An expert discussed how approaching the stigma around lung cancer in an empathetic way may be the tool to help eliminate disparities around screening for the disease.
Although inequities persist in lung cancer screening, especially among patients in the Black population, the trusted relationship that oncology nurses have with patients who may be eligible for screening can be the catalyst to increase screening rates, an expert said.
Lisa Carter-Bawa, PhD, MPH, APRN, ANP-C, FAAN, director of the Cancer Prevention Precision Control Institute at the Center for Discovery and Innovation and director of Cancer Community Outreach and Engagement at Hackensack Meridian in Nutley, New Jersey, spoke with Oncology Nursing News about the challenges oncology nurses face with lung cancer screen, some modern-day solutions that can make an impact on patients, and how authentic conversations between nurses and patients can help alleviate some of the stigma behind lung cancer screening.
Can you go into detail about the challenges oncology nurses face regarding lung cancer screening?
Sometimes we overlook the fact that oncology nursing is so critical in the early stage. We think of being diagnosed, treatment, and survivorship, but oncology nursing is such a critical component to understanding who is at risk for different types of cancer, specifically lung cancer, and the wealth of knowledge that oncology nurses have around lung cancer risk, identifying it early, the fact that many times there aren't any symptoms, and those who are eligible for lung cancer screening. It's that knowledge that nursing brings to this topic.
The challenges is really within a health system. One of the biggest challenges that we have with lung screening is being able to identify those people who are eligible for lung screening to even have this conversation with.
Equally so, there is a stigma that is associated with lung cancer; it's a smoking-related stigma. People assume that when you get lung cancer that you smoked. Does it matter if you smoked or not? We don't look at people who've had a heart attack and say, “You're not vegan, and you don't run 5 times a week.” We don't blame them for behavior. And I'm speaking to the choir, because oncology nurses know that 40% of people who are diagnosed with lung cancer either quit or never smoked.
It's really, really hard facing that stigma that's associated with a lung cancer diagnosis or being eligible for lung cancer screening, and to engage in those conversations with patients around their eligibility in an empathic way that doesn't further stigmatize them.
What are the challenges oncology nurses face regarding the inequities among underserved groups for lung cancer screening?
Lung cancer screening has been an official recommendation for a decade now. Even though it's been an official [United States Preventative Services Task Force (USPSTF)] recommendation for a decade, only 5% of the screening-eligible population in the US has screened for lung cancer. And when you look at that by race/ethnicity, it's even more abysmal. When you look at Black screening-eligible individuals, only 1.7% of those who are Black and eligible for lung cancer screening have screened. That inequity comes from lack of awareness and lack of knowledge broadly, but even more so in the African American community.
We have to be real and think about things like medical mistrust—not only just stigma—but thinking about the historical memory that African Americans have with the medical system. It's very challenging to both acknowledge the wrongs that were done historically, and to form a bridge between the health system and the Black individual who's eligible for lung screening to engage in that conversation.
But then when we also look at it from a socioeconomic status, our minoritized populations are less likely to engage with the health system. They may not have health insurance or be regularly engaging in wellness care that would have your preventive screenings conversations included. The biggest thing is, it’s not just 1 factor that is serving as a barrier to lung cancer screening, particularly in our Black population. It's multiple factors.
I'm a nurse and a nurse practitioner. And we are the most trusted profession consistently. We're rated that every year. And that's something to capitalize on; when you're thinking about how do we address lung cancer screening, the lack of awareness in lung cancer screening, and the low screening rates is capitalizing on that trusted relationship that the profession of nursing has with our general public, and to be a voice for prevention and early detection. The nurse is the ideal person to hold this banner up and be on this bandwagon.
Can you tell us more about some 21st century solutions to these challenges?
I am a scientist as well as a clinician. One of the things that I've been using in my own work is leveraging tools and platforms like social media to increase awareness.
I am currently leading a large study that's funded by the National Cancer Institute, where we're leveraging Facebook-targeted advertisements to reach screening-eligible individuals and increase their awareness. We’re not just saying, “Here's lung screening.” We actually intervene with a computer-tailored health communication and decision support tool that goes through and teaches. It's a 10-minute interactive video that is tailored based upon someone's smoking status as well as their perceived barriers. And it doesn't just talk about lung screening. We feel like someone who is eligible for lung screening has smoked for a long time, has a long history of smoking. If you scan somebody's lungs who has a long history of smoking, you're likely to find something. Ninety-five percent of time, it's not cancer, but it could be other things that are equally concerning. So the nurse in me wants to educate more broadly. We start out by educating about lung health, and then drill down on the fact of lung cancer screening. That has actually been 1 of the tools that we've been able to be very successful with in reaching individuals who aren't engaged with the health system. Thirty-five percent of our current participants are African American, 15%, I believe, are Latino ethnicity.
When you think about 21st century solutions, you think about not just the normal routes, avenues, and platforms to reach people like mass media. We have to acknowledge the fact and the power of social media.
I remember when I first started in this about 10 years ago, my mentors thought it was crazy to leverage social media to intervene in a health-related way. I disagreed because how you reach people is where they're at. Who's scrolling through Instagram, who's on Twitter, LinkedIn, all the different types of social media.
You mentioned earlier that the healthcare system has to approach this stigma or try to avoid it in an empathetic way. What advice would you give oncology nurses on how to navigate conversations around lung cancer screening, whether they smoked or not?
One of the hats that I wear is that I'm the chair of the Stigma Nihilism Task Group of the American Cancer Society's National Lung Cancer Roundtable. One of the things that we have been working on for many years now is changing the public discourse around lung cancer and the stigma associated with it.
One of the things is the word “smoker.” We don't call people “a smoker,” because it's labeling them by a behavior. So we say people who currently smoke or people who used to smoke. It's simple things about the language you don't necessarily think about until it's something that's touched you or someone you love, and to be very cognizant of the types of phrasing that you're using.
I have very good colleagues at Memorial Sloan Kettering Cancer Center who are leading some work around empathic communication skills training, and I am a co-investigator on that study. But it's really fascinating to look at how you engage with language with patients. Nobody who's in the healthcare field—at least this is my thought—I don't think that there's anybody out there who is going into a patient's room and saying, “I want to stigmatize you.” It's something that happens very subconsciously. It's something that's been baked into the way that we've been raised in the public discourse that we've heard. But when you bring someone's attention to using the word smoker, or using blaming shaming language, and interactions, it raises their awareness. And they don't do it. They want to know, how can I approach this?
One of the things that my colleague Jamie S. Ostroff, PhD, always says is, taking a smoking history doesn't have to be painful, and it shouldn't be painful. There are ways that you can come and that you can interact when you're taking that smoking history to lessen the stigma, and lessen the feelings of shame and blame. I think patients don't understand why we ask the smoking question. They think that you're looking to wag your finger at them or have a conversation that that blames them and really scolds them about it. Simple things like telling a patient why I'm asking you this, like saying, “Hey, I know you get asked this all the time, but I need to ask you about your smoking history, because it helps with your plan of care, or the medications that we might prescribe you.” And when you can remove the veil of why that question is asked, and come very authentically and very genuinely to the patient and explain, then they're like, “Oh, OK.” And it also helps to develop a trusting rapport with the patient. It's all about being authentic with your interactions, which I think in nursing gets an A+ on.
This transcript has been edited for clarity and conciseness.