Identity threat and stigma in cancer patients

Medical tattooing as a complementary cosmetic intervention to reduce body-image distress and mental health symptoms in U.S. breast cancer survivors

PURPOSE

A review of the literature revealed a high incidence of body-image distress among breast cancer survivors who had surgery. This cross-sectional study examined the relationship between medical tattooing as a complementary cosmetic intervention and body-image distress and mental health outcomes among breast cancer survivors following surgery.

METHODS

We examined 330 post-surgical breast cancer survivors collected through a nationwide online survey in the U.S., pursuing two main objectives. First, we investigated body-image distress, depression and anxiety symptoms, and perceived stress in survivors who underwent breast cancer surgery, comparing those with medical tattooing (n = 89) and those without (n = 226). Second, we assessed the influence of the participant's surgery type on body-image distress, depression and anxiety symptoms, and perceived stress. Additionally, we evaluated whether individual factors, such as appearance investment, satisfaction with decision, and cosmetic expectation discrepancy, predicted the participant's body-image distress.

RESULTS

Findings suggest that participants with medical tattoos reported significantly lower body-image distress, depression and anxiety symptoms, and perceived stress compared to those without medical tattoos. The participant's surgery type did not significantly predict body-image distress, depression or anxiety symptoms, or perceived stress. However, participants who reported greater appearance investment endorsed higher body-image distress. Participants who reported higher satisfaction with their treatment decisions and lower cosmetic expectation discrepancy endorsed lower body-image distress.

CONCLUSION

Medical tattooing may be a valuable tool in improving body-image distress and mental health for those who wish to pursue it, but more research is needed. Empirical studies supporting the mental health benefits of medical tattooing among survivors are crucial to standardize insurance coverage and promote its inclusion as a complementary intervention across insurance providers nationwide. This complementary intervention should be considered using a patient-centered approach that aligns with the patient's values and preferences.

Solving the puzzle of quality of life in cancer: integrating causal inference and machine learning for data-driven insights

BACKGROUND

Understanding the determinants of global quality of life in cancer patients is crucial for improving their overall well-being. While correlations between various factors and quality of life have been established, the causal relationships remain largely unexplored. This study aimed to identify the causal factors influencing global quality of life in cancer patients and compare them with known correlative factors.

METHODS

We conducted a retrospective analysis of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire data, alongside demographic and disease-related features, collected from new cancer patients during their initial visit to an oncology outpatient clinic. Correlations with global quality of life were identified using univariate and multivariate regression analyses. Causal inference analysis was performed using two approaches. First, we employed the Dowhy Python library for causal analysis, incorporating prior information and manual characterization of an acyclic graph. Second, we utilized the Linear Non-Gaussian Acyclic Model (LiNGAM) machine learning algorithm from the Lingam Python library, which automatically generated an acyclic graph without prior information. The significance level was set at p < 0.05.

RESULTS

Multivariate analysis of 469 new admissions revealed that disease stage, role functioning, emotional functioning, social functioning, fatigue, pain and diarrhea were linked with global quality of life. The most influential direct causal factors were emotional functioning, social functioning, and physical functioning, while the most influential indirect factors were physical functioning, emotional functioning, and fatigue. Additionally, the most prominent total causal factors were identified as type of cancer (diagnosis), cancer stage, and sex, with total causal effect ratios of -9.47, -4.67, and - 1.48, respectively. The LiNGAM algorithm identified type of cancer (diagnosis), nausea and vomiting and social functioning as significant, with total causal effect ratios of -9.47, -0.42, and 0.42, respectively.

CONCLUSIONS

This study identified that causal factors for global quality of life in new cancer patients are distinct from correlative factors. Understanding these causal relationships could provide valuable insights into the complex dynamics of quality of life in cancer patients and guide targeted interventions to improve their well-being.

Social Stigma and COVID-19 Vaccine Refusal in France

CONTEXT

In 2021, French health authorities strongly promoted vaccination against COVID-19. The authors assumed that refusing this vaccine became a stigma, and they investigated potential public stigma toward unvaccinated people among the French population.

METHODS

A representative sample of the French adult population (N = 2,015) completed an online questionnaire in September 2021. The authors focused on participants who were already vaccinated against COVID-19 or intended to get vaccinated (N = 1,742). A cluster analysis was used to obtain contrasted attitudinal profiles, and the authors investigated associated factors with logistic regressions.

FINDINGS

Regarding attitudes toward unvaccinated people, a majority of respondents supported several pejorative statements, and a significant minority also endorsed social rejection attitudes. The authors found four contrasting attitudinal profiles: moral condemnation only (32% of respondents), full stigma (26%), no stigma (26%), and stigma rejection (16%). Early vaccination, civic motives for it, faith in science, rejection of political extremes, and being aged 65 or older were the main factors associated with stigmatizing attitudes toward unvaccinated people.

CONCLUSIONS

The authors found some evidence of stigmatization toward unvaccinated people, but further research is needed, especially to investigate perceived stigmatization among them. The authors discuss their results with reference to the concept of "folk devils" and from a public health perspective.

Utilizing the Metaverse to Provide Innovative Psychosocial Support for Pediatric, Adolescent, and Young Adult Patients with Rare Cancer

This study investigated the potential of the metaverse in providing psychological support for pediatric and AYA cancer patients, with a focus on those with rare cancers. The research involved ten cancer patients and survivors from four distinct regions in Japan, who participated in metaverse sessions using customizable avatars, facilitating interactions across geographical and temporal barriers. Surveys and qualitative feedback were collected to assess the psychosocial impact of the intervention. The results demonstrated that the metaverse enabled patients to connect with peers, share experiences, and receive emotional support. The anonymity provided by avatars helped reduce appearance-related anxiety and stigma associated with cancer treatment. A case study of a 19-year-old male with spinal Ewing's sarcoma highlighted the profound emotional relief fostered by metaverse interactions. The findings suggest that integrating virtual spaces into healthcare models can effectively address the unique needs of pediatric and AYA cancer patients, offering a transformative approach to delivering psychosocial support and fostering a global patient community. This innovative intervention has the potential to revolutionize patient care in the digital age.

Stigma and related influencing factors in brain cancer patients: a cross-sectional study and parallel mediation analysis

PURPOSE

Patients with brain cancer and painful symptoms of the disease experience heavy pressure and negative inner experiences, leading to a sense of stigma. Therefore, this study assessed the level of stigma in patients with brain cancer and analyzed the risk factors for stigma to analyze the underlying relationships among depression, social support, low self-esteem, and stigma.

METHODS

Patients completed the Social Impact Scale, Self-rating Depression Scale, Rosenberg Self-Esteem Scale, Herth Hope Index, Social Support Rating Scale, and Self-Perceived Burden Scale. Multiple linear regression analysis was used to identify factors independently associated with stigma. Parallel mediation analysis was used to evaluate the mediating role of the relationship between psychoemotional factors and stigma.

RESULTS

A multivariate linear regression analysis demonstrated significant associations between age (β =  - 0.189, P = 0.002), treatment (β = 0.184, P = 0.003), self-esteem (β =  - 0.128, P = 0.046), depression (β = 0.273, P < 0.001), hope (β =  - 0.217, P = 0.003), and self-perceived burden (β = 0.260, P < 0.001) with brain cancer. It was observed that the social support received by brain cancer patients directly impacted their stigma (total effect, - 0.851, P = 0.001). Additionally, this relationship was influenced by depression and self-esteem through two distinct pathways.

CONCLUSION

Increased stigma among brain cancer patients was found to be associated with severe depression, feelings of inferiority, diminished hope, and a heavy perceived burden. The structural equation modeling (SEM) revealed that social support negatively influenced stigma through depression and self-esteem. It is imperative to grasp patients' inner needs, implement psychological interventions, and cultivate a cancer-friendly social environment to prevent stigmatization and discrimination based on their patient status.

The effectiveness of interventions to reduce cancer-related stigma: An integrative review

AIMS

The clinical significance of cancer-related stigma on patients' well-being has been widely established. Stigma can be perceived and internalised by cancer patients or implemented by the general population and healthcare workers. Various interventions have been carried out to reduce cancer-related stigma, but their effectiveness is not well-understood. This review aims to synthesise evidence on the effectiveness of interventions to reduce cancer-related stigma.

DESIGN

An integrative review.

METHODS

This integrative review combined both qualitative and quantitative studies and followed five steps to identify problems, search for the literature, appraise the literature quality, analyse data, and present data. Mixed Methods Appraisal Tool (version 2018) was applied to evaluate the quality of the included studies.

DATA SOURCES

Databases included Web of Science, MEDLINE, SpringerLink, Wiley Online Journals, Cochrane Library, ScienceDirect, OVID, and China National Knowledge Infrastructure (from the inception of each database to 30 April 2021).

RESULTS

Eighteen quantitative, six qualitative, and five mixed-methods studies were included in this review. Cultural factors should be considered when conducting interventions to reduce cancer-related stigma. For cancer patients, multi-component interventions have demonstrated a positive effect on their perceived stigma. For general population, interactive interventions show promise to reduce their implemented stigma towards cancer patients. For healthcare workers, there is a paucity of studies to reduce their implemented stigma. Existing studies reported inconclusive evidence, partially due to the lack of a robust study design with an adequate sample size.

CONCLUSIONS

Multi-component and interactive interventions show promise to relieve cancer-related stigma. More methodologically robust studies should be conducted in different cultures to elucidate the most appropriate interventions for different populations to reduce cancer-related stigma.

IMPLICATION FOR THE PROFESSION AND PATIENT CARE

These findings will facilitate healthcare workers to design and implement interventions to reduce cancer-related stigma, thus improving the quality of life for cancer patients.

PATIENT AND PUBLIC CONTRIBUTION

No patient and public contribution.

Dignity enhanced through faith & family support in palliative care: a qualitative study

BACKGROUND

Dignity is integral to palliative care. Illness can diminish it, causing hopelessness and the wish to hasten death. Yet, dignity is a complex multidimensional phenomenon, influenced by values and context. Understanding its varying interpretations can inform practice and policy. The aim of the study is to explore the understanding of dignity in adult patients with palliative care needs from a Lebanese perspective and how it is preserved during illness and while receiving health services.

DESIGN

Qualitative interview study underpinned with a social constructionist lens. Fourteen patients recruited from home-based hospice and outpatient clinics in Lebanon. Data analysed using reflexive thematic analysis.

RESULTS

Four themes were developed across all the interviews: (a) Dignity anchored through faith in God and religious practices; (b) Family support in maintaining physical, psychological wellbeing, and social connectedness; (c) Physical fitness, mental acuity, and healthy appearance through which patients may escape the stigma of disease, (d) accessible, equitable, and compassionate healthcare.

DISCUSSION

Dignity is elusive and difficult to define but faith and religious beliefs play a significant contribution in this study. For the participants, illness is seen as a natural part of life that does not necessarily diminish dignity, but it is the illness related changes that potentially affect dignity. Findings show the importance of family and children in preserving dignity during illness and how their active presence provide a sense of pride and identity. Participants aspired to restore physical, social, and mental well-being to reclaim their dignity and normalize their lives. Challenges related to physical appearance, memory loss, vitality, and social stigma associated with illness diminished dignity. Accessible, equitable and compassionate healthcare services are also crucial in preserving dignity. Participants valued clear communication, respect, and empathy from healthcare providers and identified affordability of care essential for maintaining dignity.

CONCLUSION

Faith in God, and strong family ties are dominant elements to maintaining dignity in the Lebanese context. Relational connectedness with family, children or God is also a need in maintaining dignity in other communal countries with variations in emphasis. The study indicates that religious and cultural context shapes the needs and perceptions of dignity during illness. These findings are likely to be transferable to many Middle Eastern countries but also countries with strong religious and family ties globally.

A qualitative study on experiences of stigma among postoperative oral cancer patients

AIM

This study aimed to explore the characteristics of stigma in postoperative oral cancer patients to provide a reference for the formulation of targeted intervention measures.

METHODS

A qualitative study was conducted on 25 postoperative oral cancer patients in a tertiary A hospital in Hunan, China, from March to July 2021. Semi-structured face-to-face interviews focused on experiences of stigma were performed. The interview data was analyzed using the NVivo V.12 software based on the reflexive intuitive thematic analysis method. The paper complies with the COREQ.

RESULTS

The stigma experience of postoperative oral cancer patients can be divided into 3 themes: (1) triggers (impaired appearance and oral function and psycho-social pressure); (2) forms (overall isolation, unpleasant feeling of inferiority, and unpleasant social discrimination); (3) coping strategies (positive psychological adjustment, seeking social support and coming out of the unpleasant shadows).

CONCLUSION

Postoperative oral cancer patients clearly articulated that stigma was present in their lives and they experienced multiple forms of stigma. Further work is needed to increase education and awareness about oral cancer to guide them to take positive coping and reduce stigma.

How will I live this life that I'm trying to save? Being a female breast cancer survivor in Nigeria

OBJECTIVES

Nigeria is experiencing an increasing rate of new cancer cases while marred by a weak health system. As cancer prevalence increases in Nigeria, especially among women, it is crucial to understand the experiences of female cancer survivors, given that their quality of life may be influenced by perceptions of cancer and what it means to be a cancer survivor.

DESIGN

This study employed a qualitative descriptive method. Semi-structured interviews were conducted with a purposive sample of 30 female breast cancer survivors in Abuja, Nigeria.

RESULTS

The three major themes were views about being a cancer survivor, cancer can be stigmatizing, and life after cancer diagnosis and therapy.

CONCLUSION

We argue that cancer-related identity and cancer-related stigma are key factors with help-seeking and quality-of-life implications. Tailored interventions such as cancer health education and social support for cancer survivors may help reduce the burden of cancer in Nigeria.

Cancer Stigma Among 800 Saudi Citizens: A Cross-Sectional Study and Literature Review

INTRODUCTION

Cancer-related stigmatization is a noteworthy phenomenon, yet it has not received sufficient attention in public health studies. Despite recent advancements in treatment and improvements in survival, the burden of stigma remains a challenging concern for individuals diagnosed with cancer.

AIM

This study aims to assess the presence of cancer stigma in the Saudi Arabian population by using the Cancer Stigma Scale (CASS).

METHODS

A cross-sectional study was conducted among the general population of Saudi Arabia. Data collection was facilitated through a self-administered online questionnaire, incorporating socio-demographic variables such as age, gender, and regional residence and employing the CASS instrument to gauge the prevalent attitudes and stigmas related to cancer.

RESULTS

Out of the 874 participants, a majority of 87.1% were female, with 60.2% aged between 20 and 39 years. Notably, 59% reported having a close friend or family member diagnosed with cancer. The average CASS score stood at 1.59 (SD 0.39) on a 5-point scale, with an overwhelming 97.1% registering scores under 2.5, suggesting a generally low stigma perception. In dissecting the CASS components, 'severity' recorded the highest mean score (mean: 2.23), followed by 'awkwardness' (mean: 1.86) and 'financial discrimination' (mean: 1.71). 'avoidance' registered the lowest mean score at 1.11. Notably, a trend of increasing stigma was observed with advancing age, and male respondents indicated a marginally higher propensity towards stigmatizing attitudes.

CONCLUSION

In Saudi Arabia, cancer-related stigma is generally low. However, 'severity' is the most prominent stigma aspect, with 'avoidance' being the least. Older individuals and males exhibit slightly higher stigmatizing attitudes. These insights highlight the need for targeted public health efforts to address remaining stigmatization, especially based on age and gender.

The role of stigma and depression in the reduced adherence among young breast cancer patients in Hungary

BACKGROUND

The main aim of our study was to investigate the role of depression, stigmatization, body shame and self-compassion in the adherence of young Hungarian breast cancer patients aged between 18 and 45 years.

METHODS

In a cross-sectional online survey, data were collected from 99 young breast cancer patients (BC). Participants completed self-report questionnaires on socio-demographic and cancer-specific parameters as well as psychological factors (adherence: 12-item Medication Adherence Scale; depression: Hospital Anxiety and Depression Scale; stigmatization: Stigma Scale for Chronic Illnesses; body shame: Experience of Shame Scale; self-compassion: Self-Compassion Scale). We tested the predictors and mediators of adherence using hierarchical regression, mediation and moderation analysis among BC patients.

RESULTS

We found that adherence was significantly associated with body shame and stigmatization in our BC sample. In addition, stigmatization alone was a significant predictor of lower adherence. Finally, in mediation models, where body shame was a mediator, we found a significant direct effect between stigma and adherence, in other words body shame had a significant mediating effect between these variables. According to our moderation analysis, self-compassion as a significant moderator acts as a protective factor in the linear relationship between stigma and lower adherence.

CONCLUSIONS

Our results highlight the importance of stigma and body shame in the development of adherence in oncological care among young Hungarian BC patients aged between 18 and 45 years. Assessment of stigma, body shame, self-compassion, and the improvement of the availability of evidence-based psychological interventions may increase the adherence of young Hungarian BC patients, leading to more favourable rates of survival.

Latency of breast cancer stigma during survivorship and its influencing factors: A qualitative study

Introduction

Breast cancer diagnosis and treatment have been shown in studies to have a negative impact on patients’ physical, psychological, and social well-being, as well as overall quality of life. Psychologically, it’s linked to sadness, anxiety, and demoralisation. Stigma contributes to the hidden burden of breast cancer as a chronic illness. Research on the elements that breast cancer survivors encounter as influences on stigma associated to the disease is lacking. Based on the lived experiences of breast cancer survivors, this study sought to investigate the factors that lead to the manifestations of both self- and public breast cancer stigma.

Methods

Individual semi-structured interviews with 24 patients diagnosed with breast cancer were performed, followed by five focus groups with 25 patients diagnosed with breast cancer. Interviews were verbatim transcribed and analysed using thematic framework analysis.

Results

Two major themes have emerged from the data: a) Breast cancer stigma among breast cancer survivors, highlighting the various manifestations of stigma and the variables that influence them; including disease-related factors, patients’ views of cancer, public perceptions of breast cancer, family and interpersonal dynamics, and b) Stigma resilience and empowerment, emphasising the necessity of sociocultural transformation and coping strategies to preserve resilience.

Conclusions

To improve the well-being of breast cancer survivors, practitioners and health policymakers should be aware of the breast cancer stigma that underpins patients’ emotional and behavioural outlooks and its potential consequences on patients’ quality of life. They need to develop interventions to address the different stages of cancer stigma taking into consideration sociocultural influences, norms, and beliefs.

Stigma experienced by ALS/PMA patients and their caregivers: a mixed-methods study

Objective: Previous work suggests that stigma negatively impacts quality of life in people living with amyotrophic lateral sclerosis (ALS) and progressive muscular atrophy (PMA). This study aimed to explore experiences of enacted stigma (experienced discrimination) and felt stigma (shame, fear of exclusion) among Dutch ALS/PMA patients and their caregivers. A secondary aim was to assess associated factors of enacted/felt stigma among patients. Methods: A two-phase mixed-methods study was conducted, comprising cross-sectional surveys among 193 ALS/PMA patients and 87 caregivers, and semi-structured interviews with 8 ALS/PMA patients and 11 family caregivers. Descriptive and multivariable regression analyses along with qualitative content analysis were used to analyze survey and interview data. Results: Survey findings indicate that patients and caregivers experience enacted and felt stigma. Interviews with both patients and caregivers revealed two manifestations of enacted stigma, including social exclusion (e.g. relationship distancing) and stigmatizing attitudes/behaviors displayed by others (e.g. staring), and three manifestations of felt stigma, including alienation (e.g. shame/embarrassment), perceived discrimination (e.g. feeling judged) and anticipated stigma (e.g. fear of exclusion). Patients and caregivers engaged in concealing and resisting responses to stigma. More bulbar symptoms, King's clinical stage, younger age and living without a partner were significantly associated with enacted/felt stigma among patients. Conclusions: Our findings reveal a range of perceptions and experiences underlying enacted/felt stigma among ALS/PMA patients and their caregivers that may serve as conversation topics in clinical practice. Future research may shed more light on the determinants as well as the consequences of stigmatizing experiences among patients and caregivers.

Effects of a Sound Intervention on Physical and Emotional Well-Being in Patients with Cancer: A Prospective Randomized Trial

AIM

Cancer remains a disease with a significant impact on morbidity and mortality but also on quality of life. This prospective randomized pilot study investigated the effects of a sound intervention on physical and emotional well-being in outpatients with cancer.

METHODS

Two self-applied sound interventions were used for this purpose, either active "music playing" with a body monochord or passive sound intervention with headphones to listen to a given music compilation. Interventions were carried out over a period of 4 weeks for at least 15 min in the evening before bedtime. The following self-assessment questionnaires were completed both at baseline and after 4 weeks to evaluate the response: the Pittsburgh Sleep Quality Index (PSQI), the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), Visual Analogue Scale (VAS) for pain and fatigue, and the Fear of Progression (FoP) questionnaire. Primary endpoint of this exploratory trial was to describe the rate of patients with improvement in at least one dimension without worsening of any other.

RESULTS

73 patients (29 male, 44 female) were included in the study and randomized to either active (n = 34, 47%) or passive sound intervention (n = 39, 53%). Median age was 52.0 years (range 21-79). Fourteen patients (19%) stated that they were musically active. The sound intervention was carried out on a median of 26 days (range 5-28). A higher percentage of patients in the passive group reached the primary endpoint: n = 15 (39%) versus n = 9 (27%). Response differences in favour of the passive group were seen with the VAS fatigue and with QLQ-30 questionnaires. Overall, an improvement in QLQ-30 questionnaire was seen in 12 patients (31%) in the passive group versus 3 patients (9%). Moreover, sound intervention significantly improved social functioning and shortness of breath in the passive group according to QLQ-C30. Significant improvements were also noticed in the passive group in terms of affective reactions as a domain of the FoP questionnaire. No effects on pain or sleep quality could be observed.

CONCLUSION

A 4-week self-administered sound intervention was feasible in outpatients suffering from cancer. Using a panel of 5 questionnaires, passive sound interventions appeared to be more likely to positively influence patient-reported outcomes. In particular, a positive impact was documented in social functioning and fatigue.

Assessing Knowledge and Perceptions About Cancer Among American Indians of the Zuni Pueblo, NM

American Indians (AIs) in New Mexico have lower cancer screening rates compared to other populations and are more likely to be diagnosed with cancer at an advanced stage of the disease as reported by Li et al. (Archives of Internal Medicine 163(1):49-56, 2003). AIs also have the lowest 5-year cancer survival rates compared to any ethnic/racial group in the USA as reported by Clegg et al. (Arch Intern Med 162:1985-1993, 2002) and Edwards et al. (Cancer 97:1407-1427, 2005). Numerous barriers such as cultural beliefs, fear, fatalism, mistrust, stigma, and lack of culturally appropriate interventions could contribute to low cancer screening rates as reported by Daley et al. (J Health Dispar Res Pract 5(2), 2012); Filippi et al. (J Prim Care Community Health 4(3):160-166, 2013); James et al. (Prev Chronic Dis 10:E170, 2013); and Schumacher et al. (Cancer Causes Control 19(7):725-737, 2008). Trained Community Health Representatives (CHRs) from the Zuni Pueblo and native Zuni undergraduate students led six 1-h focus group sessions using a structured focus group guide with probes. The focus groups were conducted among 51 participants from different age groups (20-29 years, n = 19; 30-49 years, n = 17; and 50 years and older, n = 15) stratified by sex. Focus groups were conducted in both English and Shiwi (Zuni) languages. Sessions were audio recorded, and team members took notes. CHRs transcribed the notes and audio recordings, and created a codebook for qualitative data analysis. In the focus groups, participants provided Zuni-specific cultural context, opinion, and experience regarding (1) general knowledge about cancer, (2) cancer risk, (3) cancer risk reduction, (4) personal experiences with cancer, and (5) culturally competent delivery of cancer information and resources. Understanding the perceptions of cancer within the Zuni Pueblo is an essential component in the development of interventional/preventative measures and improvement of current care. Ultimately, this information will provide a basis for the next steps in culturally sensitive cancer care for the Zuni Pueblo.

Health-related quality of life in cancer immunotherapy: a systematic perspective, using causal loop diagrams

Purpose

System science offers a unique set of tools, including causal loop diagrams (CLDs), for stakeholders to better grasp the complexity of factors surrounding quality of life. Because the health-related quality of life (HRQoL) of cancer immunotherapy patients exists within an intricate system affected by and affecting many factors across multiple dimensions, the development of a systems-level model can provide a powerful framework to aid the understanding of this complexity. We developed a CLD for HRQoL of cancer immunotherapy patients.

Methods

We first applied a literature-based approach to construct a CLD for patients following immunotherapy. We then iteratively reviewed and enhanced the CLD through interviews with subject matter experts.

Results

Based on the reviewed literature and subject matter expert input, we produced a CLD representing the system surrounding cancer immunotherapy patients’ HRQoL. Several feedback loops are identified that span clinical experiences, oncology teams’ perceptions about immunotherapy, social support structures, and further research and development in cancer immunotherapy, in addition to other components. The CLD enables visualization of thought experiments regarding how a change anywhere in the system can ultimately worsen or improve patients’ HRQoL.

Conclusion

The CLD illustrates the valuable contribution of a systems perspective to quality-of-life research. This systems-based qualitative representation gives insight on strategies to inhibit harmful effects, enhance beneficial effects, and inherent tradeoffs within the system. The CLD identifies gaps in the literature and offers a communication tool for diverse stakeholders. Our research method provides an example for studying the complexities of quality of life in other health domains.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03110-5.

Stigma and Quality of Life in Women With Breast Cancer: Mediation and Moderation Model of Social Support, Sense of Coherence, and Coping Strategies

Objectives

The breast cancer stigma affects Health-related quality of life (HRQoL), while general resilience resources (GRRs), namely, sense of coherence (SOC), social support, and coping skills, are thought to alleviate this effect. The study aimed to explore the mediating/moderation role of GRRs in the relationship between stigma and HRQoL and its dimensions in Iranian patients with breast cancer.

Methods

In this cross-sectional study, Stigma Scale for Chronic Illness 8-item version (SSCI-8), SOC-13, Medical Outcome Survey- Social Support Scale (MOS-SSS), Brief COPE, and Functional Assessment of Cancer Therapy-Breast (FACT-B) were investigated in a convenience sample of Iranian women with confirmed non-metastatic breast cancer. Following the establishment of correlations using Pearson's correlation, single and parallel mediation analysis and moderation analysis were conducted to determine the extent to which each GRR might be impacted by stigma or decrease the adverse impact of stigma on HRQoL.

Results

An analysis of 221 women (response rate of 87.5%) with the mean age of 47.14 (9.13) showed that stigma was negatively correlated to all HRQoL's dimensions (r = -0.27∼0.51, p < 0.05), SOC (r = -0.26∼0.35, p < 0.01), social support (r = -0.23∼0.30, p < 0.01), and the bulk of coping skills. In the single mediation analysis, stigma affected all facets of SOC, all subscales of social support, and positive reframing, which partially reduced breast cancer HRQoL. Stigma affects general HRQoL through damaging meaningfulness, social support (except for tangible), and positive reframing. Meaningfulness was marked as the most impacted GRR in terms of all domains of HRQoL. In parallel mediation, reduced meaningfulness, total social support, and positive reframing were highlighted as the pathways of diminished breast cancer HRQoL. Moderation analysis indicated the higher levels of humor, behavioral disengagement, and use of instrumental support behaviors to be functional in protecting different dimensions of HRQoL, while the results were mixed for venting, especially in patients with mastectomy surgery.

Conclusion

While GRRs may be impacted by stigma, they exert a relatively small protective effect against the impact of stigma on HRQoL. This study provides some novel findings, but longitudinal studies are needed to further verify these before any causal conclusion or recommendations for health policy can be drawn.

The relative contributions of biomarkers, disease modifying treatment, and dementia severity to Alzheimer's stigma: A vignette-based experiment

OBJECTIVE

The symptoms and prognosis of Alzheimer's disease (AD) dementia contribute to the public's negative reactions toward individuals with AD dementia and their families. But what if, using AD biomarker tests, diagnosis was made before the onset of dementia, and a disease-modifying treatment was available? This study tests the hypotheses that a "preclinical" diagnosis of AD and treatment that improves prognosis will mitigate stigmatizing reactions.

METHODS

A sample of U.S. adults were randomized to receive one vignette created by a 3 × 2 × 2 vignette-based experiment that described a person with varied clinical symptom severity (Clinical Dementia Rating stages 0 (no dementia), 1 (mild), or 2 (moderate)), AD biomarker test results (positive vs negative), and disease-modifying treatment (available vs not available). Between-group comparisons were conducted of scores on the Modified Family Stigma in Alzheimer's Disease Scale (FS-ADS).

RESULTS

The sample of 1,817 adults had a mean age two years younger than that of U.S. adults but was otherwise similar to the general adult population. The response rate was 63% and the completion rate was 96%. In comparisons of randomized groups, mild and moderate symptoms of dementia evoked stronger reactions on all FS-ADS domains compared to no dementia (all p < 0.001). A positive biomarker test result evoked stronger reactions on all but one FS-ADS domain (negative aesthetic attributions) compared to a negative biomarker result (all p < 0.001). Disease-modifying treatment had no measurable influence on stigma (all p > 0.05).

CONCLUSIONS

The stigmas of dementia spill over into preclinical AD, and availability of treatment does not alter that stigma. Translation of the preclinical AD construct from research into practice will require interventions that mitigate AD stigma to preserve the dignity and identity of individuals living with AD.

A phenomenological study on experiences of cancer stigma amongst selected people living with cancer in rural and urban Zimbabwe

Background: Cancer is a highly stigmatized illness associated with profound adverse impact on communities, families and diagnosed individuals. Notwithstanding extensive theorizing since Erving Goffman’s classical contributions, health stigma is well explicated in context-specific and situated analysis. The current study explored the manifestations of self and enacted stigma among 20 selected people diagnosed with cancer from rural and urban Zimbabwe, who sought quaternary level of health care services in the capital, Harare.

Methods: Phenomenological methodology was enlisted to capture intimate expressions of stigma as expressed about, and by people diagnosed with cancer. Data collection methods used includes semi-structured interviews, key informant interviews and focus group discussions. A semi-structured in-depth interview guide, focus group discussion guide and a key informant interview guide were the tools used to collect the data.

Results: The study identified five themes of stigma, indicating pronounced, complex and multiple catalogues of stigma embedded in the existing socio-cultural milieu.

Conclusions: This study stands to offer invaluable conceptual schemas and empirical insights on health-related stigma, and may aid in nursing and in the design of educational programs meant to combat health stigma.

Stigma and cervical cancer prevention: A scoping review of the U.S. literature

Cervical cancer is preventable through HPV vaccination and screening however, uptake falls below national targets. A scoping review was conducted to describe stigmas related to HPV infection and vaccination and cervical cancer and screening in the US. Results were organized into the domains proposed by Stangl and colleagues' Health Stigma and Discrimination Framework. Common drivers of stigma were fear of social judgement and rejection, self-blame, and shame. Positive facilitators included social norms that provided motivation to receive HPV vaccination and screening. Gender and social norms were notable negative facilitators of stigma. HPV infection and cervical cancer resulted in stigma marking through the belief that both result from incautious behavior-either multiple sexual partners or failing to get screening. Stereotyping and prejudice were stigma practices attributed to HPV infection and cervical cancer through these same behaviors. Stigma experiences related to HPV infection, cervical cancer, and abnormal screening results included altered self-image based on perceived/anticipated stigma, as well as discrimination. This review advances understanding of the multiple dimensions of stigma associated with these outcomes in the US population. Three areas warrant additional consideration. Future studies should 1) assess how stigma dimensions affect uptake of cervical cancer preventions efforts; 2) focus on US women most affected by cervical cancer incidence and mortality to identify potential differences in these dimensions and tailor interventions accordingly; 3) include women from geographic areas of the US with high rates of cervical cancer to adapt interventions that address potential regional variations in resources and need.

Overall health information exposure, its barriers and impacts on attitude toward healthcare among cancer patients. The long-term aftermath of the 2011 triple disaster in Fukushima, Japan: A single institution cross-sectional study

Disasters can hinder access to health information among cancer patients. However, little is known regarding overall health information exposure (HIE), its barriers and its impacts on attitudes toward healthcare among cancer patients in the long-term aftermath of disasters. The aims of this study were threefold: assess the extent of HIE; identify associations between family composition and a non-engagement with HIE; and examine the effects of HIE on attitudes toward healthcare among local cancer patients-5 years after the 2011 triple disaster (earthquake, tsunami, and nuclear disaster) in Fukushima, Japan. We conducted self-administered surveys with all cancer and non-cancer surgery department outpatients at Minamisoma Municipal General Hospital (MMGH), Minamisoma City, from October 2016 to January 2017. In total, 404 patients (263 cancer patients and 141 non-cancer patients) voluntarily participated in the study. The results revealed that a regular level of HIE occurred among 90.5% of the cancer patients. In cancer patients, family composition was not significantly associated with HIE, and HIE was not associated with attitude toward healthcare. In conclusion, most cancer patients visiting the MMGH surgical department were regularly engaged in HIE.

Privacy in breast cancer biobank: Chinese patients' perceptions

Drawing on 40 in-depth interviews with Chinese breast cancer patients who participated in the breast cancer biobank at a hospital in Beijing, China, this paper explores these patients' perceptions of privacy. The analysis indicates that these patients primarily perceived privacy as informational privacy; they were concerned about the disclosure of contact information, cancer diagnosis, and genetic testing results; further, their views on disclosing different kinds of personal information were dynamic and heterogeneous in various relationships and contexts, which differs from the stereotypical beliefs of privacy in China. This paper provides situated understanding of why these patients had such privacy perceptions and what strategies they adopted to cope with their privacy. It then discusses the international similarities and differences in the disclosure of cancer and genetic testing results.

Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

INTRODUCTION

Stigma has been identified as a key determinant of health and health inequities because of its effects on access to health-enabling resources and stress exposure. Though existing reports offer in-depth summaries of the mechanisms through which stigma influences health, a review of evidence on the upstream drivers of stigma across health and social conditions has been missing. The objective of this review is to summarize known structural determinants of stigma experienced across health and social conditions in developed country settings.

METHODS

We conducted a rapid review of the literature. English- and French-language peer-reviewed and grey literature works published after 2008 were identified using MEDLINE, Embase, PsycINFO, Google and Google Scholar. Titles and abstracts were independently screened by two reviewers. Information from relevant publications was extracted, and a thematic analysis of identified determinants was conducted to identify broad domains of structural determinants. A narrative synthesis of study characteristics and identified determinants was conducted.

RESULTS

Of 657 publications identified, 53 were included. Ten domains of structural determinants of stigma were identified: legal frameworks, welfare policies, economic policies, social and built environments, media and marketing, pedagogical factors, health care policies and practices, biomedical technology, diagnostic frameworks and public health interventions. Each domain is defined and summarized, and a conceptual framework for how the identified domains relate to the stigma process is proposed.

CONCLUSION

At least 10 domains of structural factors influence the occurrence of stigma across health and social conditions. These domains can be used to structure policy discussions centred on ways to reduce stigma at the population level.

Shaming and Stigmatizing Healthcare Workers in Japan During the COVID-19 Pandemic

Stigmatization and sharming of healthcare workers in Japan during the coronavirus 2019 (COVID-19) pandemic reveal uniquely Japanese features. Seken, usually translated as ‘social appearance or appearance in the eyes of others,’ is a deep undercurrent woven into the fabric of Japanese life. It has led to providers who become ill with the SARS-CoV-2 virus feeling ashamed, while concealing their conditions from coworkers and public health officials. It also has led to healthcare providers being perceived as polluted and their children being told they were not welcome in schools. Although such experiences are not isolated to Japan and have appeared in other parts of the world, the cultural forces driving them in Japan are unique. Overcoming stigmatization and shaming of Japanese healthcare providers will require concerted efforts to understand cultural barriers and to view such practices as raising human rights issues affecting the safety and well-being of all.

A scoping review of return to work decision-making and experiences of breast cancer survivors in Korea

PURPOSE

Return to work (RTW) is an important component of cancer survivorship for individual rehabilitation and economic development. The focus of prior research on cancer survivor RTW has generally been on Western and general cancer populations. There is a need to examine the existing research on RTW decisions and experiences in Korean breast cancer survivors (BCS).

METHODS

This scoping review followed the framework of Arksey and O'Malley, which consisted of identifying the research question, discovering and selecting studies, charting data, analyzing results, and incorporating expert consultations. Quality assessments and a thematic map were included.

RESULTS

Out of 863 original articles found in the literature search, 8 articles met the inclusion criteria. Majority were published in the past 5 years. The scope of the field, socio-demographic and clinical associations, and factors associated with RTW decision-making and experiences were reported. In the thematic analysis, 4 main categories were derived.

CONCLUSIONS

Future research needs to be conducted on effective RTW interventions targeting various educational backgrounds, socioeconomic levels, and job types. More institutional and social support would encourage more successful RTW through educational awareness, financial assistance, and workplace accommodations. Future studies should focus on interdisciplinary RTW efforts with multiple stakeholders.

IMPLICATION FOR CANCER SURVIVORS

BCS need programs that include social support, individual coping strategies, reliable RTW information, physical rehabilitation, vocational counseling, workplace allowances, and psychological support. More support should be provided through extending the work law and engaging employers. If they desire to resume working, BCS should be fully supported with RTW specific resources.

Correlates of stigma for patients with cancer: a systematic review and meta-analysis

OBJECTIVE

The systematic review and meta-analysis was performed to summarize the available evidence and identify the correlates of cancer stigma.

METHODS

PubMed, EMBASE, Web of Science, the Cochrane Library, and PsycINFO were electronically searched to identify eligible studies about correlates of stigma for patients with cancer. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of included studies. A meta-analysis was performed using the statistical program R.

RESULTS

Thirty-one studies involving a total of 7114 patients were included in the systematic review and meta-analysis. The results of the meta-analysis showed that cancer stigma shared positive associations with male gender, symptoms, depression, anxiety, body image loss, self-blame, social constraint, intrusive thoughts, and ambivalence over emotional expression, and negative associations with income, NK cell subsets, QOL, self-esteem, self-efficacy, cancer screening attendance, doctor's empathy, and medical satisfaction. The results of the descriptive analysis indicated that cancer stigma was positively associated with self-perception of aging, anger, internal attributions, stressful life events, self-perceived burden, and sleep dysfunction, while negatively associated with patient-provider communication and sleep quality.

CONCLUSION

Healthcare staff should pay attention to the identified correlates of cancer stigma. The results of our research can inform the design of interventions to reduce stigma and to improve clinical outcomes in people with cancer.

Understanding Men's Experiences With Prostate Cancer Stigma: A Qualitative Study

PURPOSE

The purpose of this study was to explore the experiences and perspectives of men who have had prostate cancer to better understand the effect of prostate cancer and associated stigmas on men in the Canadian province Newfoundland and Labrador (NL).

PARTICIPANTS & SETTING

Eleven men from NL who have had prostate cancer participated in semistructured interviews exploring their perspectives and experiences of prostate cancer and stigma.

METHODOLOGIC APPROACH

A social-ecological framework was used to understand experiences from different domains. Interviews were analyzed using Lichtman's three Cs approach. Analysis focused on establishing themes of the participants' lived experience of prostate cancer and related stigma.

FINDINGS

Participants described how emasculating a prostate cancer diagnosis can feel. They identified ways prostate cancer negatively affected their behaviors and sense of self, described coping with the diagnosis and different strategies, and talked about broader system change required to address prostate cancer stigma. Participants expressed a need for additional support from healthcare providers (HCPs).

IMPLICATIONS FOR NURSING

HCPs, such as oncology nurses, may be able to reduce stigmatization by providing patient navigation, improving information delivery, or providing psychosocial counseling to individuals experiencing feelings of internal or external stigmatization related to prostate cancer.

Self-identity, lived experiences, and challenges of breast, cervical, and prostate cancer survivorship in Mexico: a qualitative study

BACKGROUND

Qualitative research on cancer patients' survivor-identity and lived experiences in low- and middle-income countries is scarce. Our study aimed at exploring the concept and experience of survivorship for Mexicans living with breast, cervical, and prostate cancer.

METHODS

We conducted a qualitative study in Mexico City, Morelos, Nuevo León, and Puebla. The participants were breast, cervical, and prostate cancer patients ≥18 years of age with completed primary cancer treatment. Data were collected via in-depth interviews and analyzed using an inductive thematic approach.

RESULTS

The study included 22 participants with a history of breast, 20 cervical, and 18 prostate cancer. Participants accepted the term "cancer survivor" as a literal interpretation of being alive, medical confirmation of treatment completion, or achievement of a clinical result possibly indicative of cure. The majority of respondents perceived that the future is out of their control and under God's will. They linked cure to divine intervention and did not demonstrate the sense of empowerment that is often associated with the survivorship term. The principal themes of their narratives encompass: 1) adverse physical and sexual experiences; 2) emotional problems; 3) cancer-related stigma; 4) challenges to obtaining health-related information; 5) financial hardship; and 6) experience of strengthening family ties in order to provide them with support. In addition, women with breast cancer reported distress caused by changes in body image and positive experience with support groups.

CONCLUSION

In Mexico, cancer patients report complex survivorship experiences that demand post-treatment follow-up and support. There is the need to implement comprehensive, culturally-relevant survivorship programs focused on emotional, informational, and in-kind support and empowerment of cancer patients.

Beyond depression, anxiety and post-traumatic stress disorder symptoms: Qualitative study of negative emotional experiences in hematopoietic stem cell transplant patients

OBJECTIVE

Psychological distress impacts a variety of health outcomes in hematopoietic stem cell transplantation (HSCT). Focused qualitative studies on a wider range of psychological distress in HSCT patients are lacking. However, understanding the subtleties of psychological distress (e.g. fear, guilt, loss of control) in HSCT patients is imperative to optimising the psychological well-being of this vulnerable population. To explore psychological distress after transplantation, we conducted semi-structured interviews with 25 HSCT patients.

METHODS

Interviews were completed in the first 100 days after transplantation. Interview modules explored psychological distress symptoms in the hospital and during the first 100 days after HSCT, along with the perceived impact of these symptoms on their recovery.

RESULTS

Of the negative emotional experiences reported, feeling trapped, fear, guilt, discouragement and powerlessness were frequently expressed. Patients reported that negative emotional states interfered with their motivation to participate in health behaviours important to the transplant recovery.

CONCLUSION

As one of the few qualitative studies broadly characterising the nature of negative emotional experiences after HSCT, these findings add to our understanding of the specific psychological challenges in this growing patient population and can inform development of targeted interventions and overall management of psychological distress during HSCT recovery.

Meanings and dimensions of cancer by sick people - a structural analysis of social representations

OBJECTIVE

To describe the contents and structure of the social representation of cancer.

METHOD

A qualitative study based on the Theory of Social Representations, carried out in a High Complexity Care Unit in Oncology. Data collection included a socio-occupational and clinical characterization questionnaire and free evocations form from 100 cancer patients in chemotherapy treatment and in-depth interviews with 29 of them. The analysis was performed using EVOC software.

RESULTS

One hundred (100) patients participated in the study. The social representation of cancer has the words normal, difficult disease, death and fear in its central nucleus. The apparent ambivalence between the continuity of life and its finitude as structuring meanings of this representation enables establishing an inferential hypothesis that relates normal disease to the possibility of treatment, control and cure of cancer, while the fear of death remains in the representational field linked to the disease, which has a difficult treatment to cope with.

CONCLUSION

The social representations of cancer based on the presented interrelationships provide reflections which may contribute to increasing the individual and social care of patients with malignant neoplasm and their family in health services.

Impact of individual background on the unmet needs of cancer survivors and caregivers - a mixed-methods analysis

BACKGROUND

Cancer survivors and their caregivers may have various unmet needs that are medically difficult to solve. Previous studies have suggested the relations between individuals' backgrounds and their unmet needs. We conducted a large-scale analysis to clarify the influence of individuals' backgrounds, primarily cancer type, on specific types of unmet needs.

METHODS

Using a mixed-methods approach, we analyzed records of first-time callers to a cancer-focused telephone consultation service that was provided by the Kanagawa Cancer Clinical Research Information Organization from October 2006 to May 2014. The qualitative approach concerned extracting unmet needs mentioned in each consultation and classifying them into themes of specific needs, while the quantitative approach comprised multi-variated analysis of the relationships between the frequency by which the needs in each theme arose and the associated callers' backgrounds.

RESULTS

A total of 1938 consultation cases were analyzed. In the qualitative analysis, the needs were classified into 16 themes. The mean number of unmet needs for each caller was 1.58 (standard deviation = 0.86). In the multi-variated analysis, caregivers for colorectal cancer survivors had a lower frequency of "emotional/mental health" needs (OR: 0.31, 95%CI: 0.11-0.88, p = 0.028) than did caregivers for breast-cancer survivors. Nevertheless, this was the only significant difference in needs frequency among callers (including survivors and their caregivers) with specific cancer types. Meanwhile, there significant difference in the frequency of occurrence of each unmet need theme was found among items concerning other background elements. Among survivors, sex was related to the frequency of needs among "physical" and "resources" themes, and "emotions/mental health"; their age group with "employment"; treatment course with "physical" and "resources" themes and "cure"; residence with "physical" themes; presence of symptom with "physical," "education/information," "resources," "emotions/mental health," and "cure" themes.

CONCLUSIONS

This large-scale study suggests that cancer type is not a significant factor for specific unmet needs and that individuals' backgrounds and presence of symptoms play a more important role. Through this study, it was found that instruments to predict people's needs and a system to provide individualized cancer care across cancer types should be developed in the future.

News media stories about cancer on Facebook: How does story framing influence response framing, tone and attributions of responsibility?

This content analysis explored associations between the framing of cancer-related health news stories on Facebook and their corresponding comments. It was found that regardless of story framing the majority of responses involved users engaging in debate and discussion rather than sharing personal experiences. Furthermore, stories framed episodically had a greater proportion of both supportive and unsupportive comments than stories framed thematically. As predicted, episodic stories were associated with more attributions of responsibility directed towards the individual whereas thematic stories lead to more societal-level attributions of blame. Contrary to predictions, responses did not contribute towards the stigmatisation of lung cancer, instead more responses were aimed at reducing stigma for this illness. Within the findings strong beliefs about cancer treatment and management were also identified, which raises concern over the spread of misinformation. Overall, this research provided insight into the framing of cancer news and highlighted potential implications of Facebook comments.

The value of immunotherapy for survivors of stage IV non-small cell lung cancer: patient perspectives on quality of life

Purpose

The aim of this study was to examine what personally mattered to 24 patients who received immuno-oncology (IO) therapy for stage IV non-small cell lung cancer (NSCLC), as well as their families and friends, to understand how they evaluated their cancer treatments and the determinants of the quality of life (QoL) of long-term survivors.

Methods

Ethnographic research was conducted with 24 patients who had responded to IO (pembrolizumab, nivolumab, atezolizumab, or durvalumab) for stage IV NSCLC, and their families and friends, evenly split among field sites in Denmark, the USA, and the UK. Data were collected using in-depth qualitative interviews, written exercises, and participant observation. Data analysis methods included interpretative phenomenological analysis, coding, and the development of grounded theory. Researchers spent 2 days with participants in their homes and accompanied them on health-related outings.

Results

Our findings reveal that long-term survivors on IO experienced their journey in two phases: one in which their cancer had taken over their lives mentally, physically, and spiritually, and another in which their cancer consumed only a part of their everyday lives. Patients who survived longer than their initial prognosis existed in a limbo state in which they were able to achieve some semblance of normalcy in spite of being identified as having a terminal condition. This limbo state impacted their life priorities, decision-making, experience of patient support, and health information-seeking behaviors, all of which shaped their definitions and experience of QoL.

Conclusions

The results of this study, which identify the specific challenges of living in limbo, where patients are able to reclaim a portion of their pre-cancer lives while continuing to wrestle with a terminal prognosis, may inform how cancer research can more effectively define and measure the QoL impacts of IO treatments. Also, they may identify approaches that the cancer community can use to support the needs of patients living in a limbo state. These experiences may not be adequately understood by the cancer community or captured by existing QoL measures, which were designed prior to the emergence of IO and without sufficient incorporation of contextual, patient-driven experience.

Implications for Cancer Survivors

Increased awareness of the specific experiences that come with long-term survival on IO may direct how resources should be spent for cancer support for patients and their families. Expanding how QoL is evaluated based on patients’ lived experiences of IO can reflect a more accurate depiction of the treatment’s benefits and harms.

"Tiny Tiny Little Nothings": Minimization and Reassurance in the Face of Cancer

Drawing from a sub-sample of video recorded and transcribed oncology interviews, Conversation Analysis is used to examine moments when cancer is portrayed as absent or minimally present but not dangerously invasive. Though cancer patients and their doctors invest considerable efforts pursuing life-affirming and hopeful possibilities advancing the quality of living and healing outcomes, little is known about how"good news" and thus hopeful social actions get organized. An interactional practice is identified for depicting tumor sizes as small or shrinking - a displayed preference to tumors that are large, growing, and spreading (i.e., metastasizing). By relying on gestural depictions (e.g., pinched fingers and open hands), in precise unison with paired lexical affiliates (e.g., tiny, little, nothing), it is shown how patients seek to justify their wellness and doctors offer reassurance by demonstrating that tumor sizes are minimally threatening. These interactional practices provide a needed balance to deathly cancer stereotypes, criticisms of health-care bureaucracies as inhumane, and overreliance on biomedical authority enacted during clinical encounters. A need exists to verify the existence of a benign social order in the midst of cancer care, actions designed to address malignant diagnoses by curtailing uncontrolled cancer growth.

Cancer stigma and cancer screening attendance: a population based survey in England

Background

Cancer-related stigma attracts considerable research interest, but few studies have examined stigmatisation in the healthy population. Qualitative studies suggest that stigma can discourage people from attending cancer screening. We aimed to quantify the prevalence and socio-demographic patterning of cancer stigma in the general population and to explore its association with cancer screening attendance.

Methods

In 2016, 1916 adults aged 18–70 years took part in home-based interviews in England. Measures assessed demographic characteristics, self-reported screening uptake for cervical (n = 681), breast (n = 326) and colorectal cancer (n = 371), and cancer stigma. Cancer stigma was measured with the validated Cancer Stigma Scale which assesses six subdomains (Severity, Personal Responsibility, Awkwardness, Avoidance, Policy Opposition, and Financial Discrimination), from which a mean score was calculated. Logistic regression analyses examined the association between cancer stigma and having been screened as recommended versus not.

Results

Levels of cancer stigma were low, but varied across the six subdomains. Items regarding the severity of a cancer diagnosis attracted the highest levels of agreement (30–51%), followed by statements about the acceptability of making financial decisions on the basis of a cancer diagnosis such as allowing banks to refuse a mortgage (16–31%) and policy opposition statements such as not having a responsibility to provide the best possible care for cancer patients (10–17%). A similar proportion anticipated feeling awkward around someone with cancer (10–17%). Only 8–11% agreed with personal responsibility statements, such as that a person with cancer is to blame for their condition, while 4–5% of adults anticipated avoiding someone with cancer. Stigma was significantly higher in men (p < .05) and in those from ethnic minority backgrounds (p < .001). Higher cancer stigma was associated with not being screened as recommended for all three screening programmes (cervical: adjusted OR 1.59, 95% CI 1.15–2.20; breast: adjusted OR = 1.97, 95% CI 1.17–3.32; colorectal: adjusted OR = 1.59, 95% CI 1.06–2.38).

Conclusions

Cancer stigma is generally low, but some aspects of stigma are more prevalent than others. Stigma is more prevalent in certain population subgroups and is negatively associated with cancer screening uptake. These benchmark findings may help track and reduce cancer stigma over time.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5787-x) contains supplementary material, which is available to authorized users.

Dyadic associations between perceived social support and cancer patient and caregiver health: An actor-partner interdependence modeling approach

OBJECTIVE

Social support may have a positive impact on health outcomes for patients and caregivers, but the extent to which social support and health outcomes are interrelated for both is unknown. We examine the dyadic interrelationships between social support and health among cancer patients and their caregivers.

METHODS

Lung and colorectal cancer (CRC) patient and caregiver dyadic data were obtained from the Cancer Care Outcomes Research and Surveillance Consortium. Patients and caregivers self-reported sociodemographic, social support, and caregiving characteristics at 5 (n = 218 lung; n = 222 CRC) or 12 months post-diagnosis (n = 198 lung; n = 290 CRC). Structural equation modeling was used to examine actor-partner interdependence models (APIM) of lung and CRC dyads at 5 and 12 months post-diagnosis.

RESULTS

At 5 months post-diagnosis, no interdependence between patient and caregiver social support was detected for CRC or lung dyads (all P > 0.05). At 12 months post diagnosis, no interdependence was detected for CRC dyads (all P > 0.70); lung dyads showed complete interdependence, indicating patient social support is associated with better caregiver self-reported health (β = 0.15, P < 0.001), and caregiver social support is associated with better patient self-reported health (β = 0.18, P < 0.001).

CONCLUSION

Social support has a positive impact on patient and caregiver perceived health across the cancer trajectory, and these effects may differ by cancer site and time. Future research and translational efforts are needed to identify effective ways to bolster both patient and caregiver social support and to determine critical moments for intervention.

Acculturation and quality of life among Chinese American breast cancer survivors: The mediating role of self-stigma, ambivalence over emotion expression, and intrusive thoughts

OBJECTIVES

Highly acculturated Chinese American breast cancer survivors have greater access to health care providers, are English language proficient, and have more knowledge about the health care system. However, less is known about the potential psychosocial factors that may account for the health benefits of acculturation. As such, the current study seeks to understand how mainstream acculturation is associated with higher quality of life by investigating self-stigma, ambivalence over emotion expression (AEE), and intrusive thoughts, as serial mediators among Chinese breast cancer survivors.

METHODS

One hundred twelve Chinese American breast cancer survivors completed a self-reported questionnaire with these trait variables.

RESULTS

We found support for a serial multiple mediation hypothesis in which mainstream acculturation was indirectly associated with quality of life through self-stigma, AEE, and intrusive thoughts. Specifically, mainstream acculturation was associated with lower self-stigma, which, in turn, was associated with lower AEE and intrusive thoughts and subsequently resulted in lower quality of life among Chinese American breast cancer survivors.

CONCLUSIONS

The findings suggest that psychosocial factors are important mechanisms through which acculturation is associated with quality of life among Chinese American breast cancer survivors. As Chinese immigrants acculturate to mainstream American culture, they may benefit from the reduced public stigma toward breast cancer and incorporate new post-immigration knowledge about cancer that protects them from high levels of self-stigma. This, in turn, may lead Chinese American breast cancer survivors to experience lower AEE and intrusive thoughts and subsequently experience higher quality of life.

Stigma in health facilities: why it matters and how we can change it

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge-both approaches and methods-regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development's Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.

Pity: a qualitative study on Iranian women with breast cancer

BACKGROUND

Women with breast cancer (BC) are commonly confronted with others' pity. However, there is limited information about pity in Iranian women with BC. The aim of this study was to explore perceptions, reactions, coping strategies, and consequences of pity among Iranian women with BC.

METHODS

This qualitative study was carried out from March 2016 till October 2017. A purposive sample of 36 women with BC was selected with maximum variation from three health care centers in Alborz Province, Iran. Data were collected using semistructured interviews and analyzed using a conventional content-analysis approach.

RESULTS

Our findings indicated that Iranian women with BC experienced received pity and perceived unusual attention from others as due to certain reasons. Others' pity caused negative emotional reactions in them. They used self-protection strategies against others' pity. The consequences of self-protection against pity were normalizing the patient's flow of life and/or social isolation.

CONCLUSION

Pity is a serious psychosocial challenge in Iranian women with BC, with negative effects on quality of life. Therefore, pity should be considered in counseling and psychosocial screening of patients.

Cancer in an Historic Washington DC African American Population and Its Geospatial Distribution

Background: Cancer continues to be a major cause of morbidity and mortality in the African American community but insights into the types and incidence of cancer 85 years ago have been virtually non-existent and little is known of its geospatial distribution. Historical information on cancer can shed light on current health disparities, particularly among African Americans.

Objective: The aims of this study were to: (1) assess the frequencies of the cancer types present among Cobb Collection individuals; (2) compare these data with current research on cancer in African Americans; and (3) evaluate the pattern of cancer expression, including its geospatial distributions, as a cause of death between 1931 and 1969 in an historic African American subgroup and compare this pattern with the historic and contemporary patterns of cancer etiology and incidence.

Methods: Systematic assessments of the existing clinical, demographic, and anatomical records in the Cobb Research Laboratory were made of individuals identified as dying from specific cancers from 1931 to 1969. These were compared with the national profiles of cancer during the historic time an individual died as well as the contemporary patterns of cancer deaths. Analysis of their residential addresses just prior to death were assessed using a commercial geographic information system. Each location was assigned a geospatial location and proximity between each site and clusters of sites were investigated.

Results: Seventeen different cancer types were found within 28 individuals of the Cobb Collection between 1931 and 1969. The cancer types with the highest frequencies were carcinoma of stomach, lung, esophagus, larynx and bronchogenic carcinoma. Eighty-four percent of all cancer incidents occurred in males and 76% were among individuals identified as African American. Seventy-one percent of the highest incidence cancers were among African American males. Geospatial clustering was observed most noticeably in the redistribution of carcinoma of the esophagus.

Conclusion: Our results provide historical depth to our knowledge of the common cancer causes of morbidity among African Americans of Washington DC from 1931 to 1969. We contrast these findings with national historical data on cancer etiology and ethnic disparities in incidence. Our study suggests that historic data can provide longitudinal depth to our understanding of the persistence of cancer susceptibilities in a vulnerable subgroup.

Help-seeking behaviour in newly diagnosed lung cancer patients: Assessing the role of perceived stigma

Objective

This study explored help‐seeking behaviours, group identification, and perceived legitimacy of discrimination, and its potential relationship with perceived lung cancer stigma.

Methods

Consecutive consenting adults (n = 274) with a primary diagnosis of lung cancer within the previous 4 months were recruited at 31 outpatient clinics in Australia. A self‐report survey assessed help‐seeking, group identification, perceived legitimacy of discrimination, and perceived lung cancer stigma.

Results

Services providing assistance from health professionals (69.5%) and informational support (68.5%) were more frequently used than emotional‐based support. Only a small proportion (2.6%) of participants were unlikely to seek help from anyone, with the most popular sources of help being the general practitioner (91.0%), and oncologist/treating clinician (81.3%). One‐fifth (21.1%) indicated they identified with being a lung cancer patient, and most did not perceive discrimination against lung cancer patients. Higher perceived lung cancer stigma was significantly associated with greater perceived legitimacy of discrimination (P < 0.001), but not help‐seeking behaviours or group identification.

Conclusions

The relationship between lung cancer stigma and perceived legitimacy of discrimination may guide initiatives to reduce stigma for patients. It is encouraging that perceived stigma did not appear to inhibit help‐seeking behaviours. However, further research in this emerging field is needed to investigate patterns of perceived stigma and help‐seeking over time to identify how and when to offer support services most appropriate to the needs of lung cancer patients.

Impact of systemic juvenile idiopathic arthritis/Still's disease on adolescents as evidenced through social media posts

Purpose

To understand the experience of adolescent systemic juvenile idiopathic arthritis (SJIA) patients and those of their parents based on their social media posts.

Methods

English language posts related to SJIA, Still’s disease, or juvenile arthritis were collected and analyzed.

Results

In total, 71 posts created between 2009 and 2015 on 15 websites were identified in November 2015. Of the 32 unique authors, 17 were SJIA patients aged 13–20 years (40 posts), 7 were mothers of SJIA patients (12 posts), and 8 patients had unspecified forms of juvenile arthritis (19 posts). Many patients posted about similar diagnostic experiences marked by 5 phases: 1) early prediagnosis: pain and fatigue overlooked until crisis occurred, 2) first misdiagnosis: doctors talked about “growing pains” and psychosocial problems (“fake pains” to avoid school), 3) second misdiagnosis: severity acknowledged, but diagnosed as leukemia or another cancer, 4) tests: tests leading to diagnosis and treatment conducted, and 5) cognitive identity: patient accepted the diagnosis and its implications. Many adolescent patients, looking back at disease onset in their childhood, described themselves as a “sleeping child” rather than the typical active child. Several patients tried to hide their illness from friends, but expressed concerns openly online. Many patients described SJIA as a powerful external enemy, using terms like “bulldozer,” “dragon,” and “monster.” Many posts from patients and their mothers used superhero language/imagery to help “fight” SJIA. Some patients also posted about the risk of death.

Conclusion

Although most adolescent SJIA patients openly posted about the difficulties of their disease online, they made efforts to hide their disease in the real world. They frequently used superhero words and images in describing their fight for better health. Physicians can use these insights when counseling SJIA patients to provide a narrative that meshes with the patients’ worldview and perhaps to improve physician–patient communication to increase treatment adherence.

Maturity Level of the Stigma Concept Associated with Cancer Diagnosis in the Nursing Literature

Objective:

This study aimed to evaluate the maturity level of stigma as a concept in nursing and its relationship to care provided for patients with cancer.

Methods:

The four principles of Morse and his colleagues were used to evaluate the maturity level of the stigma concept: epistemological, logical, pragmaticl, and linguistic. Analysis was conducted with the literature published between 2006 and 2016.

Results:

The findings of this study suggest that the concept of stigma in nursing is immature, defined inconsistently, and measured with different instruments. How stigma is defined can influence nurses in their assessment of patients with cancer and identification of their needs.

Conclusion:

Although extensive studies have been conducted in the field of mental illness, it is only recently that the effect of stigma on treatment of cancer patients has attracted attention. Thus, substantial work yet needs to be done to understand the breadth and scope of stigma impacting on individuals with cancer.

Lesbian, Gay, Bisexual, and Transgender (LGBT) Survivorship

OBJECTIVE

To discuss lesbian, gay, bisexual, and transgender (LGBT)-specific survivorship issues including: integrating sexual and gender minority identities with cancer survivor identities; coordinating medical care and disclosing identities to health care providers; dealing with late effects of treatment; and addressing LGBT family and relationship issues.

DATA SOURCES

Published articles, quotes from an online survey of 311 LGBT survivors.

CONCLUSION

The transition from active cancer treatment to survivorship presents challenges, and LGBT cancer survivors may face additional challenges as they enter the survivorship phase.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can improve the quality of survivorship care delivered to LGBT survivors and their caregivers by addressing the disparities and gaps in health care.

Awareness and Perception About Cancer Among the Public in Chennai, India

PURPOSE

Cancer-related stigma influences the way people perceive cancer, which renders cancer control-beginning with prevention and proceeding to palliation-a challenging task. This study aimed to assess the current levels of awareness and perceptions about cancer among people with various socioeconomic status and diverse backgrounds in the city of Chennai, India.

PATIENTS AND METHODS

The sample population (N = 2,981; 18 to 88 years of age) was stratified into four groups: patients (n = 510), caregivers (n = 494) consulting at the Cancer Institute (Women Indian Association), college students (n = 978), and general public (n = 999). Fourteen statements related to cancer stigma or myths were identified and categorized by awareness (10 items) or perception (4 items). Responses to those statements were recorded by using a Likert scale (yes, no, and don't know). The data were described by frequency analysis and χ2 test using SPSS Version 13 (SPSS, Chicago, IL).

RESULTS

More than 70% of the study participants were aware that cancer is curable, that cancer is not contagious, and that cancer is not a curse or a death sentence. However, only approximately half believed that surgery or biopsy do not cause cancer to spread to other organs or that radiation therapy does not consist of receiving an electric shock. Higher education, younger age, male sex, personal experience with cancer (either as a patient or caregiver), and high socioeconomic status were the categories of people with increased awareness about cancer.

CONCLUSION

These factors need to be taken into consideration in tailoring information, education, and communication campaigns. Resource allocation for these campaigns is an investment in cancer control.