METHODS
This descriptive-cross section study was conducted between June 2007 and December 2007. Three-hundred
and six patients were asked to complete a questionnaire about the use of CAM along with HADS.
RESULTS
The prevalence of CAM use among cancer patients treated with radiotherapy was 35%. The patients with
severe anxiety score were more likely to use CAM than the others. The younger age were found as predicting
variables for CAM use. Majority of user patients wanted to add CAM to conventional therapies.
CONCLUSION
Oncologist might be aware of the CAM issue and talk to their patients about the use of CAM. The documentation
of CAM use in the medical history might be advised at the time of initial consultation in radiotherapy
centers. Although CAM use is a method that patients want to use in addition to conventional
treatments, it is not clear that these methods can be used together safely. It is thought that there is a need
for prospective and innovative studies in modern oncology centers.
Keywords: Alternative medicine, cancer; complementary medicine; hospital anxiety and depression score; radiotherapy
The management of treatment-related side effects is
an important goal in oncology and the use of CAM may
be a pillar in this situation. The safety and efficacy for expethe
use of CAM along with conventional therapies have
not been established and certain CAM therapies might
lead to excessive toxicity when used concurrently with
chemotherapy or radiotherapy.[
Coping with cancer and its treatment has profound
implications on individuals. Studies have demonstrated
that approximately one-third of cancer patients
deal with clinically significant anxiety and depression.
[
Few studies have evaluated the association between
CAM use and HADS scores in cancer patients.
Rakovitch et al.[
The purpose of this study was to determine: (1) the
prevalence of CAM use among Turkish cancer patients
treated with radiotherapy, (2) the characteristics of
CAM users, (3) patients" source of information about
CAM, (4) patients" perceived attitude of their physician
regarding CAM use, and (5) the association between
CAM use and HADS scores.
The Questionnaire
We used a standardized newly developed interviewer-
administered questionnaire. The questionnaire was
intended to collect information about socio-demographic
characteristics (e.g., age, income level, education status, employment status), disease (e.g., breast,
lung, head, and neck cancer) and treatment characteristics
of patients (e.g., radiotherapy, chemotherapy,
surgery) and use of CAM status (e.g., use of CAM,
reasons for CAM use, type(s) of CAM used, beliefs
the benefit of CAM). Patients were questioned if they
had discussed the use of CAM with their oncologist.
Patients were also asked to describe the perceptions
among physicians about their CAM use and about the
reasons for not discussing CAM with their physicians.
We also assessed the levels of anxiety and depression using the HADS.[19] HADS is a self-rated 14-item questionnaire, was developed to determine states of anxiety, depression, and emotional status of patients. Seven questions in the HAD deal with anxiety and seven with depression (HADS-A and HADS-D). The answers to every question are scored on a scale of 0--3. The highest score of point is thus 21. Amount higher than 10 are accepted to indicate probable severe case.
Data Collection
All patients were informed and written consent was
obtained by a face-to-face interview. In total, 306 patients
completed the questionnaire regarding the use of
CAM along with the HADS.
Ethical Considerations
The study design was approved by the administrators
of the Department of Radiation Oncology. Ethical approval
was obtained from the Ethical Review Committee
of Gazi University Medicine School.
Statistical Analysis
Statistical analysis was carried out using Statistical
Package for Social Sciences for Windows version 13
(SPSS. Inc. Chicago. IL). Categorical variables were
compared using Pearson"s Chi-square test and continuous
variables were compared using independent
samples t-test and ANOVA test. The correlations were
evaluated using Spearman"s rho correlations. For all
statistical analysis, a two-sided p<0.05 was considered
to be statistically significant.
Among 107 patients who were CAM users (the vast majority using herbal medicine), CAM use was based on their personal experiences in 13 (12.1%), the experiences or suggestions of their family members in 62 (57.9%), the experiences or suggestions of other fellow patients in 36 (33.6%), the recommendations of their physicians in 17 (15.9%) and the experiences or suggestions shared on the media in 43 (40%). Only 46 out of 107 patients (43%) had discussed their CAM use with their attending physicians.
Of 34 patients with HADS-A scores ≥11, 22 patients (65%) experienced severe anxiety whereas of 60 patients with HADS-D scores ≥11, 22 patients (37%) experienced severe depression. There was a statistically significant correlation between higher HADS-A scores and higher HADS-D scores (p<0.001, r=0.642).
Of 34 patients experiencing severe anxiety, there
were 27 females (79.4%) and seven males (20.6%), their
ages ranging from 26 to 77 years (median, 53 years).
Nine patients (26.5%) had completed high school education
or more. Twenty-six of them (76.5%) lived incities. Twenty-two patients (64.7%) had ECOG performance
scores of 0 or 1. Thirteen patients (38.2%) were
employed. Thirty-one patients (91.2%) were married,
sixteen patients (47.1%) were with children and thirtytwo
of them (94.1%) lived in a family-hood. Twentytwo
patients (64.7%) were also experiencing severe depression.
Eighteen of them (52.9%) were using CAM
and 14 of them (41.2%) had discussed CAM use with
their physicians (Table
Of 272 patients experiencing no anxiety, there were
136 females (50%), their ages ranging from 16 to 81 years
(median, 53 years). 97 patients (35.7%) had completed
high school education or more. 179 of them (65.8%)
lived in cities. 237 patients (87.1%) had ECOG performance
scores of 0 or 1. 162 patients (59.6%) were employed.
232 patients (85.3%) were married, 142 patients
(52.2%) were with children and 257 of them (94.5%)
lived in a family-hood. Thirty-eight patients (14%) were
experiencing severe depression. Ninety-four patients
(34.6%) had discussed CAM use with their physicians
and 89 of them (32.7%) were using CAM (Table
Female patients (p=0.02, χ2=10.70), patients with worse ECOG scores (p=0.002, χ2=11.69) and patients that were unemployed (p=0.03, χ2=5.61) tended to experience severe anxiety more commonly.
Of 60 patients experiencing severe depression,
there were 42 females (70%) and 18 males (30%), their
ages ranging from 17 to 78 years (median, 53.5 years).
Twenty patients (33.3%) had completed high school education
or more. Forty of them (68.3%) lived in cities.
Forty-four patients (73.3%) had ECOG performance
scores of 0 or 1. 27 patients (45%) were employed.
Fifty-two patients (86.7%) were married, 30 patients
(50%) were with children and 55 of them (91.7%) lived
in a family-hood. Twenty-two patients (36.7%) were
also experiencing severe anxiety. Twenty-four patients
(40%) had discussed CAM use with their physicians
and 20 of them (33.3%) were using CAM (Table
Of 46 patients experiencing no depression, there
were 122 females (49.6%) and 124 males (50.4%), their ages ranging from 16 to 81 years (median, 53 years). 86
patients (35%) had completed high school education
or more. One hundred and sixty-four of them (66.7%)
lived in cities. Two hundred and fifteen patients (87.4%)
had ECOG performance scores of 0 or 1. One hundred
and forty-eight patients (60.2%) were employed. Two
hundred and eleven patients (85.8%) were married,
128 patients (52%) were with children and 235 of them
(95.5%) lived in a family-hood. Twelve patients (4.9%)
were experiencing severe anxiety. Eighty-seven of them
(35.4%) were using CAM and 84 of them (34.1%) had
discussed CAM use with their physicians (Table
Female patients (p=0.004, χ2=8.39), patients with worse ECOG scores (p=0.01, χ2=7.34) and patients that were unemployed (p=0.04, χ2=4.53) tended to experience severe depression more commonly.
There was a statistically significant difference between patients that used CAM and that did not use CAM concerning rates of those experiencing severe anxiety (p=0.02, χ2=5.43). On the other hand, there was no statistically significant difference between patients that used CAM and that did not use CAM concerning rates of those experiencing severe depression (p=0.77, χ2=0.09).
Some studies suggest that CAM use is more common
in patients who are younger, who are married, who have higher income, who have higher education,
and who hold health insurance.[
Although CAM use was higher in patients with longer
survival,[
The main reasons for Turkish cancer patients to
use CAM were similar to reports from other countries.
[
One of the limitations of the present study is the
unintentional focusing of the questionnaire on the
use of "phytotherapy" rather than covering a broader
spectrum of complementary and alternative medical
approaches. This may have resulted in the participants
to report their use of herbal medicine and,
perhaps, not to appreciate the importance of the use
of other modalities in the context of the study. Therefore, a follow-up study that includes a broader set of
questions may help to better understand the attitudes
of the patients regarding CAM. Surprisingly, the oncologists
that are surveyed on CAM use are generally
enthusiastic and supportive of their patients" use
of complementary therapies. In addition to those
therapies popular among patients, at least half of the
physicians supported massages, support groups, acupuncture,
and biofeedback, and art therapy. However,
discussions of CAM are relatively rare and most likely
to be initiated by patients.[
Patients may have different needs to use CAM and
may have different perceptions on the risks of interaction
between CAM and radiation therapy, as the latter
is "not a medication." It is important that physicians
and other health care personnel involved in taking
care of cancer patients be aware of these therapies,
their prevalence, and their beneficial and adverse effects.
Adequate knowledge and training of CAM in the
medical community would promote a better physicianpatient
relationship and foster a more open discussion
on their use.
Future research needs to assess effective ways for
oncologists to gather information about CAM use by
patients during allopathic treatment and discern ways
these therapies may enhance or interfere with traditional
cancer treatments. Aiming to integrate traditional
and complementary medicine practices to modern
medical practices, hence improving the quality of
life of the society, Turkish Ministry of Health has established
The Department of Traditional and Complementary
Medicine Practices in 2011. The Department
has so far published the rules and regulations in order
to certify, license, legislate and organize traditional and
complementary medicine practices. There are many
differences in terms of the reasons to use traditional
or complementary practices on a country basis or on a regional basis, such as the increase in the demand
for health services, being more informed about and
involved in treatment, being more aware of the available
choices, the increase in the dissatisfaction with the
available health services and living up of the interest
in integrated healthcare and prevention of diseases.
An increase in the safe and effective use of CAM could
improve these services" access to the healthcare system
with the possibilities for integration of these two
(http://tcamanatolia.saglik.gov.tr.).[
Multiple studies show a willingness on the part
of physicians to get more educated about CAM use.
Many universities offer increasing number of courses
for physicians to enrich their knowledge about CAM
therapies and improve the therapeutic encounters with
their patients.[
The literature suggests that CAM use was associated
with anxiety, depression, and poor mental health.
[35] In our study, female patients, patients with worse
ECOG scores, and patients that were unemployed
tended to experience severe anxiety more commonly.
Those patients experiencing higher levels of anxiety
tended to use CAM more frequently, whereas there was
no difference in terms of CAM use based on their state
of depression. The studies evaluating the relation between
HADS scores and CAM use have reported contradictory
results.[
Better communication, detailed information, and open discussion with the patients is very important for the protection of patients from unsuitable and unhelpful use of CAM. Oncologists might be advised to be aware of the CAM issue and talk to their patients about the use of CAM in their routine practice. The documentation of CAM use in the medical history might be advised at the time of initial consultation in radiotherapy centers.
The use of validated screening tools specific to CAM therapies would assist healthcare professionals to advise patients on continuing their CAM use in light of current literature. In the first instance, healthcare professionals should recommend patients cease CAM therapies with a known risk of harm. Further research is needed to identify how a health professional can encourage and incorporate CAM therapies safely into a treatment regimen. Prospective trials and innovative evidence-based treatment concepts to include CAM into high-end oncology is what patients demand and what a modern oncology center should consider offering.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest. Ethics Committee Approval: The study was approved by the Gazi University Faculty of Medicine Ethical Review Committee at 2007.
Financial Support: This study has received no financial support.
Authorship contributions: Concept - E.E.Y., G.K.; Design - E.Y.E., G.K.; Supervision - H.B., G.K., M.A.; Funding - G.K., E.Y.E.; Materials - G.K., E.Y.E.; Data collection and/ or processing - G.K., E.Y.E.; Data analysis and/or interpretation - E.Y.E., G.K.; Literature search - G.K., E.Y.E.; Writing - G.K.; Critical review - G.K., E.Y.E., H.B., M.A.
