238 S e m i n a r s in Oneology Nursing, Vol 16, No 3 (August), 2000: pp 238-247

OBJECTIVES:

To explore how culture may play

a part in breast cancer screening,
early detection, and efforts to de- C ULTURE AS AN
crease breast mortality.

DATA SOURCES: INFLUENCE ON

Journal articles published in the
past 20 years on cultural aspects
of cancer prevention and control. BREAST CANCER
CONCLUSIONS:

Research seems directed more at

discovering cultural differences
SCREENING AND
than at identifying similarities on
how culture influences breast
cancer screening and early detec-
EARLY DETECTION
tion. The influences of poverty
and lack of educational opportu-
nities account for much of what is
termed cultural difference. NOREEN C. FACIONE AND MARIA KATAPODI

IMPLICATIONS FOR NURSING
PRACTICE:
Improving practice through an
informed understanding of cul-
ture calls for considerable self-
education and a fundamental
refinement of care delivery.
From the Department of Physiological
Nursing, School of Nursing, University of
California, San Francisco.
Noreen C. Facione, PhD, RN, PNP:Assoei-
ate Professor, Department of Physiological
Nursing, School of Nursing, University of
Cal~brtda, San Francisco; Maria Katapodi,
Pdq, MSN, PhD Student in Nursing: Depart-
ment of Physiological Nursing, School of
Nursing, University of California, San
Francisco.
Address reprint requests to Noreen C.
Fac'ione, PhD, I~V, FNP, 611Y Depa~ment of
Physiological Nursing, Box 0610 School of
Nursing, University of CaliJbrnia San Fran.
cisco, San Francisco, CA 94143-0610.
Copyright 2000 by 1KB. Saunclers Company
0 74 9~2081/00/1603-0008510. 00/0
doi. l O_lO53/sonc.2000.8118
p
ROFESSED beliefs about the benefits of breast c a n c e r
screening and early detection have b e c o m e common-
place in American culture, and breast cancer is no
longer the sensitive topic that it was only decades ago.
As we begin the 21st century, public service educa-
tion delivers information about breast cancer symptoms and
m a m m o g r a p h y guidelines to most households through printed
materials, radio, and television. Yet, early detection campaigns
continue to report lower screening rates and later stage of c a n c e r at
time of diagnosis in some of America's subpopulations, these
differences being attributed to cultural beliefs and culturally
dictated behaviors. This article examines how culture m a y play a
part in breast cancer screening, early detection, and efforts to
decrease breast c a n c e r mortality (Fig 1). Even using a broad
definition of culture, not all the influences on screening and early
detection are attributable to cultural difference. ~
The complex mosaic of cultural variation is seen in the patterned
ways groups of individuals dress, eat, bargain, comfort, express
humor, c o m m u n i c a t e needs, etc. Societal subcultures, such as
senior citizens, African-Americans, or families living below the
poverty level, m a y be highly visible_ Other subcultures, such as
nurses, Native Americans, or r e c e n t immigrants, are smaller or less
visible. Recognizing that even m e m b e r s of families hold very
different ideas on most subjects, a focus on culture predicts that
persons who are m e m b e r s of the same subculture will hold
generally similar beliefs, values, and expectations, and strive for

Culturally i
K
Cultural Beliefs
Dictated Health
about Cancer
Risk and Cure
and Illness
Behaviors
Each Individual's
Screening and Early
Detection Behavior
Stage of Disease at
Diagnosis
I Breast Cancer Survivali
F I G U R E 1. The relationship of cultural beliefs and
culturally dictated health behavior to efforts at breast
cancer control,
similar goals. Within a culture, individuals share
knowledge and beliefs about breast cancer. These
shared knowledge and beliefs are assumed to
influence participation in screening and early
deteetion behaviors.
UNDERSTANDING CULTURE IN A
MULTICULTURAL SOCIETY
Ynthesizing research reports and published
S observations about early detection posed great
diffieulty. The majority of the larger studies report
varying rates of sereening and early detection
behavior by race, ethnicity, income, age, or some
other demographic identifier_ Several identifiers
are measured with great ambiguity as to culture.
While "black" often refers to African-Americans,
blacks of other heritage and different cultural
background (Caribbean, West and East African,
ere) are not distinguished. Other studies describe
subjects only as white and of high income and
edueational level, replacing descriptions of culture
with privileged class status. 2
The studies describing "Hispanic" or "Latino"
samples were composed of different cultural
groups. West coast studies most often included
women from Mexico and Central America, while
East Coast samples were more likely to inelude
CULTURE AND BREAST CANCER EARLY DETECTION 239
Allother ] Puerto Ricans and South Americans_ In our
Influences on studies we have learned that Latino immigrants
Screening and
Early Detection self-identify using the terms "white" and "black,"
which further complicates sample deseriptions.
For this integrative discussion the categories
blacks, whites, and Latinos are used.
A focus on early detection of cancer increasingly
calls for cultural competence. 3,4 Meleis et aP
commented that in our care delivery culture, the
expectations of competent nursing care includes a
sensitivity to culture, race, gender, sexual orienta-
tion, social class, and economic situation. Because
culture is such a pervasive influence in our lives, it
i is often difficult to discuss cultural difference
I without making eulture-eentric assumptions that
have social and political implications. Even pub-
lished reports of screening programs that eonsider
cultural difference are written from a biomedical
perspeetive on health and illness_ When we talk
about monitoring breast cancer screening in terms
of tracking "complianee with established guide-
lines," we are making culture-centrie assumptions
that persons should comply with the biomedical
view on caneer screening. The biomedieal perspee-
tive integrates our scientific knowledge with our
beliefs and socially normative behavior and sug-
gests how people should live their lives. The
majority of health care providers in the United
States have been trained to view health only from
within the biomedical cultural model, but to make
new strides toward culturally relevant outreach, it
will be important to recognize the assumptions
made by the model and to negotiate collaborations
between this perspective and that of other cul-
tures.
TRACKING BREAST CANCER SCREENING BY
CULTURAL GROUP
onitoring mammography screening by mea-
M surable demographic descriptors has been
done in an effort to evaluate the effectiveness of
outreach to all population groups. Data from the
Risk Faetor Surveillance System indicate mammog-
raphy screening gains in all surveyed states in the
percentage of women aged 40 years and older, s
Screening rates increased rapidly for all women
aged 50 to 64 years, regardless of raee/ethnieity,
income, and education level, although lower
income and less-educated women continue to be
screened at a lower rate_ s,6 Some geographic areas
240 FACIONE AND KATAPODI

report that African-Americans are still more likely education, and immigration status rather than a
to be u n d e r s c r e e n e d or not s c r e e n e d at all, 7-1 direct result of culturally dictated behaviors and
while data from the 1992 National Health Inter- culturally shared beliefs. Navon 33 stresses the
view Survey and a 1992 survey in San Francisco inadequacy of attributing each and every differ-
Bay Area multiethnic communities indicate that enee to cultural factors when in fact they m a y be a
rates of self-reported breast c a n c e r screening tests result of economic or educational gaps. Education,
among African-American, Hispanic, and white whether formal of informal, influences the breadth
w o m e n no longer differ significantly. 11 Differences of ideas available to a cultural group. Rajaram and
that remain are attributed to education and Rashidi 34 have offered an exceptional explanation
income levels, the recentness of immigration, and of how social networks give rise to health decisions
English language proficiency_
L a n g u a g e a s a B a r r i e r to A c c e s s
Studies report that Spanish-speaking women T A B L E 1.
have lower m a m m o g r ~ p h y screening participation A Typology of Culture-Relevant Issues Believed to
rates. 12-17These studies cite language barriers that Influence Breast Cancer Control
limit c o m m u n i c a t i o n with providers, 13-19nonavail-
ability of explanatory reading materials, 15,~8,19 and Strategic barriers to breast cancer screening
Access to services
difficulties negotiating the demands of the service
Availability of facilities
delivery setting. 2-23 Additionally, m a n y Spanish- Continuity of care
speaking w o m e n are immigrants who come from Prejudice
countries where health screening visits are not a Immigration issues
familiar c o m p o n e n t of health care. ~6,18,24,25 Similar Spoken language
Transportation
findings have been reported for Filipino and
Child care
Korean women, a6,27 Cambodian women, 2s and Income
Chinese-American women. 29-31 These two consid- Family annual income
erations have very different implications for how Public or private insurance
to direct c a n c e r detection resources. The first Spendable dollars
Education
requires only language assistance, while the
Formal education
second requires a larger exploration of utilization Experiential learning
expectations.
Culturally reinforced health and illness behaviors
The c o m m u n a l vocabulary and structure of a Modesty
language c o m m u n i c a t e the beliefs and expecta- Viewing the breast
tions that are an integral c o m p o n e n t of a culture. Touching the breast
Researchers have begun to explore the structural Sex role behavior
Therapies
differences of language that influence communica-
Western/Eastern medicine
tion of c a n c e r relevant i n f o r m a t i o n f 1,22 Transla- Scientific/folk tradition
tion of c o m m o n words like "risk," "lump," and Complementary methods
"discharge" m a y have very different meanings in Prevention behaviors
languages other than English. "Bolita," a transla- Screening/self monitoring
tion of "lump," most often called forth the Herbs/drugs/foods
Exercise, relaxation
understanding of benign inflammation or cyst Stress reduction
rather than the possibility of a m a l i g n a n e y Y Prayer/meditation
Conversely, the word "cancer" c o n n o t e d expecta- Culturally embedded beliefs about cancer risk and cure
tions of death rather t h a n survival. 29,32 These Risk perception
findings signal culturally e m b e d d e d differences in Population vulnerability
meaning that were intrinsic to the languages. Dangers in care settings
However, it is p r e m a t u r e to attribute these Beliefs about cure
Fatalism
observations to culture alone without considering Perceived powerlessness
the influence of education and poverty. Cancer knowledge
Symptom knowledge
Interactions Between Education, Poverty, and
Treatment knowledge
Culture Misconceptions
Table 1 displays the strategic barriers to breast
c a n c e r screening that are related to income,

within cultural groups. W h e n the m e m b e r s of the
social n e t w o r k live in poverty, t h e y share informa-
tion a b o u t denied care delivery and the h u m a n
cost of u n t r e a t e d illness. Few would d e n y that
p o v e r t y inhibits breast c a n c e r screening and
detection behavior. With p o v e r t y and d e c r e a s e d
educational o p p o r t u n i t y c o m e knowledge gaps
that limit one's u n d e r s t a n d i n g of the potential
benefits of c a n c e r screening and earlier detection.
Low annual i n e o m e r e m a i n s the largest barrier to
screening m a m m o g r a p h y , 7-1,19,a5-37 and studies of
s o m e hospital samples report t h a t as m a n y as 45%
to 60% of low-income blaek w o m e n have s y m p -
toms for m o r e t h a n 6 m o n t h s before their initial
evaluation visit. 3s-4
Since i n c o m e and e d u c a t i o n are highly corre-
lated, separating the effects of i n c o m e and educa-
tion are problematic. As a result, m o s t studies of
screening b e h a v i o r have r e p o r t e d i n c o m e and
education as interactive influences on c a n c e r
screening and early detection behavior. ~s,4-44 The
observation t h a t m e m b e r s of s o m e cultural groups
are on average less well e d u c a t e d and of lower
literacy is well d o c u m e n t e d as a function of
educational opportunity. Audio and visual strate-
gies are increasingly used to address limited
accessibility to early detection materials for b o t h
English- and non-English-speaking groups. 45-47
Expectations of Access to Services
Even the definition of a d e q u a t e access to
services is d e t e r m i n e d b y culture, with m o r e
privileged populations having higher expectations
for care delivery. Hongvivitana 4s provides a cross-
cultural definition of access to care t h a t goes
b e y o n d affordability to include availability, acces-
sibility, and acceptability_ Many studies of m a m -
m o g r a p h y utilization in samples of w o m e n f r o m
u n d e r s t u d i e d groups report the lack of availability
of m a m m o g r a p h y facilities, particularly in rural,
isolated areas. 15,49-51 Depending on w h e t h e r m e m -
bers of a given culture (eg, Native A m e r i c a n s and
Alaskans) live in outlying areas, lack of access
b e c o m e s a function of their cultural group m e m b e r -
ship. Salazar ~s c a p t u r e d the realities of lack of
geographic availability in h e r s t u d y of Latino
w o m e n , describing t h e m as d e p e n d e n t on others
for transportation. W o m e n were confined to their
h o m e s unless h u s b a n d s chose to take t h e m
somewhere_ In the era of m a n a g e d care, acces-
sibility has c o m e to m e a n an a p p r o p r i a t e and
timely physician referral and location of ser-
vices within health care delivery sites.r, 35,s2 Others
have o p e r a t i o n a l i z e d accessibility to include
CULTURE AND BREAST CANCER EARLY DETECTION 241
child care, transportation, and t i m e consider-
a t i o n s . 14,15,18,35,52,53
Accessibility barriers also can be related to the
c o m p l e x i t y and lack of personal c o n t a c t within the
b u r e a u c r a t i c p r o c e d u r e s of the medical system. 34
Several r e s e a r c h e r s have r e p o r t e d t h a t for m a n y
Latino w o m e n , i m m i g r a t i o n status is a m a j o r
access barrier. 1s,32 T h e s e authors have observed
this influence in Latino, black, and white w o m e n
who are either u n d o c u m e n t e d residents or fear
that their e n t r y into the health care s y s t e m will
e n d a n g e r relatives or friends who are undocu-
mented_ 32 N u m e r o u s studies reveal that having an
established care provider relationship has a gener-
ally positive influence on breast c a n c e r screening
rates for varying cultural g r o u p s. 5'10'27'37'53'54-57
Others have r e p o r t e d t h a t African-American and
Latino w o m e n ' s failure to obtain a m a m m o g r a m
was related to not having received a physician's
r e c o m m e n d a t i o n for screening.1,ls,37, s2,Ss
In addition to poverty, i m m i g r a t i o n and social
discrimination are believed to a c c o u n t for m u c h of
the differences in c a n c e r s c r e e n i n g b e h a v -
ior_ 20'25,59-61 Rajaram and Rashidi 34 caution that
the history of institutional r a c i s m in A m e r i c a
predicates that expectations of prejudicial treat-
m e n t often will be a p a r t of a c o m m u n i t y n e t w o r k
database relevant to health-related decisions.
R e s e a r c h e r s have r e p o r t e d the influence of preju-
dice in African-American w o m e n ' s participation in
m a m m o g r a p h y screening. 14,62-64 In our s u r v e y of
838 Latino, blaek, and white w o m e n in the San
Francisco Bay Area, the personal e x p e r i e n c e of
prejudice in health care delivery was significantly
related to perceived lack of access to services. =
Black and Latino w o m e n r e p o r t e d experiencing
prejudice significantly m o r e t h a n white w o m e n in
the sample. Reporting an e x p e r i e n c e of prejudice
was significantly related to having only one
m a m m o g r a m versus following screening guide-
lines. While actual prejudice in the delivery of
c a n c e r screening has not b e e n directly studied,
50% of the w o m e n in our sample perceived health
care delivery as biased by race, income, or sexual
o r i e n t a t i o n 2 a,65 More truth-seeking studies are
n e e d e d of this r e p o r t e d influence on b r e a s t c a n c e r
sereening and early detection.
MISCONCEPTIONS ABOUT BREAST CANCER
g g ~ / [ i s c o n e e p t i o n " is the t e r m used to declare
,kVl.that a belief is false w h e n evaluated by an
established criteria_ In 1980, a survey of black
242 FACIONE AND K A T A P O D I
A m e r i c a n s r e p o r t e d a lack of knowledge of c a n c e r
s y m p t o m s and c a n c e r screening tests. 66 Since t h a t
t i m e t h e r e have b e e n m a n y articles describing
knowledge about cancer within cultural
groups, 24,2s,67-7 m o s t focusing on the lack of
n e e d e d knowledge or m i s c o n c e p t i o n s a b o u t can-
cer. Both white and non-white w o m e n endorse
m i s c o n c e p t i o n s a b o u t breast cancer, and although
m i s c o n c e p t i o n s are believed to decrease w h e n
educational level increases, t h e y are not absent in
well-educated w o m e n , a2,ss 8 0 m e m i s e o n e e p t i o n
e x a m p l e s are t h a t a m a m m o g r a m is s o m e t h i n g
t h a t w o m e n require only in the p r e s e n c e of
s y m p t o m s , 12,27,3,58,64,71,72 t h a t m a m m o g r a m s are
only n e e d e d b y w o m e n who have a family history
of b r e a s t eaneer, j3,64 and t h a t w o m e n have similar
risk of b r e a s t e a n e e r regardless of age. 2s,z6,ss
A n o t h e r frequently r e p o r t e d m i s e o n e e p t i o n is
t h a t breast c a n c e r can be eaused by an injury to
the b r e a s t as a result of aeeident or d o m e s t i e
violence. 12,2,26,32,34,53,67,6s,72,73 Holding such a belief
might influence early detection if a w o m a n feared
the n e e d to acknowledge physical abuse to be
evaluated for her s y m p t o m s . In a study b y
Perez-Stable et al, 2 the idea t h a t c a n c e r could be
caused b y bruising was endorsed b y 52.6% of the
884 batino w o m e n and 34.3% of the 510 Anglo
w o m e n surveyed. Hubbell et aP 2 r e p o r t e d an even
higher e n d o r s e m e n t of this misconception: 74% of
803 Latino w o m e n and 41% of 422 Anglo women.
Such a belief m a y be surprising to m a n y in the
health care delivery system, yet it is i m p o r t a n t to
note that m a n y of the m i s c o n c e p t i o n s r e p o r t e d in
non-white samples have y e t to be studied. 2 O t h e r
r e p o r t e d m i s c o n c e p t i o n s c e n t e r on protective
effects against b r e a s t e a n e e r for s o m e behaviors,
including b r e a s t self-examination, 3 m a m m o g r a -
phy, 32 and b r e a s t feeding. 12,2,26,32,34,67,6s,72
Phillips et a174 attributed observed m i s e o n c e p -
tions in Afriean-Ameriean subjects to the relative
lack of o p e n discussion of b r e a s t c a n c e r in the
black c o m m u n i t y . In our own r e s e a r c h 29,32 we
found t h a t c o m m u n i t y narratives s e e m e d just as
likely to reinforee a m i s c o n c e p t i o n (eg, "breast
c a n c e r l u m p s are n e v e r painful") as t h e y were to
be effective sources of reliable c a n c e r control
information. Evidence suggests t h a t w o m a n - t o -
w o m a n e o m m u n i e a t i o n is an i m p o r t a n t tool for
the t r a n s m i s s i o n of w o m e n ' s health informa-
tion_ 32,34,75,76 Skinner et a177 d e m o n s t r a t e d m o d e s t
gains in c a n c e r - r e l a t e d knowledge in the urban,
African-American w o m e n , y e t s o m e ideas critical
to screening (eg, " m a m m o g r a m s are for w o m e n
who t h i n k t h e y have a lump in their breasts") were
still e n d o r s e d b y 50% of the w o m e n after testing.
However, a t t e m p t i n g to predict individual behav-
ior b a s e d solely on cultural b a c k g r o u n d can lead to
stereotyping and frequently flawed predictions, a4
The k e y issue is w h e t h e r an individual w o m a n has
i n c o r p o r a t e d a culturally c o m m u n i c a t e d miscon-
ception into h e r personal beliefs and w h e t h e r this
m i s c o n c e i v e d belief has implications for her
c a n c e r screening behavior.
PERSONAL RISK PERCEPTION
A n u m b e r of studies have r e p o r t e d i n a c c u r a t e
estimations of personal risk for b r e a s t can-
cer, rr,rs but generally these err in the direction of
higher t h a n actual risk perception, 24,68,79 a condi-
tion that should foster b r e a s t c a n c e r screening
behavior. Behavioral r e s e a r c h on s y m p t o m ap-
praisal and personal risk p e r c e p t i o n 8-s2 supports
the claim t h a t w o m e n who feel invulnerable to
b r e a s t c a n c e r will be less likely to participate in
screening or to appraise a b r e a s t s y m p t o m as a
potential signal of breast cancer_ Breast self-
e x a m i n a t i o n b e h a v i o r was r e p o r t e d to be less
frequent in b o t h white and black w o m e n who felt
invulnerable to b r e a s t c a n c e r in a s t u d y by
Salazar, s3 while C h a m p i o n and colleagues '57,s4
studies of white and black w o m e n have consis-
tently shown awareness of b r e a s t c a n c e r suscepti-
bility. Lower awareness of susceptibility is fre-
q u e n t a m o n g Chinese-Americans. 29,3,s5 Two small
studies of r e c e n t l y i m m i g r a t e d Chinese w o m e n
r e p o r t associating the n e e d for preventive health
behaviors with white w o m e n r a t h e r t h a n t h e m -
selves, and the belief that if w o m e n r e d u c e d their
level of stress and their tendencies to be bad-
t e m p e r e d t h e y could p r e v e n t b r e a s t cancer. 29,a
A possibly related issue r e p o r t e d in a n u m b e r of
studies is that m a n y C h i n e s e - A m e r i c a n s believe
that talking about s o m e t h i n g can cause it to
happen. 29,s6,87 Carese and Rhodes ss r e p o r t e d that
this idea is also p r e v a l e n t in the Navajo culture,
which views thoughts and language as having the
ability to s h a p e reality and affect events. This
f u n d a m e n t a l cultural belief has strong implica-
tions for providing early detection services. Appar-
ent attitudes of invulnerability to b r e a s t c a n c e r in
these and other studies 32,6s and the idea t h a t it is
possible to control the disease through thoughts
and b e h a v i o r c o n t r a s t sharply with reports of over

e s t i m a t i o n of risk in o t h e r samples 24,65,79 and
require further investigation.
BELIEFS AND BEHAVIORS EMBEDDED
IN CULTURE
Preserving Modesty
Physical e x a m i n a t i o n of intimate b o d y parts is a
barrier to health care, particularly for Latino and
Asian women, ls,3,79,55-57 This b a r r i e r includes a
w o m a n ' s c o n c e r n for maintaining her own expecta-
tions of m o d e s t y and the attitudes of her male
sexual partner. Some w o m e n defer c a n c e r screen-
ing b e c a u s e of a strongly dictated cultural expecta-
tion requiring t h a t their breasts not be viewed or
t o u c h e d by others and, in s o m e eases, t h e m -
s e l v e s . 26-28'31'34,64 C o n c e r n for m o d e s t y is also seen
in cultural c o m m u n i t i e s t h a t espouse the Muslim
faith, but the c a n c e r screening behaviors of these
w o m e n are not well reported. It m a y be t h a t a
culturally c o m p e t e n t a p p r o a c h to successful breast
c a n c e r screening will necessitate modalities t h a t
do not require viewing and m a n i p u l a t i n g a w o m -
an's u n c l o t h e d breast.
R e s e a r c h e r s have r e p o r t e d t h a t gender role
dictates the support w o m e n have for c a n c e r early
detection behavior_14,15,30,32,35,86,87 W o m e n hid their
participation in b r e a s t c a n c e r screening from their
male p a r t n e r s or did not seek help for s y m p t o m s
b e c a u s e their h u s b a n d s did not w a n t a male doctor
to p e r f o r m their b r e a s t examination.14,15,32, 57 Chi-
nese, Japanese, and Latino w o m e n are e x p e c t e d to
b e h a v e less a u t o n o m o u s l y a b o u t health-related
decisions, 15,3,35,56,57 with decisions about their
b o d y s h a r e d b e t w e e n h u s b a n d and wife. T h e r e are
no studies of p r e d o m i n a n t l y white and black
w o m e n t h a t address this issue directly, but
r e s e a r c h e r s have r e p o r t e d delayed help-seeking
b e h a v i o r for self-discovered breast s y m p t o m s by
w o m e n who fear a b a n d o n m e n t b y their male
partners. 32,53,s9,9 Future r e s e a r c h is n e e d e d to
assess the actual cost in m o r b i d i t y or m o r t a l i t y
related to male s u p p o r t for c a n c e r screening, early
detection, and t r e a t m e n t b e h a v i o r in varying
cultural populations. In groups in which m e n are
considered barriers, a direct a p p r o a c h to m e d i a t e
these cultural attitudes is warranted. Most typi-
cally, a cultural e x p e c t a t i o n of obedience to a
spouse is in conflict with a n o t h e r cultural expecta-
tion to r e m a i n h e a l t h y in order to serve the needs
of the family. W o m e n who deal with these
conflicting cultural expectations and the anxieties
of a potential breast c a n c e r n e e d direct interven-
tions to help t h e m arrive at a personally acceptable
CULTURE AND BREAST CANCER EARLY DETECTION 243
solution. This requires a community-based, culturally
sensitive care delivery system that partners with
w o m e n ' s organizations and s u p p o r t agencies.
Choice of Therapies
W o m e n with late-stage breast c a n c e r are m o r e
likely to use alternative a p p r o a c h e s to m a n a g i n g
their breast c a n c e r s y m p t o m s . 53,65,73,89,9 The use
of c o m p l e m e n t a r y and alternative therapies as
p a r t of the r e c o m m e n d e d t r e a t m e n t plan is
increasing, TM b u t the p r e v a l e n c e and variation of
therapies in use in A m e r i c a ' s diverse cultural
groups is not c u r r e n t l y known_ In a study of Anglo,
Latino, and African-American women, 32 the w o m e n
spoke of friends or relatives who declined surgery
and sought alternative therapies, were not cured,
and s u b s e q u e n t l y died. Laws and Mayo 13 observed
the use of faith healing in 25% of the Latinos in
their study, but the lack of r e p r e s e n t a t i v e sam-
piing prohibits i n t e r p r e t a t i o n of their findings for
the Latino population at large. S y m p t o m a t i c
w o m e n with breast c a n c e r often struggle to
c o m b i n e the directives of their health care
provider and their c o m m u n i t y networks to decide
w h a t to do a b o u t their s y m p t o m s . Culturally
c o m p e t e n t a p p r o a c h e s to breast c a n c e r control in
the 21st c e n t u r y will require facilitating dialogues
tolerant to diverse cultural perspectives_
Expectations of Cure
It would be false to s t e r e o t y p e m e m b e r s of any
cultural group as fatalistic in relation to breast
cancer. Acknowledging the strength of forces
outside one's personal agency will only c o n t r i b u t e
to the risk of a d v a n c e d disease at the time of
diagnosis if a w o m a n believes she lacks all p o w e r in
the face of a breast c a n c e r threat. This kind of
fatalism is r e p o r t e d to be m o r e p r e v a l e n t in poor
and in less-educated people. 2,35,89,92 Many report
low c o n c e r n for c a n c e r p r e v e n t i o n w h e n w o m e n
struggle daily to m a i n t a i n their families in the face
of p o v e r t y - s t r i c k e n environments.9,2,3s, 36 Studies
rarely credit these w o m e n with m a k i n g a generally
c o r r e c t a s s e s s m e n t of their dilemma, given the fact
t h a t m o r t a l i t y rates in m a n y of our p o o r e r cultural
populations r e m a i n u n i m p r o v e d . 5,35,93
T h e s e attitudes are r e p o r t e d to be m o r e preva-
lent in black and Latino w o m e n 2,24,65,92,94 and in
older WOnlen. 22,32,65,94 Morgan et al6s studied 876
Hispanic w o m e n who were p r e d o m i n a n t l y b o r n in
C a r i b b e a n countries but c u r r e n t l y living in New
York_ T h e y reported that 56% of their sample
244 FACIONE AND KATAPODI

believed that cancer was almost always fatal and
44% agreed with the statement that cancer cannot
really be eured. In our sample of 386 Latino
women 65 and in the study of 884 Latinos by
Perez-Stable et al, 2 endorsement of such state-
ments was closer to 25%, with both samples being
born predominantly in Central America. However,
representative sampling has yet to quantify the
prevalence of fatalistic attitudes in these and other
cultural groups.
The Concept of Prevention
Women of Asian and Latino cultural groups hold
beliefs about maintaining health that differ signifi-
cantly from attitudes about prevention and early
detection of illness common in biomedicine. For
example, in one study, Chinese women believed
that preventive health behavior should be deferred
until an individual reaches 40 years of age or older
or until they married and required reproductive
care. 3 Attaining wellness or offsetting illness by
methods that maintain balance among the body
humors is an idea that is common to Chinese-
Amerieans, 2s,29 Mriean-Americans, 32 Filipino- and
Korean-Americans, 26 and Native Amerieans, 49 yet
this is not directly congruent with biomedieal
ideas. Maintaining balance involves food choiees,
the use of herbs, mental exereises, and the
avoidance of stress. For those cultural groups in
which the traditional healing method does not
prioritize the use of biomedicine, it is unusual for
individuals to seek health services unless their
illness has not responded to other efforts at
symptom management.

Culturally Dictated Health

StrategiCto
AccessBarriers ~ Income
and Illness Behaviors

Perceived Access
versus Lack of Education
Access

Individually Cultural Beliefs

Incorporated about Cancer Risk
.3ultural Beliefs and Cure
Other Influences on and Behaviors
this judgment
process?

Judgment Personal Risk

Process Perception

Knowledge Versus
Each Individual's I Misconceptions |
Screening and Early| about Cancer I
Detection Behavior I

Stage of Disease at Diagnosis

! FIGURE 2. Cultural components

Breast Cancer Survival I of the judgment process central to
I breast cancer screening behavior.

JUDGMENTS TO PARTICIPATE IN SCREENING
AND EARLY D E T E C T I O N
omen use information from family members
W a n d f r i e n d s as well as t h e i n f o r m a t i o n t h a t
they reeeive from the media and the medical
community when they make decisions about
c a n c e r s c r e e n i n g . 29,32,34,63,64,77,95-9s W o m a n - t o -
w o m a n c o m m u n i c a t i o n of c a n c e r - r e l e v a n t i n f o r m a -
t i o n is i n c r e a s i n g l y b e i n g s t u d i e d for c u l t u r a l
differences in t h e a m o u n t of social s u p p o r t r e q u i r e d to
i m p r o v e c a n c e r s c r e e n i n g participation.
F i g u r e 2 s h o w s t h e r e p o r t e d d i r e e t effect of
e d u c a t i o n a n d t h e i n d i r e c t effect of i n c o m e o n
b o t h (1) b r e a s t c a n c e r k n o w l e d g e a n d m i s c o n c e p -
t i o n s a n d (2) p e r s o n a l r i s k p e r c e p t i o n . A t t h e s a m e
t i m e it r e m i n d s us t h a t c o m m o n l y e x p r e s s e d
beliefs about cancer risk and cure are potentially
influential on b o t h of t h e s e as well. T h e m o d e l stresses
t h a t cultural beliefs are diversely i n c o r p o r a t e d b y
e a c h individual w o m a n a n d t h a t this individual
i n t e r p r e t a t i o n of c u l t u r e will m a n i f e s t as d i v e r s e
e x p r e s s i o n s of c u l t u r a l l y a p p r o p r i a t e b e h a v i o r .
CONCLUSION
his d i s c u s s i o n of t h e r e p o r t e d c u l t u r a l l y
T relevant influences on breast cancer screening
a n d e a r l y d e t e c t i o n b e h a v i o r s h a s b e e n brief. A n
e x t e n s i v e r e f e r e n c e list to e n c o u r a g e r e a d e r s to
e x p l o r e t h e s e r e p o r t s is i n c l u d e d . T h e s e p u b l i s h e d
r e p o r t s d o c u m e n t i n c r e a s i n g v a l u a t i o n of t h e e a r l y
d e t e e t i o n of e a n e e r a c r o s s c u l t u r a l g r o u p s . C u r -
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