Prevalence of complementary and alternative medicine use in cancer patients during treatment
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- Yates, J.S., Mustian, K.M., Morrow, G.R. et al. Support Care Cancer (2005) 13: 806. doi:10.1007/s00520-004-0770-7
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Goals of work
To assess complementary and alternative medicine (CAM) therapies being utilized by cancer patients during treatment and communication about CAM usage between the patient and physician.
Patients and methods
Newly diagnosed cancer patients receiving chemotherapy or radiation therapy were recruited to complete a CAM survey within 2 weeks after the termination of treatment. Patients were queried on which CAM modalities they utilized and whether or not they were discussed with either their oncologist or primary care physician.
Of the patients surveyed, 91% reported using at least one form of CAM. The most widely used forms of CAM were prayer, relaxation and exercise. CAM users tended to be women chemotherapy patients with at least a high school education. Of the patients using CAM, 57% discussed the use of at least one of these therapies with their oncologist or primary care physician. The most frequent CAM modalities discussed with at least one physician were diets, massage, and herbal medicine.
An overwhelming proportion of cancer patients are using CAM, particularly prayer, relaxation, and exercise. However, patients may not discuss the use of CAMs at all or fully with their physician; if they do, it is most likely to be their oncologist, but not about the most frequently used CAMs. Future research needs to assess effective ways for oncologists to gather information about CAM usage by patients during allopathic treatment and discern ways these therapies may enhance or interfere with traditional cancer treatments.
KeywordsComplementary medicineQuality of lifeSymptom managementBehavioral medicine
It is estimated that over 1 million individuals, approximately 668,470 women and 699,560 men, in the United States would have been diagnosed with cancer and 600,000 will have died as a result of cancer during 2004 . Despite substantial improvements in the current treatments that are available for patients diagnosed with cancer and the positive influence of these treatments on survival, chemotherapy or radiation therapy cause an array of traumatic side effects, such as fatigue, sleep disturbance, anxiety, depression, nausea, and vomiting [18, 26, 28, 30]. These side effects are often difficult to ameliorate or manage, and can significantly impair a cancer patient’s quality of life (QOL) [6, 17, 18, 31]. Given the induction of side effects by allopathic medical therapies (e.g., chemotherapy and radiation therapy), as well as the perceived ineffectiveness of conventional medicine at preventing and relieving these side effects, patients often seek help outside the traditional Western medical model through what is defined as complementary and alternative medicine (CAM) for aid in alleviating side effects and increasing QOL [6, 7, 9, 13, 14, 16, 20, 24, 25, 27, 28, 31, 32].
The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” Furthermore, NCCAM has developed a classification system for the various CAM modalities, including alternative medical systems (e.g., homeopathic medicine, naturopathic medicine), mind–body interventions (e.g., meditation, prayer, art therapy), biologically based therapies (e.g., dietary supplements, herbal products), manipulative and body-based methods (e.g., chiropractic, massage), and energy therapies (e.g., Reiki, Therapeutic Touch) .
In light of (1) the suggested benefits of CAM for cancer patients, (2) the desire of patients to feel and take control of their illness, (3) the increase in patient engagement and responsibility concerning their treatment plan, (4) the desire of patients to feel hopeful, (5) the notion that CAM modalities are completely safe and nontoxic, (6) the accessibility of CAM therapies (e.g., lower costs and nonprescription), and (7) decreased faith in traditional medicine to meet patient needs, it is not surprising that the prevalence of cancer patients seeking and using CAM is increasing [3, 12, 13, 19, 20, 25, 27, 29]. In fact, preliminary research suggests that the average cancer patient uses between four and five CAM modalities and often does not discuss them with their oncologist [3, 4, 8, 15, 22, 25, 27].
Despite the emergent literature supporting the efficacy of specific CAM modalities for managing side effects associated with cancer treatments, the exact nature of CAM usage (e.g., the number of patients using CAM, who uses CAM, what types of CAM are being used, and whether they inform their physician) is not well delineated. This may be the result of a lack of clarity about exactly what is considered a CAM therapy, which is a continually evolving term because some CAM therapies become mainstream and some traditional practices that were not previously considered a medical intervention are defined as CAM . Indeed, the term “CAM” is itself often replaced with the phrase “integrative therapy” which is defined as the combined use of traditional and alternative medical systems to meet the specific needs of patients.
In summary, although cancer patients are experiencing increased survival rates, the current standard treatments for cancer result in side effects that negatively influence patients’ QOL. Given the perceived inability of traditional medicine to completely control these side effects, cancer patients are seeking the aid of CAM. The exact nature of CAM usage among patients, the impact of CAM on standard cancer treatments (e.g., chemotherapy and radiation therapy), and patient/physician communication concerning CAM is not well understood. Thus, the purpose of this study was to assess CAM therapies being utilized by cancer patients and communication about CAM usage between the patient and physician in community clinical oncology practices across the United States.
Newly diagnosed cancer patients receiving chemotherapy or radiation therapy were recruited by 17 Community Clinical Oncology Program (CCOP) affiliates throughout the United States. Inclusion criteria were (1) having a diagnosis of breast, lung, genitourinary tract, gynecologic, hematologic, gastrointestinal, or head and neck cancer, (2) being chemotherapy or radiation therapy naive, (3) being scheduled for chemotherapy or radiation therapy, (4) having a life expectancy of at least 10 months, (5) being at least 18 years old, (6) providing written informed consent, and (7) being able to read and understand English. Patients were excluded if they were on tamoxifen alone, because their treatment duration would not coincide with chemotherapy or radiation therapy treatments. Almost all patients approached agreed to participate in the study and if patients declined it was because they felt the study consumed too much of their time. Prior to consenting and enrolling any patients, the University of Rochester Human Subjects Review Board approved the study.
Design and procedures
This cross-sectional retrospective study assessed CAM modalities that patients utilized while undergoing chemotherapy or radiation therapy. After expressing an interest at their initial oncology consultation, a research coordinator met the participant, presented the consent form, and conducted a short interview to collect demographic and medical information prior to beginning therapy. The CAM survey was then completed and collected from patients within 2 weeks after the termination of treatment. Patients were queried on which modalities they utilized and whether or not these were discussed with either their oncologist or primary care physician. The assessment was mailed to the patient’s home, along with a postage-paid, pre-addressed return envelope, during the 2 weeks immediately following the termination of cancer treatments and took about 15 minutes to complete.
The measures for this study included forms related to demographics, medical information, and CAM.
Demographic and medical information
Demographic and patient characteristics assessed included age, gender, racial/ethnic category, partnered status, occupation, education, self-rated health status, number of dependants, and financial responsibilities. Medical information consisted of diagnosis, date of diagnosis, Karnofsky performance status, previous treatment, and current treatment.
Participation in 13 of the most common CAM modalities since cancer diagnosis was assessed. The CAM treatments were part of the categories as defined by NCCAM and included alternative medical systems, mind–body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies. The specific CAM modalities asked about in this study were exercise, prayer, relaxation, chiropractic, massage, imagery, spiritual healing, diets, herbal medicine, mega-vitamins, self-help groups, hypnosis, and acupuncture.
In addition, for each modality, the patients were questioned about whether they discussed using those forms of CAM with their oncologist or primary care physician.
Data analytical methods included the calculation of descriptive and correlational statistics, as well as between-group comparisons, employing independent sample t-tests and one-way analysis of variance (ANOVA) using SPSS version 12.0 software.
Demographics of patients and their CAM use (percentages are given to the nearest whole number)
Entire sample, n=752 (%)
CAM use, n (%)
Radiation therapy only
Radiation therapy and chemotherapy
Karnofsky performance status (%)a
Patient-perceived health status
Of the patients surveyed, 91% (n=686) reported using at least one form of CAM during treatment. Of these patients, 63% (n=429) used between one and three different forms of CAM during treatment, 31% (n=213) utilized between four and six, and 6% (n=44) used seven or more CAM therapies. The most widely used forms of CAM were prayer, relaxation, and exercise, respectively. A summary of the demographics of the 686 patients who had used at least one CAM treatment since their diagnosis is presented in Table 1.
Potential moderators of CAM use
Females were more likely to use CAM than males (P<0.001). Patients with less than a high school education were less probable to use CAM than patients with at least a high school education (P<0.001) or some college education (P=0.002). Furthermore, patients undergoing radiation therapy were less likely to use CAM than patients receiving chemotherapy (P<0.001) or both treatments (P=0.006). Moreover, there were differences in CAM treatment use by diagnosis, with breast cancer patients being more likely to use CAM during treatment than all patients with other diagnoses combined (P=0.001).
Patient and physician communication
Of the patients using CAM, 57% (n=388) discussed the use of at least one of these therapies with their oncologist or primary physician, while the remaining 43% (n=298) did not discuss CAM with either physician. Of the patients who discussed CAM usage with a physician, 81% (n=314) talked about one to three different CAM modalities, while 15% (n=60) discussed four to seven, and 4% (n=14) discussed more than nine different CAM modalities.
With respect to oncologists only, 51% (n=351) of the patients who used CAM discussed at least one modality with their oncologist, and 24% (n=168) discussed between two and four modalities, while 49% (n=335) did not discuss any CAM treatments they were using with their oncologist. Regarding primary care physicians only, 28% (n=190) of the patients using CAM discussed at least one modality with their primary physician and 12% (n=82) discussed between two and four modalities, while 72% (n=496) did not discuss any CAM treatments they were using with their primary physician. Lastly, 17% (n=114) of the patients who used CAM discussed at least one modality with both their oncologist and primary physician, while 7% (n=51) discussed between two and four CAM therapies with both physicians.
Complementary therapies patients utilized and whether patients discussed these therapies with a physician (percentages are given to the nearest whole number)
Number of patients using therapy, n=752 (%)
Patients who discussed therapy with a physiciana, n (%)
Others not listed
In summary, cancer patients are using CAM along with conventional medicine to form an integrative and holistic approach for the treatment of their cancer and the associated side effects. The most common CAM users tended to be women chemotherapy patients with at least a high school education. Only a little over half the patients using CAM discussed using these modalities with their physicians (oncologist or primary care), and if they did discuss CAM use, it was more likely to be with their oncologist.
The purpose of this study was to discern the CAM therapies being employed by cancer patients during treatment, and communication about the use of CAM with physicians. Over 90% of the cancer patients surveyed were using at least one form of CAM and 80% were using between one and four during treatment, which is supportive of previous research showing an overwhelming rate of CAM use among cancer patients [1, 3, 5, 6, 11, 13, 17, 24, 27, 31, 33]. From our sample, the most common CAM users tend to be female breast cancer patients with at least a high school education who were undergoing chemotherapy. Only a little over half the patients using CAM discussed using these modalities with their physicians. The most popular forms of CAM used were prayer, relaxation, and exercise, while the forms of CAM most frequently discussed with physicians were diet, massage, and herbal medicine.
It is largely unknown what effect this widespread use of CAM by patients undergoing allopathic treatments for cancer has on the course of the disease treatment process. It is not clear whether patients utilize CAM because they feel they are treating the cancer, achieving a greater degree of control and active participation in their disease management, or reducing the pain and suffering resulting from the side effects of traditional allopathic therapies in order to maintain and improve QOL during treatment [3, 6, 9, 10, 13, 14, 20, 23–25, 29, 31]. For example, patients may decide to totally discontinue the use of standard treatment, or they may integrate the use of CAM, particularly exercise, herbal medicine, and diet, with traditional therapies (e.g., chemotherapy and radiation therapy). Conversely, the use of CAM therapies may improve patient adherence to traditional therapies by increasing the patient’s sense of control over the disease treatment process, or reducing the mental and physical pain and suffering the patient experiences as a result of these standard treatments. Presently, there is a paucity of knowledge about how these modalities factor into the course and efficacy of conventional treatments for patients, and further research is needed to discern both the positive and negative influences of CAM use on standard cancer treatments .
While some patients discussed CAM usage with their physicians, almost half the patients who reported using CAM did not tell their doctors about any of the CAM modalities they were utilizing. Moreover, while over half the patients revealed to their doctors at least one CAM therapy they were using, they did not necessarily discuss all of them. The lack of discussion of CAM modalities with a physician could have been the result of the following: (1) the doctor did not specifically ask, (2) the patient did not see the potential of the CAM to affect their standard cancer treatment, or (3) the patient did not perceive the therapy they were using as CAM. In addition, patients may have had decreased confidence in their physicians, or may have felt that the physicians would be unfamiliar or lack knowledge of CAM modalities, would be uninterested, or would have a negative response [1, 3, 4, 16, 19, 25, 27, 31, 32]. If a patient discussed CAM modalities with a physician, it was more likely to be with their oncologist and rather than their primary care physician, probably because there is more interaction with their oncologist throughout treatment for cancer. Unfortunately, medical doctors, particularly oncologists, are not taught about CAM in medical school and rarely receive any training in this area as part of a residency, so meeting the needs of patients in this arena may be very challenging.
In summary, cancer patients were using CAM therapies, such as prayer, relaxation, and exercise during chemotherapy and radiation therapy and possibly did not discuss the use of these therapies with their physicians. However, if cancer patients did discuss CAM use with a physician, it will more likely to be with their treating oncologist. Thus, it is important to (1) understand the rate and type of CAM use among patients undergoing chemotherapy and radiation therapy, (2) understand the influence of the use of these CAM therapies on the disease treatment process, and (3) train oncologists and provide them with the necessary resources in order to appropriately query and advise their patients regarding CAM use.
We wish to thank the following CCOP institutions: Metro-Minnesota CCOP, Dayton CCOP, Central-Illinois CCOP, Kalamazoo CCOP, Colorado CCOP, Northern NJ CCOP, Columbus CCOP, Mayo-Scottsdale CCOP, Marshfield CCOP, Gulf Coast CCOP, and Wichita CCOP. This report contains information presented in abstract form at the 2004 ASCO meeting in New Orleans, LA, and also at the 2004 URCC CCOP meeting in Rochester, NY. This work was supported in part by a supplement from the Division of Cancer Control and Population Sciences, NCI, to Public Health Service Grant U10 CA37420 and by Grant RSG-01-071-PBP from the ACS.