Knowledge and Perceptions of Cancer and Cancer Prevention among Malaysian Traditional Healers : a Qualitative Study

Globally there is an increase interest in traditional based approaches to managing the public health (Zollman and Vickers, 1999). According to World Health Organization (WHO, 2002), traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or to maintain wellbeing. Traditional medicine also is known as alternative medicine, complementary medicine, natural medicine,


Introduction
Globally there is an increase interest in traditional based approaches to managing the public health (Zollman and Vickers, 1999).According to World Health Organization (WHO, 2002), traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or to maintain wellbeing.Traditional medicine also is known as alternative medicine, complementary medicine, natural medicine, self-regulatory mechanisms are relatively weak in the region.India, Myanmar, Nepal, Thailand and to some extent Sri Lanka have incorporated TCAM into their public health systems.While Indonesia and Maldives have not yet adopted them into their health delivery systems, Bhutan, Democratic Republic of Korea and Nepal have initiated strategies for integration (Gaitonde and Kurup, 2005).
In many developing countries, local healers subsidize the costs for patients who cannot pay and go unaccounted for in official statistics.The Complementary and Alternative Medicine (CAM) expenditure is significant and rapidly growing.For instance, the estimated figures are: USA $2,700 million, Australia $80 million, Canada $2,400 million and United Kingdom £2,300 million (WHO, 2002).
One of the popular Traditional Chinese Medicine (TCM) practices in Malaysia is traditional healing.The first National Health and Morbidity Survey in 1986 recorded that Malaysians made 0.1 visits per person per year to traditional healers as compared to 1.4 visits per person per year to out-patient clinics (Vickers and Cassileth, 2001).One study found that 96% of mental health patients in Malaysia had visited a traditional healer before seeking psychiatric care (Razali and Najib, 2000).

Traditional Chinese Medicine (TCM)
Traditional Chinese Medicine (TCM) is an ancient practice dating back to the 1st Century BC (Shen and Chen, 1994).It is basedprimarily on the principles of Yin and Yang and the five elements (fire, earth, metal, water, and wood).According to the Yin and Yang philosophy, illness develops when there is an imbalance between Yin (which is represented by negative dark and feminine attributes) and Yang (which is represented by positive, bright and masculine attribution).The Yin and Yang framework is profoundly important in Chinese culture and has applications beyond medicine, in fact, all of life encompasses this philosophy (Shen and Chen, 1994).Of the four major systems of traditional medicine, viz.Chinese, Indian, Greek and Egyptian, perhaps the most sophisticated one isthe Chinese.While solitary plants or simple combinations are used inthe Greek and Egyptian systems, both the Chinese and Indian systems (notably the Chinese) are fond of using formulae involving multiple herbs (Kleinman, 1975;Goldbeck-Wood et al., 1996;WHO, 2000).Chinese medicinal herbs such as Ginkgo biloba hasbeen reported to have chemo-preventive activities fortreating certain cancers such as ovarian, breast and brain cancers (Amin et al., 2009).Acupuncture is being used to relieve sideeffects of conventional cancer treatment.While somelaboratory and clinical research found some immune-boosting capabilities of acupuncture in cancer patients (Liu et al., 1995, Wu et al., 1994), most clinical research have focused on symptom management of chemotherapy induced nausea and vomiting (Dundee et al., 1989;Aglietti et al., 1990;Shen et al., 2000).

Traditional Indian Healers
Ayurveda, which means the science of life, is the oldest medical science in the Indian subcontinent and has been practiced since the 12 th Century BC.Ayurveda is not merely a system of medicine; rather it is a way of life.Its objective is to accomplish physical, mental, social and spiritual well-being by adopting preventive and promotive approaches as well as treating diseases with the holistic approach.Ayurveda iseffective not only in common ailments but also in many incurable, chronic and degenerative diseases as well as iatrogenic conditions.Ayurveda is prevalent not only in India but also in Nepal, Sri Lanka, Mauritius, Bangladesh, Pakistan,Indonesia, Malaysia, Singapore, and in the Maldives.The traditional systems prevalent in Myanmar, Bhutan and Thailand bear aclose resemblance to Ayurveda.It is also practiced in Japan, Australia, USA, Russia, UK, and Germanyas herbal medicine oralternative medicine.Australia, Netherlands and Hungary haverecognized Ayurveda as an alternative medicine.A White House Commission for Alternative Medicine has been constitutedin the US to find ways and means of recognizing alternative medicine, which includes Ayurveda also for the purpose ofpractice.Four types of Ayurvedic practitioners existin various parts of the world (WHO 2001).

Traditional Malay Healers
There are several types of traditional Malay healers including the following: (1) Islamic healers who draw on Islamic religious beliefs and use verses from the Qur'an as the major component of their treatment, (2) traditional healers who "know the folklore of disease causation, treatment and prevention" and are known by the term "bomoh."Bomoh uses a variety of handed-down, traditional methods in diagnosing and treating patients including "herbal remedies, ceremonial rites, incantation, exorcism and sorcery" (Razali and Najib 2000), (3) and "bomohpatah" which loosely translates to bone doctors or bone setters (Heggenhougen 1980, Razali andYassin 2008).Bomohs are so embedded in the Malay culture that they are sometimes the first and only source of information and treatment.Even those who seek standard Western medical treatment often simultaneously consult bomohs.Malaysia is a multicultural society consisting of approximately 60% Malays, 30% Chinese, 10% Indian and others (Muhamad et al., 2012).
Healing through Ruqyah (incantation) especially by using the Qur'anicverses, recitation of Du`a (prayer) and Ruqyah (jampi) with Mu`awwidhat verses are among the mostwidely and popular traditional practices intended to afford protection and healing of disease caused by Jinn and Devil in Malay Muslim society (Riji, 2000).With theinfluence of the Qur'an and the traditions of the Prophet (S.A.W), especially through Kitab al-TibbofSahihBukhari on the Malay-Muslim's world view, they practice Al-Ruqyah,an Islamic way for the purpose of prevention and treatment of disease caused by Jinn and Devil (Ahmad, 1988).
On how Islamic worldview has been shaped in the Malay-Muslimsociety, a Malay Muslim thinker and scholar, in his Preliminary Statement on a General Theory of the Islamization of the Malay-Indonesia Archipelago found that Islamization in the Malay world was the most influential factor for shaping Islamic world view in Malay world since it isconsidered the most momentous event in the history of the Archipelago (al-Attas, 1976).
Most Malay-Muslims using Qur'anic verses for healing for example: Surah al-Fatihah has been used widely in the Malay-Muslim society for incantation.The official ceremony and meeting usually commence with the recitation of Surah al-Fatihah and ending with Du`a (prayer).Al-Fatihah, the first Surah of the Qur'an, is regarded as an infallible aid in healing.The recitation of Surah al-Fatihah is one of the most frequent exercise especially during compulsory Salah, five times aday in the prayers.The Prophet (S.A.W) had expected that the Muslim is able to recite and use it for medical purposes.In connection to the medical benefit of Surat al-Fatihah, Ibn al-Qayyim in his al-Tibb al-Nabawi said: "If one's faith, soul, and spirit are strong, and if he adapts himself to the essence of the opening chapter (Al-Fatihah), and by Allah's leave, by reciting its holy words and blowing them onthe affected person followed by his spittle upon the victim.Allah willing, such reading will incur the reaction of the evil spirits and cause the elimination of their evil actAllah knows best (al-Qayyim 1985;Dols, 1992).Fatihah is one of recommended surah to be recited for recovering from illness: spiritual, mental or physical (al-Qayyim 1985).The Malay Muslim in Malaysia often uses the Ayat al-Kursi for prevention and treatment of diseases and self-protection.Allah's Apostle said: "… when you go to your bed, recite Ayat-al-Kursi, for then there will be a guard from Allah who will protect you all night long, and Satan will not be able to come near you till dawn (Deuraseh, 2009).
There is another Surah which is commonly used by Malay Muslims in the prevention and treatment of diseases namely Surah Yasin.It is said that if one issuffering from toothache, verse 78, wadarabalanamathalanwanasiyakhalqahuqala man yuhyi al-`izamwahiyaramim, to the end of the Surah Yasin is advised to relieve the pain by writing the mentioned verse on paper and hung over the ear on the side of the aching tooth and it will cure the pain.In addition, the Muslim uses certain a verse of Surah Yasinto protect his property and his household.Thirdly, a Muslim is of the opinion that if one has an enemy he wishes to harm and that without injury tohimself or one whose love he wishes to gain, he recites seven parts of Surah Yasin.At each mubin part, which ends with the word mubin, which means open or clear, he ties a knot in a cord which he has ready athand.When the recitation is completed he nails the cord into the ground, then, he might get his desire (Deuraseh, 2009).
The Malay Muslim believes that protection from evil spirits, satan and Jinn canbe had by hanging the verses of Qur'an most notably of the mu`awwidhat verses.According to IbnHajar the mu`awwidhat verse consisted in three major surah of the Quran namely Surah al IbnHajar,10: 239).Surah al-Ikhlasdenies begetter and begotten and any equal.His name the Eternal (al-Samad) confirms all perfection; the denial of any equal declares none is likeunto Him.Therefore, it is said that Surah al-Ikhlas equals a third of the whole Qur'an (al-Sabuni, 1981).
Reciting al-mu`awwidhat, as the word means, is crucial for protection from the devil, i.e.: Satanand Jinn.In Bab Ruqyah al-Nabiyy (Ruqyah of the Prophet) of Kitab al-Tibb, Imam al-Bukhari, inorder to show the spiritual benefit of mu`awwidhat, reported that 'Aishah (r.a) said: "Whenever Allah'sApostle went to bed, he used to recite Surat-al-Ikhlas, Surat-al-Falaq and Surat al-Nas and then blowson his palms and passes them over his face and those parts of his body that his hands could reach.And when he fell ill, he used to order his wife, to do like that for him (SahihBukhari, Kitab al-Tibb, Bab Ruqyah al-Nabiyy).
The Complementary & Alternative Medicine (CAM) use is more common among patients with cancer thanamong individuals in the general population.The prevalence ofCAM use by breast cancer patients varies (Adler and Fosket, 1999;Burstein et al., 1999;VandeCreek et al., 1999;Boon et al., 2000) with reportsindicating that 63% (Sparber et al., 2000) to 83% (Richardson et al., 2000) of breast cancer patients use at least one type of CAM.In addition to inadequate resources to deal with cancer in Malaysia, in this majority Muslim country, some believe that cancer is a test of one's faith and should be treated with thehelp of spiritually-oriented healers.With regard to breast cancer in particular, women in Asian countries are at risk due to issues of modesty, a fatalistic perspective, fear of screening tests, theirresults, and recommended treatment, "inability to act without husband's permission, fear ofcasting stigma on one's daughters, fear of being ostracized, fear of contagion, reticence, language barriers, and preference for traditional healers" (Parsa et al., 2006).Even among immigrants in California they "seek the first course of treatment from traditional healers" for cervical cancer resulting in late diagnosis and "mortality rates three and four times higher than Asian/Pacific Islanders and non-Hispanic white women, respectively" (Yang et al., 2004).There fore, this is the first study conducted to fill the gap of knowledge and to explore the knowledge and perceptions of Malaysian tradition healers towards cancer and cancer prevention in Malaysia.

Methodology
Google search was done to locate the Malaysian traditional healers from various races (Malays, Chinese and Indians) in Kuala Lumpur and Selangor state.A total number of 50 traditional healers were contacted through telephone calls to explain the purpose of the study and were invited to participate.Only twenty five agreed to participate during the period from 20 th July 2011 until 24 th of September 2011.The main reasons for them not participating were the lack of time and language barriers of the traditional healers.The proposal of this study was approved by the Ethics Committee of Management and Science University (MSU).Consent form was obtained from the participants before the interview began.Once the participant agreed to be interviewed, the date, time and place of the interview were determined.Once the interview started, the participants were briefed about the study and its purpose and the voice of the participants was recorded after asking his permission.The interviews lasted for approximately one hour.The data was organized into themes and analyzed manually.

Results
A total number of twenty five Malaysian traditional healers participated in this qualitative study.Their ages ranged between 26 to 78 years old.The majority of them were in the age group of 31-60 years old, were males, Chinese, degree holders, and had a monthly income ranging between 1,000 to 5,000 RM and were married (56%, 80%, 48%, 52%, 68%,84% respectively) (Table 1).

DefiningCancer
The majority of traditional healers defined cancer as having high cholesterol orhave an abscess accumulation.Few traditional healers defined cancer as a type of cell growth.
One of theTraditional Chinese healers said "When someone falls sick and didn't take care of him/herself, sooner or later if they prolong the sickness and continue to eat unhealthy food, somehow the cancer cells will accumulate and start to mutate because everyone has cancer cells in their body which are passive." One of the Traditional Indian healers said "Cancer is an abscess that forms at any part of the body." One of the Traditional Malay healers said "Cancer is a disease caused by the accumulation of cholesterol in blood vessels." Another Traditional Malay healer said "Cancer caused by a virus called 'virus juta' and cannot be treated by normal treatment."

Causes of Cancer
The majority of the traditional healers mentioned that food and unhealthy lifestyles are the primary causes of cancer.Some of them mentioned that cancer is caused by ghost interference.
As quoted by a Traditional Chinese Healer "People nowadays have low intake of oxygen in their body because on unbalanced 'CHI' (energy) in the body because of unhealthy lifestyle such as smoking, sleeping late hours and emotional health." Another said "For women who gave birth, if the breast milk doesn't flow out and for prolonged period of time, if it is still stuck there; it would lead to breast cancer." A Traditional Indian Healer mentioned that "Many people love to eat spicy food which will cause irritation to the stomach lining that will then cause stomach cancer." Another healer said "The causes of cancer are the deficiency of Vitamin B17 and the continuous irritation of tissues due to chemicals or spicy food that we eat which all will lead to cancer." Another healer said that "Overeating is the main cause of cancer.In Ayurvedic, they suggest only 2 meals per day (breakfast and lunch) except for laborers".The meals that we eat must also be balanced according the six tastes in order: Sweet, Sour, Salty, Spicy, Bitter and the taste of Star Fruit." According to a Traditional Malay Healer "The food choice and lifestyle of people nowadays is very bad.People would prefer eating oily and fried food as compared to steamed food.Oily and fried food will cause the accumulation to cholesterol to begin and when it is too much in the body it will restrict the blood flow which causes cancer." Most of the other Traditional Malay Healers that we interviewed have the same opinion as quoted "Cancer is also caused by ghost interference.When someone is under stress and also lives in an unhealthy lifestyle, it would make the person weak and this would give the opportunity for the ghost to take over the person's soul.The ghost stays in the body and travels along the blood vessels while releasing its unwanted substances such as its feces which causes pain and problem to the person and would lead to cancer."

Cancer Diagnosis
The majority of the traditional healers mentioned that they refer to modern physicians' medical reports when it comes to diagnosing or treating someone with cancer.
From the Traditional Chinese Medicine, the healer will check the patient's pulse and the overall appearance.If the patient has high deficiency in their "CHI", weak kidney or low immune system, the healer will treat by performing acupuncture and give certain herbs to help boost up the patient's "CHI" and immune system but that depends on certain types of cancers only.Another method is that the healer would suggest the patient to do "Chi Kong" a system which helps to generate "CHI" for example Tai Chi.It is done in slow motion which helps the patient to heal from the inside and thus more oxygen are taken in.
From the Traditional Malay Medicine, the healer would recite specific verses from the Holy Quran.The healer would then ask the patient to practice drinking the holy water and also to apply or drink extra-virgin olive oil for the period of time that the healer suggests.For chronic cases, the healer will add on wild honey and 'Baraka' herbs to cool down the patient's body temperature because according to the healer "when the patient has cancer, the body temperature of the patient will be very high.Then for extremely weak patients, 'ZamZam water is given and also blood cupping is done.All of these together by reciting specific verses from the Holy Quran are done for faster recovery." From the Traditional Indian Medicine, one of the healers quoted "The best and basic treatment in Ayurveda is by checking pulse".Then, the healer would check the balance or imbalance in the body by checking the three basic elements of the body which are Vata (Air), Pitta (Fire) and Kapha (Water).By doing so, the healer would know the different stages of cancer.Another healer quoted that "for whatever disease, I will treat based on the AshtamgahrudayamBhashabook.Basically, I will touch, find, examine, talk and ask questions to the patient and also read the patient's pulse and I would know what the patient is suffering from".

Knowledge of Treating Cancer
Majority of traditional healers mentioned that they got their knowledge from formal education.Some other sources of their knowledge would be the combination of both experience and ancestral inheritance.The traditional healers that we have interviewed mostly got their knowledge from formal education.This includes all three Chinese, Malay and Indian Traditional Healers.There were only a few of them who got their knowledge from their ancestors and through experience.

What Are the Most Common Cancers That Patients Come For Your Treatment?
The most common cancer that patients come to obtain traditional treatment from the healers would be breast cancer (48% of the population).All three ethnic traditional healers said "nowadays women are not aware of their unhealthy daily lifestyle they are living in."According to a Traditional Malay Healer, "there are many women in this world compared to men.That is why breast cancer is common".Other cancers that are considered common in many patients would be intestine, colon, liver and lung cancer.As quoted by one of the Traditional Chinese Healer "Liver cancer is also common because liver is the site for detoxification in our body.Due to the environment now, the food we eat, the water we drink and sleeping late will increase the amount of toxins in the body thus the liver has to work extra than normal which will lead to liver cancer."The healer also said that sleeping from 11pm to 3am is when the liver undergoes detoxification."If we do not sleep during that time, which is why toxins accumulate in our body which will increase the liver cancer possibility."

Is Traditional Healing Better Than Modern Medicine?
According to the each of the three ethnic traditional healers, nearly half of the traditional healers agreed that traditional medicine is better than modern medicine forwhich the reasons are that they havelittle or no side effects and is cheaper.Some of them claim that the combination of both is better because the results would be better and the condition has its own advantages and disadvantages.

Are the Risk Factors of Traditional Medicine Higher Than Modern Medicine? Explain Why.
Most of the traditional healers said that traditional treatments have no risk as compared to modern medicine.One Traditional Chinese Healer claimed that "the only risk factor they faced is the production of the herbs itself.Even though they are natural but nowadays with pollution, chemicals and pesticides used may increase the risk factors on patients".
According to one Traditional Indian Healer the risk factor would be "the production of the medicine by the company in an unethical way".

Why Do You ThinkPeople Adopt Traditional Healing As An Alternative Treatment?
Most of the traditional healers agreed that when modern medicine is of no use and cannot help, that is when most patients come to seek traditional treatment as a last resort.Some also commented that low cost and less sideeffects are contributing factors.The Traditional Chinese Healer said that patients come to seek Traditional Chinese Medicine treatment when Western Medicine cannot help them and some of them also know that Traditional Chinese Medicine treatment has no side effects.As quoted, "When someone has normal fever, cough or flu most of them will seek treatment from modern clinic or just take Panadol but those who are health cautious will come to Traditional Chinese Treatment as they will be given some herbs to boil and drink which has no side effects".According to a Traditional Malay Medicine, the healer said that people adopt traditional healing because the cost is low and there are no side effects.From the Traditional Indian Healer, he claims that "Patients cannot and do not want to be treated anymore by needles and injections.That is why they seek traditional treatment".

What are the Outcomes of Your Practice? Any Successes or Failures? Why?
According to most of the traditional healers, there is a mixture of successes and failures.However, it is mostly successful as compared to failures due to various reasons.According to one of Traditional Indian Healers, there is both success and failure.The healer has successfully treated lung cancer and also bone cancer because those were still in the early stages.For failures, it would be liver cancer because the patient was already in second stage and the life span was only for 6 months.According to one of the Traditional Malay Healers, the healer also has both successes and failures.A 5-year old patient with stomach cancer was successfully treated because as claimed by the healer, children have a faster recovery rate.For failures, it would be mouth cancer because the patient was in a very severe stage.

In Your Opinion, How To PreventCancer?
The majority agreed that to prevent cancer one should be cautious about food intake and habits.According to a Traditional Chinese healer, most of the healer's opinions are that cancer can be prevented by a person's lifestyle, good eating and sleeping habits and also good emotional health (being happy).The patient should also follow the procedure given by the healers because all of this will boost up their 'CHI' (energy) of the body.When the amount of energy in the body is at a normal level, only then the patient can undergo a normal lifestyle.As for Traditional Malay Medicine, the healer advises to always do blood cupping every four monthsto remove infected blood and also consume wild honey which will always keep the body cool.According to the Traditional Indian Medicine, also most of the healer's opinion is that cancer can be prevented by proper lifestyle, doing normal walking and cooking, exercise, drinking a lot of water, no smoking or alcohol.One of the healers also said to not eat irritants and quoted "Stop eating KFC.All of these will cause disease not only cancer but also other dangerous diseases."

AreThere any Laws, Rulesor a Governing Body That Monitors or Regulates Their Procedures?
Most of the traditional healers agree that there are general rules or laws by the government or by their own ethics in their traditional medicine.For Traditional Chinese Medicine, the healers claim that they need to have a license (Chinese Physicians License) to practice.To open up a clinic they also need to have a license, but in Malaysia, the governmentis yet to be very strict about this.The healer also said that "In Taiwan, Japan, Hong Kong and China, the traditional healers are at the same standard as the western physicians but in Malaysia is yet to achieve this stage".According to a Traditional Malay Healer, the he said "Only next year, the Ministry of Health will enforce the law towards traditional medicines".For Traditional Indian Medicine most of the healers claim that "in Malaysia there are no laws that monitor traditional medicine".

Discussion
The majority of traditional healers defined cancer as having high cholesterol or an abscess accumulation.Few traditional healers defined cancer as a type of cell growth.This indicates that this group of healers does not know the basics of diseases.Therefore, they are not able to treat patients in an appropriate and professional manner.The majority of the traditional healers mentioned that food and unhealthy lifestyles are the primary causes of cancer.Some of them mentioned that cancer is caused by ghost interference.

Causes
Lung cancer often has been viewed as the sentinel disease for cigarette smoking in approximately 90% of all lung cancer deaths among women and is attributed to smoking (DHHS, 2001).The evidence that smokeless tobacco causes oral cancer was confirmed by the International Agency for Research on Cancer (Petersen, 2005).The alcohol content varies from 25%-45% and adulteration with methyl alcohol is quite frequent, which has been responsible for causing deaths, night blindness or total blindness.Experimental studies in rats showed that methyl and ethyl alcohol were multi potential carcinogenic agents causing malignant tumors of the oral cavity, tongue, and lips.These sites have been shown to be target organs in man by epidemiologic studies (Soffritti et al., 2002).
Evidence also has suggested that those adolescents who carry the BRCA1 and 2 familial breast cancer gene mutations were highly likely to develop breast cancer with age, and may delay the onset of disease by as much as 12 years if they practiced a physically active lifestyle and controlled their body weight (King et al., 2003).One of the most relevant findings in studies of cancer risk factors is the protective role of physical activity for many of the common cancers (Warburton et al., 2006).The protective effect is related to a wide range of biological mechanisms (Friedenreich and Orenstein 2003).

Common Type of Cancers
The most common cancer that most patients come to obtain traditional treatment from the healers were breast cancer, followed by colon cancer, liver and lung cancer.This is due to that breast cancer is the most common cancer among Malaysian women (NCR, 2006).

Ethnic Differences
The prevalence of Complimentary & Alternative Medicine (CAM) use by ethnicity has been studied.In a San Francisco-based study, CAM use was consistently high across four different ethnic groups, though the type of CAM used varied to some degree by ethnicity (Lee et al., 2000).The study found that African-American women used spiritual healing more frequently than other types of CAM (36%), Chinese women most often reported using herbal remedies (22%), and Latino women used dietary therapies (30%) and spiritual healing (26%).The study also reports significant predictors of CAM use for African-American, Chinese, Latino, and white women: higher income, engaging in exercise, and membership in community or support groups.Alferi et al (2001) reported that of 231 breast cancer patients, more black women used herbal therapies and spiritual healing than did Hispanic or non-Hispanic white patients.A qualitative study used focus group data to compare CAM use between African-American and Hispanic women (Cushman et al., 1999).The authors reported higher CAM use among older women of both groups, with younger Hispanic women indicating the most distrust toward the effectiveness of CAM techniques.

Reasons for Using Traditional Medicine
Breast cancer patients report varying reasons for incorporating CAM into their health care practices.Boon et al (2000) queried a random sample of Canadian breast cancer survivors to understand the motivation behind CAM use.Women indicated that they sought to boost the immune system (63%), increase quality of life (53%), DOI:http://dx.doi.org/10.7314/APJCP.2012.13.8.3841 Knowledge of Cancer and Cancer Prevention among Malaysian Traditional Healers prevent a cancer recurrence (42%), provide a feeling of control over their life (38%), and to aid conventional medical treatment (38%).Richardson et al. (2000) reported similar expectations from CAM treatments in a group of mixed cancer patients at a major cancer center.Patients hoped to improve their quality of life (77%), boost their immune system (71%), and to prolong life (62%).A cohort of Italian breast cancer survivors cited their main reasons for using CAM as physical distress (61%) and psychological distress (21%) (Crocetti et al., 1998).
As revealed by Taib et al. (2007), there are a number of possible motivations for seeking therapies outside the Western medical system, including fear of surgery, a friend's influence, an earlier bad experience in a hospital, thought that alternative therapy works.He also found that 15.5% of cancer patients sought alternative treatment beforevisiting a breast cancer clinic.In developing countries, inadequate medical facilities in the primary health system, poor infrastructure, and information systems become barriers to the development of comprehensive screening programs and the effective control of cancer (Pai, 2002).Moreover, lack of financial resources often compels many cancer patients to venture into inexpensive alternative medicines in search of cure and palliation (Al-Adawi, 1993;Pai 2002;Tovey et al., 2005).A previously unpleasant experience in a hospital also drives cancer patients to seek traditional healers (Taib et al., 2007).Misconception about Western healing is another push factor towards traditional healing.Leong et al. (2009) reported that patient's fear of surgery will disturb the cancer and cause it to grow larger.Overall, the inadequacy or failure of modern medicine and the health care system lead patients to turn towards traditional healing (Moodley et al., 2008).
In India, according to government sources, for the 65% of population, traditional medicine is the only available source of healthcare (WHO 2002).It is also an affordable source of health in many countries.Another reason is that it is firmly embedded in the belief systems and can be termed "culturally compatible".In developed countries, higher income and higher education are guiding factors of patient preference for traditional medicine.Due to difficulties in accessing modern health care, ethnic minorities in developed societies who are disadvantaged both economically and socially, use TCAM as a first health care choice, making it non complementary (Bodeker et al., 2007).

Effectiveness of Traditional Medicine
In this study, most traditional healers mentioned that traditional medicine is better than modern medicine because it is cheaper and has no side-effects.Some traditional healers mentioned that the combination of both is better because the result will be better.Moreover, lack of financial resources often compels many cancer patients to venture into inexpensive alternative medicines in search of cure and palliation (Al-Adawi 1993;Pai 2002;Tovey et al., 2005).Overall, the inadequacy or failure of modern medicine and the health care system lead patients to turn towards traditional healing (Moodley et al., 2008).In Tovey et al.'s study of cancer care in Pakistan, unconventional methods were perceived as useful and nontoxic by patients and were often used prior to presentation to physicians (Tovey et al., 2005).
The authors concluded that patients interested in exploring CAM for cancer treatment are left with little scientific evidence on which to base their decisions.Because of the limited scientific data on the effectiveness of CAM for cancer treatment, patients may have no alternative but to rely on anecdotal evidence.Gotay and Dumitriu (2000) reported on the role played by health food stores in educating cancer patients on the efficacy of CAM treatments; they indicate that shark cartilage is the most frequent recommendation for breast cancer treatment.
According to WHO, the quantity and quality of safety and efficacy data available on TCAM are far from to be considered as sufficient to meet the criteria needed to support its use world-wide.This is due to a variety of reasons such as lack of proper documentation, appropriate policies and even a suitable research methodology.It is argued that while modern medicine emphasizes on a scientific approach, and content that is value-free and unmarked by cultural aspects, TCAM have developed rather differently with much influence by the culture and historical context in which they first evolved.Their epistemic framework, principles, concepts and practices are quite different from those of Western biomedicine (Shankar et al., 2006).They generally tend to focus on a holistic approach to life, equilibrium between mind and body and the environment and adopt a preventive approach (WHO, 2002) thus making it difficult to develop appropriate methodologies without harming these unique features.Moreover issues such as chemical complexity of multiple plant based formulations are also challenges for developing a suitable methodology for research.
In popular parlance there is a general understanding that herbal medicines are safe.However, reports of toxicity in traditional medicines have been a matter of concern currently.Another study reported heavy metal content in Ayurvedic herbal preparations sold in the American market and have recommended mandatory toxic heavy metal testing for all herbal products.Researchers argue that such studies are important and needed, however are more related to the quality control failures of the mass manu facturing activities.Often these reports are wrongly interpreted and have a negative implication on the use.Effective quality control and regulation are certainly needed without limiting public access to these preparations or resorting to restrictive trade practice, at the same time ensuring public interest (Patwardhan, 2005).

Cancer Prevention
Other behavioral modalities have also been studied, such as massage and body therapy, and have been found to provide some physical and emotional benefits for cancer patients (Kullmer et al., 1999;Billhult and Dahlberg, 2001).The role of nutrition in health promotion, disease prevention and treatment of chronic diseases is well recognized (Hu et al., 1997;Schaller and James, 2005).Nutrition plays a critical role in numerous pathophysiological conditions, including such prevalent diseases as diabetes, cancer, and cardiovascular diseases (McGinnis and Foege, 1993).Dietary factors have been thought to account for about 30% of cancers in western countries (Doll and Peto, 1981) making diet second only to tobacco as a preventable cause of cancer.
Primary prevention strategies and goals for Malaysia 2020 are to promote healthy weight maintenance and to eat more than 2 servings of fruits and 3 servings of vegetables per day with a saturated fat intake of less than 10% of calories (Appel et al., 1997).Dietary manipulation is considered in all reports to be the cornerstone of prevention and management efforts of the above mentioned diseases.Therefore, health professionals should be prepared to provide nutritional guidance to their patients, and in developing countries, physicians are in the front line of responding to patients' questions regarding their diet.Several studies have indicated relatively less knowledge of nutrition in students and educators within the medical education system causing much mortality in the UnitedStates (Temple, 1994;Schulman, 1999).
A significant modifiable risk factor associated with cancer is diet.According to Willett, "the inverse relationship between the intake of fruits and vegetables and the risk of lung cancer represents one of the best established associations in the field of nutritional epidemiology" (Willett, 1990).Findings from several cohort studies have demonstrated a significant protective effect of the intake of fruits and vegetables against cancer (Willett, 1990;Patterson and Block 1991;Block et al., 1992;Chen et al., 1996, Al-Naggar andChen 2011).In a recent study by Rothwell et al. (2012) suggesting that daily aspirin can be used to help prevent and possibly treat cancer.
In conclusion, as the saying goes "a smooth sea never made a wise mariner".Relativity, in the research that we have done, we evidently observed various opinions from different traditional healers, be it; Malay, Indian or Chinese.Nevertheless, there were some similarities between them which guided us to our notion.The common perception for the definition of cancer is; it is a disease related to cell growth.As cited in the analysis above, there are many causes of cancer.Most of the traditional healers say that the main cause is food intake and lifestyle.Some of the other causes mentioned are the fact that people nowadays have low intake of oxygen in their body and also some factors associated with paranormal/ supernatural interference and stress.Besides, most of them commented that breast cancer is the commonest cancer amongst patients because nowadays women are not aware of their unhealthy lifestyle they are living in.Other common types of cancers include liver cancer as stated by one of traditional Chinese healers.On other hand, most of the traditional healers (80%) agree that to prevent cancer one should be cautious about the food intake and habits.In addition, some of other ways to prevent cancer are to look after a person's lifestyle, emotional health and also to consume wild honey.Others comprise of exercise, drinking a lot of water and not smoking or taking of alcohol.Therefore, there are some incontrovertible similarities between the Malay, Chinese and Indian traditional medicines.Hence, in our observation we would conclude that these similarities are the bona fide proof that traditional medicine works in levels that can't be completely explained through modern science and perhaps that is why it is still largely appreciated by people all around the globe.
While we are conducting the research, we confronted many difficulties.When we sat and did the analysis we found out that a number of difficulties could be avoided if a better plan or strategy was executed.During the period of two months, we managed to interview 25 traditional healers around the Kuala Lumpur and Selangor area.If we were given a longer period of time, we can interview more traditional healers not only in Kuala Lumpur and Selangor but also from other states.Thus, we would like to propose a longer duration to carry out this similar specific type of research.
Besides that, we would also like to propose that in future, more funding should be attained.The main reason is so that our research would not be restricted within a small location; instead it would be throughout all of Malaysia because most traditional healers are found in rural areas.For example, traditional Malay healers are found mainly in the state of Kelantan, traditional Chinese healers are found in the inner states of Ipoh and the traditional Indian healers are found mainly in Penang.