Cultural Influences, Surgical Decision-Making Approaches for Non-Caucasian Women With Breast Cancer

3 women with breast cancer of different ethnicities | Image Credit: Mary Long - stock.adobe.com

A systemic review revealed common barriers in surgical decision-making among non-Caucasian women diagnosed with breast cancer were fear, misinformation, patient-doctor relationships, well-being, external influences, and culture while exploring suggestions on surgical shared decision-making (SDM), a technique dependent on patient empowerment.

The most common forms of surgery include mastectomies, breast conserving surgeries (BCS), and breast reconstructions. Professionals view surgical decision-making as a personal preference, local health care provision, demographics, and clinical information. Factors impacting SDM include education levels, evidence on potential outcomes of surgery, numbers of potential surgical options and results on the quality-of-life post-operation.

Out of 5243 studies, 10 English publications from 2015 to 2021 were included for review. Of the 241 women analyzed, various ethnicities were represented, including African American, Ghanaian, Chinese, Iranian, Asian immigrant, and Caucasian.

Fear was a common theme among patients with breast cancer during surgical decision-making, however, the causes varied across ethnicities. For example, the fear of cancer generally was noted as an important influence among Iranian and Ghanaian women, which could be linked to low health literacy levels, while African American and Chinese women were more likely to choose mastectomies to lessen their fear of reoccurrence. Asian-immigrant Americans and Vietnamese-speaking Australian women expressed doubts towards breast reconstruction, fearful implants would trigger the cancer, causing further complications or additional issues upon return.

Many non-Caucasian women reported feeling they lacked information on surgical options due to poor communication and education. Asian-immigrant American women were more likely to encounter misinformation, usually from social media. Language barriers were also a significant issue for immigrant women, leaving them struggling to gain accurate information of both medical and English-language terminology. Asian American women reported being overwhelmed by their lack of knowledge, resulting in feeling frustrated with decision-making. Similarly, Iranian women had little understanding about their conditions since they had trouble identifying and correcting false information, resulting in consent forms signed without proper information. African American and Chinese women were the most informed because they proactively sought resources, including internet research.

Various ethnicities trusted doctors too much without considering their preferences. Cultural expectations led Iranian women to limit their input on treatment withdrawal. Ghanaian women felt uncomfortable challenging medical professionals, fearing it would strain relationships and worsen healthcare. Body image concerns, particularly regarding breast reconstruction, affected Asian immigrant and African American women, impacting feelings of femininity and attractiveness. Vietnamese-speaking Australian women noted age and life stage influenced these decisions. Psychological distress affected decision-making for immigrant and native Chinese patients, reflecting the burden of surgical choices amidst cultural values.

In African American communities, factors beyond medical advice, such as input from family and friends, contributed to surgical decision-making processes. Chinese Australian and African American women were more likely to consider seeking a second medical opinion while Asian immigrant American women found it was important to hear surgical experiences from other women. In Asian communities, families, often husbands, influenced women's decisions on breast reconstruction by weighing in on their "attractiveness." Other external influences included frequent interruptions of appointments and lack of time with their doctors among Ghanaian and Iranian women. Time itself was an influence African American and Vietnamese-speaking Australian women considered since recovery hinders daily life.

Cultural, social, and religious normalcies among ethnicities were a large factor impacting surgical decision-making. For instance, a common theme was the cultural expectation of the doctor being the expert, where Iranian and Chinese Australian women left the preferred treatment plan in the doctors’ hands. Many Chinese women felt it was imperative to hide their emotions, maintaining a stable front to avoid stigmatization, and avoid surgical conversations in general.

This study offers valuable, up-to-date insights into factors influencing surgical decision-making, applicable to current clinical practices. While insightful, the study's generalizability is limited by focusing on specific ethnicities and excluding non-English sources. Additionally, the data for African Americans was biased due to the sample being drawn from religious populations, and the Chinese data may not represent all Asian populations.

Cultural sensitivity training for health care professionals should address inaccurate beliefs and provide accurate, tailored information for consultations across ethnicities, fostering collaborative decision-making. Engaging consultations with clear understanding and ability to ask questions are crucial. Patient preference for trustworthy doctors over pure medical knowledge highlights the need for multilingual, written information and explanatory campaigns, especially for immigrants, to empower patients in expressing their needs. Finally, social media offers a powerful platform for sharing accurate information, combating misinformation, and challenging harmful cultural norms surrounding cancer.

Reference

Murray A, Francks L, Hassanein ZM, Lee R, Wilson E. Breast cancer surgical decision-making. experiences of non-caucasian women globally. A qualitative systematic review. Eur J Surg Oncol. 2023;49(12):107109-107109. doi:10.1016/j.ejso.2023.107109