A population-based study on social inequality and barriers to healthcare-seeking with lung cancer symptoms

Lung cancer is a leading cause of cancer-related deaths globally. Early diagnosis is crucial for improved prognosis, and contacting a GP upon experiencing symptoms is a prerequisite. While awareness campaigns have increased awareness of some cancer symptoms, healthcare-seeking remains a complex process influenced by socioeconomic status and lifestyle factors. Studies show that only about 40% of individuals with lung cancer symptoms contact their GP, with even lower rates among smokers. Social inequalities in lung cancer prevalence and mortality persist, with smoking being a major contributor, but socioeconomic factors also play a role. While lung cancer screening offers potential for early diagnosis, it doesn't detect all cancers, making symptom-based healthcare-seeking vital. Previous research primarily focused on socioeconomic status, neglecting smoking status. This study aims to explore barriers to healthcare-seeking with lung cancer symptoms in the general population and analyze the impact of social inequality by considering age, sex, smoking status, and socioeconomic factors.

Existing literature highlights the significant impact of early diagnosis on lung cancer survival. Several studies have shown that only a minority of individuals with lung cancer symptoms seek medical attention, particularly among smokers. Qualitative studies suggest that fear of stigma, neglect, or normalization of symptoms contribute to delayed healthcare-seeking among smokers. Patients have reported feelings of blame and shame when presenting symptoms or receiving a diagnosis. Prior research has primarily focused on socioeconomic status or anticipated barriers, lacking a comprehensive population-based perspective incorporating smoking status. This gap in knowledge necessitates further research to improve early diagnosis and survival rates.

This population-based study utilized data from the Danish Symptom Cohort (DaSC), a nationwide survey of 100,000 individuals aged 20 years or older. After exclusions (death, unreachable, severe illness, language barriers, emigration), 95,253 individuals were eligible, with 49,706 completing the questionnaire (52.2% response rate). Further exclusion of individuals under 40 and those with incomplete data resulted in a final sample of 35,938 respondents. The survey collected information on lung cancer symptoms (prolonged coughing, shortness of breath, haemoptysis, prolonged hoarseness), GP contacts, barriers to healthcare-seeking (using the Awareness and Beliefs About Cancer (ABC) measure: "Being too embarrassed," "Being worried about wasting the doctor's time," "Being worried about what the doctor might find," and "Being too busy"), and smoking status. Socioeconomic data were obtained through linkage to Danish Registers. Descriptive statistics and multivariate logistic regression models were used to analyze the data, adjusting for age, smoking status, labor market affiliation, educational level, and ethnicity.

The study population consisted of 35,938 respondents aged 40 years or older (53.2% women). The most frequent symptoms were prolonged hoarseness (8.9%) and shortness of breath (8.1%), while haemoptysis was the least frequent (0.1%). The proportion of GP contacts varied significantly across symptoms (31.3% for prolonged hoarseness to 54.5% for shortness of breath). Experiencing multiple specific lung cancer symptoms increased the likelihood of GP contact. Among individuals without GP contact, 38.2% to 47.7% reported no barriers. "Being worried about wasting the doctor's time" and "being too busy" were the most frequent barriers. Current smokers were three times more likely to report "being worried about what the doctor might find" for prolonged coughing and shortness of breath and almost five times more likely to report "being too embarrassed" about shortness of breath compared to never smokers. Immigrants or descendants of immigrants with prolonged coughing showed higher odds of reporting "being too embarrassed." Individuals out of the workforce were less likely to report "being too busy" compared to those working.

This large population-based study provides valuable insights into healthcare-seeking behavior and barriers related to lung cancer symptoms. The finding that reporting multiple symptoms increases GP contact suggests the importance of symptom awareness and recognition. The identified social inequalities highlight the need for targeted interventions. The higher prevalence of barriers among smokers points to the need for strategies addressing stigma, blame, and normalization of symptoms. The differences observed between working and non-working individuals suggest that interventions should consider social and economic factors that might hinder healthcare-seeking. The study's limitations include potential recall bias and the web-based survey format, which might have limited participation from elderly individuals.

Healthcare-seeking for lung cancer symptoms varied considerably across symptoms and was influenced by multiple factors. Social inequalities were evident, particularly among smokers, immigrants, and individuals out of the workforce. Targeted interventions are crucial to address these barriers and improve timely diagnosis. Future research should explore strategies to overcome these barriers, including community-based support systems and enhanced communication between GPs and vulnerable populations.

The study's limitations include potential recall bias, as participants were asked about symptoms and healthcare-seeking within the preceding 4 weeks. The web-based survey design might have excluded individuals with limited internet access, particularly older individuals. The relatively small sample sizes for some subgroups (e.g., former smokers, immigrants) could have limited the statistical power for certain analyses. Finally, while the study explored reported barriers, it did not directly assess the impact of these barriers on the actual decision to seek healthcare.