The Cancer-Culture Connection

For nearly 10 years, I lived in the metropolitan Washington, DC, area. At any given time, our oncology unit was representative of a mini United Nations. You name the country, we had a patient from there. In the Fairfax County region of northern Virginia where I lived, over 100 languages were spoken within the elementary school system. I found myself practicing in a melting pot of immigrants, foreign visitors, and a considerable population where English was spoken only sporadically or as a second language. I became intrigued by the degree of this diversity I was exposed to, as this was not my norm in my formative years. I subsequently made it my mission to foster not only my own cultural sensitivity, but also that of my colleagues.

On the oncology unit, we established a series of “Brown Bag” lunches where we invited professional colleagues born outside the United States to have lunch with us to share with nursing staff their country’s beliefs, practices, and norms. I chaired the multicultural task force for my hospital. Our group organized lunches for hospital staff where restaurant owners from over 20 countries set up tables with their most popular foods for us to sample. It was a great event! We subsequently created a program on our computer system where staff could access information about a variety of cultural and religious norms— something that there was an established need for at the institution.¹ Common phrases in Spanish, Korean, Vietnamese, Mandarin, and Farsi were on this site, and the nursing staff identified the most common statements or questions that were needed. A nurse could subsequently show the non-English equivalent of a phrase to the patient/ family to inform and educate them about what would be transpiring. Phrases such as, “You will be taken for an x-ray,” “Point to where it hurts,” or “This is the medicine to help you sleep” were translated. Our efforts were a huge success both for our patients throughout our hospital system and for our professional staff who were eager to enhance their cultural connections.

Now, more than 20 years later, this agenda of cultural sensitivity is even more pressing within our specialty. This is particularly true in the Unites States where our demographics are undergoing radical change. Consider the following:

• Non-Caucasians will more than double between 2012 and 2060 to represent 57% of the American populace;

• Within the past 5 years, Asians have doubled in number, now representing 8% of the US population:

• Hispanics are the most rapidly growing minority group in the Unites States; unfortunately, cancer in this group is diagnosed at earlier ages and the patients have mortality rates higher than non-Hispanics.^2-3

As the country evolves and becomes more diverse, the presentation of prominent cancers will change, too. Immigrants may present with risk factors associated with their country of origin. Cancers associated with lifestyle factors (ie, diet, smoking, obesity) and viral exposure (ie, human papillomavirus, hepatitis B) may increase in regions with high numbers of select immigrant groups. This may influence the need for cancer-specific community education and screening in specific regions. Case in point is Asian immigrants living on the West Coast not receiving hepatitis vaccinations in their formative years and now being vulnerable to primary hepatocellular cancers.⁴

Being culturally astute is much more than knowing cancer rates and risk factors specific to ethnicity and country origins. It requires sensitivity to numerous issues linked with patient and family attitudes and behaviors exhibited within the US healthcare system. These include participation in screening, interpersonal exchange using the word “cancer”; diagnosis disclosure; the roles of diet, rest, and complementary approaches; acceptance of care provided by other genders; role of the family in decision making; and symptom reporting.⁵ Of critical importance is the role of cultural sensitivity within the paradigm of end-of-life care. This is inclusive of religious orientation, communication of family norms, reluctance to withdraw life support, responses to pain, and the implementation of rituals at the end of life.⁶ Because of this broad scope of influence, health professionals’ perceptions, attitudes, and behaviors related to those of other cultures must be addressed. Considerable personal awareness underscores this sensitivity.⁷

Most cultural norms are culturally prescribed. Those from outside the United States can differ from our American standard, often leading to judgmental reactions and frequent labeling of these interactions as “difficult.” The diversity of our American mosaic requires reflection. Does the traditional staunch New England norm of nondisclosure of feelings differ from those reared in the more liberal West Coast culture of expression? It is time to mandate all professionals consider their bias as our future portends a dramatically different cultural environment.

References:

• Boyle DA, Sheridan M, McClary J & White J. A multifocal education strategy to enhance hospital-based cultural competency in professional staff. Oncology Nursing Forum. 2002. 29(5): 764-768.
• U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now. U.S. Census Bureau. [online] Census.gov. 201. Available at: https://www.census.gov/newsroom/releases/archives/population/cb12-243.html [Accessed 7 Jun. 2019].
• Petty M (2019). Disparities in hispanic care. Clin J Oncol Nurs, 23(3): 235.
• Pham C, Fong TL, Zhang J, Liu L (2018). Striking racial/ethnic disparities in liver cancer incidence rates and temporal trends in California, 1988-2012. J Natl Cancer Inst, 110(11): djy051. Doi: 10.1093/jnci/djy051.
• Licqurish S, Phillipson L, Chiang P, et al. Cancer beliefs in ethnic minority populations: A review and meta-synthesis of qualitative studies. European Journal Cancer Care. (2017) 26: e12556; doi: 10.1111/ecc.12556.
• Schrank B, Rumpold T, Amering M, et al. Pushing boundaries — culture-sensitive care in oncology and palliative care: A qualitative study. Psycho-Oncol. 2016. 26: 763-769.
• Cope D.G. Cultural competency in nursing research. Oncology Nursing Forum. 2015. 42(3): 305-307.