Andrew J. Roth
A recent study in the journal PLOS ONE
showed greater levels of shame and stigma associated with lung cancer compared with breast cancer. The two-part study analyzed survey results and implicit-association test results from 1,778 individuals.
To gain insight into the methodology and impacts of this research, CURE
interviewed Joan H. Schiller, an author on the study.
Schiller is the Chief of the Hematology/Oncology Division at University of Texas Southwestern, Deputy Director of the Harold C. Simmons Cancer Center and holds the Andrea L. Simmons Distinguished Chair in Cancer Research.
CURE: How was this study conducted?
It was an online study and it involved a unique method called the implicit-association test. This is a test where people are shown two pictures and two words and they have to put the picture and word together — the study measured how quickly people did that. Some of the words and pictures had to do with breast cancer and some had to do with lung cancer.
It was a large study of about 1,700 people — people in the community, patients, caregivers, health care providers and more.
It turns out that, basically, people matched breast cancer pictures with more favorable word more quickly than they did lung cancer. With lung cancer pictures, they matched with words such as 'bad,' 'dirty' or 'contagious' much faster than they matched breast cancer with those words.
Can you explain the time element of the methodology?
The idea here is that small time differences can measure subconscious biases. The differences were in milliseconds, but those differences can determine a reflexive response.
What was the reasoning behind comparing breast cancer, specifically, and lung cancer?
Breast cancer has really overcome stigma, compared with how it was viewed in the 1960s, when it was a disease in the closet. Breast cancer represents a cancer that people are behind conquering, and it is a cancer that everyone is aware of.
Were you surprised by the results?
I was not. Our hypothesis was that there would be more of a subconscious bias against lung cancer compared with breast cancer, and that's what we saw.
There were two parts to the study, actually. The other part — not the picture association segment — was just asking people how they felt about breast cancer or lung cancer. The picture association part of the study brought out the fact that these associations were subconscious. Again, because it was so fast, subjects didn't have a chance to think.
It did not matter which group of participants we looked at — patients, caregivers, health care professionals or the general public — the conclusions were the same.
Why might this stigma exist in the first place?
There are several reasons. The stigma started in the 1960s when the American Cancer Society depicted smokers as ugly. That campaign had an unfortunate set of consequences, including that lung cancer is a self-induced disease. While that's true for many patients with lung cancer, it's not true for all, and there are many other self-induced diseases that don't have this stigma. When someone has a heart attack, the first question is not 'How many Big Macs did you eat?' But if someone is diagnosed with lung cancer, the first question often asked is, 'Did you smoke?'
Another major reason for the stigma is that until recently there were not many survivors of lung cancer. It also was, previously, a disease of men. Men do not advocate well compared with women.
Many people who smoke started before they understood the dangers or understood how easy it was to get hooked. The government gave away cigarettes to soldiers in World War II and the Korean War. Tobacco companies minimized the risks of smoking in the 1960s. All of these facts contributed to getting a lot of people addicted.
What do you think a patient or survivor should know about this study?
Until this, we had little hard data to show that there actually was a stigma against lung cancer. Now that we can point to this stigma with hard data, we hope to investigate the ramifications of it.
One ramification that may exist is that if there are negative associations with lung cancer, perhaps patients and caregivers may not be as proactive to seek treatment or advocate for research. We need to figure out how to overcome this.
We have a study going on right now that asks lung cancer patients about whether or not they can sense this stigma and how it may have affected them. We're also designing an intervention to channel negative feelings into positive action. We want people to not accept the negative feelings but rather to use them to be proactive.
What should health care professionals — oncologists, oncology nurses and even social workers — take away from this study?
I hope they recognize that something may be going on subconsciously. They should be asking themselves how a subconscious thought may be impacting patient care. Are they a little less aggressive when treating lung cancer patients? Are they ready to give up earlier? Are they less likely to refer a lung cancer patient to large academic medical centers? I think health care professionals need to realize that these things may be happening.