Table 1.

Characteristics and results of qualitative studies on stigma and nihilism in lung cancer

Study	Design (Level of evidence)	Participants	Aim of interview	Study factor	Results
Chapple 2004a & b, UK	Home interview (Level III)	Lung cancer patients	Lung cancer patients’ experience of lung cancer including their perceptions, how others reacted to the diagnosis and financial issues	Stigma	Some participants perceived lung cancer as being viewed in the broader society as a self-inflicted disease resulting from smoking and leading to a horrible death. One participant noted that the stigma applied to all lung cancer patients; smokers and non-smokers. As a result of the smoking related stigma it was thought that lung cancer research and screening was neglected.
		N = 45			The press was criticised for blaming lung cancer patients in particular for their disease.
		NSCLC, SCLC and mesothelioma; All stages.			Medical and treatment outcomes
		Recruited through general practices, nurses, oncologists, chest physicians and support groups and through study website.			Smoking related stigma was thought to be a reason for lung cancer symptoms not being taken as seriously as those for other cancers leading to delays in diagnosis.
					Psychosocial outcomes
					Stigma was perceived to result in social isolation, and deterred support group participation (1 participant) and seeking financial relief (1 participant).
Conlon 2010, USA	Interview, (Level III)	Oncology social workers	Social workers’ perceptions of the lung cancer experience	Stigma	Smoking stigma
		N = 18			Lung cancer was always associated with smoking and patients often reported stigma, guilt, blame and shame. Smoking stigma was seen as a reason why support, funding and advocacy for lung cancer were lower.
		Recruited from 17 cancer hospitals in 13 states with experience with approximately 25,000 lung cancer patients.			Division between lung cancer patient smokers and non-smokers.
					Poor prognosis stigma
					Patient reported lung cancer stigmatised as being mostly fatal.
					Psychosocial outcomes
					Patients reported smoking stigma sometimes resulted in reluctance to tell others that they have lung cancer.
					Psychosocial outcomes
					Poor prognosis stigma potentially led to difficulties attending support groups.
Corner 2005 & 2006, UK	Semi-structured interviews with a time-line prompt mostly in home and often with a relative present (Level III)	Patients recently (<3 months) diagnosed with lung cancer	To explore delays in lung cancer diagnosis	Stigma	Medical and treatment outcomes
		All experienced symptoms for 4 months or more prior to visiting doctor			Factors potentially leading to delay in seeking medical treatment included expectation and fear that smokers would be denied treatment (reported by 1 participant who was a smoker)
		N = 22; 12 men, 10 women
		Median age = 68 years
		15/22 inoperable disease
		1/22 never smoker
		Recruited from 2 hospital outpatient clinics.
Leydon 2003, UK	Telephone and face-to-face semi-structured interviews (Level IV)	Cancer patients diagnosed < 2 years ago with a focus on those of lower SES	Perceptions of cancer diagnostic process	Lung cancer specific fear	Medical and treatment outcomes
		N = 17; 5 men, 12 women			Lung cancer viewed as fatal (by 1 participant). This theme was reported as arising in the context of potential barriers to seeing a doctor
		Included 2 lung cancer patients; a 67 year old male and a 59 year old female.
		Recruited through cancer support community organisations.
Sharf 2005 USA, Texas	Interview with guiding questions (Level III)	Patients with NSCLC or a suspicious pulmonary mass who refused or did not follow-up for physician-recommended treatment (N = 7) or invasive investigation (N = 2).	Reasons for declining physician-recommended treatment or follow–up options	Nihilism	Medical and treatment outcomes
		100% male, 89% white			Reasons reported included the view that lung cancer treatments were futile (5 participants).
		Identified at multidisciplinary pulmonary conferences and review of pathology reports at a university affiliated Veterans Affairs hospital.
		9/31 eligible patients interviewed
		2 with history of depression
Tod 2008, UK	Semi-structured home interviews with partner or a friend participating at the request of 12 participants (Level III)	Lung cancer patients	Factors influencing delay in reporting symptoms (patient delay)	Stigma	Medical and treatment outcomes
		N = 20; 12 men, 8 women.		Nihilism	Factors identified that might result in patient delay in consulting a doctor about their symptoms included the stigma that it was caused by smoking and fear.
		18 diagnosed in past 6 months
		3 non smokers; 9 previous smokers.
		Recruited from deprived health district by a respiratory physician and lung cancer nurse specialists.
Tod 2010 UK	3 focus groups, (Level III)	Focus group 1; 6 community pharmacists (50% female)	Factors influencing delay in reporting symptoms (patient delay)	Stigma	Medical and treatment outcomes
		Focus group 2: 6 clinical nurse specialists (100% female)			Factors identified that might result in lung cancer patient delay in consulting a doctor about their symptoms included fear of negative evaluation and expectation of denial of treatment especially for smokers.
		Focus group 3: 2 practice nurses (100% female)
		Recruited an area with high levels of lung cancer and smoking and a history of heavy industry

NSCLC = Non small cell lung cancer; SCLC = Small cell lung cancer.