Does lung cancer attract greater stigma than other cancer types?

Highlights

• We explore stigma across five cancer types using a multidimensional measure.

• Lung cancer stigma is not limited to personal responsibility attributions.

• Lung also perceived as more severe than other cancer types.

• Financial discrimination against lung cancer patients is considered more acceptable.

Abstract

Objectives

Cancer stigma can have widespread effects, influencing the behaviour and wellbeing of patients as well as the community and even research funding. Patients with lung cancer report feeling particularly stigmatised because of the association with a behaviour (smoking) that is perceived to be personally controllable. However, there are other dimensions of cancer stigma, that might be more severe for other cancers. The present study therefore examined differences in attitudes towards lung cancer and four other cancer types, using a multidimensional measure of cancer stigma, to extend findings beyond personal responsibility attributions.

Materials and methods

Participants were a non-patient sample (n = 1205) who were randomised to complete a survey online relating to one of five cancer types (lung, colorectal, skin, breast and cervical). Stigma was assessed using the Cancer Stigma Scale (CASS).

Results

There were significant differences across the five cancer types on all CASS subscales: awkwardness (F(4, 1009) = 5.16, p < 0.001), severity (F(4, 984) = 26.24, p < 0.001), avoidance (F(4, 1008) = 5.38, p < 0.001), policy opposition (F(4, 1009) = 8.38, p < 0.001), personal responsibility (F(4, 995) = 31.67, p < 0.001) and financial discrimination (F(4, 957) = 9.45, p < 0.001). Lung cancer attracted higher stigma scores than breast and cervical cancer on all subscales. Lung cancer was similar to skin cancer on personal responsibility, avoidance, and policy opposition, but attracted higher stigma in the domains of awkwardness, severity and financial discrimination. Lung cancer was similar to colorectal cancer for awkwardness, but significantly higher on all other subscales.

Conclusion

Lung cancer stigma extends beyond personal responsibility attributions to other dimensions, particularly perceived severity of the disease and tolerance of financial discrimination against patients with the disease. Future work is needed to develop and evaluate interventions designed to limit cancer stigma for patients, health professionals and the community. Health policies should acknowledge the existence of lung cancer stigma and make a commitment to minimising this.

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.