Cancer care should leave no stone unturned, and this is especially true as we work to address persistent cancer health disparities. Take cultural determinants related to spiritual beliefs, for instance.

There are documented, especially problematic, health disparities among individuals with limited financial resources, from specific racial/ethnic groups, and those who reside in isolated rural locations such as the Appalachians. However, according to the American Cancer Society,1 the greater burden of cancer continues to exist among African Americans as evident from the disparities that persist with advanced stage cancers and 5-year relative survival rates.1 So, what are we missing with this group?

Cultural determinants related to beliefs around the origins of illness, religious beliefs in divine control over life and death, and supportive familial relationships are increasingly examined for their role in cancer disparities. However, much of what has been captured and reported in the healthcare literature on culture and cancer has been perceived as overwhelmingly negative. This deficit perspective of the influence of culture on cancer disparities may obscure the strengths as well as realities of what is meaningful to that population, limiting our ability to provide optimal cancer care.2

Beliefs related to the origins of cancer are 1 example of a cultural determinant generally perceived as negative. In the healthcare literature, emphasis has been placed on the misconceptions that cancer is a punishment from God, possibly for some sinful behavior. Closely related are perceptions that cancer or the big "C" is a death sentence, that cancer treatment is worse than the illness itself, and that surgery causes cancer to spread. However, among African Americans, the belief that cancer is a death sentence is not unfounded and is, in fact, a reality of their past experiences with this illness. For example, approximately 50 years ago, the 5-year relative cancer survival rate among African Americans for all sites was 27%.3 Therefore, a reality for many African Americans is that the overwhelming majority of individuals who looked like them died shortly after being given a diagnosis. The widespread history of racism, discrimination, and lack of access to quality healthcare among this population contributes to beliefs that quality cancer care and chances for survival from this illness are not likely.

Today, a different reality is possible. Overall 5-year cancer survival rates for African Americans are now 62%.1 As evident from our research, African American cancer survivors and their family members are able to successfully complete cancer treatment despite their fatalistic attitudes, fears of impending death, and many other negative perceptions about cancer and its treatment.4,5 Spirituality and religious beliefs were preferred strategies that enabled these participants to overcome their fears and anxieties, to endure treatment, and to find meaning and purpose in the illness experience. One religious belief useful in positively influencing cancer treatment was that God is in control of life, death, and illness. The comment, "God is in control and will heal me," does not always imply that treatment is not wanted or needed. Rather, survivors adhering to prescribed cancer treatment believed that healing occurred through the power God gave man to facilitate healing. For these survivors, sickness and death were part of the human experience, but God gave "doctors" the knowledge to treat cancer. Survival from cancer was dependent on following God's direction to seek out healthcare providers He placed in charge of treating the cancer.

God's divine control over life and death is another religious belief and cultural determinant. Survivors who delay or drop out of treatment may express the belief that their date with death is predetermined and not within man's control. In our research, survivors completing treatment also believed that God was in control over life and death, yet they continued treatment. For these survivors, only God had the final say in when death would occur. The act of discontinuing treatment was similar to taking this control away from God, which was in conflict with their religious beliefs. The discontinuation of lifesaving efforts could also be evidence of a lack of faith in God or a show of weakness, both of which are perceived as negative character traits among the African American community.

Finally, beliefs in how one should interact with or disclose illness information may isolate the cancer survivor from family and friends or serve to bring them closer. Beliefs that isolate and prevent the disclosure of a cancer diagnosis might be that, when ill, God is the only one to depend on. Expressions such as "turning it [the cancer] over to God" or "I'm going to leave this [the cancer] in God's hands" may be used to convey this belief. Reference is also frequently made to the many Biblical scriptures advising that trust should be placed in God and not man. On the other hand, a trust in God for help and support may influence survivors to also trust mankind and to have positive and engaging relationships with family, friends, and healthcare providers. In our research, survivors completing treatment trusted God and realized that all help came through this powerful deity. Therefore, these survivors trusted that God would send someone to provide support and prayers when needed. Given that help came from God, these survivors were open to the receipt of support from individuals known (family, friends, neighbors) and unknown (passing strangers) to them.

Understanding the strengths as well as weaknesses of spirituality and religious beliefs is necessary as we strive to deliver optimal cancer care to diverse cancer populations. However, when diverse aspects of spirituality and religious beliefs are perceived as negative and lacking health benefit, mainstream healthcare providers may be reluctant to incorporate the positives of these beliefs into cancer care. A strong religious background has been used for generations to alleviate mental suffering among African Americans. It is important that we as healthcare providers understand and respect diverse perspectives of spirituality and religious beliefs of those we care for. This understanding is critical as we work not only toward reducing cancer disparities but also in providing optimal cancer care that treats the patients' cancer and their psychosocial needs as well.

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