- Email: [email protected]
Complementary and Alternative Medicine in Gynaecologic Oncology
GYNAECOLOGY
Complementary and Alternative Medicine in Gynaecologic Oncology Deanna J McKay, BSc(H),l James R Bendey, MBChB, FRCSC,2 Robert N Grimshaw, MD, FRCSC2 1Faculty of Medicine, Dalhousie University, Halifax NS 2Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS
a
Abstract Objectives: To explore complementary and alternative medicine (CAM) use among gynaecologic oncology patients in Nova Scotia. Methods: Over a 3-month period, 163 patients were asked to fill out a questionnaire concerning CAM. Those entering the study provided demographic information such as age, address, and employment status, as well as medical information and details of their use of alternative therapies. Results: A total of 152 patients were entered into the study, giving a response rate of 93.3%. Of these, 116 had used at least one type of CAM, classifying them as users (76.3%). Women who considered themselves "more religious" were more likely to be CAM users (P 0.001). There were no significant differences found between users and nonusers with respect to other patient characteristics reported. Patients with cervical cancer were less likely to use CAM than participants with another primary gynaecological malignancy (P 0.040). The most frequent CAM therapy practised was spirituality/prayer (52.6%). Most women used CAM to improve their physical well-being, and 53.3% of the women were interested in receiving more information on CAM.
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Conclusion: A significant number of women undergoing conventional treatment for gynaecologic cancer in Halifax, Nova Scotia, also use CAM. Women"are using CAM for numerous reasons and believe they are benefiting from CAM in many ways. PhysiCians need to be aware of this high usage rate and should explore their patients' attitudes to and opinions about CAM.
Resume Objectifs : Etudier Ie recours a la medecine complementaire et parallele (MCP) par les patientes en oncologie gynecologique de la Nouvelle-Ecosse.
a
Methodes : On a demande 163 patientes, sur une periode de trois mois, de remplir un questionnaire portant sur la MCP. Celles qui ont participe I'etude ont foumi des renseignements demographiques comme I'age, I'adresse et i'emploi, ainsi que des renseignements medicaux et des details relativement leur utilisation de traitements paralleles.
a
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Resultats : Un total de 152 patientes ont ete inscrites I'etude, pour un taux de reponse de 93,3 %. De ces patientes, 116 ont eu
Key Words: Gynaecologic oncology, complementary medicine. alternative therapies Competing interests: None declared. Received on February 8. 2005
Accepted on March 22, 2005
562
• JUNE lOGe JUIN 2005
recours au moins un type de MCP, ce qui en fait des utilisatrices (76,3 %). Les femmes qui consideraient etre « plus croyantes » avaient davantage de chances d'etre des utilisatrices (P = 0,001). On n'a constate aucune difference significative entre les utilisatrices et les autres patientes par rapport aux autres caracteristiques des patientes. Les patientes atteintes d'un cancer du col uterin avaient moins tendance avoir recours la MCP que les patientes atteintes d'une autre malignite gynecologique primaire (P = 0,040). La MCP pratiquee Ie plus frequemment est la spiritualite ou la priere (52,6 %). La plupart des femmes avaient recours la MCP pour ameliorer leur bien-etre physique, et 53,3 % des femmes etaient interessees obtenir de plus am pies renseignements .au sujet de la MCP.
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Conclusion: Un nombre significatif de femmes subissant des traitements conventionnels pour un cancer gynecologique Halifax, en Nouvelle-Ecosse, a egalement recours la MCP. Les femmes utili sent la MCP pour differentes raisons et croient en tirer des bienfaits de bon nombre de faeons. Les medecins doivent etre au fait de ce taux eleve d'utilisation de la MCP et devraient porter attention I'attitude et I'opinion des patientes i'egard de la MCP.
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J Obstet Gynaecol Can 2005;27(6):562-568
INTRODUCTION
C
omplementary and alternative medicine (CAM) refers to those practices and products used in conjunction with, or instead of, conventional medicine to treat disease and enhance health. The scope of CAM is broad and includes mind-body interventions, traditional or folk remedies, diets and nutrition programs, and manual healing. The Cochrane Collaboration has defined CAM as encompassing resources "other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period."l Use of CAM is widespread and is increasing in the general population as well as in cancer patients. A review of alternative medicine use by the general US population showed that use of CAM, excluding self-prayer,2 increased from 33.8% in 1990 to 42.1 % in 1997. Cancer patients have been identified as CAM users: a systematic review of 21 studies of CAM utilization in adults showed a range of use from 7% to 64%, with an average of 31.8%.3 Women are more likely
Complementary and Alternative Medicine in Gynaecologic Oncology
Table 1. Characteristics of patients completing questionnaires (N=152) Characteristic
Number (%)
Region
METHODS
Rural
50 (32.9)
Nonmetropolitan area
70 (46.1)
Metropolitan area
32 (21.1)
Marital status Single
18 (11.8)
Married
97 (63.8)
Separated/divorced
16 (10.5)
Widowed
21 (13.8)
Education
< Grade 12
49 (32.2)
Grade 12
103 (67.8)
~
the therapies used and the anticipated effects. The study also explored how patients' use of unconventional medicine varied with different cancers and treatments. to
Employment Employed
56 (36.8)
Unemployed
73 (48.0)
Other
23 (15.1)
Annual Income
< 30 000
54 (40.6)
~ $30 000
79 (59.4)
Religion More religious
77 (69.4)
Less religious
34 (30.6)
than men to be CAM users (48.9% vs. 37.8%).2 The importance of this issue in gynaecologic oncology has recently been shown in a report describing a rate of CAM use of 49.6% after a diagnosis of gynaecologic cancer.4 This study included religion as a CAM practice only if it was used in combination with faith healing or mental imagery.4 Physicians should be aware of their patients' use of CAM. This is especially important with cancer patients undergoing treatment, because several herbal therapies have toxicities and interactions with chemotherapeutic agents. 5,G An investigation of physicians' attitudes toward CAM showed that most had noticed the trend toward increasing interest in CAM but felt they lacked knowledge about these unconventional therapies.? Besides knowing about their patients' CAM use, physicians should be aware of their patients' expectations of and feelings about CAM. This study reviewed the use of CAM by gynaecologic oncology patients and explored their attitudes
We recruited women with gynaecologic malignancies from the gynaecologic oncology clinics at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. Women with a new or existing diagnosis of a gynaecologic malignancy who attended these clinics during a 3-month period Gune 2003 to August 2003) were approached by the clinic nurse to determine their interest in participating in a study. Those who agreed to participate and who were able to give informed consent met with one of the investigators, who reviewed the consent form and gave the participant the questionnaire to complete. The questionnaire was adapted with permission from Swisher (E. Swisher, written communication, February 2003), and the modified version is available on request from the corresponding author. Those entering the study provided demographic and medical information (Table 1) and gave details about their use of complementary and alternative medical therapies and their expectations of these therapies. Patients were asked to list any CAM medications they were taking; a list of known complementary and alternative therapies was provided for participants to choose from, with the option of adding others. The questionnaire asked participants to provide details of their expectations of CAM therapies, perceived benefits, and the costs of the therapies. Patients were asked where they had obtained their information about CAM therapies, whether they would be interested in receiving more information about CAM therapies and medications from their doctor, and what kind of information would be most useful to them. Responses were entered into a FileMaker Pro Database program (FileMaker Pro 5.5vl, FileMaker Inc., Santa Clara). The Statistical Package for the Social Sciences (SPSS, Version 11.5.1 , Chicago) was used to perform data analysis. Comparisons of patient demographics were calculated with chi-square tests for categorical data and t tests for continuous data. Statistical significance was set at a value of P < 0.05. The Research Ethics Board for the Capital District Health Authority approved the study.
RESULTS During a 3-month period Gune 2003 to August 2003), all women who met the study criteria were approached to participate in the study. Of 163 patients approached, 152 (93.3%) agreed to participate. Most patients completing the questionnaire were married (63.8%), had a grade 12 or higher level of education (67.8%), and considered
JUNE JOGe JUIN 2005 •
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GYNAECOLOGY
Table 2. Characteristics of users and nonusers of complementary medicines Characteristics
Users, n (%)
Nonusers, n (%)
P
Region Rural
38 (73.1)
14 (26.9)
Nonmetropolitan area
51 (75.0)
17 (25.0)
Metropolitan area
27 (23.3)
5 (13.9)
Single
12 (66.7)
6 (33.3)
Married
75 (77.3)
22 (22.7)
Separated/divorced
12 (75.0)
4 (25.0)
Widowed
17(81.0)
4 (19.0)
< Grade 12
36 (73.5)
13 (26.5)
Grade 12
80 (77.7)
23 (22.3)
0.446
Marital status
0.742
Education
~
0.569
Employment Employed
41 (73.2)
15 (26.8)
Unemployed
58 (79.5)
15 (20.5)
Other
17 (73.9.)
6 (26.1)
< $30000
40 (74.1)
14 (25.9)
~ $30 000
62 (78.5)
17(21.5)
More religious
66 (85.7)
11 (14.3)
Less religious
18 (52.9)
16(47.1)
0.681
Annual income"
Religion
a
0.001
19 patients did not answer the question about annual income.
b Ranked on a Likert scale of 1-7 (1-3 disregarded.
=more religious; 5-7 =less religious); all incomplete and rankings of 4 were
themselves to be "more religious" (69.4%). Table 1 shows the characteristics of these patients. For investigative purposes, the patients were divided into 2 categories: users of CAM (defined as those who were using CAM currently or who had used CAM since their diagnosis of cancer) and nonusers of CAM. Of the 152 participants, 116 women (76.3%) were classified as CAM users because they had used at least one type of CAM, and 36 (23.7%) were considered nonusers. The average age of patients entering the study was 58.2 years. The mean age of patients who used some form of CAM was 58.6 years and that of nonusers was 56.7 years (J> = 0.235). Other comparisons between users and nonusers of CAM are shown in Table 2. A statistically significant difference in the 2 groups was found only with respect to religion. CAM users considered themselves to be more religious than nonusers of CAM (P 0.001).
=
Patients were asked about their medical history. They documented their current and past treatment as well as their primary cancer diagnosis. Most patients in the trial were not
564
0.555
b
• JUNE lOGe JUIN 2005
receiving treatment at the time of completing the questionnaire (104, 68.4%), and most of those who were being treated were receiving chemotherapy (33, 68.8%). The primary cancer diagnoses are shown in Table 3. The primary site of gynaecologic cancer was correlated with patterns of use. A trend was observed with respect to a diagnosis of ovarian cancer and use of CAM therapies, but this did not reach statistical significance (P = 0.065). Women with cervical cancer were less likely to use CAM than were women with other primary gynaecologic malignancies (P 0.040).
=
A list of known alternative therapies was included in the questionnaire. The participants were asked if they had ever used any of the therapies. If they had, they were asked about the frequency of use and whether use began before or after the diagnosis of cancer. Participants reported a total of 414 uses of CAM, with individual frequencies shown in Figure 1. Spirituality/prayer (61 users, 52.6%) was the most popular of all therapies used; other common modalities were diet (44,37.9%), exercise (32,27.6%), and massage therapy (30, 25.7%). Rolfing, colour therapy, crystal therapy, and
Complementary and Alternative Medicine in Gynaecologic Oncology
Table 3. Comparison of primary cancer source between CAM users and nonusers User, n (%)
Nonuser, n (%)
Total
Cervix
13 (59.1)
9 (40.9)
22 (14.5)
Primary cancer source
Endometrium
39 (79.6)
10 (20.4)
49 (32.2)
Ovary
50 (80.6)
12 (19.4)
62 (40.8)
Vagina
1 (100.0)
0(0)
1 (0.7)
Vulva
6 (60.0)
4 (40.0)
10 (6.5)
Other
7 (87.5)
1 (12.5)
8 (5.3)
Total
116 (76.3)
36 (23.7)
152
Table 4. CAM users' expectations and perceived benefits (n = 79)
Fight cancer
Expectations, n (%)
Perceived benefits, n (%)
47 (59.5)
38 (48.1)
Achieve cure
6 (7.6)
2 (2.5)
Boost immune system
46 (58.2)
38(48.1)
Improve physical well-being
60 (75.9)
51 (64.6)
Improve emotional well-being
37 (46.8)
38 (48.1)
Avoid progression of cancer
12 (15.2)
5 (6.3)
Avoid recurrence of cancer
24 (30.4)
11 (13.9)
Prevent I treat side effects
13 (16.5)
10 (12.7)
Other
14 (17.7)
15 (19.0)
osteopathy had one reported use each. Use of CAM began before the diagnosis of cancer was made in 265 cases (64.0%) and after diagnosis in 123 cases (29.7%). In 26 cases (6.3%), no comment was made about when CAM use began. Patients were asked about their use of ingested complementary and alternative medications such as herbs, teas, extracts, and vitamins. This provided a further classification of CAM users into "therapy users" and "medication users," with some overlap between the categories. Users of complementary medications were more likely to be religious (p:::: 0.014) and to live in urban areas (p:::: 0.009). Almost all of the participants spent less than $100 monthly on either therapies (82.3%) or medications (84.9%). Two women reported a cost of between $300 and $500 monthly for therapies; one woman stated that she spent the same amount on medications. The number of participants reporting that their oncologist knew about their CAM use and the number reporting that their oncologist did not know were equivalent. Thirty percent of participants were unsure whether their oncologist knew of their CAM practices.
Expectations of CAM and perceived benefits of its use are documented in Table 4. A total of 79 women completed this section of the questionnaire, with most including several expectations and perceived benefits. Only 6 women perceived no benefit from their use of complementary or alternative therapies (7.6%). The most commonly cited reasons for using CAM therapies and medications were "to improve physical well-being," "to fight cancer," and "to boost the immune system." These, in addition to improved emotional well-being, were regarded as the most common benefits of CAM use. The fmal section of the questionnaire concerned patient information about complementary and alternative medicine. We wished to identify where the participants had received their information and whether more information on CAM practices, medicines, and practitioners would be useful (Figure 2). Friends and the media were the most frequendy cited sources of information; family members and medical doctors were also common sources. Some of the women %) noted that they had never heard of complementary or alternative medicine before they were asked to participate in the study. Approximately one-half the women completing the questionnaire commented that they would
r.1
JUNE JOGe JUIN 2005 •
565
GYNAECOLOGY Figure 1. Number of patients using CAM-therapies ~ r---------------------------------------------111 10
.
!!l 50 c:
Q)
co
D..
o
...
Q)
.0
30
2e
E
;:) 20
Z
32
30
20
23
2S
18
11
CAM Therapy like more information on CAM from their oncologist. Participants were asked to select all types of information they wanted and to add any others that interested them. The information most desired by participants was "which therapies to try" (84.1 %), "drug information" (56.1 %), "availability" (42.7%), and "contact information" (41.5%). DISCUSSION
This study explored complementary and alternative medicine use among gynaecologic oncology patients in Halifax, Nova Scotia. To our knowledge, this is the first study of its kind in Canada. CAM use is an important topic to explore, as similar studies worldwide have reported high rates of usage and have stressed the need for physician awareness of the subject. 3,4,8,9 The study's response rate of 93.3% indicates that the results are probably representative of Nova Scotian women undergoing standard treatment for a gynaecologic cancer. Because they did not attend the cancer clinics, women who chose to treat their gynaecologic malignancies solely with alternative therapies are not represented in this trial. We found an overall CAM use rate of 76.3% in this study. This high rate could be a result of the specific patient population studied or could be because of the broad definition of CAM used in the survey. Being female and the diagnosis of cancer have both been associated with higher rates of CAM use,2,3 and these 2 characteristics taken together may
566
• JUNE lOGe JUIN 2005
account for the high percentage of users. Because spiritual therapy is indexed as one of the major subheadings under complementary therapies in Medline and is included in the relevant literature,4,8,10 we included spirituality I prayer as a form of CAM therapy in the questionnaire. It produced the highest usage rate in the study. If this therapy had not been included in the questionnaire, the overall usage rate would have been dramatically lowered (36.2%). Religion was found to be a predictor of CAM use in this study. Use of spiritualityI prayer was found to be correspondingly high in a recent study in Texas,11 but religion was not analyzed as a predictor for use. Instead, this study found that younger age, female sex, indigent pay status, and surgery as part of treatment were indicative of current or predictive of future CAM use.!! Swisher et al. analyzed religion as a predictor for CAM use but found that it did not reach statistical significance. 4 When our patient population was divided into the 2 categories of use (users of therapy and users of medication), religion was found to be a predictor of CAM therapy use, but it did not predict use of CAM medication because spiritualityI prayer was not part of the CAM medication category. Living in urban areas was predictive of CAM medication use. Most of the patients in this trial were not receiving treatment when they completed the survey, so the difference between treatments and CAM use was not examined. Cervical cancer patients were significantly less likely to use CAM
Complementary and Alternative Medicine in Gynaecologic Oncology
Figure 2. Sources of CAM Information
Internet 6
than were partiCipants with other primary gynaecologic malignancies. This echoes the finding of Swisher et al. that women with a gynaecologic malignancy other than cervical cancer are more likely to use CAM.4 It may be expected that a less optimistic prognosis is associated with greater use of complementary and alternative medicine. Therefore, in the present study, we compared use of CAM by women who had ovarian cancer with CAM use by women who had other gynaecologic cancers. Women with ovarian cancer showed a trend toward using CAM therapies, but this trend did not reach statistical significance. This observation requires further study to determine whether the trend toward CAM use is significant only with noncervical gynaecologic malignancies. Figure 1 shows the specific frequencies of CAM use for therapies included in the study. The distribution of use is quite varied, although the most popular practices are similar to those in other studies on the subject.8--11 Use of some therapies was reported by only one study participant. This might have been a result of limited availability of the practice: in the Halifax metropolitan area, massage therapy and acupuncture have been available for several years, but biofeedback and magnet therapy are relatively new practices. Zone therapy and reflexology are identical practices but are given different names by different practitioners. We therefore included both practices in the list Qf CAM options. If
they had been grouped together, however, every CAM therapy included in the questionnaire would have been attempted or practised by at least one participant. It is important for physicians to be aware of their patients' use of CAM therapies and medications. According to this study, 30% of the participants were unsure whether their physician knew about their use of CAM. This lack of open communication has been reported in other studies and was stressed in a recent study in New Zealand. 12 Among the remaining 70% of the study group, one-half thought that their physician knew about their CAM use, and the remaining one-half were certain that their physician did not know. This uncertainty has highlighted the importance of including questions about CAM use in the initial history, especially with a patient who has gynaecologic cancer. When physicians are more informed of their patients' use of CAM, they will be able to anticipate potential risks of certain CAM practices when used either alone or in combination with conventional therapy. The most common botanical and herbal remedies used in gynaecologic oncology populations have been identified, but determining their safety prof11es and potential interactions requires further study.13,14 Important interactions between these remedies and chemotherapeutic agents have
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GYNAECOLOGY
been proposed and need to be investigated, specifically with regard to this patient population.1 5 The money spent on CAM therapies and medication is not insignificant. In this study, we determined that most of the participants who spent money on CAM were spending less than $100 monthly. However, since participants were asked separately about the cost of CAM therapies and the cost of CAM medications, it is possible that some participants responded with an overall combined cost and others responded with the cost of each component. Other studies that examined the cost of CAM have documented median costs of less than $100 monthly, but they did not divide costs into those related to medications and those related to therapies. 4,8,12 Only 6 of the 152 women completing the questionnaire felt that they had received no benefit from their use of CAM therapies. This is an impressive perceived success rate of 92.4% for alternative therapies, although the perceived benefits ranged widely from beneficial effects on cancer to improvement of general well-being and limitation of the side-effects of conventional therapy. One CAM option, therapeutic touch, is currently being offered in our chemotherapy clinic, and this could account for the high use of this modality reported in the study. Patients have commented that they are satisfied with the therapeutic touch program and that they would like to have other therapeutic modalities offered as part of the clinic's services. As a result of this study, we learned that approximately one-half of our patients would like more information on CAM and that we are currently only providing about 15% of the information that our patients receive. Patients expressed an interest in receiving information on CAM medications and therapies, especially about safety and effectiveness. We hope that this study is a step toward providing the requested information and promoting discussions between patients and their caregivers about complementary and alternative treatment.
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ACKNOWLEDGEMENTS We acknowledge the support of the Norah Stephen Oncology Scholarship.
REFERENCES 1. Zollman C, Vickers A. ABC of complementary medicine: what is complementary medicine? BMJ 1999;319:693--6. 2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States: 1990--1997. JAMA 1998;280:1569-75. 3. Ernst E, Cassileth BR. The prevalence of complementary / alternative medicine in cancer: a systematic review. Cancer 1998;83:777-82. 4. Swisher EM, Cohn DE, GoffBA, ParhamJ, Herzog T], Raider ]S, et al. Use of complementary and alternative medicine among women with gynecologic cancers. Gynecol Oncol 2002;84:363--7. 5. Spaulding-Albright N. A review of some herbal and related products commonly used in cancer patients.] Am Diet Assoc 1997;97:S208--S15. 6. Shannon M. Alternative medicines toxicology: a review of selected agents. J Toxicol Clin ToxicoI1999;37:709-13. 7. Munstedt K, Entezami A, Wartenberg A, Kullmer U. The attitudes of physicians and oncologists towards unconventional cancer therapies (VCT). Eur J Cancer 2000;36:2090--5. 8. Von Gruenigen VB, Wbite LJ, Kirven MS, Showalter AL, Hopkins MP, Jenison EL. A comparison of complementary and alternative medicine use by gynecology and gynecologic oncology patients. Int J Gynecol Cancer 2001;11:205--9. 9. Munstedt K, Kirsch K, Milch W, Sachsse S, Vahrson H. Unconventional cancer therapy-survey of patients with gynaecological malignancy. Arch Gynecol Obstet 1996;258:81-8. 10. Granai CO. Expectations about alternative therapies and women with gynecological cancer. CUff Opin Obstet Gynecol 1999;11:3--10. 11. Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/ alternative medicine use in a comprehensive cancer center and the implications for oncology. ] Clin Oncol 2000;18:2505--14. 12. Chrystal K, Allan S, Forgeson G, R Isaacs. The use of complementary/alternative medicine by cancer patients in a New Zealand regional cancer treatment centre. NZ MedJ 2003;116(1168):296--303. 13. Wenner CA, Parker K, Simon MA, Adams L, Greene K, Standish LJ. Botanical medicines with gynecological anticancer activity: a literature review. ] Am Med Womens Assoc 1999;54:184--90. 14. Bessette P. Natural products and gynecology. The Canadian Journal of CME August 2001: 57-71. Available at: www.stacommunications.com/journals/ cme/images/ cmepdf/ augustOl / naturalproducts/ pdf. 15. Labriola D, livingston R. Possible interactions between dietary antioxidants and chemotherapy. Oncology 1999;13:1003--8.
Complementary and Alternative Medicine in Gynaecologic Oncology Deanna J McKay, BSc(H),l James R Bendey, MBChB, FRCSC,2 Robert N Grimshaw, MD, FRCSC2 1Faculty of Medicine, Dalhousie University, Halifax NS 2Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS
a
Abstract Objectives: To explore complementary and alternative medicine (CAM) use among gynaecologic oncology patients in Nova Scotia. Methods: Over a 3-month period, 163 patients were asked to fill out a questionnaire concerning CAM. Those entering the study provided demographic information such as age, address, and employment status, as well as medical information and details of their use of alternative therapies. Results: A total of 152 patients were entered into the study, giving a response rate of 93.3%. Of these, 116 had used at least one type of CAM, classifying them as users (76.3%). Women who considered themselves "more religious" were more likely to be CAM users (P 0.001). There were no significant differences found between users and nonusers with respect to other patient characteristics reported. Patients with cervical cancer were less likely to use CAM than participants with another primary gynaecological malignancy (P 0.040). The most frequent CAM therapy practised was spirituality/prayer (52.6%). Most women used CAM to improve their physical well-being, and 53.3% of the women were interested in receiving more information on CAM.
=
=
Conclusion: A significant number of women undergoing conventional treatment for gynaecologic cancer in Halifax, Nova Scotia, also use CAM. Women"are using CAM for numerous reasons and believe they are benefiting from CAM in many ways. PhysiCians need to be aware of this high usage rate and should explore their patients' attitudes to and opinions about CAM.
Resume Objectifs : Etudier Ie recours a la medecine complementaire et parallele (MCP) par les patientes en oncologie gynecologique de la Nouvelle-Ecosse.
a
Methodes : On a demande 163 patientes, sur une periode de trois mois, de remplir un questionnaire portant sur la MCP. Celles qui ont participe I'etude ont foumi des renseignements demographiques comme I'age, I'adresse et i'emploi, ainsi que des renseignements medicaux et des details relativement leur utilisation de traitements paralleles.
a
a
a
Resultats : Un total de 152 patientes ont ete inscrites I'etude, pour un taux de reponse de 93,3 %. De ces patientes, 116 ont eu
Key Words: Gynaecologic oncology, complementary medicine. alternative therapies Competing interests: None declared. Received on February 8. 2005
Accepted on March 22, 2005
562
• JUNE lOGe JUIN 2005
recours au moins un type de MCP, ce qui en fait des utilisatrices (76,3 %). Les femmes qui consideraient etre « plus croyantes » avaient davantage de chances d'etre des utilisatrices (P = 0,001). On n'a constate aucune difference significative entre les utilisatrices et les autres patientes par rapport aux autres caracteristiques des patientes. Les patientes atteintes d'un cancer du col uterin avaient moins tendance avoir recours la MCP que les patientes atteintes d'une autre malignite gynecologique primaire (P = 0,040). La MCP pratiquee Ie plus frequemment est la spiritualite ou la priere (52,6 %). La plupart des femmes avaient recours la MCP pour ameliorer leur bien-etre physique, et 53,3 % des femmes etaient interessees obtenir de plus am pies renseignements .au sujet de la MCP.
a
a
a
a
Conclusion: Un nombre significatif de femmes subissant des traitements conventionnels pour un cancer gynecologique Halifax, en Nouvelle-Ecosse, a egalement recours la MCP. Les femmes utili sent la MCP pour differentes raisons et croient en tirer des bienfaits de bon nombre de faeons. Les medecins doivent etre au fait de ce taux eleve d'utilisation de la MCP et devraient porter attention I'attitude et I'opinion des patientes i'egard de la MCP.
a
a
a
a
a
J Obstet Gynaecol Can 2005;27(6):562-568
INTRODUCTION
C
omplementary and alternative medicine (CAM) refers to those practices and products used in conjunction with, or instead of, conventional medicine to treat disease and enhance health. The scope of CAM is broad and includes mind-body interventions, traditional or folk remedies, diets and nutrition programs, and manual healing. The Cochrane Collaboration has defined CAM as encompassing resources "other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period."l Use of CAM is widespread and is increasing in the general population as well as in cancer patients. A review of alternative medicine use by the general US population showed that use of CAM, excluding self-prayer,2 increased from 33.8% in 1990 to 42.1 % in 1997. Cancer patients have been identified as CAM users: a systematic review of 21 studies of CAM utilization in adults showed a range of use from 7% to 64%, with an average of 31.8%.3 Women are more likely
Complementary and Alternative Medicine in Gynaecologic Oncology
Table 1. Characteristics of patients completing questionnaires (N=152) Characteristic
Number (%)
Region
METHODS
Rural
50 (32.9)
Nonmetropolitan area
70 (46.1)
Metropolitan area
32 (21.1)
Marital status Single
18 (11.8)
Married
97 (63.8)
Separated/divorced
16 (10.5)
Widowed
21 (13.8)
Education
< Grade 12
49 (32.2)
Grade 12
103 (67.8)
~
the therapies used and the anticipated effects. The study also explored how patients' use of unconventional medicine varied with different cancers and treatments. to
Employment Employed
56 (36.8)
Unemployed
73 (48.0)
Other
23 (15.1)
Annual Income
< 30 000
54 (40.6)
~ $30 000
79 (59.4)
Religion More religious
77 (69.4)
Less religious
34 (30.6)
than men to be CAM users (48.9% vs. 37.8%).2 The importance of this issue in gynaecologic oncology has recently been shown in a report describing a rate of CAM use of 49.6% after a diagnosis of gynaecologic cancer.4 This study included religion as a CAM practice only if it was used in combination with faith healing or mental imagery.4 Physicians should be aware of their patients' use of CAM. This is especially important with cancer patients undergoing treatment, because several herbal therapies have toxicities and interactions with chemotherapeutic agents. 5,G An investigation of physicians' attitudes toward CAM showed that most had noticed the trend toward increasing interest in CAM but felt they lacked knowledge about these unconventional therapies.? Besides knowing about their patients' CAM use, physicians should be aware of their patients' expectations of and feelings about CAM. This study reviewed the use of CAM by gynaecologic oncology patients and explored their attitudes
We recruited women with gynaecologic malignancies from the gynaecologic oncology clinics at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia. Women with a new or existing diagnosis of a gynaecologic malignancy who attended these clinics during a 3-month period Gune 2003 to August 2003) were approached by the clinic nurse to determine their interest in participating in a study. Those who agreed to participate and who were able to give informed consent met with one of the investigators, who reviewed the consent form and gave the participant the questionnaire to complete. The questionnaire was adapted with permission from Swisher (E. Swisher, written communication, February 2003), and the modified version is available on request from the corresponding author. Those entering the study provided demographic and medical information (Table 1) and gave details about their use of complementary and alternative medical therapies and their expectations of these therapies. Patients were asked to list any CAM medications they were taking; a list of known complementary and alternative therapies was provided for participants to choose from, with the option of adding others. The questionnaire asked participants to provide details of their expectations of CAM therapies, perceived benefits, and the costs of the therapies. Patients were asked where they had obtained their information about CAM therapies, whether they would be interested in receiving more information about CAM therapies and medications from their doctor, and what kind of information would be most useful to them. Responses were entered into a FileMaker Pro Database program (FileMaker Pro 5.5vl, FileMaker Inc., Santa Clara). The Statistical Package for the Social Sciences (SPSS, Version 11.5.1 , Chicago) was used to perform data analysis. Comparisons of patient demographics were calculated with chi-square tests for categorical data and t tests for continuous data. Statistical significance was set at a value of P < 0.05. The Research Ethics Board for the Capital District Health Authority approved the study.
RESULTS During a 3-month period Gune 2003 to August 2003), all women who met the study criteria were approached to participate in the study. Of 163 patients approached, 152 (93.3%) agreed to participate. Most patients completing the questionnaire were married (63.8%), had a grade 12 or higher level of education (67.8%), and considered
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Table 2. Characteristics of users and nonusers of complementary medicines Characteristics
Users, n (%)
Nonusers, n (%)
P
Region Rural
38 (73.1)
14 (26.9)
Nonmetropolitan area
51 (75.0)
17 (25.0)
Metropolitan area
27 (23.3)
5 (13.9)
Single
12 (66.7)
6 (33.3)
Married
75 (77.3)
22 (22.7)
Separated/divorced
12 (75.0)
4 (25.0)
Widowed
17(81.0)
4 (19.0)
< Grade 12
36 (73.5)
13 (26.5)
Grade 12
80 (77.7)
23 (22.3)
0.446
Marital status
0.742
Education
~
0.569
Employment Employed
41 (73.2)
15 (26.8)
Unemployed
58 (79.5)
15 (20.5)
Other
17 (73.9.)
6 (26.1)
< $30000
40 (74.1)
14 (25.9)
~ $30 000
62 (78.5)
17(21.5)
More religious
66 (85.7)
11 (14.3)
Less religious
18 (52.9)
16(47.1)
0.681
Annual income"
Religion
a
0.001
19 patients did not answer the question about annual income.
b Ranked on a Likert scale of 1-7 (1-3 disregarded.
=more religious; 5-7 =less religious); all incomplete and rankings of 4 were
themselves to be "more religious" (69.4%). Table 1 shows the characteristics of these patients. For investigative purposes, the patients were divided into 2 categories: users of CAM (defined as those who were using CAM currently or who had used CAM since their diagnosis of cancer) and nonusers of CAM. Of the 152 participants, 116 women (76.3%) were classified as CAM users because they had used at least one type of CAM, and 36 (23.7%) were considered nonusers. The average age of patients entering the study was 58.2 years. The mean age of patients who used some form of CAM was 58.6 years and that of nonusers was 56.7 years (J> = 0.235). Other comparisons between users and nonusers of CAM are shown in Table 2. A statistically significant difference in the 2 groups was found only with respect to religion. CAM users considered themselves to be more religious than nonusers of CAM (P 0.001).
=
Patients were asked about their medical history. They documented their current and past treatment as well as their primary cancer diagnosis. Most patients in the trial were not
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b
• JUNE lOGe JUIN 2005
receiving treatment at the time of completing the questionnaire (104, 68.4%), and most of those who were being treated were receiving chemotherapy (33, 68.8%). The primary cancer diagnoses are shown in Table 3. The primary site of gynaecologic cancer was correlated with patterns of use. A trend was observed with respect to a diagnosis of ovarian cancer and use of CAM therapies, but this did not reach statistical significance (P = 0.065). Women with cervical cancer were less likely to use CAM than were women with other primary gynaecologic malignancies (P 0.040).
=
A list of known alternative therapies was included in the questionnaire. The participants were asked if they had ever used any of the therapies. If they had, they were asked about the frequency of use and whether use began before or after the diagnosis of cancer. Participants reported a total of 414 uses of CAM, with individual frequencies shown in Figure 1. Spirituality/prayer (61 users, 52.6%) was the most popular of all therapies used; other common modalities were diet (44,37.9%), exercise (32,27.6%), and massage therapy (30, 25.7%). Rolfing, colour therapy, crystal therapy, and
Complementary and Alternative Medicine in Gynaecologic Oncology
Table 3. Comparison of primary cancer source between CAM users and nonusers User, n (%)
Nonuser, n (%)
Total
Cervix
13 (59.1)
9 (40.9)
22 (14.5)
Primary cancer source
Endometrium
39 (79.6)
10 (20.4)
49 (32.2)
Ovary
50 (80.6)
12 (19.4)
62 (40.8)
Vagina
1 (100.0)
0(0)
1 (0.7)
Vulva
6 (60.0)
4 (40.0)
10 (6.5)
Other
7 (87.5)
1 (12.5)
8 (5.3)
Total
116 (76.3)
36 (23.7)
152
Table 4. CAM users' expectations and perceived benefits (n = 79)
Fight cancer
Expectations, n (%)
Perceived benefits, n (%)
47 (59.5)
38 (48.1)
Achieve cure
6 (7.6)
2 (2.5)
Boost immune system
46 (58.2)
38(48.1)
Improve physical well-being
60 (75.9)
51 (64.6)
Improve emotional well-being
37 (46.8)
38 (48.1)
Avoid progression of cancer
12 (15.2)
5 (6.3)
Avoid recurrence of cancer
24 (30.4)
11 (13.9)
Prevent I treat side effects
13 (16.5)
10 (12.7)
Other
14 (17.7)
15 (19.0)
osteopathy had one reported use each. Use of CAM began before the diagnosis of cancer was made in 265 cases (64.0%) and after diagnosis in 123 cases (29.7%). In 26 cases (6.3%), no comment was made about when CAM use began. Patients were asked about their use of ingested complementary and alternative medications such as herbs, teas, extracts, and vitamins. This provided a further classification of CAM users into "therapy users" and "medication users," with some overlap between the categories. Users of complementary medications were more likely to be religious (p:::: 0.014) and to live in urban areas (p:::: 0.009). Almost all of the participants spent less than $100 monthly on either therapies (82.3%) or medications (84.9%). Two women reported a cost of between $300 and $500 monthly for therapies; one woman stated that she spent the same amount on medications. The number of participants reporting that their oncologist knew about their CAM use and the number reporting that their oncologist did not know were equivalent. Thirty percent of participants were unsure whether their oncologist knew of their CAM practices.
Expectations of CAM and perceived benefits of its use are documented in Table 4. A total of 79 women completed this section of the questionnaire, with most including several expectations and perceived benefits. Only 6 women perceived no benefit from their use of complementary or alternative therapies (7.6%). The most commonly cited reasons for using CAM therapies and medications were "to improve physical well-being," "to fight cancer," and "to boost the immune system." These, in addition to improved emotional well-being, were regarded as the most common benefits of CAM use. The fmal section of the questionnaire concerned patient information about complementary and alternative medicine. We wished to identify where the participants had received their information and whether more information on CAM practices, medicines, and practitioners would be useful (Figure 2). Friends and the media were the most frequendy cited sources of information; family members and medical doctors were also common sources. Some of the women %) noted that they had never heard of complementary or alternative medicine before they were asked to participate in the study. Approximately one-half the women completing the questionnaire commented that they would
r.1
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GYNAECOLOGY Figure 1. Number of patients using CAM-therapies ~ r---------------------------------------------111 10
.
!!l 50 c:
Q)
co
D..
o
...
Q)
.0
30
2e
E
;:) 20
Z
32
30
20
23
2S
18
11
CAM Therapy like more information on CAM from their oncologist. Participants were asked to select all types of information they wanted and to add any others that interested them. The information most desired by participants was "which therapies to try" (84.1 %), "drug information" (56.1 %), "availability" (42.7%), and "contact information" (41.5%). DISCUSSION
This study explored complementary and alternative medicine use among gynaecologic oncology patients in Halifax, Nova Scotia. To our knowledge, this is the first study of its kind in Canada. CAM use is an important topic to explore, as similar studies worldwide have reported high rates of usage and have stressed the need for physician awareness of the subject. 3,4,8,9 The study's response rate of 93.3% indicates that the results are probably representative of Nova Scotian women undergoing standard treatment for a gynaecologic cancer. Because they did not attend the cancer clinics, women who chose to treat their gynaecologic malignancies solely with alternative therapies are not represented in this trial. We found an overall CAM use rate of 76.3% in this study. This high rate could be a result of the specific patient population studied or could be because of the broad definition of CAM used in the survey. Being female and the diagnosis of cancer have both been associated with higher rates of CAM use,2,3 and these 2 characteristics taken together may
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account for the high percentage of users. Because spiritual therapy is indexed as one of the major subheadings under complementary therapies in Medline and is included in the relevant literature,4,8,10 we included spirituality I prayer as a form of CAM therapy in the questionnaire. It produced the highest usage rate in the study. If this therapy had not been included in the questionnaire, the overall usage rate would have been dramatically lowered (36.2%). Religion was found to be a predictor of CAM use in this study. Use of spiritualityI prayer was found to be correspondingly high in a recent study in Texas,11 but religion was not analyzed as a predictor for use. Instead, this study found that younger age, female sex, indigent pay status, and surgery as part of treatment were indicative of current or predictive of future CAM use.!! Swisher et al. analyzed religion as a predictor for CAM use but found that it did not reach statistical significance. 4 When our patient population was divided into the 2 categories of use (users of therapy and users of medication), religion was found to be a predictor of CAM therapy use, but it did not predict use of CAM medication because spiritualityI prayer was not part of the CAM medication category. Living in urban areas was predictive of CAM medication use. Most of the patients in this trial were not receiving treatment when they completed the survey, so the difference between treatments and CAM use was not examined. Cervical cancer patients were significantly less likely to use CAM
Complementary and Alternative Medicine in Gynaecologic Oncology
Figure 2. Sources of CAM Information
Internet 6
than were partiCipants with other primary gynaecologic malignancies. This echoes the finding of Swisher et al. that women with a gynaecologic malignancy other than cervical cancer are more likely to use CAM.4 It may be expected that a less optimistic prognosis is associated with greater use of complementary and alternative medicine. Therefore, in the present study, we compared use of CAM by women who had ovarian cancer with CAM use by women who had other gynaecologic cancers. Women with ovarian cancer showed a trend toward using CAM therapies, but this trend did not reach statistical significance. This observation requires further study to determine whether the trend toward CAM use is significant only with noncervical gynaecologic malignancies. Figure 1 shows the specific frequencies of CAM use for therapies included in the study. The distribution of use is quite varied, although the most popular practices are similar to those in other studies on the subject.8--11 Use of some therapies was reported by only one study participant. This might have been a result of limited availability of the practice: in the Halifax metropolitan area, massage therapy and acupuncture have been available for several years, but biofeedback and magnet therapy are relatively new practices. Zone therapy and reflexology are identical practices but are given different names by different practitioners. We therefore included both practices in the list Qf CAM options. If
they had been grouped together, however, every CAM therapy included in the questionnaire would have been attempted or practised by at least one participant. It is important for physicians to be aware of their patients' use of CAM therapies and medications. According to this study, 30% of the participants were unsure whether their physician knew about their use of CAM. This lack of open communication has been reported in other studies and was stressed in a recent study in New Zealand. 12 Among the remaining 70% of the study group, one-half thought that their physician knew about their CAM use, and the remaining one-half were certain that their physician did not know. This uncertainty has highlighted the importance of including questions about CAM use in the initial history, especially with a patient who has gynaecologic cancer. When physicians are more informed of their patients' use of CAM, they will be able to anticipate potential risks of certain CAM practices when used either alone or in combination with conventional therapy. The most common botanical and herbal remedies used in gynaecologic oncology populations have been identified, but determining their safety prof11es and potential interactions requires further study.13,14 Important interactions between these remedies and chemotherapeutic agents have
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GYNAECOLOGY
been proposed and need to be investigated, specifically with regard to this patient population.1 5 The money spent on CAM therapies and medication is not insignificant. In this study, we determined that most of the participants who spent money on CAM were spending less than $100 monthly. However, since participants were asked separately about the cost of CAM therapies and the cost of CAM medications, it is possible that some participants responded with an overall combined cost and others responded with the cost of each component. Other studies that examined the cost of CAM have documented median costs of less than $100 monthly, but they did not divide costs into those related to medications and those related to therapies. 4,8,12 Only 6 of the 152 women completing the questionnaire felt that they had received no benefit from their use of CAM therapies. This is an impressive perceived success rate of 92.4% for alternative therapies, although the perceived benefits ranged widely from beneficial effects on cancer to improvement of general well-being and limitation of the side-effects of conventional therapy. One CAM option, therapeutic touch, is currently being offered in our chemotherapy clinic, and this could account for the high use of this modality reported in the study. Patients have commented that they are satisfied with the therapeutic touch program and that they would like to have other therapeutic modalities offered as part of the clinic's services. As a result of this study, we learned that approximately one-half of our patients would like more information on CAM and that we are currently only providing about 15% of the information that our patients receive. Patients expressed an interest in receiving information on CAM medications and therapies, especially about safety and effectiveness. We hope that this study is a step toward providing the requested information and promoting discussions between patients and their caregivers about complementary and alternative treatment.
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ACKNOWLEDGEMENTS We acknowledge the support of the Norah Stephen Oncology Scholarship.
REFERENCES 1. Zollman C, Vickers A. ABC of complementary medicine: what is complementary medicine? BMJ 1999;319:693--6. 2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States: 1990--1997. JAMA 1998;280:1569-75. 3. Ernst E, Cassileth BR. The prevalence of complementary / alternative medicine in cancer: a systematic review. Cancer 1998;83:777-82. 4. Swisher EM, Cohn DE, GoffBA, ParhamJ, Herzog T], Raider ]S, et al. Use of complementary and alternative medicine among women with gynecologic cancers. Gynecol Oncol 2002;84:363--7. 5. Spaulding-Albright N. A review of some herbal and related products commonly used in cancer patients.] Am Diet Assoc 1997;97:S208--S15. 6. Shannon M. Alternative medicines toxicology: a review of selected agents. J Toxicol Clin ToxicoI1999;37:709-13. 7. Munstedt K, Entezami A, Wartenberg A, Kullmer U. The attitudes of physicians and oncologists towards unconventional cancer therapies (VCT). Eur J Cancer 2000;36:2090--5. 8. Von Gruenigen VB, Wbite LJ, Kirven MS, Showalter AL, Hopkins MP, Jenison EL. A comparison of complementary and alternative medicine use by gynecology and gynecologic oncology patients. Int J Gynecol Cancer 2001;11:205--9. 9. Munstedt K, Kirsch K, Milch W, Sachsse S, Vahrson H. Unconventional cancer therapy-survey of patients with gynaecological malignancy. Arch Gynecol Obstet 1996;258:81-8. 10. Granai CO. Expectations about alternative therapies and women with gynecological cancer. CUff Opin Obstet Gynecol 1999;11:3--10. 11. Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/ alternative medicine use in a comprehensive cancer center and the implications for oncology. ] Clin Oncol 2000;18:2505--14. 12. Chrystal K, Allan S, Forgeson G, R Isaacs. The use of complementary/alternative medicine by cancer patients in a New Zealand regional cancer treatment centre. NZ MedJ 2003;116(1168):296--303. 13. Wenner CA, Parker K, Simon MA, Adams L, Greene K, Standish LJ. Botanical medicines with gynecological anticancer activity: a literature review. ] Am Med Womens Assoc 1999;54:184--90. 14. Bessette P. Natural products and gynecology. The Canadian Journal of CME August 2001: 57-71. Available at: www.stacommunications.com/journals/ cme/images/ cmepdf/ augustOl / naturalproducts/ pdf. 15. Labriola D, livingston R. Possible interactions between dietary antioxidants and chemotherapy. Oncology 1999;13:1003--8.