2.1. Study Design and Participants

A cross-sectional study was conducted at Yunnan Cancer Hospital, which was the Cancer Center of Yunnan Province, China. A convenience sampling method was used to recruit a total of 1016 participants (254 pairs of SLCPs and families and 254 pairs of LCPs and their families) consecutively from March 2022 to August 2022. Whenever one participant from SLCPs or LCPs was selected, one of their families (spouse, parents, son, or daughter) also correspondently was selected for survey. LCPs and their families had known the patients’ lung cancer diagnoses, which generally families of patients were informed first, and patients were informed within a week, while SLCPs and their families did not know the patients’ diagnoses yet.

The inclusion criteria for SLCPs included (1) visiting a lung cancer outpatient department without a confirmed cancer diagnosis; (2) living with family; (3) aged 18 or older; (4) willing to sign the informed consent. The exclusion criteria included (1) cannot finish the questionnaire due to a serious physical or mental illness. The inclusion criteria of the SLCPs’ families included (1) identified by SLCPs as the primary caregivers playing the most important role in SLCPs’ therapy decisions and care; (2) aged 18 or older; and (3) willingness to sign informed consent. The exclusion criteria included: (1) cannot finish the questionnaire due to a serious physical or mental illness.

The inclusion criteria of LCPs included (1) having a confirmed and primary lung cancer diagnosis; (2) being informed of their lung cancer diagnosis; (3) living with family; (4) aged 18 or older; and (5) willingness to sign informed consent. The exclusion criteria included (1) cannot finish the questionnaire due to serious physical or mental illness. Inclusion criteria of the LCPs’ family included (1) identified by LCPs as the primary caregivers playing the most important role in LCPs’ therapy decisions and care; (2) being informed of the patient’s lung cancer diagnosis; (3) aged 18 or older; and (4) willingness to sign informed consent. Families who cannot finish the questionnaire due to serious physical or mental illness were excluded.

2.2. Procedure

This study was approved by the Institutional Research Ethics Committee of Yunnan Cancer Hospital (KY202004). Participants were approached and recruited from the outpatient and inpatient departments of thoracic surgery by well-trained nurse investigators who have been working in the departments and have known the patients well. Investigators explained the research purpose and procedure clearly to eligible participants. Participants were fully informed that they could withdraw from this survey at any time, and their choice to participate in or refuse the study will not affect their rights to receive medical services. The researchers guaranteed that all data were collected anonymously, kept confidential, and used for research purposes only. After providing written informed consent, the patients and their families were invited to finish a battery of questionnaires independently in separate rooms so that they didn’t influence each other’s answers. At the end of the survey, the investigators checked the questionnaires to ensure the integrity of the information and that there was no missing data. A total of 1016 questionnaires (254 pairs of SLCPs and families and 254 pairs of LCPs and their families) were distributed, and all of them were effectively retrieved. In Chinese culture, cancer is still a sensitive topic, and it is considered unlucky and bad manners to talk about one’s cancer or assume someone has cancer, especially for SLCPs. Therefore, we used “if a patient got cancer” instead of “if you got cancer” for the questions about cancer disclosure.

2.3. Measurement

3.1. Sociodemographic Characteristics

This study recruited 1016 participants including 254 SLCP-family pairs and 254 LCP-family pairs between March 2022 and August 2022. The majority of participants were married, were of Han ethnicity, and lived in urban areas. For participants from the LCPs group, 213 (83.86%) were in the early stages. The median combined score of resilience ranged from 27.00 to 30.00 across the different groups. Detailed characteristics relating to the surveyed subject are summarized in Table 1.

3.2. Attitudes towards CDD and Resilience

Table 2 shows the comparison of attitudes towards CDD between the SLCP group and the LCP group. Compared with LCPs, more SLCPs believed that patients should be told of their cancer diagnoses (63.8% vs 43.7%, p < 0.001), and the distribution of the first one to know the diagnosis was disequilibrium (p < 0.05). Figure 1(a) further shows a comparison of participants’ attitudes toward patients being informed of their cancer diagnoses among the SLCP group, LCP group, SLCP family group, and LCP family group. In general, patients were more likely to think that patients should be told the facts about their cancer diagnoses than their families. The significant difference was identified in participants’ attitudes toward patients being told the facts by resilience levels among the SLCP group (p < 0.001), LCP group (p = 0.003), SLCP family group (p < 0.001), and LCP family group (p < 0.02). In general, participants with higher resilience were more likely to think that patients should be told the facts about their cancer diagnoses than those with lower resilience (Figure 1(b)).

3.3. Influencing Factors of CDD Attitudes

We conducted a series of multivariate logistic regression analyses to explore the influencing factors of CDD attitudes among the SLCP group, LCP group, SLCP family group, and LCP family group, respectively. In each model, the dependent variable was whether participants believed that patients should be informed of their cancer diagnoses, while the independent variables were the social demographic characteristics that were significant in each univariate analysis. As shown in Tables 3 and 4, resilience was associated with participants’ preference for patients being informed of their cancer diagnoses in the SLCPs group (adjusted OR: 1.87, 95% CI: 1.08–3.25), LCPs group (adjusted OR: 2.21, 95% CI: 1.32–3.74), and family of LCPs group (adjusted OR: 1.79, 95% CI: 1.04–3.12). For participants who were from these groups, a higher level of resilience was associated with an increase in odds of cancer diagnosis disclosure by at least 79%.

We further performed a sensitivity analysis using quantiles of resilience, which revealed that the odds of preferring to disclose a cancer diagnosis increased with an escalated level of resilience, but the trend for dose-response association was weak (Figure 1(c)).

4.1. Attitudes toward “Whether a Patient with a Lung Cancer Diagnosis Should Be Told the Fact” among SLCP, LCP, and Their Families

Our study revealed that patients were more likely to believe that patients should be told their cancer diagnoses than their families. This finding is consistent with the various studies showing that most cancer patients wanted to know their diagnoses in various countries and reflects a general trend toward patient autonomy worldwide [29, 30]. The discordance between patients and their families might have originated from Chinese Confucianism and the beneficence principle [20]. Confucianism, one of the most influential philosophies in the history of China, emphasizes familial responsibility and harmony, as an important reason for nondisclosure [31]. On the other hand, the beneficence principle refers to actions done for the benefit of others and is closely associated with mercy and kindness, which lead families to tend to protect patients. Therefore, families perceive nondisclosure as nonmaleficence for the patients being treated as a vulnerable group.

However, attitudes toward CDD varied by the cancer diagnosis state in both patients and families. SLCPs were more willing to be told about a cancer diagnosis than LCPs. A similar tendency was observed in the families with the SLCP families being more willing to inform patients about their cancer diagnoses than the LCP families.

One possible explanation may be that patients with a confirmed cancer diagnosis may experience significant mental harm after being informed of the diagnosis, leading to deteriorating physical status. Previous studies demonstrated that knowing a lung cancer diagnosis brings a high level of emotional problems and a detrimental relevant score of quality of life (QoL) to patients and their families simultaneously [5, 32–34], potentially leading to a shorter survival period [5]. As a result, LCP patients and their families may believe that concealing a cancer diagnosis is an effort to protect patients from the psychological burden of knowing. What is noticeable is that, during the clinical practice, the individuals to whom the first-time oncologist discloses the lung cancer diagnosis are SLCPs and their families. Therefore, the attitudes towards CDD between SLCPs and their families should be respected and considered more by health providers. Another implication of these findings is that the discrepancy in attitudes toward CDD between SLCPs families and LCPs families should be highlighted for further research to clarify the influencing factors of this discordance and the changed trajectory of attitudes. Moreover, future coping strategy, mental intervention, and communication training should be implemented to decrease the negative associations with CDD, facilitating full and effective CDD which is the precondition for high-quality medical decisions [14].

4.2. Attitudes toward “Who Should Be the First Person to Notify” among SLCP, LCP, and Their Families

Regarding who should be the first to know a lung cancer diagnosis, our study showed that both SLCPs and their families were more willing to have patients and families informed together, while the LCPs and their families were more willing to have their families informed first. Obviously, regardless of the group, families are permanent candidates to be informed of patients’ cancer diagnosis. The possible explanation would be that Confucian tradition is the most predominant sociocultural factor in the Chinese medical setting, emphasizing familial autonomy and family harmony. Previous studies have identified the different attitudes toward CDD between patients with a confirmed cancer diagnosis and their family members [35]. Our study further adds more information on the various attitudes toward CDD among patients with suspected cancer diagnosis. When a health provider tells patients’ diagnosis initially, they usually face suspicious cancer patients and their families, so the preference of SLCPs and their families should be given priority when telling the cancer diagnosis to patients and their families simultaneously. Furthermore, the attitude of LCPs and their families implies that the family would be the appropriate first person to notify during the later disclosure such as the prognosis, treatment effects, and life expectancy. Our study showed that there were different preferences on CDD between patients with suspicious lung cancer and confirmed lung cancer diagnosis, further highlighting the importance of our study. It is suggested that CDD for lung cancer should distinguish between SLCP and LCP and balance the needs of both patients and their families.

4.3. Association between Resilience and CDD Attitudes

In China, family involvement in CDD also reflects that the family plays an important role in clinical decision-making to protect patients from the psychological burden of truth-telling [14]. Previous studies have identified various psychological factors associated with cancer patients’ truth-telling preference, such as distress, anxiety, and fighting spirit [36]. To our best knowledge, our study is the first to examine the association between resilience and CDD attitudes. Our study found that patients and families with higher levels of resilience were more willing to have patients be told their true cancer diagnoses, regardless of their diagnosis status. Although receiving a cancer diagnosis may cause tremendous stress for most people, not everyone copes with this challenge in the same way. Previous studies have shown resilience as a crucial protective factor to help people cope with distress and adapt to challenging events, such as the diagnosis of a life-threatening disease [37]. People with higher levels of resilience hold more optimistic life attitudes and are more accepting of bad news such as a cancer diagnosis [38]. What is noteworthy is that resilience was an independently influential factor in CDD attitudes for SLCP by multivariate analysis. Therefore, before disclosing a cancer diagnosis, resilience assessment and training are highly warranted as a complement to promote better CDD, especially among SLCPs.

Compared with normal adults and Chinese military personnel, SLCPs, LCPs, and their families show lower resilience scores [39]. Nevertheless, previous studies reveal the resilience of SLCPs and LCPs is both higher than that of colorectal and breast cancer patients [40, 41], while SLCPs’ and LCPs’ families have worse resilience than other cancer caregivers [42]. Considering these findings, we suggest that resilience among SLCPs, LCPs, and their families should be concerned and improved, particularly to the families, so as to promote CDD efficiently. It has been noted that resilience is a dynamic process [43] and changes accordingly based on experiences and learning [44, 45]. Our study showed that both LCPs and their families had lower resilience scores than SLCPs and their families. This result highlights the possibility of a resilience shift based on the changeable state of cancer diagnosis but needs to be tested in a future longitudinal study. The findings of this study suggest that more assessments and interventions should be developed to enhance resilience and promote CDD.