Original Article Gynecol Obstet Invest 2007;64:75–81 DOI: 10.1159/000099634
Received: April 6, 2005 Accepted after revision: November 1, 2006 Published online: February 14, 2007
Self-Application of Complementary and Alternative Medicine by Patients with Gynecologic Cancer Aygul Akyuz a Murat Dede b Ayse Cetinturk a Tulay Yavan a Mufit Cemal Yenen b S. Umit Sarici c Saffet Dilek d a
Department of Obstetrics and Gynecology, School of Nursing, Departments of b Obstetrics and Gynecology, and c Pediatrics, Gulhane Military Medical Academy, Ankara, and d Department of Obstetrics and Gynecology, Faculty of Medicine, Mersin University, Mersin, Turkey
Key Words Complementary and alternative medicine Gynecologic cancer
Abstract Objectives: In this study we aimed to determine the epidemiology and demographic data on complementary and alternative medicine (CAM) use along with the medical/surgical treatment modalities in patients with gynecologic cancers in Turkey. Materials and Methods: A cross-sectional study was designed to determine demographic data on CAM use of patients with gynecologic cancers who had medical and/ or surgical treatments. Semistructured questionnaires were used for collecting data from 126 patients. Results: When the CAM use ratio of patients was evaluated with respect to demographic characteristics, patients using any type of CAM were younger and more educated, and there were no significant differences between the patients who used and who did not use any type of CAM with respect to geographical region. There were no significant correlations between the use of CAM and the type of malignancy, treatment modality and time period after diagnosis. Conclusion: There is
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critical concern about the probable serious risks associated with non-educated CAM practitioners. Therefore, informed and educated healthcare professionals should inform and help in relieving patients in a more professional and multidisciplinary way. Copyright © 2007 S. Karger AG, Basel
Introduction
Every year, 10 million people are diagnosed worldwide as having cancer and 6 million die because of it [1, 2]. Gynecologic cancers constitute a substantial number of cancers among women. Endometrium and ovarian cancers are the second and the fourth reasons of cancer among women in the USA [3, 4]. Despite the scientific progress, many diseases such as malignancy, acquired immune deficiency syndrome and multiple sclerosis do not have absolute and permanent therapies [5]. Therefore, patients often refer to complementary and alternative medicine (CAM) practices in addition to conventional treatment modalities. Cancer patients are often unsatisfied with standard medical care and
Murat Dede Department of Obstetrics and Gynecology, Gulhane Military Medical Academy TR–06018 Etlik/Ankara (Turkey) Tel. +90 312 304 5816, Fax +90 312 304 3900 E-Mail
[email protected]
Table 1. CAM data collecting form
1
Date of birth?
2
Educational situation?
3
The district where you have been living for a long time?
4
What is your diagnosis?
5
Which treatments have you gone through till now?
6
To date which therapies did you take? _ Surgical therapy _ Radiotherapy _ Chemotherapy
7
Is there a therapy that is still going on? What is it?
8
Have you heard the term of ‘alternative medicine or complementary medicine’?
9
If yes, where and from whom? _ Internet _ Newspaper/magazine/TV _ Other
_ Other patients _ Relatives/friends
10 Do you believe that CAM is useful? _ Yes (please explain) _ No (please explain)
ever, usually untrained people in this district practice CAM techniques. CAM methods demonstrate a large spectrum including herb prescriptions and mystic applications (written charms, folk remedies such as drinking turtle blood, eating dead male meat, etc.) [5]. Although CAM is widely used in patients with gynecologic cancers [9, 10], there are no detailed data about its incidence and how it is administered. Furthermore, there is, to our knowledge, no published study about the use of CAM in patients with gynecologic cancers in Turkey. The aim of the present study was therefore to determine the epidemiology and demographic data of CAM therapies administered in addition to conventional medical/surgical treatment modalities in patients with gynecologic cancers in Turkey. Although the term CAM includes a wide range of therapies, all therapies not provided by the official healthcare providers were defined as CAM in this study. Materials and Methods
11 Are you planning to use CAM methods? 12 To date have you ever used any of these techniques? _ Yes _ No 13 Can you explain the techniques you have used? (type of the method, frequency of using, etc.) 14 Do you think you had benefit from these therapies? _ Yes (please explain) _ No (please explain) 15 What do you think about the usefulness of medical therapy and alternative-complementary therapy? Which is true for you? _ Using them together _ Using them alone
prefer CAM as an effective defensive mechanism against the disease, which however has no absolute cure [6–8]. The National Center for Complementary and Alternative Medicine (NCCAM) has grouped CAM into five major classes as: alternative medical systems like traditional oriental medicine and homeopathy; mind-body interventions including meditation, prayer and mental healing; biologically based treatments such as melatonin, herbs, shark cartilage, and high-dose vitamins; manipulative and bodybased methods including chiro/practic manipulation, massage and other hands-on techniques, and energy therapies like therapeutic touch, as Reiki and Pigang [9]. CAM has been performed for centuries and is still being accepted as an alternative therapy in Anatolia. How76
Gynecol Obstet Invest 2007;64:75–81
A cross-sectional study was designed to determine demographic data (whether and why they use(d) CAM therapy, type of CAM therapy) on CAM use of patients with gynecologic cancers who had or have had medical and/or surgical treatments. The study was performed on 126 patients with gynecologic cancers who were admitted to the Gynecologic Oncology Department of Gulhane Military Medical Academy between September 2001 and May 2003. A questionnaire was prepared and all patients were requested to fill in the form after they were informed about the aim of the study and their consent was obtained. No patients rejected to fill in the form. Semistructured questionnaires prepared after a detailed literature search and analysis were used for collecting data. The questionnaires included 15 subjects about demographic (age, education, region) and historical parameters (type of malignancy, previous and present treatments) and information about CAM (source of information about treatment, treatment method, reasons for usage, whether benefited or not) (table 1). The most commonly used 17 CAM methods (praying, worshipping, therapeutic touch, high-dose vitamin and mineral therapy, herbal therapy, animal organs, aroma therapy, diet regimens, acupuncture, electromagnetic therapy, psychologic therapies, dreaming, animating on eyes, oxygen and ozone therapies, massage therapy, relaxation therapies, meditation, hypnotherapy and hypnoses) were additionally listed so that patients could mark the method which they heard or used. A pilot study was initially performed on a small group of patients during a 4-month period, and methodological problems and understanding difficulties were corrected and revised on the questionnaire form before starting the study. Statistical analysis was performed by SPSS 11.0 software. Descriptives were shown as either mean 8 SD or n (%) notation. Relations between groups and the categorical variables were investigated by 2 test. The probability value was set at ^ 0.05.
Akyuz /Dede /Cetinturk /Yavan /Yenen / Sarici /Dilek
Table 2. Demographic data of the patients
Whether she used any type of CAM used %
n
%
Age 37–49 years 50–64 years 65–75 years
33 52 21
100 85.2 65.6
– 9 11
14.8 34.4
Educational status Illiterate Primary school Senior high school University
20 51 20 15
64.5 85.0 100.0 100.0
11 9 – –
35.5 15.0
Geographical origin of patients Marmara region Aegean region Inner Anatolia region Black Sea region East Anatolia region
13 13 53 19 8
86.7 92.9 79.1 86.4 100.0
2 1 14 3 –
13.3 7.1 20.9 13.6
Demographic data revealed that 47.6% of the patients had graduated from primary school, 53.2% were from the region of Inner Anatolia, and 48.6% of the patients were between 50 and 64 years of age, 43.7% had endometrial cancer and 31.7% had ovarian cancer. When the CAM use ratio of patients was evaluated with respect to age, educational status and the origin (geographical regions), it was seen that patients using any type of CAM were younger and more educated, there were no significant differences between the patients who used and who did not use any type of CAM with respect to geographical region (table 2). There were no significant correlations between the use of CAM and the type of malignancy, treatment modality and time period after diagnosis (table 3). Ninety-two percent of all patients (n = 116) were informed about at least one method of CAM, and 69 of these (69/116, 59.4%) had learned it from their friends or relatives while 47 cases had learned it from the media. Out of these 69 patients, 60 had used at least one method of CAM (table 4). The number of patients using at least one method of CAM after learning it from the media was significantly higher than that learning it from friends or relatives (p = 0.03, 2 = 4.22) (table 4). Self-Application of CAM by Patients with Gynecologic Cancer
2
not used
n
Results
p
0.00 14.48
0.00 15.56
0.44
3.72
Of all the patients filling the data collecting form (n = 126), 78 (61.9%) regarded CAM as being beneficial. Out of these 78 patients, 74 (94.8%) used CAM, whereas 4 (5.1%) used none. Thirty-two (66.7%) of 48 patients regarding CAM as not being beneficial had used CAM, although they did not believe in CAM, whereas 16 out of 48 (33.3%) not regarding CAM as being beneficial had used CAM (p = 0.00, 2 = 17.70) (table 4). Of the 78 patients regarding CAM as being beneficial, 32 found it psychologically relaxing and 46 regarded plants as safe and at least harmless. Of the 32 cases regarding CAM psychologically relaxing, 28 (97.5%) used any type of CAM, whereas all (100%) of the 46 cases regarding CAM as being beneficial because plants were safe and useful used at least one method of CAM (p = 0.02, 2 = 6.06) (table 4). Forty-eight patients regarded CAM as not being beneficial and 36 of these (75%) considered medical treatment modalities sufficient in the disease progress. Twelve patients found CAM not to be beneficial because they thought that CAM might be harmful. Of the 32 cases defining medical treatment as sufficient, 26 (72.2%) used any type of CAM, whereas only 6 of the 12 cases (50%) defining CAM might be harmful used CAM (p = 0.14, 2 = 2.0) (table 4). When 106 patients (who used any methods of CAM) were questioned about the benefits of the method(s) they Gynecol Obstet Invest 2007;64:75–81
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Table 3. Type of malignity and treatment modality at the time of the data collection
Whether she used any type of CAM used
p
2
not used
n
%
n
%
Type of malignancy Cervix carcinoma Ovarian carcinoma Endometrium carcinoma Breast carcinoma
20 30 48 8
87.0 75 87.3 100.0
3 10 7 –
13.0 25 12.7
0.20
4.55
Treatment modality1 Radiotherapy (n = 37) Chemotherapy (n = 67) Surgical treatment (n = 115)
33 59 95
89.2 88.1 82.6
4 8 20
10.8 11.9 17.4
0.23 0.14 0.13
1.00 1.65 2.27
Time after diagnosis 1–5 years 6–10 years >11 years
73 25 8
83.9 89.3 72.7
14 3 3
16.1 10.7 27.3
0.44
1.63
1 Line percent was calculated and number (n) was multiplied since patients could have taken combined treatments.
Table 4. Patient characteristics about how they were informed about CAM and the information about the usefulness of CAM (a total of 126 cases with gynecologic cancer)
Characteristics
n
%
p
2
Hearing from any source and having information about CAM Using any type of CAM
116 106
92.0 84.1
–
–
Using/learning from relatives/friends Using/learning from the media
60/69 46/47
86.9 97.8
0.03
4.22
Using/thinking it to be beneficial Using/thinking it not to be beneficial
74/78 32/48
94.8 66.6
0.00
17.70
Cases regarding CAM to be beneficial (n = 78) Using/psychologically relaxing Using/defining plants are safe and useful
28/32 46/46
87.5 100.0
0.02
6.06
Cases regarding CAM not to be beneficial (n = 48) Using/defining medical treatment is sufficient Using/defining it might/may be harmful
26/36 6/12
72.2 50.0
0.14
2.0
used, 42 patients (39.6%) found it psychologically relaxing and 15 patients (14.2%) said that they were not sure, whereas 49 patients (46.2%) declared no benefits. Mystic practices like praying, herbal remedies and diet regimens were the most frequently preferred CAM methods (table 5). All of the patients had knowledge about herbal remedies, and 84.1% of them had been using these products. 78
Gynecol Obstet Invest 2007;64:75–81
Stinging nettle either alone or mixed with honey and garden thyme was the most commonly used herb by the patients (table 5). When the CAM method selected by the patient was evaluated according to the parameters including age and educational level, young (p = 0.04, 2 = 9.859) and welleducated (p ! 0.00, 2 = 15.576) people preferred herbal therapies more frequently, whereas less educated people Akyuz /Dede /Cetinturk /Yavan /Yenen / Sarici /Dilek
Table 5. Information of patients related to
CAM methods and experience of CAM
CAM method
Ratio of cases using CAM to cases already having information about CAM in all (n = 126) of the study group
Praying Worshipping Therapeutic touch High-dose vitamin and mineral therapy Herbal therapy (garden thyme, stinging nettle, Sweden syrup) Animal organs (turtle blood) Aromatherapy (lavender oil) Diet regimens (high protein content fruit and vegetable-based) Acupuncture Electromagnetic therapy Psychologic therapies (rely on therapy, belief in healing) Dreaming, animating on eyes Oxygen and ozone therapies Massage therapy Relaxation therapies Meditation Hypnotherapy and hypnoses
preferred praying (p = 0.004, 2 = 13.300) and worshipping (p = 0.02, 2 = 15.300) mostly. All the patients who used worship and praying (n = 98 and 108, respectively) as a disease control method stated that these methods made them feel good. When patients were asked for their opinion about the status of CAM in cancer therapy, 52.4% answered that ‘medical therapy and CAM could be combined’. Most of the patients were satisfied by medical therapy, however they wish CAM techniques would be presented in a more professional way by healthcare people.
Discussion
In the present study most commonly used CAM techniques were religion practices (such as worship and pray), herbs, nutrition and diet regimens, high-dose vitamin and mineral support. Our results are in accordance with the previous studies in cancer, and especially gynecologic cancer patients [6]. According to previous data by Ceylan et al. [5], herbal products are used by 60% of cancer patients. Gözüm et Self-Application of CAM by Patients with Gynecologic Cancer
n/n
%
108/114 98/103 3/56 13/46
94.7 95.1 5.3 28.2
106/116 6/35 2/46
91.3 17.1 4.3
20/53 7/76 3/44
37.7 9.2 6.8
4/66 13/30 –/15 17/60 5/40 3/37 –/40
6.0 43.3 – 28.33 12.5 8.1 –
al. [11] have stated that herbal products are used by 93.2% of people in East Anatolia. In Yoon and Horne’s [12] study, herbal products are used in a range between 3 and 70% in the USA. In Turkey, the most frequently used CAM method in oncology patients was herbal therapy [13]. In the current study this ratio was 84.1%. Studies from the USA demonstrate that rates of CAM use are 33.8% in 1990, and 41% in 2000 [10, 14]. In a review article by von Gruenigen et al. [10], the prevalence of CAM use in all cancer patients has been reportedly between 7 and 64%. In a recent article by Algier et al. [13], all the studies about the prevalence of CAM use in oncology patients in Turkey since 1998 were reviewed, and an overall prevalence of 39.2–60.1% was reported. Among all patients with cancer, young and well-educated females undergoing chemotherapy tend to use CAM methods more frequently than other patients [5, 8, 9, 12]. In the current study also, younger and well-educated women used CAM more frequently. In the present study, the type of malignancy and duration of disease did not affect the use of CAM, similar to the previous data by Gözüm et al. [11]. On the other hand, Gynecol Obstet Invest 2007;64:75–81
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Swisher et al. [6] and Von Gruenigen et al. [10] have reported that CAM is used more commonly among patients with cervix and breast cancers. Ceylan et al. [5] report that Turkish society is highly respectful to their traditions and the exchange of information usually occurs in social groups. Chen and Chang [15] report that patients with dermatological disorders mostly learn CAM techniques from social and religion groups. The most important sources are newspapers, books and the internet that are easily available in our country. Turkish web sites advertise several CAM techniques and it is possible to purchase the products from these web sites. In the present study, patients mostly received information about CAM from relatives and/or friends. However, the use of CAM was more frequent in patients getting information about CAM from the media. This finding suggests that patients consider mediatic information more valuable. Thus, mediatic publications should be safer and more controlled in order to avoid misdirecting people. In our study, well-educated and young patients prefer herbal methods, whereas less educated and older people prefer religious practices. These findings are parallel with previous studies [8, 10, 12, 16]. In the current study, 61.9% of patients believe that CAM could be useful or at least would not lead to harmful outcomes. A similar belief was present for herbal products [5, 15, 17]. However, there are few data about how these herbs interact with cancer drugs and whether they are harmful and toxic. If these products can mask the real symptoms of disease, therapy may be delayed. Besides, all the CAM techniques are not natural and even some of the natural elements may lead to health problems [10, 15, 17]. CAM methods are not direct risk factors when they are used as an alternative to medical therapy, however they may pose risks indirectly [17]. It is extremely important for healthcare professionals to support can-
cer patients about making decisions on CAM methods [6, 10, 12]. Another interesting finding in the present study was that 66.7% of the patients considering CAM not to be beneficial had used at least one method of CAM. This discrepancy may be due to the intense emotion and effort of the patients in that they try to overcome the disease. Some cancer patients state that CAM methods lead to psychological relaxation. Patients use these methods not only for controlling symptoms of the disease but also for increasing quality of life and constructing psychological support mechanisms [9]. In our study also, 39.6% of the patients using any method of CAM stated that they benefited from a psychologically relaxing effect. Most of the patients report that they are satisfied by medical therapy, however they also wish healthcare people would present CAM techniques in a professional way. Most of the CAM users believe that CAM is beneficial and 25.4% of them prefer these methods, although they do not consider them as useful. The latter group, probably wish to do something defensive against cancer. Most of the patients report that they are satisfied with medical therapy [6, 8, 11], however they wish CAM methods could be presented in a professional manner [5]. In conclusion, a significant number of patients with gynecologic cancers prefer CAM techniques as an additional therapy to modern cancer therapy. However, it was determined that patients with cancer usually received information about CAM from not so scientifically reliable sources such as relatives, friends and the media. There is critical concern about the probable serious risks associated with non-educated CAM practitioners. Therefore, informed and educated healthcare professionals should inform and help in relieving patients in a more professional and multidisciplinary way.
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