Although cultural factors such as age, gender, religion, or ethnic group can influence patients’ behaviors and attitudes toward cancer care, these differences can be minimized if physicians delve more deeply and ask patients open-ended questions, according to experts interviewed for this article.

Recognizing the need for taking cultural factors into account when treating patients has gained favor over the past decade. Now states such as New Jersey and California mandate that physicians take a course in “cultural competency,” while many other states recommend that physicians take these courses.1

According to Eduardo Bruera, MD, F.T. McGraw chair and medical director in the Supportive Care Center at the University of Texas MD Anderson Cancer Center, in Houston, Texas, 2 aspects of culture are important. Oncology fellows need to understand the culture to which the patient and family belong, as well as the culture of the group or institution where the physician works.

“The clinician has to try to understand the patient’s cultural context. Some cultures are better to understand and easier to know, because they and their values are more aligned with mainstream society,” Dr. Bruera commented. “Not all cancer centers and regions of the country share the same values. Fellows need to understand the culture of the institution where they work and then they need to understand that in the cultural context of patients and their families,” he said.

For example, a physician may work in a group or institution where palliative care is not supported. If that physician refers the patient for palliative services, there may not be support for those.

Although culture provides a context, care needs to be individualized. “Culture shouldn’t guide your practice regarding individual patients. Patients may not share all of the values of the group to which they belong. You need to do a personalized assessment of every patient and [his or her] family’s needs regarding communication and care,” Dr. Bruera said.

The level of endorsement of certain cultural principles of a person who becomes ill might be different, and also might change with illness, fatigue, anxiety, and/or depression. “The trick is to be attentive and sensitive to your patient. Be careful to assess repeatedly how the patient might change over time,” Dr. Bruera advised.

Cultural groups may have different expectations regarding the role of the family (Table). For example, Latin Americans and Asians typically believe that the patient should be protected from the doctor by the family and that the family should negotiate all aspects of care and communication for that patient. But sometimes a cancer patient who belongs to one of those groups may feel isolated and want to communicate with the doctor directly. The physician needs to determine the patient’s needs by asking the patient how he or she wants to manage communication, Dr. Bruera said.

Table. Further Reading on Cultural Competency
National Network of Libraries Medicine. Minority health concerns: cultural competency resources. Accessed November 23, 2011.
Natale-Pereira A, Enard KB, Nevarez L, Jones LA. The role of patient navigators in eliminating health disparities. Cancer. 2011;117(15 suppl):3543-3552.
Breaking bad news to Asian patients. Accessed November 23, 2011.
Shin HB, Kominski RA. Language Use in the United States: 2007. American Community Survey Reports, ACS-12. Washington, DC: US Bureau of the Census; 2010.
US Census Bureau Newsroom Web site. An older and more diverse nation by midcentury. Accessed November 23, 2011.

Another example of cultural differences has to do with handling emotions. Many Asian cultures endorse stoicism and nonexpression of physical and emotional distress when confronted with serious illness, whereas some Mediterranean cultures value the open expression of emotions and symptoms, noted Dr. Bruera.

“Just because a patient doesn’t express physical and emotional distress doesn’t mean he doesn’t experience it. This can be assessed using rating scales from 0 to 10 and asking patients about symptoms or emotions; also ask patients to compare their present state with their pre-sickness state and what would be acceptable to them,” Dr. Bruera suggested.

“Try to tune in to your patient,” he advised. “Is this person a Mediterranean type who values expression or a patient who keeps his or her feelings and experiences to him or herself?

“Culture affects a patient’s choices, but the goal is to treat the patient, not a culture,” Dr. Bruera emphasized. “We need to understand the cultural background, but that shouldn’t be the mechanism by which we treat them. If we treat each patient as an individual and are present and empathic with his or her experience, we align ourselves with that patient,” he stated.

In a separate interview, Murray F. Brennan, MD, chairman emeritus Department of Surgery, vice-president for International Programs at Memorial Sloan-Kettering Cancer Center in New York City, agreed that cultural beliefs are dual-sided.

“There are the cultural beliefs of physicians and the cultural beliefs of patients. Physicians’ cultural beliefs should not get in the way of cancer care, but patients’ cultural beliefs will influence their willingness to accept care,” Dr. Brennan stated.

One example of a cultural conflict is when an oncologist believes that a patient should receive no further treatment, but the patient and/or the family want every option explored. Groups such as Catholics may believe that no extraordinary measures should be used, whereas orthodox Jews may want to try every possible treatment option despite what the oncologist advises, noted Dr. Brennan.

“Sometimes these difficulties arise not from the patient’s beliefs, but rather from the family’s beliefs. A family may impose more rigid interpretations. For example, a patient may want supportive care, but the family wants everything possible done for the patient,” Dr. Brennan explained.

He suggested that the best way to negotiate cultural differences is to strive for “an equilateral triangle” between the patient’s, physician’s, and family’s expectations. This can best be accomplished by asking open-ended questions about the patient’s expectations. “Open-ended questions can be used to avoid cultural conflict,” Dr. Brennan said.

Acknowledging the importance of cultural differences, Dr. Brennan said that in the long run cultural differences may be over-exaggerated. All patients—whatever their culture—have in common the goal of getting better. “At the risk of not being politically correct, cultural considerations may be a secondary event. If you ask the patient directly, sometimes the perceived issue is a non-issue,” he stated.

“Age, gender, and cultural considerations can be minimized and even obviated by asking patients open-ended questions about their expectations. Culture is just another event, like age, religion, and race. It’s all about expectations. If the patient and physician have similar expectations, everything will turn out well. Problems arise when the expectations are not in line.

“Early identification of mutual expectations of what the patient wants and what the physician can deliver is the best way to avoid cultural misunderstanding and conflicts.

“I say to physicians, ‘do not promise what you can’t deliver,’” Dr. Brennan said.


  1. American Medical News. Mandating cultural competency: should physicians be required to take courses? Accessed December 15, 2011.

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