There are many powerful associations that may come to mind upon hearing the word “cancer.” Fear. Sadness. Bravery. But, chances are, even as a healthcare professional, you have different associations with lung cancer compared to breast cancer. You simply may not realize it because 80-90% of decisions are made subconsciously.
A new study published in the journal PLOS ONE has shown for the first time that people subconsciously associate shame, guilt, and hopelessness significantly more with lung cancer compared to breast cancer. In fact, 3 out of 4 of the 1,778 people studied had this hidden negative bias. The study found that not even physicians were immune to these subconscious associations. Cancer patients and caregivers were equally biased against lung cancer, which is the most commonly diagnosed cancer worldwide.1,2
Why is a lung cancer bias a problem?
The PLOS ONE study is part of The Lung Cancer Project, a movement to identify, understand, and remove the stigma and other barriers faced by people with lung cancer—so everyone receives the care they deserve. In 2012, my fellow researchers at Genentech started The Lung Cancer Project with nearly 20 cancer advocacy and industry organizations in response to a shocking statistic: nearly 25 % of people with stage IV non-small cell lung cancer do not receive anticancer therapy, compared to about 13% of people with stage IV breast cancer.3
Considering that lung cancer is the leading cause of cancer deaths in the United States4, this is a big problem. One of our initial hypotheses was that there were a hidden stigma and nihilism towards lung cancer in society, and this could be a factor in the lack of treatment.
To test this hypothesis, we partnered with Project Implicit®, a network of scientists from Harvard University, the University of Virginia, and the University of Washington who study subconscious cognition. Researchers from Project Implicit had designed a research tool called an Implicit Association Test, which has been used widely in social psychology research for nearly 20 years to measure hidden biases. We worked with Project Implicit to modify the test to specifically examine subconscious attitudes towards lung cancer compared with breast cancer. We conducted the study with oversight from an Institutional Review Board (IRB).
Here’s what we found in our study5:
- 67% of people associated lung cancer with shame
- 74% associated lung cancer with stigma
- 75% associated lung cancer with hopelessness
- 86% associated lung cancer with smoking
Why does this bias exist?
Society’s attitudes and the understanding of lung cancer have played a role in shaping perceptions of people with the disease. In the 1950s, for example, smoking was the norm. Then, when the U.S. Surgeon General reported on a link between smoking and lung cancer in 1965, we started to view lung cancer as a self-induced disease and this has become deeply engrained in society. This is why it is important to continually communicate that smoking is only one cause of lung cancer, particularly since we are seeing a growing number of people diagnosed who are ‘never smokers’.6
Further, until recently, there were not many survivors of lung cancer who could collectively spread hope like other cancer advocacy movements. But now, there are many reasons for people with lung cancer to be hopeful. For people at high risk of developing lung cancer, Medicare now covers routine lung cancer screening so that the disease can be detected in its earlier stages when it’s more treatable.7 Only a decade ago, there were limited treatments available for people diagnosed with lung cancer, and now there has been an explosion of new options. More needs to be done to substantially improve lung cancer treatment, but we’re headed in the right direction.
How might bias impact care?
The Lung Cancer Project is conducting research to further understand the impact of the lung cancer bias on patient care. In healthcare professionals, this means determining if subconscious thoughts may be resulting in less aggressive treatment or fewer referrals to an oncologist.
For example, we knew from another study that primary care doctors were less likely to refer people with advanced lung cancer to an oncologist for anti-cancer treatment than they were for people with advanced breast cancer.8 In fact, people with lung cancer were often referred only to receive symptomatic care. Was this also true for pulmonologists, who are often among the first specialists to diagnose lung cancer? We collaborated with the International Association for the Study of Lung Cancer (IASLC) to conduct research to answer this question.
Again, the study results were surprising: 38% of people with lung cancer and 28% of people with advanced lung cancer never saw a cancer specialist within one year of their diagnosis.9 Approximately 1 in 10 patients with advanced lung cancer did not receive any type of cancer-directed therapy.10
Our vision for change
If we can increase the treatment rate of advanced lung cancer by understanding and removing the stigma and other barriers, we can ensure that more people with this disease receive the care they deserve.
We know from our study with researchers at the Fred Hutchinson Cancer Research Center that even a 10% increase in the number of people with advanced lung cancer getting treated with currently available medicines could add more than 35,000 years of life across the entire population compared to what was possible in 1990, when no anti-cancer treatment was available for these patients. 11
What can you do?
We all have a role in improving the lives of people with cancer. Whether it’s understanding the barriers to care, educating others about the stigma to change the way they think about lung cancer, encouraging screening for high-risk individuals, or referring a patient to a specialist, together we can help everyone get the care they deserve.
Sriram. Mills J, Lang E, et al. Attitudes and Stereotypes in Lung Cancer versus Breast Cancer. PLOS ONE. 2015; 10(12): e0145715.
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.1, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2014.
Small AC, Tsao C-K, Moshier EL, et al. Prevalence and Characteristics of Patients With Metastatic Cancer Who Receive No Anticancer Therapy. Cancer. 2012;118:5947-5954.
American Cancer Society. Cancer Facts & Figures 2016. Atlanta: American Cancer Society; 2016.
Schiller JH, Bowden CJ, Mills J, et al. Explicit and implicit attitudes toward lung cancer (LC) relative to breast cancer (BC). Program and abstracts of the 2013 Annual Meeting of the American Society of Clinical Oncology; May 31-June 4, 2013; Chicago, Illinois. Abstract 8017.
Pelosof L, et al. “Increasing Incidence Of Never Smokers In Non-Small Cell Lung Cancer Patients.” Oral presentation at the 2015 World Conference on Lung Cancer on September 8.
National Cancer Institute. Surveillance Epidemiology and End Results Stat Fact Sheets: Lung and Bronchus. http://seer.cancer.gov/statfacts/html/lungb.html.
Differences in primary care clinicians’ approach to non-small cell lung cancer patients compared with breast cancer. J Thorac Oncol. 2007;2(8):722–728.59.
Ganti AK, Borghaei H, Hirsch FR, et al. Real-World Patterns of Access to Cancer Specialist Care among Patients with Lung Cancer in the United States: A Claims Database Analysis. Oral presentation at the 2015 World Conference on Lung Cancer on September 7.
Ganti AK, Hirsch FR, Wynes MW, et al. Access to Cancer-Directed Therapies and Cancer Specialists in Patients with Metastatic Lung Cancer. Oral presentation at the 2015 World Conference on Lung Cancer on September 8.
Roth JA, Goulart BHL, Ravelo A, et al. Survival Gains from Systemic Therapy in Advanced Non-Small Cell Lung Cancer in the U.S., 1990-2015: Progress and Opportunities. Poster presentation at the 2015 World Conference on Lung Cancer on September 7.
Here are some books you might enjoy (from the TDWI Team):