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

© The Author 2012. Published by Oxford University Press on behalf of the European Society for Medical Oncology.
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Annals of Oncology
– myths and stigma can have a silencing effect, whereby efforts
to increase cancer awareness are negatively affected;
– myths and stigma can affect individual’s behaviors, such that
they are less likely to adopt cancer-risk-reducing behaviors
or seek out the support and services they need when they
are diagnosed with the disease.
Unfortunately, stigma and myths associated with cancer are
not directly addressed or challenged in many countries,
especially in Middle Eastern (ME) countries.
reasons that cancer is stigmatized
in ME countries
Interviews with people have shown the belief that nothing can
be done to prevent cancer and that cancer is always fatal. It
may be seen as a punishment. The most common mentioned
myths and stigma are reported in Table 1.
Myths about cancer treatment were also common. Patients
are often reluctant to undergo surgery because they believe ‘if
you cut into the cancer, it will spread immediately all over the
body’. Some others perceived cancer treatment to be as bad as,
or worse than, the disease itself.
Cancer symptoms or body parts affected by the disease can
cultivate stigma. For example, cervical cancer is highly
stigmatized because the cervix is ‘part of the body you don’t
speak about’. Gynecological or breast cancers may present
symptoms that women are reluctant to disclose to their
doctors, and they may be even less willing to undergo the
necessary physical exams to investigate the cause of such
symptoms [10].
When coming to individuals personally affected by cancer
they often express a feeling of ‘isolation’; silence surrounding
the disease is frequent. This kind of denial and avoidance can
perpetuate a person’s sense of isolation.
Family members can alternatively be a source of stigma.
They try to isolate the patient. When this happens, cancer care
professionals play a critical role in supporting the patient.
Treatment of cancer is considered by many to be a
financially devastating burden to the family because in many
countries expenses for diagnosis, treatment, and patient
support are completely or partially paid by the patient and the
family. There is also a perception that a person who has been
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
employment. That is why in the workplace, cancer is often
kept a secret.
Table 1. The myths and perception of cancer [16]
▪ Death
▪ Fear
▪ Pain and suffering
▪ Loss of control and independence
▪ Helplessness
▪ Isolation
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symposium article
We expect that some individuals with cancer will seek
alternative medicine; this is a situation which is common.
When a patient talks about his desire to seek alternative
medicine, the physician should listen and avoid being
judgmental and ask himself: does conventional medicine have
all the answers? Nevertheless, potential harm of such
alternative medicine must be explained by the physician.
spirituality and cancer patients in ME
countries
Spirituality is a distinctive, potentially creative and universal
dimension of human experience arising both within the inner
subjective awareness of individuals and within communities,
social groups and traditions. Religion is a belief in a
supernatural power which governs the universe, and
recognition of God as object of worship (Webster’s
Dictionary).
In ME countries, many individuals rely on their spirituality
and faith when coping with illness; they may experience
positive outcomes [11–13]:
– less depression and longer survival;
– fewer post-surgical complications;
– delayed onset and slower progression of physical disability;
– influence serotonin pathways in the brain that regulate
mood and possibly pain, while negative spirituality (e.g.
‘God is abandoning me’) is related to increased pain
sensitivity.
Overall, we can say that spiritual care decreases aggressive
end-of-life (EOL) care and improves quality of life [14, 15].
There are several reasons for a physician to address spiritual
needs and support a patient’s religious beliefs:
– physicians addressing spiritual needs is not new, but rooted
in the long historical relationship between religion,
medicine, and healthcare;
– many patients are religious, and religious beliefs help them
to cope;
– religious beliefs influence medical decisions, especially when
patients are seriously ill;
– religious beliefs and activities are related to better health and
quality of life [12, 13, 15].
cancer and the family in ME countries
In the United States, cancer affects approximately three out of
four families; in the Western world, it touches one in every
three families. In Eastern countries, based on the World Health
Organization estimations, we can expect reaching this last
situation within one decade.
While the focus in Western biomedicine is on the individual,
respecting the patient autonomy, requesting his informed
consent, and his participation in the decision-making, the
focus in Eastern countries is on the family and, for diverse
population groups, family welfare often is primary.
When confronted with cancer, most patients in Eastern
countries will not go to nursing homes and hospices. This
doi:10.1093/annonc/mds091 | iii
symposium article
behavior is because the family feels responsible for the care of
the patient in the process of illness and /or impending death.
Most of the time women provide all the caregiving to the
patient during the disease.
So, good practice requires an understanding of cultural and
social aspects of life and death to enable care professionals to
best meet the needs of patients and their families. Family
involvement plays a key role in the provision of good EOL care
for cancer patient. Workforce education is important in the
provision of culturally appropriate palliative and EOL
care [16].
cultural myths in EOL care
EOL care is challenging and can be influenced by cultural and
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
different levels of observance for religious or cultural practices.
Consequently, health care professionals must be prepared for
a diversity of attitudes, values, and practices of dying and
bereaved persons:
– religions consider death to be a transition from one form of
being to another: ‘death is a natural end to humans’;
– life on earth for a Christian, Muslim, and Jew is an
examination and an opportunity to be prepared for life after
death, where one’s deeds on earth will be judged and
accordingly people will be sent to either Heaven or Hell.
To optimize our care, we must ensure that social and
cultural aspects of life and death are identified, embraced and
understood by health professionals so that the needs of
patients and their families are met as they approach death.
Planning and preparation will ensure that practitioners
understand different cultural perceptions of dying and death
and respect patients’ belief systems and cultural norms
[17, 18].
how can we develop opportunities
for progress in cancer control?
Despite the existence of cancer-related myths and stigma, there
is evidence of positive change:
– improvements in cancer control have reduced many of the
fears that trigger stigmatic thinking;
– some cancer survivors talk about feeling completely
comfortable discussing their diagnoses;
– advancements in treatment may lead toward open
discussions about cancer: ‘Now that [cancer] can be cured,
people can discuss it openly’;
– in many countries, there was media coverage of a national
celebrity who was a cancer survivor.
There is still a significant amount of work to be done to
improve the degree to which people feel informed about
cancer. Awareness is the ‘number one’ strategy to improve
cancer prevention and control. People need also guidance in
understanding that cancer is a complex disease and a media
iii | Daher
Annals of Oncology
coverage that promote a reduction of cancer-related stigma by
providing information on topics such as declines in cancer
incidence; improvements in screening and early detection;
treatment options; palliative care; cancer survivorship;
government efforts in cancer prevention and control; new
research or funding devoted to cancer; and cancer-related
activism. Training journalists on cancer myths and health
reporting is a good way to breaking down cancer myths and
misconceptions [19].
In 2008, the Union for International Cancer Control
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
misconceptions about the disease will be dispelled’ in reference
to the importance of this issue.
conclusions
In order to challenging cancer-related stigma and finding
opportunities for increased cancer awareness, it is urgent to
address the cancer problem at national and international levels.
Based on what is reported in this article, we can affirm the
following:
– Cancer continues to carry a significant amount of myths and
stigma; however, there are opportunities to capitalize upon
shifting perceptions and positive change. Where
opportunities exist to raise awareness, public education and
resource campaigns are needed that directly address the
cancer-related stigma
– Communication is critical to decreasing cancer-related
myths and stigma, raising cancer awareness, and
disseminating cancer education. The global cancer
community should capitalize upon positive shifts in
attitudes and disseminate effective media campaigns and
behavioral interventions to decrease the incidence of and
morbidity and mortality associated with cancer.
Multiple mass media channels are key resources for
dissemination:
– The school system represents a potential venue for cancer
education, and increasing cancer awareness among children
may be an investment with high returns
– When facing cancer, people around the world want
information and emotional support for themselves and their
families. We need to strengthen patient advocacy in
international settings to build a global grassroots movement
having accurate perceptions of cancer; to prevent stigma
from inhibiting people in their cancer control efforts; to help
people affected by cancer receive the support, services, and
information they need; all of which will help in decreasing
the global cancer burden
– Tobacco use and poor nutrition are widely acknowledged as
cancer risks. Programs and policies that help people
translate this awareness into action are needed.
Cancer is here to stay, and calling it ‘that which is not to be
named’ will not make it disappear. It must be named and
faced.
Volume 23 | Supplement 3 | June 2012
Annals of Oncology
disclosure
The author declares no conflicts of interest.
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