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| Journal of the New Zealand Medical Association,
24-January-2003, Vol 116 No 1168
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The use of complementary/alternative medicine by cancer
patients in a New Zealand regional cancer treatment centre
Kathryn Chrystal, Simon Allan, Garry Forgeson and Richard
Isaacs
The use of Complementary/Alternative Medicine (CAM) is
increasing worldwide. A national survey in the United States demonstrated an
increase in use from 33.8% to 42.1% between 1990 and
1997.1 The overall use of CAM in Australia was
48.5% in 1993, with a reported AU$981 million per annum spent by
patients.2
There has been extensive literature published recently on
the use of CAM by cancer patients, with the prevalence of reported use ranging
from 22% in Australia, up to 70% in the United States and
Canada.3–5 Studies have also found that
cancer patients have a higher usage of CAM than patients with other medical
conditions.6 In New Zealand, there has been
recent public and media attention regarding the use of CAM, particularly in
relation to the management of cancer.7–9
There have been only three studies to date addressing the use of CAM in this
country, none of which directly addressed the prevalence of use in cancer
patients.10–12
The aim of this study was to determine the prevalence of use
by cancer patients attending outpatient clinics at a regional cancer treatment
unit in New Zealand, and to identify types of CAM being used; reasons for use;
satisfaction; and financial cost of CAM to the patient.
MethodsPatients attending oncology
outpatient clinics at either Palmerston North or Taranaki Base Hospitals,
between April and December 2001, were offered a self-administered questionnaire
by reception staff. Information sheets explaining the purpose of the study and
return post-paid envelopes were attached. Responses were voluntary and anonymous
and assumed consent.
The questionnaire obtained demographic, disease and treatment-related data, as well as expectations of conventional treatment for all patients. Patients using CAM were asked to indicate the types of CAM therapies used, and these were divided into multiple categories. CAM users were also asked about timing of CAM use, reasons for CAM use, its perceived effectiveness, and to describe any side effects. They were asked whether they had discussed CAM use with their oncologist, and to estimate the monthly financial cost of CAM therapies and of visits to CAM practitioners. Data were entered into an Excel spreadsheet and StatView statistical package for analysis. Associations between patient characteristics and CAM use were assessed by bivariate analysis (χ2 test for categorical variable and t-test for continuous variables). A p value of 0.05 was considered significant. This study was approved by the Whanganui-Manawatu and Taranaki Ethics Committees, and the Palmerston North Hospital Cancer Treatment Protocol & Research Committee. Table1. Characteristics of questionnaire respondents
(n=200)
NHL=Non-Hodgkin’s lymphoma
Results350 questionnaires were distributed
and 203 (58%) of these returned. 200 were included in the analysis. The
remaining three were excluded because patients had not indicated if they had
used CAM therapies.
Patient characteristics and
conventional treatment Characteristics of respondents are shown in Table
1. Ages ranged from 20–88 years, with a median age of 58 years. Females
made up 71% of the total respondents; 86% of patients were European and 13%
Maori. Breast cancer was the most common diagnosis (40%), with a range of other
malignancies reflecting patients treated by Oncologists as outpatients. Cancer
diagnosis was not indicated by 6% of patients.
Of all patients, 67% had received chemotherapy, 52%
radiotherapy, and 22% hormonal treatments. Fifty two per cent of patients had
the expectation that conventional treatment would cure their cancer, 46% that it
would control the cancer and prolong life, and 12% expected it to improve
symptoms and quality of life.
Use of CAM Of the
200 respondents, 97 patients (49%) reported using at least one form of CAM
therapy. Of CAM users, 80% used more than one type of therapy, 40% reported
using four or more different types of therapies, and 14% used at least seven
different therapies.
Table 2 shows the types of CAM therapies used, with vitamins
(68%), and antioxidants (54%), being the most frequent. Other commonly-used
therapies were (in descending order of frequency of use) spiritual, diets,
relaxation, herbal, imagery, naturopathy and massage.
Table 2. Types of CAM therapies used
Over one third (35%) of patients began using CAM therapies
before they were diagnosed with cancer, and 39% commenced them at the time of
diagnosis. A significant proportion of patients (38%) reported using CAM during
conventional treatment, and 20% only began using CAM following conventional
treatment.
Most patients reported learning of CAM therapies from family
(39%) and friends (41%); however a further 23% of patients gained information
from media sources. Other cancer patients provided information about CAM
therapies to 21% of patients. Of health professionals, doctors were a source of
information for 14% of patients, while pharmacists and nurses were a less common
source (8% and 2% respectively). Only 3% of patients reported gaining
information from the Internet. Some patients cited more than one source of
information.
Reasons for CAM use
Nearly 50% of patients reported improvement in quality of life as one of the
reasons they were using CAM. Reasons for CAM use are shown in Table 3, with many
patients giving more than one reason. Over half of patients were using CAM in
the hope of anticancer effects, with over one quarter (28%) of CAM users hoping
for cure, and a further 30% for control of cancer.
Table 3. Reasons for CAM use
Patient characteristics
associated with CAM use Younger patients were significantly more likely
to use CAM than older patients (p = 0.01). There was no difference between CAM
users and non-users with regards to gender, ethnicity, employment status,
diagnosis, or conventional treatment received. Patients whose expectation of
conventional treatment was that it would improve symptoms and quality of life,
rather than cure cancer or prolong life, were significantly more likely to use
CAM (p = 0.03)
Helpfulness and safety of
CAM Patients were asked to rank on a numerical scale from 1 to 5 how
helpful they felt CAM therapies had been in the treatment of their cancer, (1
being not at all helpful, 5 being extremely helpful). Of CAM users, 71% felt
these therapies had given them some benefit and, of those, 32% thought they had
been extremely helpful. Only 6% thought that the CAM had not been helpful at
all.
When asked if they believed CAM therapies were safe, 89%
felt they were, 5% did not know, and 5% did not answer. Only one patient in this
study thought CAM therapies were unsafe. Most patients using CAM also stated
that they had not been aware of any side effects from CAM therapies (91%). Only
four patients reported having side effects, and 6% did not answer this
question.
Cost The estimated
financial cost of CAM therapies, including visits and travel to
complementary/alternative practitioners ranged from NZ$0–650 a month, with
the median amount spent being NZ$55 a month and the average NZ$102.
Discussions with
oncologist Only 41% of CAM users had informed their oncologist that they
were using CAM, 54% had not informed their oncologist, and 5% did not answer
this question. Older patients were significantly less likely to inform
oncologists than younger patients (p = 0.0002).
DiscussionOur study is the first to
directly assess the prevalence of CAM use
in New Zealand cancer patients, and to compare the characteristics of CAM and
non-CAM users. The Clinical Oncology Group carried out a survey in 1987 of
medical advice concerning alternative treatments given to cancer patients in
several New Zealand centres. They found that 32% of patients had been given
advice about alternative medicine, 65% of whom intended to follow some of the
treatment advice. However, the study did not assess the actual prevalence of CAM
use.10
We found that 49% of cancer patients reported using at least
one form of CAM therapy. As response to the survey was voluntary and anonymous,
no information was obtained about non-responders. This may have created a
potential selection bias if non-responders over-represented a particular
subgroup. Anonymity of the survey, however,
was designed to minimise nondisclosure of CAM use due to fear of disapproval.
Patients who choose CAM therapies as their sole treatment for cancer are also
not represented, as they are unlikely to be attending oncology clinics. The
prevalence of CAM use in our centre is consistent with reports from other
countries.3–5,13,14 In a systematic
review of published data of 26 surveys from 13 countries, the use of CAM
therapies in adult cancer populations ranged from 7–64%, with the average
prevalence across all adult studies being
31.4%.15
Several studies have looked at the predictors of CAM use and
found younger age, female sex, and higher education were associated with greater
CAM use.2, 4, 5, 13, 14, 16 We found that
younger age was the only significant demographic variable associated with CAM
use in our population.
Vitamins and antioxidants were the most commonly-used CAM
therapies in this study.
Eisenberg et al1 found a
130% increase in the use of high-dose vitamins and a 380% increase in the use of
herbal remedies between 1991 and 1997. Published trials of vitamins and
antioxidants, however, have not shown any significant benefits in the treatment
or prevention of cancer.18,19 Acupuncture and
hypnotherapy are complementary therapies that have been shown to improve
chemotherapy-related nausea and
vomiting,20–22 and also have benefit in
pain control, yet these were not widely used by patients in our study (8% and 2%
respectively).
We found, as have
others,4,5 that a significant proportion of CAM
users used multiple different therapies, with 40% of patients using four or more
therapies. Patients using multiple therapies commonly combined potential
perceived “alternative anti-cancer treatments” (such as
antioxidants), with more psychosocial therapies (such as imagery, aromatherapy,
spiritual and relaxation techniques), suggesting that they hoped to gain a more
holistic management of their disease than conventional medicine can offer. Our
finding that 47% of patients reported using CAM therapies to improve their
quality of life supports this. In our study, 29% of patients were using CAM
therapies for the hope of cure, and 64% to either control cancer or prevent
recurrence, which is consistent with other
studies.3,4 Controlled studies of cancer
patients comparing CAM users and non-users have found no improvement in survival
with CAM use,13,23,24 and quality-of-life
scores were significantly better in conventionally treated
patients.23 Patients, however, perceive that
they are benefiting from CAM therapies; 70% of patients in our study felt that
they had been moderately to extremely helpful in the treatment of their cancer.
Many patients in our study reported using CAM therapies
during conventional treatment. CAM therapies are often advertised as safe for
use, but drug interactions can occur and are seldom appreciated by patients or
health professionals. Indeed, such interactions cannot be discussed when a
health professional is not aware that a patient is taking CAM, which is
frequently the case as this study shows. Potential antagonistic interactions of
CAM with chemotherapy agents have been
suggested,25 and interactions of many herbal
remedies with commonly-used medicines such as anticoagulants have now been
shown.26 Some herbal therapies can have
hepatotoxic and nephrotoxic effects, which may be interpreted wrongly as disease
progression and lead to unnecessary investigations, or at worst precipitate
organ failure.27,28 “Alternative
diets” can be poorly balanced and lead to nutritional deficiencies and
weight loss.29 Despite these documented adverse
effects, as well as the many unknown potential side effects of some CAM
therapies, 89% of patients in this study thought that they were safe. Ideally,
patients should be aware of such interactions whilst receiving conventional
treatments.
The financial cost to patients of many CAM therapies is not
insignificant. Estimates of monthly costs ranged from no cost for patients
altering their diet, to NZ$660 for some specific immune-based therapies.
Comparable financial costs have been found in Australia, but the majority of
patients felt they were getting value for
money.5
Previous studies have found that under half of patients
inform their physicians of their use of CAM
therapies,1,3,4 which is consistent with our
results (41% disclosure). It is important that oncologists are able to identify
patients taking CAM therapies, as some of these have been shown to have
detrimental effects on health and interfere with conventional treatments. Older
patients were significantly less likely to report CAM use to their oncologist,
however, reasons for non-disclosure were not specifically asked. We suggest that
older patients may still perceive the traditional “paternalistic”
doctor–patient relationship and fear their oncologist’s disapproval.
The addition of direct questioning about CAM use as part of history taking has
been shown to significantly increase disclosure of the use of these therapies to
the oncologist.16 Therefore, including
nonconfrontational questioning about CAM therapies as part of the standard
history and examination of oncology patients will need to become routine if we
are to increase our knowledge of CAM use.
While many ‘alternative’ cancer therapies
promoted for use instead of mainstream medicine have no proven benefit and
indeed may be harmful, there is evidence supporting certain
‘complementary’ therapies (such as acupuncture, hypnosis, imagery
and relaxation) as being useful adjuncts to conventional medicine in improving
cancer-related symptoms and quality of life. It was this desire to obtain
improved quality of life that was the most common reason cancer patients chose
to use CAM therapies in our study. This indicates that we need to help patients
identify those CAM therapies that are likely to benefit them, and to provide
greater access to these in the New Zealand public health system. We also need to
have ready access to reliable patient information regarding such therapies,
which should be discussed as a matter of routine with cancer patients.
Author information:
Kathryn Chrystal. Clinical Research Fellow, Guy’s Hospital, London; Simon
G Allan, Medical Oncologist; Garry Forgeson, Medical Oncologist, Richard Isaacs,
Medical Oncologist, MidCentral Health Regional Cancer Treatment Service,
Palmerston North Hospital.
Acknowledgements:
Thanks to reception staff at the oncology clinics in Palmerston North
Hospital and Taranaki Base Hospital for their distribution of surveys.
Correspondence: Dr
Richard Isaacs, MidCentral Health Regional Cancer Treatment Service, P O Box
2056, Palmerston North. Fax: (06) 355 0616; email: richard.isaacs@midcentral.co.nz
References:
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