Keywords
Cancer - complementary and alternative medicine - traditional medicine
Introduction
Present day advances in diagnostic techniques have led to a greater incidence of cancer
detection. Application of current treatment modalities has resulted in better survival
rates and better quality of life, even in patients diagnosed with advanced cancer.
At the same time, there are concerns about the adverse effects of chemotherapeutic
medicines and radiotherapy. In this particular setting, patients are liable to experiment
with CAM. The incidence of cancer is on the rise, and with it, the use of CAM is likely
to increase as well.
The WHO defines traditional medicine as “The sum total of the knowledge, skills, and practices based on the theories, beliefs,
and experiences indigenous to different cultures, whether explicable or not, used
in the maintenance of health as well as in the prevention, diagnosis, and improvement
or treatment of physical and mental illness.”[1] The WHO also states, “The terms 'complementary medicine' or 'alternative medicine' are used interchangeably
with traditional medicine in some countries. They refer to a broad set of health-care
practices that are not part of that country's own tradition and are not integrated
into the dominant health-care system.”[1]
Surveys conducted worldwide show that the use of complementary and alternative medicine
(CAM) is gaining popularity with studies conducted in Europe, America, and Asia suggesting
a high prevalence of use.[2],[3],[4],[5] It has been shown from these studies that a vast majority of patients who use alternative
forms of medicine do so without obtaining enough information about it.[2],[3] This is particularly disturbing as some studies show evidence of drug interactions
between conventional chemotherapeutic drugs and CAM. One such study showed that the
use of St John's-wort reduced the blood levels of SN-38, the active metabolite of
irinotecan, thus reducing its action.[6] Another major problem faced by health care staff is the unwillingness of most patients
to divulge their use of CAM. A study conducted in Australia found a high rate of nondisclosure,
with reasons primarily pertaining to the fact that patients were concerned about negative
responses from the practitioners. They also felt that the practitioners did not need
to know about alternative medicines used or the practitioners did not inquire into
CAM use to begin with.[7] Studies have indicated that a majority of the health-care professionals do not have
sufficient knowledge regarding CAM.[2],[3],[4] This may affect the doctor–patient communication, invariably affecting treatment.
Furthermore, traditional medicine varies from country to country and from region to
region in its use. Such varied uses can be attributed to culture, tradition, food
habits, and attitudes of its practitioners. Being an ancient system of medicine passed
on from generation to generation, it has stood the test of time.
The primary goal of the study was to determine the prevalence of the use of traditional
and CAM use by the patients visiting a tertiary cancer care center. This study laid
an emphasis on the predictors of the use of CAM such as the cause of initiation, the
benefits, and side effects associated with it, and the cost of care.
Materials and Methods
This was an observational study conducted at a tertiary cancer care center in South
India. The survey was conducted from March 2017 to May 2017. Before conducting the
survey, the study protocol was reviewed and approved by the Institutional Ethics Committee.
The survey was conducted among patients who were diagnosed with cancer at that point
in time or at any time in the past. The patients included in the survey were those
attending the medical oncology and radiotherapy departments. Patient selection was
discontinuous. The patients who were participating were explained regarding the nature
of the survey, were assured anonymity, and were handed over a questionnaire after
taking a verbal as well as written consent. Patients or the patient's relatives were
encouraged to fill the questionnaire independently wherever possible. Those requiring
help were interviewed.
The questionnaire prepared for the survey was adapted from the questionnaire used
in the study done in Japan.[3] The questionnaire was reviewed by two medical oncologists and was given validation
after the modifications were made. The questionnaire was prepared in English as well
as two other local languages. The questionnaire included sociodemographic data, diagnosis,
modalities of treatment received, duration of the use of traditional medicine, reasons
for the use of traditional medicine, side effects noticed, and mean expenditure per
month, whether treating physician was consulted before CAM initiation and the subjective
benefits experienced by the use of CAM. Patient education levels mentioned in the
study were as defined by the International Standard Classification of Education (2011).
Statistical analysis
Data analysis tool of Microsoft Office Excel version 2007 was used.
Results
Four hundred and seven patients were enrolled in the study with a mean age of 53.6
years (18–86). Of the 407, 182 patients were interviewed. The prevalence of traditional
medicine and CAM use was found to be 23.5% (96 patients). The mean age of patients
on traditional medicine and CAM was 55.3 years (33–80), of which 40% were male and
60% were female. Among the CAM users, the majority (77%) had an education level below
the upper primary level and 30.02% were illiterate. The economic status of patients
was inferred from their ration cards, issued by the state government. Multiple variables
such as Per capita income and access to basic facilities are taken into account to
define the poverty line in their particular state. In our study, 62.5% of patients
met the criteria for Below Poverty Line set by their respective state governments.
The distribution of the site of the cancers is as depicted in [Table 1]. The responses to the questionnaire by the patients are as listed in [Table 2]. Of the enrolled patients, 41.7% were treatment naive, while the rest had received
some form of cancer-directed therapy. Most patients utilized traditional medicine
and CAM of their own volition or after it was recommended by an acquaintance. The
mean duration of use of CAM and traditional medicine prior to hospital admission was
4 months. About 68.75% used traditional medicine and/or CAM along with allopathic
medicine.
Table 1
Baseline characteristics of patients using complementary and alternative medicine
|
Characteristics
|
No. of patients (%)
|
|
APL - Above poverty line; BPL - Below poverty line;
HCC - Hepatocellular carcinoma; NHL - Non-Hodgkin’s lymphoma; RCC - Renal cell carcinoma
|
|
Age
|
|
|
Mean
|
55.3 years
|
|
Range
|
33-80 years
|
|
Sex
|
|
|
Male
|
38 (39.6)
|
|
Female
|
58 (60.4)
|
|
Education
|
|
|
Primary
|
15 (15.60)
|
|
Upper primary
|
30 (31.20)
|
|
Secondary
|
11 (11.540)
|
|
Tertiary
|
4 (4.10)
|
|
Bachelors
|
5 (5.30)
|
|
Masters
|
2 (2.10)
|
|
Illiterate
|
29 (30.20)
|
|
Socioeconomic status
|
|
|
APL
|
36 (37.5)
|
|
BPL
|
60 (62.5)
|
|
Diagnosis
|
|
|
Breast cancer
|
25
|
|
Pancreaticobiliary cancers
|
6
|
|
Head-and-neck cancers
|
16
|
|
Ovarian cancer
|
12
|
|
Hematological cancers
|
6
|
|
Lung cancers
|
4
|
|
Esophagogastric cancers
|
12
|
|
Cancer of cervix
|
2
|
|
Colorectal cancers
|
6
|
|
Primary peritoneal
|
1
|
|
Prostate cancer
|
1
|
|
Urothelial cancers
|
3
|
|
HCC
|
1
|
|
NHL with prostatic Ca with RCC
|
1
|
Table 2
Responses received for the questions in the questionnaire
|
Background Questions
|
Replies
|
No. of patients (%)
|
|
CAM - Complementary and alternative medicine
|
|
Treatment received (before the time of interview)
|
No treatment received previously Received prior treatment
|
17 (17.70) 79 (82.3)
|
|
Why did you start CAM?(multiple choices were allowed)
|
a. Recommended to you by a family member or friend
|
69 (71.8)
|
|
b. Your own free will
|
47 (48.9)
|
|
c. Recommended to you by a physician
|
2 (2.08)
|
|
d. Other
|
0
|
|
Have you tried CAM before coming to the hospital
|
Yes
|
40 (41.7)
|
|
If yes, then how long
|
No
|
56 (58.3)
|
|
Mean number of months
|
4.1125 months
|
|
Simultaneous use of CAM with allopathic medicine
|
|
66 (68.75)
|
|
Duration of therapy (total including previous CAM treatment)
|
Mean number of months
|
4.7968 months
|
|
Range
|
0.25-48 months
|
|
What did (do) you expect out of CAM? (Multiple choices allowed)
|
a. Cure
|
63 (65)
|
|
b. Arrest the progress of the disease
|
47 (48.9)
|
|
c. Improve the symptoms
|
37 (38.5)
|
|
d. Complementary effects to the present medicine
|
26 (27.08)
|
|
e. Others
|
0
|
|
Did you perceive any symptomatic benefit?
|
Yes
|
51 (53.1)
|
|
No
|
24 (25.1)
|
|
Difficult to judge
|
21 (21.8)
|
|
Did you perceive any side effects?
|
Yes
|
8 (8.33)
|
|
No
|
87 (90.63)
|
|
Difficult to judge
|
1 (1.04)
|
|
Cost and mean expenditure per month
|
Nil
|
4 (4.2)
|
|
1-4999
|
79 (82.2)
|
|
5000-9999
|
9 (9.4)
|
|
10000-15000
|
4 (4.2)
|
|
Use of CAM disclosed to the treating physician?
|
Yes
|
53 (55.2)
|
|
No
|
43 (44.8)
|
The mean duration of CAM use overall was 4.8 months (0.25 months–48 months). The majority
of them expected a cure (65%) or significant control of the cancer symptoms, and 53%
claim to have noticed symptomatic benefit with traditional medicine and CAM, with
minimal side effects.
The majority (86.4%) spent <Rs. 5000 per month for traditional medicine and CAM, and
its use was disclosed to the treating doctor by 55% of the patients.
Discussion
Over the past two decades, there has been a revival in the popularity of traditional
and CAM. In a survey conducted in Delhi, the prevalence of traditional and CAM use
was found to be 34%. About 11.5% of the users were found to take at least 6 months
after first noticing cancer-related symptoms before consulting the primary care physician.[8] The prevalence of traditional medicine use in cancer patients in the study was found
to be 23.5%. The prevalence of CAM use was significantly higher in patients concurrently
receiving conventional therapy with low education and socioeconomic levels being an
important factor. The survey revealed that many of the traditional medicine users
had taken the therapy before visiting the hospital, for an average of 4 months. This
aspect is important in curable stages of cancer when treatment delays could be detrimental
to the prognosis.
Few studies have shown CAM to be beneficial in quelling the cancer-related/treatment-related
complications on the body. Ezzo et al. evaluated the therapeutic efficacy of acupuncture in controlling chemotherapy related
side-effects and found that electro acupuncture reduced vomiting in the acute phase
after chemotherapy.[9] Certain herbal medicines have been found to stimulate immunocompetent cells and
reduce the side effects of chemotherapy.[10] Curcumin, a constituent of turmeric, has shown to have several anti-inflammatory
and antioxidant properties and has been the subject of multiple studies which explore
its effectiveness in the prevention and treatment of cancer.[11]
These positive aspects of CAM are overshadowed by disadvantages such as limited scientific
research on the efficacy of CAM therapy, lack of a governing body that approves CAM
therapy, and a possibility for potentially dangerous cross reactions between conventional
modes of therapy and CAM.[6] Hence, in cancer patients, the use of CAM should not be encouraged unless there
is definitive scientific data on benefit. Further, the primary care physician must
actively inquire regarding the use of traditional medicine and CAM in patients.
Conclusion
Traditional medicine and CAM use have been shown to have a high prevalence in Indian
cancer patients. The usage is more among the less-educated and the economically backward
sections of the society. There is not sufficient data to support the effectiveness
and safety of traditional medicine and CAM. Hence, primary care physicians as well
as oncologists have to acknowledge the increasing use of traditional medicine and
CAM amongst cancer patients and actively inquire and educate the patients on its use.
