Does lung cancer attract greater stigma than other cancer types?
Introduction
Research into public perceptions of cancer suggests that it is often appraised more negatively than other serious illnesses such as heart disease [1], [2]; attracting a particular sense of dread. In a large representative sample of the US population, 61% of adults agreed that when they think of cancer they automatically think of death [3], and a quarter thought 5-year cancer survival rates were 25% or less [4], despite the overall 5-year figure being 68% [5]. Studies with cancer patients and health professionals suggest that lung cancer in particular attracts stigma because of its poor prognosis and established link with smoking [6], [7]. Recent decades have seen an increase in tobacco control policy initiatives, which aim to de-normalise smoking [8]. Initiatives include bans on smoking in public places and mass media campaigns persuading smokers to stop, often by using graphic images and emotional appeals. These have successfully shifted public perceptions, with smoking now widely seen as undesirable. In qualitative work non-smokers described smoking as ‘dirty’, ‘anti-social’ and ‘unacceptable’ [9], and just under two-thirds of non-smokers say they would mind if someone smoked near them [10]. This shift in perceptions has resulted in dramatic decreases in smoking prevalence in most high-income countries. With most lung cancers caused by smoking, and high public awareness of this, lung cancer is often seen as a self-inflicted illness and negative attitudes to smoking, as a result of health policy and promotion over the last twenty years, have arguably contributed to the stigmatisation of lung cancer patients [7].
Goffman's classic definition of stigma defined it as an attribute that makes a person different from others and results in them being discredited [11]. Link and Phelan agree that stigma occurs when a difference that is considered salient is labelled, this labelled difference is associated with negative attributes, those with the label are seen as a separate group (‘them versus us’) and the label results in loss of status or discrimination [12]. In line with these definitions, lung cancer patients may be seen as distinct from other cancer patients because they are assumed to be smokers with smoking seen as a negative attribute. In a vignette study, participants were randomised to read about a lung cancer patient with a genetic, smoking or combined cause [13]; patients in the genetic condition were attributed less personal responsibility, less anger and more pity than those with a smoking-related or combined cause. Similar findings have been shown with other cancers that have controllable causes, for example in another vignette study, participants were randomised to read about a patient with cervical cancer (caused by a sexually transmitted infection) or ovarian cancer (caused by family history) [14]; the patient with cervical cancer was judged more negatively (considered more dirty, dishonest and unwise), and attracted more moral disgust.
Else-Quest et al. [15] compared perceived stigma scores (agreement with the statement: ‘People judge me for my cancer type’) in patients with lung, breast and prostate cancer. Scores were highest for lung cancer, lowest for breast cancer and in between for prostate cancer, although group differences were not significant. In a general population survey, a large sample of women were asked to indicate how much they would blame someone with lung, colorectal, breast, cervical cancer or leukaemia [16]. Consistent with previous work, lung cancer attracted the highest blame scores (mean rank: 4.9), while breast cancer and leukaemia attracted the lowest scores (mean ranks: 2.7 and 2.5).
Stigma of cancer can influence engagement with prevention behaviours [17], [18], [19], help-seeking behaviours in the presence of symptoms [20], [21], disclosure of the disease [6], [22], and wellbeing following a diagnosis [23], [24]. For lung cancer in particular, recent work has shown that higher stigma is associated with greater depression and lower quality of life and this is the case among smokers and non-smokers [25]. Stigma could also affect community-wide responses to people who have cancer [26] and charitable donations to support research funding [27]. Previous studies have focused on personal responsibility judgements as a means of operationalising lung cancer stigma. The aim of the present study was to take a broader perspective using a multidimensional scale to explore stigma between lung cancer and four other cancer types.
Section snippets
Participants
Participants were recruited through an online survey panel. The panel was supplied by Survey Sampling International, who hold a panel of participants willing to complete online questionnaires in exchange for small incentives (e.g. air miles). At the time of recruitment, their panel size was almost 250,000, of whom 57% were female, 66% were between 18 and 44 years old, and 23% had a university degree. The sample directed to our questionnaire was representative of the UK population in terms of
Sample characteristics
Overall 1205 participants completed the questionnaire. Cases with >20% missing data on the CASS were excluded (16%). After exclusions, 1014 cases were available for further analyses: cervical cancer (n = 187), lung cancer (n = 204), breast cancer (n = 213), colorectal cancer (n = 195) and skin cancer (n = 215). Half the participants were female (49%) and the mean age was 37.8 years (range 16–80). Sample characteristics are shown in Table 1. There were no significant differences in gender, age, ethnicity
Discussion
This study used a multidimensional measure of stigma to explore differences between lung cancer and four other cancer types. As others have reported [6], [15], [16], the study participants saw lung cancer as more severe than other cancers, and were more likely to feel awkward around, and avoid, someone with lung cancer. Lung cancer was attributed more personal responsibility than the other cancers (except for skin cancer). In addition, there was less support for policy initiatives to protect
Conflict of interest statement
None declared.
Acknowledgements
All authors are funded by Cancer Research UK. This study was funded by Cancer Research UK (C1418/A6837). The funders played no role in the design or interpretation of this study. We would like to thank Mark Livermore for programming the online survey, and all the participants who took part.
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