symposium article Annals of Oncology 23 (Supplement 3): iii66–iii69, 2012

doi:10.1093/annonc/mds091

Cultural beliefs and values in cancer patients

M. Daher*
Professor of Surgery, University of Balamand, Saint George Hospital, President, Lebanese Cancer Society, Beirut, Lebanon

In 2008, the International Agency for Research on Cancer (IARC) released its World Cancer Report, which indicated
that cancer accounts for approximately 12% of all-cause mortality worldwide. IARC estimated that globally 7.6 million
peopled died from cancer and that 12.4 million new cases were diagnosed in 2008. The report went on to project that,
due to increases in life expectancy, improvements in clinical diagnostics, and shifting trends in health behaviors (e.g.
increases in smoking and sedentary lifestyles), in the absence of significant efforts to improve global cancer control,
cancer mortality could increase to 12.9 million and cancer incidence to 20 million by the year 2030. Looking deeper into
the data, it becomes clear that cancer-related stigma and myths about cancer are important problems that must be
addressed, although different from a country to another. Stigmas about cancer present significant challenges to cancer
control: stigma can have a silencing effect, whereby efforts to increase cancer awareness are negatively affected. The
social, emotional, and financial devastation that all too often accompanies a diagnosis of cancer is, in large part, due to
the cultural myths and taboos surrounding the disease. Combating stigma, myths, taboos, and overcoming silence will
play important roles in changing this provisional trajectory. There are several reasons that cancer is stigmatized. Many
people in our area perceived cancer to be a fatal disease. Cancer symptoms or body parts affected by the disease can
cultivate stigma. Fears about treatment can also fuel stigma. There was evidence of myths associated with cancer, such
as the belief that cancer is contagious, or cancer may be seen as a punishment.
After reviewing these different examples of cultural myths and taboos met in cancer care, we can report these lessons
symposium

learned: 1. Around the world, cancer continues to carry a significant amount of stigma, myths, and taboos; however, there
article

are opportunities to capitalize upon shifting perceptions and positive change. 2. Awareness of cancer prevention, early
detection, treatment, and survival are on the rise; however, too many people still report that they feel uninformed when it
comes to cancer. 3. Communication is critical to decreasing cancer-related stigma, raising cancer awareness, and
disseminating cancer education. People with a personal history of cancer—especially well-known or celebrity survivors—
and multiple mass media channels are key resources for dissemination. 4. The school system represents a potential venue
for cancer education, and increasing cancer awareness among children may be an investment with high returns. 5. When
facing cancer, people around the world want information and emotional support for themselves and their families. 6.
Tobacco use and poor nutrition are widely acknowledged as cancer risks. Programs and policies that help people
translate this awareness into action are needed. The global cancer community should capitalize upon positive shifts in
attitudes about awareness of cancer and leverage these shifts to develop, and disseminate effective media campaigns
and behavioral interventions to decrease the incidence of and morbidity and mortality associated with cancer.
Key words: cultural myths, patients values, cancer

introduction the same time, previous research has demonstrated that world
views, as well as their subsequent attitudes, beliefs, and values
Culture is defined as a set of shared and socially transmitted related to health, differ among ethnically diverse groups [4, 5].
ideas about the world that are passed down from generation to That is why, concerning cancer, cultural beliefs and values are
generation [1, 2]. Culture as a socially transmitted phenomenon increasingly being recognized as important determinants of not
carries with it the idea that people who interact on a regular only of cancer prevention and control behaviors but also of
basis know the same unwritten rules and criteria for social life psychological and behavioral outcomes following cancer
that confer status as a member of the group [1]. When applied diagnosis and treatment [6, 7].
to illness, the beliefs and values from a cultural model of disease
influence perceptions about the meaning of an illness, the types
of treatment that are useful, and the likely outcome of health cultural myths and stigma about cancer
behaviors related to the prevention and control of disease [3]. At
and their effects on patients
Cancer-related myths and stigma about cancer are important
*Correspondence to: Dr M. Daher, President, Lebanese Cancer Society, Professor of
problems that must be addressed [8, 9]. They present
Surgery, University of Balamand, Saint Georges Hospital - UMC, PO Box: 166378,
Beirut, Lebanon. E-mail: [email protected] significant challenges to cancer control:

© The Author 2012. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
All rights reserved. For permissions, please email: [email protected]
Annals of Oncology symposium article
– myths and stigma can have a silencing effect, whereby efforts We expect that some individuals with cancer will seek
to increase cancer awareness are negatively affected; alternative medicine; this is a situation which is common.
– myths and stigma can affect individual’s behaviors, such that When a patient talks about his desire to seek alternative
they are less likely to adopt cancer-risk-reducing behaviors medicine, the physician should listen and avoid being
or seek out the support and services they need when they judgmental and ask himself: does conventional medicine have
are diagnosed with the disease. all the answers? Nevertheless, potential harm of such
Unfortunately, stigma and myths associated with cancer are alternative medicine must be explained by the physician.
not directly addressed or challenged in many countries,
especially in Middle Eastern (ME) countries.
spirituality and cancer patients in ME
countries
reasons that cancer is stigmatized Spirituality is a distinctive, potentially creative and universal
in ME countries dimension of human experience arising both within the inner
subjective awareness of individuals and within communities,
Interviews with people have shown the belief that nothing can social groups and traditions. Religion is a belief in a
be done to prevent cancer and that cancer is always fatal. It supernatural power which governs the universe, and
may be seen as a punishment. The most common mentioned recognition of God as object of worship (Webster’s
myths and stigma are reported in Table 1. Dictionary).
Myths about cancer treatment were also common. Patients In ME countries, many individuals rely on their spirituality
are often reluctant to undergo surgery because they believe ‘if and faith when coping with illness; they may experience
you cut into the cancer, it will spread immediately all over the positive outcomes [11–13]:
body’. Some others perceived cancer treatment to be as bad as,
or worse than, the disease itself. – less depression and longer survival;
Cancer symptoms or body parts affected by the disease can – fewer post-surgical complications;
cultivate stigma. For example, cervical cancer is highly – delayed onset and slower progression of physical disability;
stigmatized because the cervix is ‘part of the body you don’t – influence serotonin pathways in the brain that regulate
speak about’. Gynecological or breast cancers may present mood and possibly pain, while negative spirituality (e.g.
symptoms that women are reluctant to disclose to their ‘God is abandoning me’) is related to increased pain
doctors, and they may be even less willing to undergo the sensitivity.
necessary physical exams to investigate the cause of such
Overall, we can say that spiritual care decreases aggressive
symptoms [10]. end-of-life (EOL) care and improves quality of life [14, 15].
When coming to individuals personally affected by cancer There are several reasons for a physician to address spiritual
they often express a feeling of ‘isolation’; silence surrounding needs and support a patient’s religious beliefs:
the disease is frequent. This kind of denial and avoidance can
perpetuate a person’s sense of isolation. – physicians addressing spiritual needs is not new, but rooted
Family members can alternatively be a source of stigma. in the long historical relationship between religion,
They try to isolate the patient. When this happens, cancer care medicine, and healthcare;
professionals play a critical role in supporting the patient. – many patients are religious, and religious beliefs help them
Treatment of cancer is considered by many to be a to cope;
financially devastating burden to the family because in many – religious beliefs influence medical decisions, especially when
countries expenses for diagnosis, treatment, and patient patients are seriously ill;
support are completely or partially paid by the patient and the – religious beliefs and activities are related to better health and
family. There is also a perception that a person who has been quality of life [12, 13, 15].
diagnosed with cancer is too ill to be employed. Thus, it will be
difficult for individuals with a cancer history to return to work
after an illness-related absence, or to try to secure new cancer and the family in ME countries
employment. That is why in the workplace, cancer is often
kept a secret. In the United States, cancer affects approximately three out of
four families; in the Western world, it touches one in every
Table 1. The myths and perception of cancer [16] three families. In Eastern countries, based on the World Health
Organization estimations, we can expect reaching this last
situation within one decade.
▪ Death While the focus in Western biomedicine is on the individual,
▪ Fear respecting the patient autonomy, requesting his informed
▪ Pain and suffering consent, and his participation in the decision-making, the
▪ Loss of control and independence focus in Eastern countries is on the family and, for diverse
▪ Helplessness population groups, family welfare often is primary.
▪ Isolation When confronted with cancer, most patients in Eastern
countries will not go to nursing homes and hospices. This

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symposium article Annals of Oncology

behavior is because the family feels responsible for the care of coverage that promote a reduction of cancer-related stigma by
the patient in the process of illness and /or impending death. providing information on topics such as declines in cancer
Most of the time women provide all the caregiving to the incidence; improvements in screening and early detection;
patient during the disease. treatment options; palliative care; cancer survivorship;
So, good practice requires an understanding of cultural and government efforts in cancer prevention and control; new
social aspects of life and death to enable care professionals to research or funding devoted to cancer; and cancer-related
best meet the needs of patients and their families. Family activism. Training journalists on cancer myths and health
involvement plays a key role in the provision of good EOL care reporting is a good way to breaking down cancer myths and
for cancer patient. Workforce education is important in the misconceptions [19].
provision of culturally appropriate palliative and EOL In 2008, the Union for International Cancer Control
care [16]. published the famous World Cancer Declaration. The fifth
target of this Declaration stated that ‘in 2020 public attitudes
towards Cancer will improve and damaging myths and
cultural myths in EOL care misconceptions about the disease will be dispelled’ in reference
EOL care is challenging and can be influenced by cultural and to the importance of this issue.
religious values. The specific practices at the last moments of
life differ among the religious sects. It is also important to note
that individuals within the same community may have conclusions
different levels of observance for religious or cultural practices. In order to challenging cancer-related stigma and finding
Consequently, health care professionals must be prepared for opportunities for increased cancer awareness, it is urgent to
a diversity of attitudes, values, and practices of dying and address the cancer problem at national and international levels.
bereaved persons: Based on what is reported in this article, we can affirm the
– religions consider death to be a transition from one form of following:
being to another: ‘death is a natural end to humans’; – Cancer continues to carry a significant amount of myths and
– life on earth for a Christian, Muslim, and Jew is an stigma; however, there are opportunities to capitalize upon
examination and an opportunity to be prepared for life after shifting perceptions and positive change. Where
death, where one’s deeds on earth will be judged and opportunities exist to raise awareness, public education and
accordingly people will be sent to either Heaven or Hell. resource campaigns are needed that directly address the
To optimize our care, we must ensure that social and cancer-related stigma
cultural aspects of life and death are identified, embraced and – Communication is critical to decreasing cancer-related
understood by health professionals so that the needs of myths and stigma, raising cancer awareness, and
patients and their families are met as they approach death. disseminating cancer education. The global cancer
Planning and preparation will ensure that practitioners community should capitalize upon positive shifts in
understand different cultural perceptions of dying and death attitudes and disseminate effective media campaigns and
and respect patients’ belief systems and cultural norms behavioral interventions to decrease the incidence of and
[17, 18]. morbidity and mortality associated with cancer.
Multiple mass media channels are key resources for
how can we develop opportunities dissemination:
for progress in cancer control? – The school system represents a potential venue for cancer
Despite the existence of cancer-related myths and stigma, there education, and increasing cancer awareness among children
is evidence of positive change: may be an investment with high returns
– When facing cancer, people around the world want
– improvements in cancer control have reduced many of the information and emotional support for themselves and their
fears that trigger stigmatic thinking; families. We need to strengthen patient advocacy in
– some cancer survivors talk about feeling completely international settings to build a global grassroots movement
comfortable discussing their diagnoses; having accurate perceptions of cancer; to prevent stigma
– advancements in treatment may lead toward open from inhibiting people in their cancer control efforts; to help
discussions about cancer: ‘Now that [cancer] can be cured, people affected by cancer receive the support, services, and
people can discuss it openly’; information they need; all of which will help in decreasing
– in many countries, there was media coverage of a national the global cancer burden
celebrity who was a cancer survivor. – Tobacco use and poor nutrition are widely acknowledged as
cancer risks. Programs and policies that help people
There is still a significant amount of work to be done to translate this awareness into action are needed.
improve the degree to which people feel informed about
cancer. Awareness is the ‘number one’ strategy to improve Cancer is here to stay, and calling it ‘that which is not to be
cancer prevention and control. People need also guidance in named’ will not make it disappear. It must be named and
understanding that cancer is a complex disease and a media faced.

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Annals of Oncology symposium article
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