The home countries of many immigrants are plagued by an insufficient number of healthcare providers, especially physicians trained to treat complex diseases such as cancer. In China and India, for example, there is a severe shortage of oncologists, especially in rural areas [2]. Immigrant patients who are not accustomed to modern medical care are far less familiar with cancer prevention and modern treatment than are their indigenous, acculturated peers.

In many countries such as China, patients seek medical care only when symptoms arise. Routine or regular health screenings are rarely sought. Chinese patients tend to base their sense of well-being on how they feel day-to-day without consideration of preventing future disease [3]. Similarly, most cancer centers in China focus on treatment only, rather than on prevention and detection [4]. As with Chinese immigrants, South Asian immigrants are not aware of the concept of screening for asymptomatic diseases in seemingly healthy individuals, and routine screening is not practiced in their home countries [5]. Mammograms are not included in routine breast cancer screening in the public hospitals of many immigrants’ home countries. Instead, healthcare providers recommend mammograms only after a lump has been detected [6].

India’s highly patriarchal society plays an integral role in the inaccessibility of proper cancer care, as the healthcare problems of men and young family members take precedence over those of women and the elderly [7]. Male partners and elders in the family can block women’s access to medical care by not consenting to doctor visits. In a study performed in Karnataka, India, 66.4 % of rural and 37.9 % of urban underprivileged women stated needing the permission of their male spouse or elder for medical testing [8]. In another study, 40 % of noncompliant Indian women stated that their domestic chores and family care responsibilities prevented them from undergoing screening [9]. Therefore, it is not surprising that Indian women are diagnosed with breast cancer at much more advanced stages than are women in developed countries [2]. The same observation has been noted in many Middle Eastern countries [10].

The United States and Canada have large and heterogeneous immigrant populations . The largest immigrant groups in the United States come from Mexico, China, and India [11]. The Middle East also represents a substantial and diverse immigrant group in the United States. These areas of the world are the focus of this chapter. The majority of immigrants described here were found to have resided in the United States for 10–20 years.

Ethnic minorities in the United Statesare disproportionately uninsured. In one study, approximately 38 % of Latinos, 24 % of African-Americans, and 22 % of Asian Americans/Pacific Islanders were found to be uninsured, compared to 14 % of non-Latino whites [12]. The absence of access to insurance is a new reality for many immigrants, such as those from Mexico and Columbia, where cancer care and control is a component of health insurance programs throughout the country [13].

Studies show that immigrants, especially those of low–middle income, are less likely to utilize cancer screening, putting themselves at risk of being diagnosed with advanced-stage cancer [14]. In a study investigating breast cancer-screening practices among first-generation immigrant women from South Asia and the Middle East, only 52 % reported having had breast cancer screening in the previous 2 years [6]. This is substantially lower than the national average of 67 % for all women in the United States[15]. Another study reported that only 32 % of non-English-speaking Chinese-American women, compared to 86 % of white American women, had ever had a mammogram [16]. Data from the New York State Cancer Services Partnership (CSP) reveal low participation in breast and cervical screening among Arab women living in America. In the Queens and Brooklyn Partnerships, less than 1 % of Arab American immigrant women living in the area were screened over a period of 3 years [17].

In addition, several studies demonstrate that cancer disparities continue to exist among immigrants even after controlling for influential confounders such as health care coverage, age, and education [18]. This suggests that immigrants’ seemingly lower access to cancer care and screening may be explained by more than socioeconomic differences.

Latino and Asian immigrants have a high incidence of gastric cancer. Typically, this is due to the high rates of Helicobacter pylori infection in their countries of origin [19, 20]. Such circumstances stem from immigrants’ life conditions in their home countries. Immigrants tend to continue their cancer-promoting habits when they migrate to the United States Arab American tobacco rates (41 % and 38 % among men and women, respectively) are well above the national US average of 23 % [21, 22]. In many Arab immigrants’ home countries, tobacco rates are among the highest in the world, and tobacco cessation programs are just beginning to take ground [23].

In South Asia, chewing areca nut (the seed of the areca palm tree) is a popular pastime. In addition to being used for religious purposes areca nut is regarded by many South Asians to have health benefits. It is often used as a traditional Ayurvedic medicine, specifically as a purgative and intoxicant to treat various infections as well as certain gynecologic problems [24]. However, areca nut use has been associated with oral cancer [25].

South Asians are at much greater risk for developing oral cancer due to high rates of tobacco chewing and smoking as well as areca nut consumption [24]. Oral cancer rates among South Asians are much higher than the national average in the United States and the United Kingdom [26, 27]. This is attributed to the continuation of areca nut use among South Asians after migration [28]. In a study investigating paan and gutka (smokeless tobacco combined with areca nut) usage in 138 first-generation Bangladeshi and Indian-Gujarati immigrant adults in the New York metropolitan area, 77 % of Indian-Gujaratis were current users of gutka, and 70 % of Bangladeshis were current users of paan [29].

It is essential to understand how cultural beliefs influence patients’ understanding and behavior concerning risk assessment and care. Cancer fatalism, the notion that cancer, regardless of stage or specific diagnosis, is a “death sentence,” and is prevalent among many ethnic groups. In a study investigating cervical cancer screening among immigrants, cancer fatalism was a shared belief across Middle Eastern, Asian, and Hispanic groups [30]. The belief that death is an inevitable outcome of cancer is a major barrier to cancer screening and treatment.

In China, Ming Dynasty (1368–1644) Taoist beliefs are said to underlie pervasive cancer fatalism. Ming Dynasty beliefs hold that there is an “invisible force,” similar to fate, that is responsible for everything in the course of human life, including illness and death [31]. This fatalistic attitude is not conducive to participation in health care interventions, especially preventive efforts and screening.

Among Arab Americans, cancer fatalism is associated with a strong identification of God in the day-to-day happenings of human life. In a study of the cancer beliefs of US Arab immigrants, Arab women were reported to thank God if they received a positive health diagnosis. They perceived cancer diagnosis as “God’s punishment,” and believed that the course of their cancer was predominantly under God’s control as opposed to their own. God was viewed as the “omnipotent protector and healer,” thus minimizing the value of prevention or treatment [32].

In addition to cancer fatalism, other cultural beliefs may hinder timely cancer care. In China, for example, there is widespread perception that death after cancer diagnosis is inevitable, and that the final outcome is predestined and unchangeable by medical intervention. In addition to Ming Dynasty notions, Chinese patients are reluctant to speak openly about their cancer before and after diagnosis, believing that “negative thoughts” will lead to worry and to poorer health conditions. Both primary and secondary cancer prevention measures are thought detrimental to a harmonious state of health [2]. Breast and cervical cancers, because they are associated with female sexual organs, are particularly taboo topics in rural China and for that reason are barriers to screening. Chinese women in rural China not only avoid participation in screening for these cancers, but are also reluctant to discuss their health status in their personal lives before and after breast and cervical cancer screening [33].

In India, cancer is a socially stigmatized disease. This prevents patients from seeking treatment until the cancer has progressed to an advanced stage. Patients keep the diagnosis a secret from family and friends, often going to extreme lengths at the expense of a positive outcome with proper treatment [2]. One study showed that Indian women refused colorectal cancer screening because cancer diagnosis was “synonymous with death,” and, ironically, that need for a diagnostic biopsy was sufficient justification to avoid attending screening [34].

Cancer fatalism, nihilism, and related beliefs are barriers to cancer screening and to immigrant patients’ willingness to participate in clinical trials [35]. A New York City study found that Chinese cultural beliefs were the primary reason that immigrant Chinese patients declined to participate in clinical trials. Some patients were under the impression that merely screening for cancer would ultimately cause cancer [36]. As these data indicate, immigrants’ low cancer-screening rates may be largely attributed to their cancer-related beliefs and attitudes, especially among those migrating from low–middle income countries. Having spent the majority of their lives in their home countries and having adopted certain belief systems and ways of life, immigrants bring these beliefs with them when they migrate to the West.

In developed countries and elsewhere where evidence-based therapies are the rule, complementary therapies are applied for purposes of symptom control. At Memorial Sloan Kettering Cancer Center (MSK) , the home base for the authors of this chapter, and in many other evidence-based practices worldwide, complementary t herapies are appropriately applied as adjuncts to mainstream cancer treatment. They are not used to treat cancer because complementary therapies do not treat disease. Rather, they control many physical and emotional symptoms associated with cancer and with modern cancer treatment [37].

Multiple publications in oncology and other medical journals worldwide document the evidence for various complementary therapies to successfully control such symptoms. These manageable symptoms include pain, nausea and vomiting, fatigue, hot flashes, xerostomia (extreme dry mouth), sexual dysfunction, stress, anxiety and depression, neuropathy, insomnia, and possibly lymphedema [38].

Internationally, evidence-based complementary therapies for symptom control include some or all of those practiced at MSK: meditation, yoga, and other mind–body therapies, massage therapy, acupuncture, dietary, nutrition, and herbal remedy counseling, music therapy, and exercise [39]. The importance of exercise and maintaining fitness cannot be overstressed. It is the one complementary therapy that is well documented to produce survival benefits. Overweight and sedentary lifestyles are not healthy, and there is an inverse relationship between level of post-cancer-diagnosis physical activity and risk of cancer recurrence and mortality [40].

The many ways in which culture and health beliefs impact health-seeking behavior also guide patients’ use of complementary therapies. These beliefs also may influence a patient’s decision to rely not on modern medicine to treat cancer, but rather on complementary therapies such as acupuncture, meditation, or herbal remedies from their home countries. Many patients seek the typically ancient therapies of their ethnic groups, all of which have rich histories of traditional medicine. For example, Asian Americans use Traditional Chinese Medicine (TCM) , which consists of a broad range of medicine practices including acupuncture and herbal remedies [41]. In China, patients mainly rely on TCM to personalize their cancer treatment and to achieve either of the following effects: anticancer activity, chemo-sensitization, or a yin-yang balance. The underlying principle behind TCM is that mitigating disruptions in the flow of vital energy (qi) in the body through meridian channels is necessary to restore health and “balance.” While some patients seek TCM for symptom relief, others hope that TCM will exert a curative effect [42].

Latinos tend to seek healers such as curanderos (folk curer), espiritistas (spiritists), and yerberas (herbalists) [43]. In a study conducted in Mexico, approximately 70 % of the parents of pediatric patients reported using unproven methods. The reasons cited were to mitigate the side effects of conventional treatment (53 %), to fight or cure cancer (32 %), and to achieve both (14 %). Although herbal remedies were most commonly reported (69 %), other products taken orally included rattlesnake, coral calcium, shark cartilage, propolis, royal jelly, opossum, crab, urine therapy, and turkey vulture. Homeopathy also was used (25 %) [44].

India’s population also relies largely on traditional medicines to treat cancer, as many patients perceive them as effective as Western medicine. Indian clinicians often integrate popular traditional remedies into their treatments. India has 250,000 homeopathic doctors, and homeopathy is one of the seven recognized national medical systems in that part of the world, despite the absence of data indicating that homeopathy offers any benefit whatsoever [2].

In the Middle East, frequently used natural remedies include honey for the prevention of mucositis in head and neck cancer patients, kefir and yogurt to improve sleep in colorectal cancer patients, and HESA-A (a formulation containing wild celery, cumin, and king prawn) to improve the quality of life in breast and colon cancer patients [45].

Across immigrant groups in the United States, Asian Americans reportedly have higher rates of complementary or alternative therapy use (31.8 %) compared to other ethnic minority groups [46]. In the literature, more studies have been conducted investigating such use for cancer among Chinese immigrants (due to their well-established use of TCM both in their home countries and in the West) followed by Hispanic immigrants. These are the main groups discussed in this section.