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

Abstract

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.

What are the similarities and differences in lung cancer symptom appraisal and help‐seeking according to smoking status? A qualitative study with lung cancer patients

“…Comorbidities due to smoking, and perceptions of the current state of health are driving interpretation and coping responses to new symptoms for current smokers, rather than perceived lung cancer risk. This novel finding builds on several qualitative studies that also found a lower self‐perception of risk in never smokers 5,7,14 …”

“…A key message from our research is that perceived urgency is an important driver of timely help‐seeking and follow up, and that patients who experience low levels of concern are less likely to remain vigilant to symptoms. Building on our rapid review of evidence, this study fills a gap in evidence around the way that never smokers seek help for respiratory symptoms, and re‐appraise their symptoms following contact with health services 5 …”

“…However, regular contact with health services to manage chronic disease can trigger opportunistic investigations, for example, changes in blood tests, 17,18 and lung cancer is often diagnosed incidentally, including through ‘non‐cancer’ pathways 19 . Overall, much more is known about smokers' health behaviours than never smokers' health behaviours, particularly in the time between noticing a symptom and being diagnosed with cancer 5 . More research is needed to understand the potential barriers and delays experienced by this growing group of patients, and how their needs differ from patients with a smoking history.…”

“…The relationship between smoking status, symptom appraisal and help‐seeking behaviour is complex. People who have never smoked are less likely to consider themselves at risk of lung cancer, 4 , 5 , 6 , 7 or worry about lung cancer. 8 However, never smokers are more knowledgeable about both smoking‐related and non‐smoking related causes of cancer than smokers, 9 , 10 and are more likely to seek help for a lung cancer ‘alarm’ symptom than smokers.…”

“… 19 Overall, much more is known about smokers' health behaviours than never smokers' health behaviours, particularly in the time between noticing a symptom and being diagnosed with cancer. 5 More research is needed to understand the potential barriers and delays experienced by this growing group of patients, and how their needs differ from patients with a smoking history.…”