Do you think the high rate of nontreatment in lung cancer is related to the stigma surrounding the disease?

Dr Masters: It’s hard to answer that factually, but in terms of my sense there probably is some impact of that. I don’t think that we see clinicians – I hate to use this term – but sort of punishing people for smoking. Treatment isn’t withheld because it’s “their fault,” in a sense.

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We did see some of that in the past but that’s 20 years or more ago. I think that many pulmonologists who have been telling their patients to quit smoking for years and years can sometimes have a nihilistic approach to advanced lung cancer. But I don’t think there are people who are not referred for treatment just because it’s “their fault.”

I think there are some patients who feel they did this to themselves and don’t see the point of getting treatment, especially when it’s palliative and may only improve their survival by a few months. But that may also be ingrained in someone’s personality.

How do you deal with patients who are either unwilling or unable to quit smoking after their diagnosis?

Dr Masters: Many patients do quit smoking when they’re diagnosed with cancer, but at the same time there are some that don’t, and some don’t even try. But I try not to give up. I try to help them understand intellectually how quitting can help them. I try to help them deal with it emotionally in terms of taking that responsibility for themselves.

I work in other factors like group therapy or other things we can do to help quit smoking. We have a hotline where I work in Delaware that they can call. They can meet with a psychologist at our cancer center and talk about some of the barriers to quitting.

In a way, when you can’t quit smoking it’s partly that you’re having trouble helping yourself. That’s a bigger problem than just the smoking – the addiction is clearly a big part of it too. I try to discuss it at most visits and help them understand the benefits of quitting, but some people just don’t quit. It’s frustrating, but you can’t fix every problem.

How do you help patients deal with stigmatization by friends or family around their diagnosis?

Dr Masters: I go back to the fact that there are things that we’ve all done that probably weren’t in our best interests. No one’s perfect that I know, and so clearly someone who’s been a heavy smoker and develops lung cancer is the extreme end of that, but at the same time you can’t go backwards.

You can say “This is where you are now, let’s do the best we can to help you feel better, to help you live longer, and to manage a tough situation.” When I see the patients they’re in that tough situation already. I’m trying to help them get through it or get out of it, but I can’t help them from getting into it.

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If you’re a primary care doctor dealing with younger patients, trying to get them to quit smoking when they’re in their 20s is a different end of the spectrum. Clearly if you can get them to quit, you’ve really helped someone long term.

What are the key approaches you think clinicians can use to address these problems?

Dr Masters: Dealing with these issues from a multifaceted point of view is how we best help our patients. I think that is becoming better recognized as we better understand what our job is and incorporate more of a team approach. That’s really the way that we help patients best, and it’s being strongly condoned by societies in guidelines, recommendations, and training programs. So I think we’re getting better at helping people with these problems.