Younger and more educated patients are most likely to take an active role in medical decision making. Some researchers have observed that low-income women who are not as well educated do not communicate as well with their physicians about their treatment preferences or concerns and fears.[4,9,10,11] Being unmarried, having a lower socioeconomic status, and having treatment options discussed less frequently are risk factors that, in addition to older age, predicted receiving conservative primary tumor therapy. Limited financial resources have been shown to be a barrier to receiving radiation therapy after lumpectomy. Transportation to and from a radiation therapy facility is another impediment. Additionally, research data suggest that differences in physician-patient communication patterns could contribute to variance in BCS rates among income strata.
Influence of Culture/Ethnicity/Language
Using culturally appropriate approaches to communicating about cancer may lessen levels of distress for the patient and/or members of the patient's family. Developing an awareness of cross-cultural practices regarding cancer disclosure issues allows the clinician to become more sensitive to the expectations of culturally and individually diverse cancer patients. When discussing diagnoses and treatment options with patients from different cultures, it is important for clinicians to consider how to balance a commitment to frank discussion and a respect for the cultural values of the patient.
In general, patients whose dominant culture is derived from a Western philosophy subscribe to certainty, predictability, control, and obtainable outcomes. This culture has engendered an approach that fosters self-determination and autonomy in making treatment decisions. This patient-centered society values having fully informed patients who make accurate assessments about their health as a cultural prerogative. Western cultural assumptions exist about what is good and just in medical care. One such assumption is the principle of self-determination and its importance in enabling patients to make autonomous treatment decisions.
On the other hand, patients in Italy, China, and Japan; patients in Spain; patients in Tanzania; and Korean Americans and Mexican Americans believe that there is a positive value inherent in nondisclosure of diagnosis and of a terminal prognosis.[14,15,16] In the family-centered model of medical decision making, such as that found among Mexican Americans and Korean Americans, among Ethiopian refugees, and in Italy, autonomy is seen as isolating.[14,16] Patients with an Egyptian background believe that dignity, identity, and security are conferred by belonging to a family and dealing with illness within a family context. Navajo culture provides another example of diverse cultural attitudes toward illness. Navajos feel that order and harmony are disrupted by receiving negative information; receiving an unfavorable diagnosis and prognosis is seen as a curse.
In some cultures, the negative stigma associated with the word cancer is so strong that the use of the word can be perceived as rude, disrespectful, and even causal. A study investigating the puzzling factors and solutions of family-related barriers to truthfulness with patients who have terminal cancer was conducted through a nationwide survey conducted in Taiwan. The results showed that families believe it is unnecessary to tell aged patients the truth, and patients can be happier without knowing the truth. For Ethiopian refugees who are diagnosed with cancer, it is important to tell the family first but also important not to give unfavorable information at night so as to avoid the burden of a sleepless night. An awareness of the use of nonverbal communication in some cultures and the psychosocial impact of terms such as cancer is helpful. Often, phrases such as malignant tumor or growth are less inflammatory and are more readily accepted, as is approaching loaded topics indirectly. Thus, it is essential to assess and consider patients cultural beliefs when communicating with them about their cancer.