Lung cancer screening participation: attitudinal, socioeconomic and smoking-related factors

Socioeconomic and smoking-related biases in participation threaten the equity and effectiveness of any future UK lung cancer screening programme. This thesis used a mixed methods approach to investigate psychosocial and cognitive factors that might contribute to these biases, with the aim of identifying possible targets for intervention in screening communication strategies. This informed the design of screening invitation materials aimed at engaging low socioeconomic position (SEP) smokers with a screening offer, which were tested using a randomised controlled pilot trial. The findings of these studies suggest that the introduction of a lung cancer screening programme would be acceptable to older English adults. However, while there was high willingness to be screened (>91%), this was not matched by high uptake of screening in the pilot trial (55%). Chapters 4 to 7 showed that negative beliefs about outcomes and early detection for lung cancer were prevalent among participants recruited from low SEP communities, and associated with current smoking status. Compared with their non-smoking counterparts, smokers more commonly expressed fatalistic beliefs about risk, survival and treatment for lung cancer (including early stage disease), worried about lung cancer and the outcome of screening, and perceived smoking and lung cancer to be stigmatised. Intervention screening invitation materials were designed to improve uptake by minimising these factors but an early interim analysis of the pilot trial testing these materials showed no effect on uptake of lung cancer screening appointments (n=241; final target N=2000). Lower SEP smokers’ more negative expectations of risk, stigma, treatment and outcomes for lung cancer, particularly for older high risk adults, appear to undermine the salience and perceived personal benefit of lung cancer screening. Further work needs to be done to explore whether interventions can effectively modify these perceptions to improve engagement with screening among the very group most likely to benefit

Examining Facilitators of HPV Vaccination Uptake in Men Who Have Sex with Men: A Cross-Sectional Survey Design

Men who have sex with men (MSM) in England are eligible for vaccination against human papillomavirus (HPV) via specialist sexual health services and HIV clinics. Uptake among clinic attendees is incomplete, but the reason for this is unclear. We do not know who is accessing and being offered the vaccine. This cross-sectional study conducted in England examined socio-demographic correlates of vaccine uptake for MSM and how frequently the vaccine is being offered in clinics. MSM completed an online questionnaire asking about socio-demographic characteristics, whether they had recently attended a sexual health or HIV clinic, and if so, whether they had been offered the vaccine, and vaccination status. Around 52% of MSM (N = 115; mean age = 30.2) had received at least one dose of the vaccine, and 70% of clinic attendees had been offered the vaccine. MSM were more likely to have initiated the vaccine series if they were homosexual (versus bisexual; OR: 5.22; 95% CI: 1.55–17.51) or had heard about the vaccine from one or two types of sources (versus no sources: OR: 14.70; 95% CI: 4.00–54.00 and OR: 26.00; 5.74–117.77 respectively). Initiation was not associated with age, ethnicity, education level, or number of sexual partners. Hepatitis B vaccination status was associated with vaccination initiation only in unadjusted models. The majority of eligible MSM are being offered the vaccine in clinics. Socio-demographic differences in uptake of the HPV vaccine among MSM may lead to inequalities in HPV-related disease

Attitudes towards lung cancer screening in socioeconomically deprived and heavy smoking communities: informing screening communication

BACKGROUND: While discussion continues over the future implementation of lung cancer screening, low participation from higher risk groups could limit the effectiveness of any national screening programme. OBJECTIVES: To compare smokers' beliefs about lung cancer screening with those of former and never smokers within a low socioeconomic status (SES) sample, to explore the views of lower SES smokers and ex-smokers in-depth, and to provide insights into effective engagement strategies. DESIGN, SETTING AND PARTICIPANTS: Using proactive, community-based recruitment methods, we surveyed 175 individuals from socioeconomically deprived communities with high smoking prevalence and subsequently interviewed 21 smokers and ex-smokers. Participants were approached in community settings or responded to a mail-out from their housing association. RESULTS: Interviewees were supportive of screening in principle, but many were doubtful about its ability to deliver long-term survival benefit for their generation of "heavy smokers." Lung cancer was perceived as an uncontrollable disease, and the survey data showed that fatalism, worry and perceived risk of lung cancer were particularly high among smokers compared with non-smokers. Perceived blame and stigma around lung cancer as a self-inflicted smokers' disease were implicated by interviewees as important social deterrents of screening participation. The belief that lungs are not a treatable organ appeared to be a common lay explanation for poor survival and undermined the potential value of screening. CONCLUSIONS: Attitudes towards screening among this high-risk group are complex. Invitation strategies need to be carefully devised to achieve equitable participation in screening

Socioeconomic inequalities in attitudes towards cancer: an international cancer benchmarking partnership study.

Socioeconomic status (SES) differences in attitudes towards cancer have been implicated in the differential screening uptake and the timeliness of symptomatic presentation. However, the predominant emphasis of this work has been on cancer fatalism, and many studies focus on specific community subgroups. This study aimed to assess SES differences in positive and negative attitudes towards cancer in UK adults. A population-based sample of UK adults (n=6965, age≥50 years) completed the Awareness and Beliefs about Cancer scale, including six belief items: three positively framed (e.g. 'Cancer can often be cured') and three negatively framed (e.g. 'A cancer diagnosis is a death sentence'). SES was indexed by education. Analyses controlled for sex, ethnicity, marital status, age, self-rated health, and cancer experience. There were few education-level differences for the positive statements, and overall agreement was high (all>90%). In contrast, there were strong differences for negative statements (all Ps<0.001). Among respondents with lower education levels, 57% agreed that 'treatment is worse than cancer', 27% that cancer is 'a death sentence' and 16% 'would not want to know if I have cancer'. Among those with university education, the respective proportions were 34, 17 and 6%. Differences were not explained by cancer experience or health status. In conclusion, positive statements about cancer outcomes attract near-universal agreement. However, this optimistic perspective coexists alongside widespread fears about survival and treatment, especially among less-educated groups. Health education campaigns targeting socioeconomically disadvantaged groups might benefit from a focus on reducing negative attitudes, which is not necessarily achieved by promoting positive attitudes

Pulmonary nodules and CT screening: the past, present and future

Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK

Mapping the spectrum of psychological and behavioural responses to low-dose CT lung cancer screening offered within a Lung Health Check

BACKGROUND: Research on the psychological impact of low-dose computed tomography (LDCT) lung cancer screening has typically been narrow in scope and restricted to the trial setting. OBJECTIVE: To explore the range of psychological and behavioural responses to LDCT screening offered as part of a Lung Heath Check (LHC), including lung cancer risk assessment, spirometry testing, a carbon monoxide reading and smoking cessation advice. METHODS: Semi-structured interviews were carried out with 28 current and former smokers (aged 60-75), who had undergone LDCT screening as part of a LHC appointment and mostly received an incidental or indeterminate result (n = 23). Framework analysis was used to map the spectrum of responses participants had across the LHC appointment and screening pathway, to their LDCT results and to surveillance. RESULTS: Interviewees reported a diverse range of both positive and negative psychological responses, beginning at invitation and spanning the entire LHC appointment (including spirometry) and LDCT screening pathway. Similarly, positive behavioural responses extended beyond smoking cessation to include anticipated implications for other cancer prevention and early detection behaviours, such as symptom presentation. Individual differences in responses appeared to be influenced by smoking status and LDCT result, as well as modifiable factors including perceived risk and health status, social support, competing priorities, fatalism and perceived stigma. CONCLUSIONS: The diverse ways in which participants responded to screening, both psychologically and behaviourally, should direct a broader research agenda to ensure all stages of screening delivery and communication are designed to promote well-being, motivate positive behaviour change and maximize patient benefit

Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership.

Smoking cessation is the key cancer prevention behaviour for smokers; nonetheless, smokers can still benefit from earlier diagnosis of cancer. However, fewer smokers participate in screening despite their increased risk, which may reflect different beliefs about cancer

Lung cancer symptom appraisal, help-seeking and diagnosis - rapid systematic review of differences between patients with and without a smoking history

BACKGROUND: Lung cancer is the leading cause of cancer death in the world. A significant minority of lung cancer patients have never smoked (14% in the UK, and ranging from 10% to 25% worldwide). Current evidence suggests that never-smokers encounter delays during the diagnostic pathway, yet it is unclear how their experiences and reasons for delayed diagnoses differ from those of current and former smokers. This rapid review assessed literature about patient experiences in relation to symptom awareness and appraisal, help-seeking, and the lung cancer diagnostic pathway, comparing patients with and without a smoking history. METHODS: MEDLINE, PsychINFO and Google Scholar were searched for studies (2010-2020) that investigated experiences of the pathway to diagnosis for patients with and without a smoking history. Findings are presented using a narrative synthesis. RESULTS: Analysis of seven quantitative and three qualitative studies revealed that some delays during symptom appraisal and diagnosis are unique to never-smokers. Due to the strong link between smoking and lung cancer, and low awareness of non-smoking related lung cancer risk factors and symptoms, never-smokers do not perceive themselves to be at risk. Never-smokers are also likely to evaluate their experiences in comparison with other non-smoking related cancers, where prognosis is likely better, potentially leading to lower satisfaction with healthcare. CONCLUSION: Never-smokers appear to have different experiences in relation to symptom appraisal and diagnosis. However, evidence in relation to help-seeking, and what is driving diagnostic delays for never-smoker patients specifically is lacking

Changing from face-to-face to virtual meetings due to the COVID-19 pandemic: Protocol for a mixed-methods study exploring the impact on cancer multidisciplinary team (MDT) meetings

INTRODUCTION: In the UK, the National Cancer Plan (2000) requires every cancer patient’s care to be reviewed by a multidisciplinary team (MDT). Since the introduction of these guidelines, MDTs have faced escalating demands with increasing numbers and complexity of cases. The COVID-19 pandemic has presented MDTs with the challenge of running MDT meetings virtually rather than face-to-face. This study aims to explore how the change from face-to-face to virtual MDT meetings during the COVID-19 pandemic may have impacted the effectiveness of decision-making in cancer MDT meetings and to make recommendations to improve future cancer MDT working based on the findings. METHODS AND ANALYSIS: A mixed-methods study with three parallel phases: Semistructured remote qualitative interviews with ≤40 cancer MDT members. A national cross-sectional online survey of cancer MDT members in England, using a validated questionnaire with both multiple-choice and free-text questions. Live observations of ≥6 virtual/hybrid cancer MDT meetings at four NHS Trusts. Participants will be recruited from Cancer Alliances in England. Data collection tools have been developed in consultation with stakeholders, based on a conceptual framework devised from decision-making models and MDT guidelines. Quantitative data will be summarised descriptively, and χ2 tests run to explore associations. Qualitative data will be analysed using applied thematic analysis. Using a convergent design, mixed-methods data will be triangulated guided by the conceptual framework. The study has been approved by NHS Research Ethics Committee (London—Hampstead) (22/HRA/0177). The results will be shared through peer-reviewed journals and academic conferences. A report summarising key findings will be used to develop a resource pack for MDTs to translate learnings from this study into improved effectiveness of virtual MDT meetings. The study has been registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/D2NHW)