Discussing cancer is never easy.
Not long ago, few people would talk about it. Cancer was considered a death sentence, frequently referred to in hushed tones. Treatments failed to offer much hope, and in many cases, a diagnosis of cancer was kept from the patient for his or her own good.
But all of this began to change in the 1970s, when cancer finally crept out of the closet and into the public consciousness. First Lady Betty Ford and Vice President Nelson Rockefeller's wife Happy openly discussed their battles with breast cancer. Patient rights became an issue. Patients began challenging doctors' authority, voicing opinions, and making choices.
Today, thanks to continuing improvements in cancer chemotherapy, more precise radiation therapy, and less disfiguring surgery, patients are living longer, healthier lives. Cancer is increasingly viewed as a chronic disease people are learning to live with. The growing discipline of psycho-oncology has ushered in a new optimism of helping patients, families, and caregivers learn to cope with cancer.
Cultural Clout
But this is not true in every society.
In many cultures, the patient may be the last to be told he has cancer. In Japan, for example, a 1994 survey of bereaved family members cited in October in the Japanese Journal of Clinical Oncology found that only one in five cancer patients were told of their diagnosis.
"Culture has a huge influence on how cancer is discussed, especially regarding the truth about a diagnosis," maintains Jimmie C. Holland, M.D., chair of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan-Kettering Cancer Center, N.Y., who pioneered the field of psycho-oncology. "It affects how patients and families perceive the disease and treatment, and how they cope with it."
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"The United States is out in front of this [truth-telling] issue because it's now a legal matter," Holland said. "Informed consent laws, particularly in clinical trials, make it impossible not to discuss this," she said.
Physicians in other countries often have different views.
"Whether and how I discuss a cancer diagnosis depends on the individual patient and family," said Korean gastroenterologist Hie-Won Yvonne L. Hann, M.D., professor of medicine at Jefferson Medical College of Thomas Jefferson University, Philadelphia. "The No. 1 priority is the patient."
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Strong Denial
In many Asian nations such as Korea and Japan, both doctor and family often decide on the appropriate cancer therapy and management with little say from the patient. Families try to protect the patient, and decide if the patient should know. Right-to-know laws and malpractice suits are rare.
In Korean culture, said Hann, the family tries to protect the patient from the truth, though the patient often knows he or she is getting sicker. All too often, said Hann, telling an unprepared patient he has cancer and suddenly outlining an appropriate treatment plan often leaves him scared and confused, and the family angry. "Denial of cancer among Koreans is strong."
Hann attributes differences from American practice to cultural disparities. "I think that Americans are more straightforward, more vocal, and want to plan ahead," she said. "Americans are more realistic. The first thing an American patient usually asks me is, How long do I have?' "
Doctors in many European nations also take on similar responsibilities for the cancer patient.
Croatian doctors, for example, make most treatment decisions when it comes to cancer, said Macedonia-born physician Tatjana Kolevska, M.D., a hematology-oncology fellow at Columbia-Presbyterian Hospital in New York. "Many patients would feel confused otherwise, and often intimidated and angry," she said. "They frequently expect and depend on the doctor to be the decision-maker." Still, she said that she frequently discussed the cancer diagnosis directly with her patients under 50, along with the family.
At Columbia, she notes, some of her patients are not used to being part of the medical decision-making process. "Many of my Hispanic patients, for example, frequently are confused and say, decide for me.' "
Many believe that openly discussing cancer has some way to go before becoming the rule rather than the exception. Holland believes that attitudes worldwide are only gradually changing. "People are becoming more educated about cancer and treatments," she said.
"There is a movement toward more open communication in many parts of the world," said Carolyn C. Gotay, Ph.D., an associate professor at the University of Hawaii Cancer Research Center, who studies multicultural attitudes about cancer.
Opening Up
Japanese oncologist Takami Sato, M.D., agrees. "Japanese public figures newscasters, actors, and politicians have come public with their disease, which helps to change people's thinking," he said.
"It's generational," said Armand Bouzaglou, M.D., medical director of the cancer center at St. Vincent's Hospital in downtown Los Angeles, which sees many Latin American and Korean immigrants. "The newer generations of immigrants are more Westernized and willing to discuss cancer."
Still, some patients don't want to know if they have cancer. In many developing nations in particular, there is a general lack of awareness of what cancer is and how to deal with it. In some cultures, for example, a woman with cancer may face abandonment by her husband, Holland said.
Holland contends that American doctors need to pay particular attention to multicultural issues. "While American patients demand to know about treatment options, discussing this with patients from other countries is problematic for doctors," she said. "It's important for them to be aware of patients' tradition and culture. Some may not be able to readily handle the truth."
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