Table 2 Themes and participant quotes in the appraisal interval

Barriers

Minimization or misattribution of symptoms

“I’ve always had really, really bad allergies, so I blamed a lot on the allergies.” (Patient #12, 44-year-old female, Stage IV, Never smoking history)

“Why would you think you have lung cancer, if you have back pain, or if you just [have] allergy symptoms?” (Provider #12, Lung oncology)

“I was not doing anything differently. I was not eating better. I was not exercising more significantly… just thought that the stars were aligned and I (was losing weight)” (Patient #12, 44-year-old female, Stage IV, Never smoking history)

“If you’re not educated to look for symptoms, you don’t understand that your cough or your weight loss isn’t necessarily just lack of food.” (Provider #4, Gastroenterology)

“My energy level was not there, and my concentration was not there, I was having a heck of a hard time concentrating… that was probably going on for about 4 months before.” (Patient #4, 65-year-old male, Stage IIIB, 40 pack-year current smoking history)

“I just wish I could have been told earlier…if I [had] a persistent cough, go get checked because that is a sign of cancer.” (Patient #1, 61-year-old female, Stage IVB, Never smoking history)

Facilitators

Acknowledgment of symptoms

“I was coughing so much and losing a lot of weight. I lost 30 pounds” (Patient #13, 66-year-old male, Stage IV, Never smoking history)

“Then sometimes when you probe the patients a little bit further, especially the ones that don’t want to come in, they’ll say, ‘I knew something was wrong,’ or ‘I didn’t want to know’, or ‘my family member actually made [me] come in.’” (Provider #2, Gynecologic oncology)

“That’s when I decided to go in. It was affecting my job and I couldn’t do the things that I was doing.” (Patient #8, 54-year-old male, Stage IV, 20 pack-year former smoking history, quit 14 years prior to diagnosis)

“It was just a nagging cough…and my daughter-in-law did say something like I just don’t like the sound of that.” (Patient #7, 67-year-old female, Stage IIIA, 20 pack-year former smoking history, quit 27.5 years prior to diagnosis)

“I felt normal, but…I owned a business and a couple of my employees [had] noticed that my attitude, my go-get- ‘em attitude seemed to be getting less.” (Patient #6, 60-year-old male, Stage IV, Never smoking history)