Supportive Care in Cancer

, Volume 16, Issue 7, pp 763–769

Herbal use among cancer patients during palliative or curative chemotherapy treatment in Norway

Authors

    • Department of Cancer Research and Molecular Medicine, Faculty of MedicineNorwegian University of Science and Technology (NTNU), Medical Technical Research Centre
  • Aslak Steinsbekk
    • Department of Public Health and General Practice, Faculty of MedicineNorwegian University of Science and Technology (NTNU)
  • Olbjørn Klepp
    • Department of OncologySunnmøre Public Hospital Enterprise, Ålesund Hospital
  • Odd Georg Nilsen
    • Department of Cancer Research and Molecular Medicine, Faculty of MedicineNorwegian University of Science and Technology (NTNU), Medical Technical Research Centre
Supportive Care International

DOI: 10.1007/s00520-007-0371-3

Cite this article as:
Engdal, S., Steinsbekk, A., Klepp, O. et al. Support Care Cancer (2008) 16: 763. doi:10.1007/s00520-007-0371-3

Abstract

Goals of work

This survey aims to explore the differences between cancer patients undergoing chemotherapeutic treatment with palliative or curative intention with respect to concurrent herbal use, experiences of adverse effects, motives of herbal intake, and communication about herbal use with health care providers.

Materials and methods

One hundred and twelve adult cancer patients from the west coast of Central Norway, currently undergoing chemotherapeutic treatment, were recruited to a cross-sectional descriptive survey.

Main results

Palliative and curative patients used herbal remedies concurrent with chemotherapy equally frequent (37% and 38%). One palliative patient reported adverse effects when doubling the dose of injected mistletoe used. Garlic was only used by palliative patients (p = 0.009) who also tended to have a more frequent everyday herbal use (78% vs 67%, respectively) than curative patients (p = 0.075). Curative patients, however, used herbal remedies more often to counteract adverse reactions (31% vs 3%, respectively; p = 0.026). A bivariate logistic regression, which was adjusted for age, showed that palliative patients used herbal remedies more frequently to improve their immune system (adjusted OR = 7.5, 95% CI = 1.1–49.7).

Conclusions

This is the first survey comparing concurrent herbal use between cancer patients undergoing palliative or curative chemotherapy. Both groups frequently use herbal remedies concurrent with chemotherapy, but with a slightly different intent. The frequent concurrent use emphasizes the need for clinicians to include questions on complementary and alternative medicine in routine history taking and for further studies on possible herb–drug interactions among the cancer patient.

Keywords

NeoplasmsMedicinal herbsChemotherapyPalliativeCurative

Introduction

A high and increasing tendency for the use of complementary and alternative medicine (CAM), including herbal remedies, is seen in the population as a whole [2] and especially amongst cancer patients [1]. Herbal use gives possibilities for unwanted herb–drug interactions with conventional medicine as chemotherapeutics, which can lead to adverse effects and treatment failure [12]. It is found that the patients knowledge of such possible dangers of CAM/herbal use is limited [4, 5, 15].

Research in this area often refers to the wider term “CAM use”, which, in addition to herbal remedies, includes a variety of different treatment forms as, amongst others, massage, prayer, and acupuncture. This research, which is flourishing [3, 10, 20], shows that cancer patients mainly use CAM to improve the quality of life [12], boost the immune system [8, 12], and increase the feeling of hope [15]. Furthermore, that family and friends are important factors in recommending herbal remedies [9, 13]. But, although the prevalence of CAM/herbal use is increasing and health care providers are somewhat positive [16], communication between patients and health care providers is scarce [5].

Cancer patients undergoing chemotherapeutic treatment may be divided into two distinct groups: palliative patients, treated to prolong life and decrease symptoms, and curative patients, treated to cure the cancer. Having widely different life expectancies, differences in factors as quality of life [11] and hope [7] are expected.

There are no previous studies published on differences between these two groups of patients in their use of herbal remedies. Therefore, this survey was undertaken to explore possible differences between cancer patients undergoing chemotherapeutic treatment with palliative or curative intention with respect to parameters as concurrent herbal use, experiences of adverse effects, motive of herbal intake, and communication with health care providers.

Materials and methods

This study was performed as a cross-sectional descriptive survey. The survey was approved by the Regional Committee for Research Ethics, Central Norway and reported to the Norwegian Social Science Data Services. Informed consent was collected from all participating patients and the questionnaires were coded with identification numbers to ensure confidentiality. Patients were recruited by trained nurses at two outpatient clinics in a rural area on the west coast of Central Norway in the period March 2006–March 2007. The patients gave written informed consent before they answered the questionnaire during a scheduled visit at the outpatient clinic, or if desired, at home.

The patients were included if they were able to read and understand the questionnaire, over 18 years old, and currently undergoing chemotherapeutic treatment. The wide inclusion criteria were set to ensure a diverse sample.

To validate the questionnaire and identify herbs to be included, a pilot was carried out with face to face interviews with six cancer patients. The interviews were performed by the first author at one of the outpatient clinics. The responses were not included in the final material.

In addition to demographic data such as sex, age, education, and employment status, the patients were presented with a predefined list of 19 herbal remedies for the identification of herbal use and extra space for the patients to add additional herbs as needed. Herbal products were defined as products of both botanical and animal origin [19]. The list was designed to represent a variety of herbal remedies, including those reportedly used by the cancer patients in the pilot, by the health personnel participating in the survey, in the literature, and those traditionally used by the Norwegian population. The patients were asked to indicate present or earlier use, either before or during chemotherapy. In addition, the patients’ motives for using herbal remedies, their communication with health care providers, adverse effects, and monthly expenditures were requested.

Users were defined as patients that have used or were using herbal remedies concurrent with chemotherapy treatment. Not concurrent users were defined as patients that had never used or stopped using herbal remedies before they started the chemotherapy treatment. The nurses reported the diagnosis, treatment regime, and whether the treatment was given with a palliative or curative intent.

Statistics

SPSS 13.0 (SPSS, Chicago, IL, USA) was used for statistical analysis. Due to small sample sizes, differences between palliative and curative patients were estimated by the Fisher’s exact test. The Mann–Whitney test for nonparametric samples was used to assess the differences in cost and number of herbal remedies used by the two groups. Binary logistic regression was performed controlling for age in 10-year intervals. Variables associated with palliative or curative treatments were explored. p values <0.05 were defined as statistically significant, while tendencies were ascribed differences where 0.05 < p < 0.10.

Results

One hundred and forty four patients were invited to participate in the survey and 121 (84%) gave their written consent. Nine questionnaires were excluded from the final analysis due to incomplete answers. Thus, the results are based on the 112 (78%) eligible patients.

Demographic data for the participants are presented in Table 1. Men and women were evenly distributed in all groups, 90 (80%) of the patients were older than 50 years, 25 (22%) of the patients had a university degree, and 52 (46%) were currently employed or on sick leave.
Table 1

Demographics of all eligible patients and the portions of palliative and curative patients in herbal not current user and user groups

 

All patients

Not current usera

Usera

n

Palliative, %

Curative, %

p valueb

Palliative, %

Curative, %

p valueb

Number of participants

112

49

21

 

29

13

 

Male

55

51.0

42.9

0.607

51.7

46.2

1.000

Female

57

49.0

57.1

 

48.3

53.8

 

Age (years, range)

(28–86)

(40–86)

(28–76)

 

(35–76)

(31–77)

 

 <49

22

10.2

38.1

0.002

10.3

46.2

0.054

 50–59

35

18.4

42.9

 

48.3

23.1

 

 60–69

34

40.8

14.3

 

31.0

15.4

 

 70–79

18

24.5

4.8

 

10.3

15.4

 

 >80

3

6.1

 

 

 

 

 

Education

 

 

 

 

 

 

 

 Compulsory

37

77.6

66.7

0.134

17.2

30.8

0.150

 Middle level

49

2.0

14.3

 

51.7

46.2

 

 University

25

20.4

14.3

 

31.0

23.1

 

Employment

 

 

 

 

 

 

 

 Employed/off sick

52

22.4

66.7

0.000

65.5

61.5

0.561

Retirement pension

36

55.1

9.5

 

17.2

15.4

 

Disability pension

20

20.4

14.3

 

17.2

15.4

 

Unemployed

2

2.0

 

 

 

7.7

 

Home

1

 

4.8

 

 

 

 

Herbal use

 

 

 

 

 

 

 

Present

37

 

 

 

86.2

92.3

1.000

Earlier + chemotherapy

5

 

 

 

13.8

7.7

 

Earlier − chemotherapy

9

14.3

9.5

 

 

 

 

Never

61

85.7

90.5

 

 

 

 

aSee the “Materials and methods” section.

bFisher’s exact test.

All patients were treated with chemotherapeutics. Palliative treatment was given to 78 (70%) of the patients with an equal palliative to curative ratio for herbal nonusers and users, 2.3 and 2.2, respectively. Among the herbal users, there tended to be a difference in the age distribution with the palliative patients being older than the curative patients (p = 0.054; Table 1).

Nearly half of the patients (46%) had some kind of herbal use, either before or during chemotherapy (Table 1). Forty two (38%, 95% CI = 28–47%) of the patients recorded using at least one herbal remedy concurrent with chemotherapy (user), and there was no difference in herbal use between patients treated with palliative (37%) or curative intent (38%), p = 0.916.

None of the patients, except one in the palliative group, reported to have experienced any adverse effects of the herbal remedies. The adverse effect reported was nausea, fever, and headache after doubling the dose of injected mistletoe; the discomfort disappearing when reducing the dose.

Patterns of herbal use

Palliative patients tended to use herbal remedies more frequently than curative users (p = 0.075; Table 2). However, the number of herbal remedies used were the same among palliative and curative patients (2.62 herbs, 95% CI = 1.88–3.36 vs 2.23 herbs, 95% CI = 0.85–3.61, respectively, p = 0.177).
Table 2

Frequency of herbal use among palliative and curative patients

 

Palliative, n (%)

Curative, n (%)

p valuea

Everyday

21 (78)

8 (67)

0.075

Not everyday, but at least once a month

2 (7)

4 (33)

 

Occasionally

4 (15)

 

 

aFisher’s exact test.

Green tea (36%) and garlic (26%) were the herbal remedies most frequently used concurrent with chemotherapy (Table 3). However, garlic was only used by the patients in the palliative group (38%, p = 0.009), while green tea, although not significant, was used twice as often by the curative patients (54% vs 28%, respectively, p = 0.163). The herbal remedies utilized by few patients in this survey were classified according to the assumed primary objective of the use. Herbal remedies thought to “fight cancer generally” were equally used by palliative and curative patients (21% vs 23%, respectively, p = 1.000). Similarly, the herbal remedies thought to “strengthen the body/immune system” were used similarly by the two groups (41% vs 23%, respectively, p = 0.314; Table 3).
Table 3

Herbal remedies used by palliative and curative patients’ concurrent with chemotherapy

 

Total use, n (%)

Palliative, %

Curative, %

p valuea

A

Green tea

15 (35.7)

28

54

0.163

Garlic

11 (26.2)

38

0

0.009

Ginger

6 (14.3)

10

23

0.353

Noni juice

6 (14.3)

14

15

1.000

Aloe vera

2 (4.8)

7

0

1.000

Other

2 (4.8)

7

0

1.000

B

Herbal remedies used to

 Fight cancer generallyb

11 (26.2)

21

23

1.000

 Strengthen the body/immune systemc

22 (52.4)

41

23

0.314

 Treat adverse effectsd

2 (4.8)

3

8

0.528

A: percent of palliative/curative patients using each herb, B: herbal remedies not presented in A were categorized according to assumed primary objective of use. Presented as percent of palliative/curative patients using at least one herb in the category

aFisher’s exact test.

bAgaricus, mistletoe, shark cartilage, beet root juice, fenugreek, agrimony, and Atractylodes.

cArtic root, ginseng, Echinacea, chilli pepper, blueberries, Cordyceps, rand tea, red tea, Avant-Garden, MultiChi and Immunoplex.

dValeriane and supersoy.

Reasons and communication

Both palliative and curative patients most often used herbal remedies to improve their immune system (79% and 54%, respectively, 95% CI for the difference = −6% to 56%, p = 0.141; Table 4). It should be noticed, however, that curative patients used herbal remedies more often to relieve adverse effects than palliative patients (31% and 3%, respectively, 95% CI for the difference = 2% to 54%, p = 0.026). Both palliative and curative patients were most often recommended to use herbal remedies by family and friends, 72 and 62%, respectively (Table 4).
Table 4

Comparison of palliative and curative patients with respect to reasons and recommendations for herbal use, communication with care providers, and monthly costs of herbal remedies

 

Concurrent patients, n

Palliative, n (%)

Curative, n (%)

p valuea

Reasonsb

 

 

 

 

 Improved prospects of living

14

11 (38)

3 (23)

0.485

 Improved immune system

30

23 (79)

7 (54)

0.141

 Adverse effects

5

1 (3)

4 (31)

0.026

 Better than nothing

3

2 (7)

1 (8)

1.000

Recommendationsb

 

 

 

 

 By family and friends

29

21 (72)

8 (62)

0.495

 By the doctor

4

2 (7)

2 (15)

0.576

 From weekly magazines/press/internet

8

7 (24)

1 (8)

0.398

 In a health food store/by an alternative practitioner

12

9 (31)

3 (23)

0.722

Communicated with health care providers

 

 

 

 

 Never discussed

15

8 (28)

7 (54)

0.163

Reasons for never discussing

 

 

 

 

 I was never asked

9

5 (63)

4 (57)

1.000

 It is my choice

2

1 (13)

1 (14)

1.000

 I do not know if there is any effect of the herb

3

2 (25)

1 (14)

1.000

 I have never thought about it

1

 

1 (14)

0.467

Communication withb

27

21

6

 

 An oncologist

18

15 (71)

3 (60)

0.367

 A general practitioner

5

3 (14)

2 (40)

0.303

 Nurses

12

10 (48)

2 (40)

0.662

The health care providers response

26

21

5

 

 Encouraged continued use

3

2 (10)

1 (20)

0.545

 Recommended stopping/warned about risks

7

5 (24)

2 (40)

0.633

 Neutral/indifferent

15

13 (62)

2 (40)

0.357

Costs

 

 

 

 

 Median (range)

386 (20–3,600)

400 (20–3,600)

300 (50–1,800)

0.094

aFisher’s exact test.

bThe patients were allowed to give multiple responses.

Although not statistically significant, nearly twice as many curative as palliative patients had never discussed herbal remedies with any health care providers (54% vs 28%, respectively, p = 0.163). More than half of both palliative and curative patients said this was due to never being asked. Among palliative and curative patients discussing herbal remedies with health care providers, oncologists were the most frequently encountered (71% and 60%, respectively) followed by hospital nurses (48% and 40%, respectively). The responses given by the health care providers for both patient groups were, however, mainly neutral or indifferent.

The median of the mean monthly expenditure on herbal remedies was 50 Euro (range 2.5–455 Euro) among palliative patients and 38 Euro (range 6.3–228 Euro) among curative patients, showing that palliative patients tended to spend more money on herbal remedies than curative patients (p = 0.094).

Regression analysis

In Table 1, it can be observed that the palliative group was mainly represented by people in the age groups 50–59 and 60–69 years (48.3% and 31.0%, respectively). Therefore, binary logistic regression was performed adjusting each variable for age in 10-year intervals. The use of herbal remedies to improve the immune system was then statistically significantly related to the palliative group (adjusted OR = 7.5, 95%CI = 1.1–49.7), and patients discussing herbal remedies with the health care providers tended to be related to the palliative group (adjusted OR = 3.1, 95% CI = 0.7–14.2). No other questions were associated with either the palliative or curative group when adjusted for age.

Discussion

In this survey, the use of herbal remedies among cancer patients receiving chemotherapy was equally frequent in those treated with palliative or curative intent. However, among the herbal users, garlic was highly preferred by the palliative group, while the curative group wished to counteract chemotherapeutic side effects by a concomitant herbal intake. Only one patient in the palliative group reported adverse effects due to doubling the dose of injected mistletoe used. When adjusting for age, palliative and curative patients were similar in most aspects except for the improvement of the immune system, which was more important for palliative patients than for curative patients.

The survey has two main limitations. First, all patients are from a confined, mostly rural area, which may limit the external validity of the results. Second, all prevalences are based on self-reported herbal use, which may result in inaccuracies due to possible recall bias and varying definitions of what to report as herbal products.

The prevalence of herbal use of 38% in this survey is moderate compared to prevalences of total CAM use but high compared to prevalences of herbal use. Yates et al. [20] registered a 91% total CAM use in their group of cancer patients but only 9% were using herbal remedies. Indeed, higher prevalences of biological therapies have been reported [12, 15], but these also included the use of vitamins. However, the use of herbal remedies is reported to depend on tradition and is varying between countries [13] and ethnic groups [10].

The high prevalence of herbal remedies used concurrent with chemotherapeutics, both for patients treated with a palliative or a curative intent gives the risk of clinically relevant interactions [12]. However, only one of the patients in this survey reported discomfort or adverse effects due to the use of herbal remedies. During cancer treatment, patients are likely to experience adverse effects due to the received chemotherapy. This may blur possible herbal interactions or adverse effects, emphasizing the importance of elucidating possible herb–drug interaction mechanisms also for the individual patient. The belief among a large group of users that herbal remedies are safe [15] and lack of knowledge about possible adverse effects [5] may further reduce this awareness.

Although the prevalence of herbal use among patients treated with palliative and curative intent was equal, the patterns of herbal use tended to differ. The tendency for more frequent use of herbal remedies among palliative patients may be attribute to a wish to improve the quality of life [18] or increase the feeling of hope [17]. The age difference with most palliative patients being older than 50 years may explain why the palliative patients preferred garlic, the herb with longer traditions in anticancer treatment. Curative patients, on the other hand, did not use garlic at all, but preferred green tea. Palliative patients had a somewhat higher monthly expenditure on herbal remedies than curative patients, suggesting that palliative patients are more willing to use some more money on herbal remedies. However, the expenditure on herbal remedies was low, equal to 35 l of gasoline pr month. Reports indicate that cancer patients perceive that boosting of the immune system will increase the chances of healing or survival and that it will support the body through tough chemotherapeutic treatment [8]. This might be the reason why, after adjusting for age, palliative patients, more often than curative patients, used herbal remedies to “improve the immune system.” Curative patients, however, used herbal remedies to counteract adverse effects.

As for other cancer patients, both palliative and curative patients reported that family and friends advised them to use herbal remedies, suggesting that personal relations are important in the process of giving advice. This confirm earlier reports where family and friends are shown to be important in the decision process [14], both for the patients, but also for the family members as a way to contribute in a difficult situation.

Almost half of the patients in the curative group had never talked to any health care providers about herbal remedies, which is comparable with recent literature [5, 9, 20]. However, after adjusting for age, palliative patients tended to talk to the health care providers more often than the curative patients. This suggests that palliative patients might have a longer history with the health care provider due to a more progressed disease, thus feeling more confident in talking about herbal use. The main reasons for not talking to health care providers were in both groups “I was never asked”, as have also been reported in other studies [9, 12, 20]. Patients want health care providers to initiate the discussion [15] possibly so because they are uncertain of the oncologists response [8] or they are afraid to jeopardize their relationship with the oncologist. The fear of rising the issue of CAM and herbal use with the oncologist and health care providers might, however, be unfounded because more than half (53% of men and 79% of women) of the health care providers in a Norwegian study seemed to be positive toward alternative medicine [16]. The indifferent/neutral responses given by the health care providers may be explained by the physicians’ attitudes toward CAM. In fact Giveon et al. [4] surveyed 165 primary care physicians’ attitudes toward CAM and found that 51% of the physicians thought that herbal remedies had no or only mild interactions with conventional medicine. Nevertheless, as long as herbal medicine may have the potential to interact with conventional medicine [6], clinicians ought to show interest in the patient’s herbal use and in CAM as a topic.

This is the first survey comparing herbal use between cancer patients, currently undergoing chemotherapy, treated with palliative or curative intent. Two out of five patients in both groups used herbal remedies concurrent with chemotherapy. The frequent concurrent use emphasizes the need for clinicians to include questions on complementary and alternative medicine in routine history taking and for further studies on possible herb–drug interactions among cancer patient.

Acknowledgments

We wish to thank the nurses and patients at the Department of Oncology at Sunnmøre Public Hospital Enterprise, Ålesund Ward and Volda Ward. This research was founded by the Norwegian Cancer Society.

Copyright information

© Springer-Verlag 2007