Incidence and risk factors of vaccination hesitancy among early-stage lung cancer patients: a cross-sectional study

Introduction

Since the emergence of the coronavirus disease 2019 (COVID-19) outbreak in Wuhan, China, in 2019, the global numbers of confirmed cases and deaths have increased rapidly (1). On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic (2). As of November 2025, more than 778 million individuals have been diagnosed with COVID-19, and more than 7.10 million deaths have been reported (3). Undeniably, the COVID-19 pandemic represents one of the most daunting challenges to both socioeconomic progress and global public health in recent years (4). Traditional Chinese medicine and Western medicine have demonstrated efficacy in combating COVID-19; meanwhile, COVID-19 vaccines are believed to be the most efficient way to halt the spread of the virus (5-9). According to information provided by the WHO, more than 380 vaccine candidates are in development, with 183 being in clinical development and 199 being in preclinical development (10).

Global Cancer Statistics (GLOBOCAN) 2022 estimates that lung cancer is the most frequently diagnosed cancer, with approximately 2.5 million new cases, accounting for 12.4% of all cancer globally (11). Furthermore, in China, lung cancer is the most commonly diagnosed cancer, with a heavy burden of disease due to the country’s vast population size, resulting in significant deaths (12,13). Evidence suggests that lung cancer patients have a 2.31-fold greater risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and severe complications than the general population or patients with other malignancies (14-16). The National Comprehensive Cancer Network (NCCN), the European Society of Medical Oncology (ESMO) and the National Health Commission of the People’s Republic of China all advocated prioritizing cancer patients, including those with lung cancer, for COVID-19 vaccination, despite limited safety data in this specific population (17-19).

Vaccine hesitancy, classified as the reluctance or refusal to vaccinate despite vaccine availability, has been identified by the WHO as one of the top-ten health threats (20,21). Multiple studies have explored the challenges surrounding COVID-19 vaccination hesitancy in cancer patients, revealing heightened concerns regarding vaccine safety and efficacy within this population (22-24). However, until recently, few studies have explored the concerns and hesitancy of COVID-19 vaccination among lung cancer patients. Besides, the guidelines recommend that COVID-19 vaccination should be withheld for patients with serious chronic diseases in the acute phase, such as advanced lung cancer, who are receiving chemotherapy, radiotherapy or immunotherapy. Therefore, this survey among patients with early-stage lung cancer was conducted in China to evaluate the rate of COVID-19 vaccination hesitancy and identify its predictors. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2545/rc).

Methods

Study design and participants

A cross-sectional survey was performed among early-stage lung cancer patients before surgery at the Lung Neoplasm Department of Tianjin Medical University Cancer Institute and Hospital from May to November 2023. Eligible participants included individuals aged 18 years and above, with a preliminary diagnosis of lung cancer upon admission, who were scheduled to undergo surgical treatment. Patients with limited or no educational background and who could not understand the study objectives were excluded from participation. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Ethics Committee of Tianjin Medical University Cancer Institute and Hospital (No. bc2022163) and written informed consent was obtained from all participants.

Measurement

A structured self-report questionnaire was meticulously crafted, drawing insights from the literature, to delve into the realm of COVID-19 vaccination hesitancy among patients with early-stage lung cancer (25,26). The final questionnaire was developed through expert consultation and a small sample pre-study, which included three key sections: (I) basic information, including demographic profiles, clinical outlook of lung cancer and impact of the COVID-19 pandemic on participants; (II) knowledge and perceptions of COVID-19 vaccination; (III) vaccination intentions: initial inquiries revolved around the participants’ completion status of full COVID-19 vaccination doses. Participants were asked about their willingness to be vaccinated or finish the rest of the vaccination; if the answer was no, they were informed to determine their hesitancy. A detailed questionnaire was provided in Appendix 1.

Data collection

Considering that many older patients might not have access to smartphones, paper questionnaires instead of electronic questionnaires were distributed to all participants. After admission, eligible participants were invited to a single quiet office and informed about the aim of the study, the study procedures, and their rights by the investigators. Upon consenting to take part in the survey, participants were provided with paper questionnaires. In cases where participants found certain items confusing, the investigators explained using unifying terms. Additionally, for patients who might face challenges with reading or writing, the researchers offered assistance. Finally, each questionnaire was checked by investigators to ensure that all the questions were answered comprehensively.

Statistical analysis and sample

The collected data were analyzed via SPSS software, version 20.0 (IBM, USA). The univariate analysis between the independent variables (basic information, knowledge and perceptions of COVID-19 vaccination) and vaccination intentions was initially characterized via chi-square tests. Individuals who expressed a willingness to be vaccinated or proceed with vaccination belonged to the “vaccination acceptance” group, and those who displayed reluctance toward vaccination belonged to the “vaccination hesitancy” group. Variables with P<0.10 in univariate analysis were included in multivariate stepwise logistic regression to screen for predictors. The results were elucidated through odds ratios (ORs) accompanied by 95% confidence intervals (CIs), and statistical significance was attributed to two-sided P values <0.05. What is more, concerns regarding COVID-19 vaccines are presented as numbers and percentages.

A minimum sample size of 500 individuals was mandated for logistic regression analysis according to the Sample Size Guideline (27). Furthermore, after considering the possible independent variables (i) in the logistic regression model, a refined estimation formula (n=20i) was employed to ascertain the requisite sample size. In the context of this survey, 34 potential independent factors were included. Therefore, the calculated minimum validated sample size was scaled up to 680 participants in this study.

Results

Basic characteristics

Among the 728 preoperative patients with early-stage lung carcinoma, 484 (66.5%) received full COVID-19 vaccination, 44 (6.0%) did not receive vaccination, and 200 (27.5%) received partial vaccination. Besides, 577 (79.3%) participants expressed their acceptance of vaccination, whereas the remaining 151 (20.7%) expressed hesitancy. Among the three vaccination status subgroups, 25 out of 44 non-vaccinated patients (56.8%) reported vaccination hesitancy, 125 out of 200 partially vaccinated patients exhibited hesitancy (62.5%), and only 1 out of 484 fully vaccinated patients (0.2%) expressed hesitancy (Table 1).

The demographic characteristics, history of present disease, and clinical status of the participants revealed that educational level, residence, and current drinking status were significantly different between the two groups (P<0.05). Early-stage lung cancer patients with a college degree and above, living in cities, and not drinking expressed greater vaccination hesitancy. For the impact of the COVID-19 pandemic on lung cancer patients in the early stage, a majority of the participants underscored a range of impacts, including disruptions to regular medical care (53.4%), daily life (78.7%), and income (75.7%), and 27.3% of the respondents perceived themselves to be at heightened risk of COVID-19 infection compared with the general population. For the impact of COVID-19 on daily life, there was a significant difference between the two groups (P<0.05, Table 2).

Knowledge and perceptions of COVID-19 vaccination

As for knowledge and attitude towards the COVID-19 vaccination, the results showed that the majority of participants didn’t know the post-vaccination incubation period (75.5%) and the vaccine’s developmental journey (86.5%). Besides, more than half of lung cancer patients with early stage exhibited confidence in the safety (59.9%) and efficacy (69.6%) of the COVID-19 vaccine, would like to recommend family members or friends to get vaccinated (75.3%) and wear a mask after vaccination (92.4%). Moreover, 65.9% perceived the vaccine as a potent tool in combating the COVID-19 pandemic, with 65.1% demonstrating readiness to bear the cost associated with vaccination. In addition, some participants expressed their concerns that COVID-19 vaccination would trigger an allergy (22.7%) and worsen the prognosis of cancer (12.6%). Univariate analysis showed that preoperative early-stage lung cancer patients with the following characteristics had higher vaccination hesitancy (P<0.001): unclear about the onset of vaccine efficacy, perceiving the vaccine as unsafe or ineffective, believing the vaccine cannot control the pandemic, fearing the vaccine may trigger allergy or worsen cancer prognosis, unwilling to recommend vaccination to relatives and friends, unwilling to pay for vaccination, and thinking mask-wearing after vaccination is unnecessary (Table 3).

Factors associated with COVID-19 vaccination hesitancy

In the multivariate logistic regression analysis, a comprehensive analysis encompassed 13 independent variables with statistically significant P values <0.10. The results showed that admitted patients with early-stage lung cancer before surgery who thought the vaccine was not safe (vs. yes) (OR =5.305, 95% CI: 1.964–14.327; P=0.001), who would not recommend their family members or friends to get vaccinated (vs. yes) (OR =2.511, 95% CI: 1.287–4.901; P=0.007), and who would not like to pay for the vaccine (vs. yes) (OR =3.841, 95% CI: 2.091–7.054; P<0.001) were more likely to refuse vaccination. Participants who expressed no concerns about the vaccine potentially exacerbating their cancer prognosis (vs. yes) (OR =0.203, 95% CI: 0.071–0.577; P=0.003) demonstrated even higher likelihood of opting for vaccination (Table 4).

Concerns of COVID-19 vaccination hesitancy

For 151 participants with COVID-19 vaccination hesitancy, the top 2 concerns were the immediate serious adverse effects post-vaccination (48.3%) and long-term adverse effects after vaccination (87.4%) (Figure 1).

Figure 1 Percentage of concerns about receiving COVID-19 vaccines among preoperative patients with early-stage lung cancer. COVID-19, coronavirus disease 2019.

Discussion

Few studies have focused on COVID-19 vaccine acceptance among patients with cancer in China (25), although COVID-19 vaccines play an important role in controlling this epidemic. This is the first study to explore the incidence and risk factors of COVID-19 vaccination hesitancy among Chinese lung cancer patients in the early stage before surgery, filling the gap in the current research. Moreover, a paper questionnaire with face-to-face interviews was used in this survey, which avoided potential bias in the reporting of online surveys (28).

Among the 728 admitted lung cancer patients with early stage before surgery in China, 20.7% were concerned with COVID-19 vaccination. The result was similar to the data reported in other studies (29-31). A survey was conducted among 150 patients with digestive and thoracic cancer towards COVID-19 vaccination choice, and the result revealed that 17.4% hesitated to get vaccinated (30). However, one study concentrating on individuals with lung cancer or pulmonary ground-glass opacity unveiled a greater prevalence of vaccine hesitancy (66.7% vs. 20.7%) compared to the findings delineated in this present research (32). This discrepancy may be partly explained by our finding that vaccination hesitancy was extremely rare among fully vaccinated patients, who accounted for the majority of participants. Another reason may be due to the effect of the active vaccination campaign promoted by the Chinese government during the past 1 year, and people could get access to vaccines for free in China.

Multivariable analysis revealed that perception of vaccine insecurity, concerns about exacerbated cancer prognosis due to vaccination, unwillingness to recommend the vaccine to family or friends, and refusal to pay for vaccination were independent predictors of COVID-19 vaccination refusal in preoperative early-stage lung cancer patients. Furthermore, the immediate serious adverse effects and long-term adverse effects after vaccination were the top 2 concerns among participants. Similar results were found in other studies; the safety and effectiveness of COVID-19 vaccines were key influential factors of vaccination hesitancy (25,33-36). However, scant studies have reported the safety and efficacy of COVID-19 vaccines in lung cancer patients (37-40). Gounant et al.’s research found that SARS-CoV-2 vaccines are safe and efficient in patients with thoracic cancer, with most achieving immunization after two doses; however, the study has limitations, including a small sample size and observational design (37). Another study showed that lung and breast cancer patients have a lower antibody response than the non-cancer population after systematic therapy with two doses of the CoronaVac vaccine, and deaths due to COVID-19 may still occur in these patients despite vaccination (40). Thus, no convincing conclusion has been reached, and high-level evidence is urgently needed to form a strong recommendation for COVID-19 vaccine administration in this vulnerable population.

There are still some limitations in this survey. First, this study was limited to a single cancer center, potentially limiting its broader applicability to lung cancer patients with early-stage disease nationwide. Second, this study was a cross-sectional design, so the factors that impact the intention to take COVID-19 vaccination may not be causal. Third, the willingness to accept COVID-19 vaccines may change over time. Finally, while the COVID-19 epidemic was gradually controlled, it is hard to say whether another pandemic may occur in the future. Nevertheless, this study contributes to an understanding of key influential factors of vaccination hesitancy, and thus may help to promote the vaccination campaign to control the spread of infectious diseases. We acknowledge that a qualitative approach could further explore the psychological mechanisms underlying hesitancy, and this will be the focus of our future research to supplement the current findings.

Conclusions

This study revealed that 20.7% of patients with early-stage lung cancer in China were concerned about COVID-19 vaccination. Participants who thought the vaccine was not safe, would not recommend their family members or friends to take the vaccination, and would not like to pay for the vaccine were contributors to COVID-19 vaccination hesitancy. The safety of COVID-19 vaccines is the top concern of vaccination acceptance. Research on the safety and efficacy of COVID-19 vaccines among patients with lung cancer is urgently needed to promote a global vaccination campaign. Although the COVID-19 pandemic is beginning to ease, this study would be useful for understanding key determinants of vaccination acceptance and thus, might promote vaccination to control the spread of another pandemic in the future.

Acknowledgments

We are grateful to Jingxia Sun, Peng Ren and Jianping Zhou from Department of Lung Neoplasms of Tianjin Medical University Cancer Institute and Hospital for recruiting participants in this study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2545/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2545/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2545/prf

Funding: This research was supported by Tianjin Key Medical Discipline (Specialty) Construction Project (No. TJYXZDXK-011A) and Discipline Research Special Project of Tianjin Medical University (No. 2024XKHL06).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2545/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Ethics Committee of Tianjin Medical University Cancer Institute and Hospital (No. bc2022163) and written informed consent was obtained from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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