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On Being a Doctor |

Taking Responsibility for Lung Cancer

Chang-Qing Gao, MD, PhD
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From Central South University, Changsha, Hunan 410013, China.

Requests for Single Reprints: Chang-Qing Gao, MD, PhD, The Third Hospital of Xiangya School of Medicine, Central South University, Tongzipo Road 138, Changsha, Hunan 410013, China; e-mail, cgao9@yahoo.com.

Ann Intern Med. 2009;151(3):214-215. doi:10.7326/0003-4819-151-3-200907210-00012
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While it thundered and rained outside one Thursday evening, I sat comfortably in my office reading a new report on TB. According to the article, the incidence of TB has increased recently in China, especially in the elderly population.





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Smoking, "responsibility", and lung cancer.
Posted on August 6, 2009
Douglas Arenberg
University of Michigan
Conflict of Interest: None Declared

Dr. Gao wrote an elegant and poignant essay about a man he met with lung cancer, his experience with care of this patient, and his observations of tobacco use in China among both patients and physicians. While one could sense some empathy for Mr. Liu (the patient with the lung cancer), the title of his essay "Taking responsibility for lung cancer" and its implication that the patient was less worthy of our sympathy because he had smoked, left me feeling uneasy. Lung cancer enjoys a unique, but unfortunate place among common deadly diseases.

Somehow, somewhere along the line, it became acceptable for us to lay the blame upon the patients with this disease, perhaps more so than in the case of any other behavior-related disease. HIV and AIDS are other diseases which we allowed to become stigmatized because of behavioral risk factors. AIDS activists rightfully stood up and spoke out against this, and in Western cultures, the acknowledgment of this stigma has lessened it somewhat. By pointing out bias, we reduced it. Lung cancer seems to be the exception to this. Tobacco smoking rates have decreased markedly in the U.S., thanks in large part to successful public health campaigns aimed at stigmatizing the behavior. While, as a pulmonologist, I laud the decrease in smoking rates, I cannot help but cringe when I see the stigma we intentionally attach to smoking be transferred on to the victims of tobacco exposure, and by extension to those lung cancer patients who do not smoke. It seems that the natural reaction to the statement "I have lung cancer" is "Did you smoke?". Is it equally acceptable to say this in response to "I had a heart attack"? Lung cancer survivors, their families and friends have been driven underground by this stigma, and as a result generally do not become vocal advocates for their cause. Meanwhile, breast cancer, with a nearly 90% 5 year projected survival rate, is visible on the pages of magazines, on boxes of cookies covered with pink ribbons, and on roadside billboards. The result is a marked imbalance in the earmarking of research dollars that is well out of proportion to the relative mortality of these two diseases.

In 1992 the federal government was spending $100 million a year on breast cancer research. The National Breast Cancer Coalition deluged Congress with signatures and phone calls demanding an increase in federal funding for breast cancer research. Senators Tom Harkin (whose two sisters had breast cancer) and Alfonse D'Amato, helped Congress appropriate $210 million from the Department of Defense (DOD) budget to establish a breast cancer research program. Senators and congressional representatives anxious to show their support and attach themselves to this image have continued to fund this program each year bringing its total to more than $2.1 billion since then.

Where are the responses from veterans groups who have clearly lost more of their comrades to lung cancer than breast cancer? This last year, for the first time, congress directed the DOD to establish a lung cancer research program, funding it with $20 million. Meanwhile lung cancer continues to kill more people every year than breast, colon, and prostate cancer combined. As long as we continue to focus our blame on smokers, expecting them to "take responsibility for lung cancer", this disparity is unlikely to diminish. If shifting-the-blame is what we need to address this injustice, perhaps we can shift our focus to the tobacco companies, and the insidious means with which they advertise their products designed to promote this powerful addiction.

I do not advocate absolving people of taking responsibility for their own health, but the stigma we attach to smoking should not be allowed to affect the way we view and treat patients with lung cancer. Really taking responsibility for lung cancer would require public support, and increased research on early detection, novel treatments and anti-smoking efforts that do not focus shame on those with smoking related diseases.

Conflict of Interest:

None declared

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