung cancer (mNSCLC) patient interest and preferences for a hope-enhancing intervention.

METHODS

We conducted a sequential mixed-methods (survey followed by semi-structured interviews) study with patients with mNSCLC. Surveys assessed patient interest in, perceived helpfulness of, and preferences for a hope intervention. A subset of 12 patients (and caregivers, when present) completed semi-structured interviews to elicit feedback on proposed intervention content and procedures.

RESULTS

Survey data from 60 patients (40% male; Mean age = 62.5; SD = 9.3) suggested high perceived importance of pursuing personal goals during cancer treatment, moderate perceived helpfulness in discussing personal goals, and preference for a nurse-led intervention. Based on these data, a 5-session, nurse-led intervention protocol was drafted and reviewed with 12 patients. Interviewed patients and caregivers agreed working towards goals was beneficial, liked the intervention concept, and thought prompts and rating scales on handouts would facilitate discussion. The majority preferred nurse delivery during infusions.

CONCLUSIONS

A nurse-led hope-enhancing intervention delivered primarily during infusions may be acceptable to mNSCLC patients. Future work should test feasibility and identify ways to incorporate caregivers and oncology providers into hope interventions.

Evaluating relationships between lung cancer stigma, anxiety, and depressive symptoms and the absence of empathic opportunities presented during routine clinical consultations

OBJECTIVE

Empathic communication in clinical consultations is mutually constructed, with patients first presenting empathic opportunities (statements communicating emotions, challenges, or progress) to which clinicians can respond. We hypothesized that lung cancer patients who did not present empathic opportunities during routine consultations would report higher stigma, anxiety, and depressive symptoms than patients who presented at least one.

METHODS

Audio-recorded consultations between lung cancer patients (N = 56) and clinicians were analyzed to identify empathic opportunities. Participants completed questionnaires measuring sociodemographic and psychosocial characteristics.

RESULTS

Twenty-one consultations (38 %) did not contain empathic opportunities. Unexpectedly, there was a significant interaction between presenting empathic opportunities and patients' race on disclosure-related stigma (i.e., discomfort discussing one's cancer; F = 4.49, p = .041) and anxiety (F = 8.03, p = .007). Among racial minority patients (self-identifying as Black/African-American, Asian/Pacific Islander, or other race), those who did not present empathic opportunities reported higher stigma than those who presented at least one (t=-5.47, p = .038), but this difference was not observed among white patients (t = 0.38, p = .789). Additional statistically significant findings emerged for anxiety.

CONCLUSION

Disclosure-related stigma and anxiety may explain why some patients present empathic opportunities whereas others do not.

PRACTICE IMPLICATIONS

Clinicians should intentionally elicit empathic opportunities and encourage open communication with patients (particularly from diverse racial backgrounds).

Primary and Secondary Prevention of Lung Cancer: Tobacco Treatment

Tobacco dependence is the most consequential target to reduce the burden of lung cancer worldwide. Quitting after a cancer diagnosis can improve cancer prognosis, overall health, and quality of life. Several oncology professional organizations have issued guidelines stressing the importance of tobacco treatment for patients with cancer. Providing tobacco treatment in the context of lung cancer screening is another opportunity to further reduce death from lung cancer. In this review, the authors describe the current state of tobacco dependence treatment focusing on new paradigms and approaches and their particular relevance for persons at risk or on treatment for lung cancer.

Dispositional shame and guilt as predictors of depressive symptoms and anxiety among adults with lung cancer: The mediational role of internalized stigma

PURPOSE

The current study investigated whether dispositional tendencies to experience shame and guilt (i.e., shame- and guilt- proneness) were associated with higher levels of internalized stigma and, in turn, higher depressive symptoms and anxiety in adults with lung cancer.

METHOD

Participants (N = 50, 56.0% female) were men and women who received a clinical consultation for lung cancer and completed validated questionnaires. Mediation modeling using bootstrapping was used to characterize relationships between shame- and guilt-proneness, lung cancer stigma, depressive symptoms, and anxiety.

RESULTS

Higher guilt-proneness was associated significantly with higher anxiety (b = 0.69, SE=0.28, 95% CI [0.13, 1.26]) and higher shame-proneness was associated significantly with higher depressive symptoms (b = 0.56, SE = 0.19, 95% CI [0.18, 0.93]), beyond sociodemographic, medical, and smoking-related characteristics. Higher lung cancer stigma also significantly mediated the relationship between guilt-proneness and anxiety (indirect effect = 0.43, SE = .20, 95% CI [0.08, 0.89]) but not between shame-proneness and depressive symptoms.

CONCLUSIONS

Shame- and guilt-proneness are associated significantly with depressive symptoms and anxiety, respectively, and the relationship between guilt-proneness and anxiety is explained in part by internalized stigma in a sample of newly diagnosed lung cancer patients. Findings carry implications for the early identification of lung cancer patients in need of additional supportive care services and highlight internalized stigma as a target for psychosocial intervention.

Lung cancer stigma and depression: Validation of the Lung Cancer Stigma Inventory

OBJECTIVE

In an effort to provide further evidence for the validity of the Lung Cancer Stigma Inventory (LCSI), this paper examined group differences in lung cancer stigma for patients who report clinically significant depressive symptoms and established a suggested scoring benchmark to identify patients with clinically meaningful levels of lung cancer stigma.

METHODS

Patients (N = 231) who were diagnosed with lung cancer and treated within the past 12 months at one of two National Cancer Institute (NCI)-designated Cancer Centers located in the northeast and southern parts of the United States completed a single battery of questionnaires examining lung cancer stigma and depressed mood. Group differences, bivariate correlations, and receiver operating characteristic (ROC) analyses were conducted.

RESULTS

Slightly more than a third of patients (35.9%) reported an elevated level of depression. There was a significant correlation (r = 0.44) between lung cancer stigma and depressive mood. The ROC curve analysis indicated an area under curve (AUC) of 0.71. A LCSI cutoff score of 37.5 yielded the optimal ratio of sensitivity (0.93) to specificity (0.70) for identifying patients with clinically meaningful lung cancer stigma.

CONCLUSIONS

Consistent with prior work, lung cancer stigma, as measured by the LCSI, was found to be moderately associated with depressed mood. Clinical investigators may use an LCSI total score above 37.5 (ie, greater than or equal to 38 on the LCSI scale of integer scores) as a clinical threshold for identifying patients who may be experiencing clinically meaningful stigma and may benefit from stigma-reducing interventions.

A Longitudinal Investigation of Internalized Stigma, Constrained Disclosure, and Quality of Life Across 12 Weeks in Lung Cancer Patients on Active Oncologic Treatment

INTRODUCTION

Internalized lung cancer stigma (i.e., feelings of regret, shame, and self-blame about one's lung cancer) is related to poorer psychological outcomes. Less is known about how internalized stigma relates to physical and functional outcomes or how constrained disclosure (i.e., avoidance of or discomfort about disclosing one's lung cancer status to others) relates to well-being. Furthermore, no study has examined whether internalized stigma and constrained disclosure predict changes in well-being for lung cancer patients. This longitudinal study characterized relationships of internalized stigma and constrained disclosure with emotional and physical/functional outcomes.

METHODS

Participants (N = 101, 52.4% male, 63.4% currently/formerly smoked) were lung cancer patients on active medical treatment who completed questionnaires on stigma and well-being at study entry and at 6- and 12-week follow-up. Multivariable linear regressions characterized relationships of internalized stigma and constrained disclosure with emotional and physical/functional well-being at study entry and across time.

RESULTS

Participants who currently or formerly smoked reported higher levels of internalized stigma (but not constrained disclosure), compared to never smokers (p < 0.001). Higher internalized stigma and constrained disclosure were uniquely associated with poorer emotional and physical/functional well-being at study entry (all p < 0.05), beyond sociodemographic characteristics, time elapsed since diagnosis, and smoking status. Higher internalized stigma predicted significant declines in emotional well-being across 6 and 12 weeks (all p < 0.01) and declines in physical/functional well-being across 6 weeks (p < 0.05).

CONCLUSIONS

Internalized lung cancer stigma and constrained disclosure relate to emotional and physical/functional maladjustment. Findings carry implications for provider- and patient-focused interventions to reduce internalized stigma and promote well-being.

Multilevel Opportunities to Address Lung Cancer Stigma across the Cancer Control Continuum

The public health imperative to reduce the burden of lung cancer has seen unprecedented progress in recent years. Fully realizing the advances in lung cancer treatment and control requires attention to potential barriers in their momentum and implementation. In this analysis, we present and evaluate the argument that stigma is a highly significant barrier to fulfilling the clinical promise of advanced care and reduced lung cancer burden. This evaluation of the stigma of lung cancer is based on a multilevel perspective that incorporates the individual, persons in the individual's immediate environment, the health care system, and the larger societal structure that shapes perceptions and decisions. We also consider current interventions and interventional needs within and across aspects of the lung cancer continuum, including prevention, screening, diagnosis, treatment, and survivorship. Current evidence suggests that stigma detrimentally affects psychosocial, communication, and behavioral outcomes over the entire lung cancer control continuum and across multiple levels. Interventional efforts to alleviate stigma in the context of lung cancer show promise, yet more work is needed to evaluate their impact. Understanding and addressing the multilevel role of stigma is a crucial area for future study to realize the full benefits offered by lung cancer prevention, control, and treatment. Coordinated, interdisciplinary, and well-conceptualized efforts have the potential to reduce the barrier of stigma in the context of lung cancer and facilitate demonstrable improvements in clinical care and quality of life.