Jung Hye Kwon and Sang-Cheol Lee contributed equally to this work.
A cross-sectional survey was conducted to explore the current awareness and use of complementary and alternative medicine (CAM), as well as attitudes toward CAM, in patients with cancer and their family members in South Korea.
Between September 21 and October 31, 2017, a 25-item questionnaire regarding CAM experiences among cancer patients and their family members was conducted in 10 oncology clinics in South Korea after institutional review board approval at each institution.
In total, 283/310 patients were analyzed. The median age was 60 years, and 60% were male. Most of the patients were actively receiving anticancer treatment at the time of the survey. A total of 106 patients (37%) had experienced a median of two types (interquartile range, 1 to 3) of CAM. Belief in CAM (odds ratio [OR], 3.015; 95% confidence interval [CI], 1.611 to 5.640) and duration of disease (OR, 1.012; 95% CI, 1.004 to 1.020) were independent factors for using CAM in multivariable analysis. Belief in CAM was significantly associated with current use of CAM (OR, 3.633; 95% CI, 1.567 to 8.424). Lay referral was the most common reason for deciding to use CAM, and only 25% of patients (72/283) discussed CAM with their physicians.
Patient attitudes toward and confidence in CAM modalities were strongly associated with their CAM experiences, and only a small number of patients had an open discussion about CAM with their physicians. A patient education program for CAM is needed.
Cancer is a leading cause of death worldwide, including in South Korea. An estimated 14.1 million new cancer cases and 8.2 million cancer deaths occurred worldwide in 2012 [
Many cancer patients have expressed interest in complementary and alternative medicine (CAM). Cancer survivors have been found to use CAM more than cancer-free populations [
Cancer patients use CAM for various reasons, including to alleviate cancer symptoms, enhance immunity, reduce the side effects of conventional medicine, and even as an alternative to conventional medicine [
Most CAM modalities have no proven scientific data for to support their efficacy or safety, and drug interactions with conventional medicine can occur; thus, CAM could cause patients to be exposed to unexpectedly harmful situations [
This study was conducted to explore the characteristics of the use of CAM among cancer patients as well as factors related to their decision to disclose their use of CAM to their oncologists.
This cross-sectional study included both family members and cancer patients who received treatment between September 21 and October 31, 2017, at 10 oncology clinics in South Korea.
The survey instrument was a 25-item questionnaire, consisting of demographics (2 items: age, sex), oncology-related variables (6 items: diagnosis, date of diagnosis, stage of cancer at the time of diagnosis, current stage of cancer, previous and current treatment), attitudes toward CAM (3 items: belief, self-confidence, unmet need in knowledge), various aspects of CAM experiences (9 items: types, experiences, sources, reasons, effectiveness, satisfaction, side effects, duration of usage, cost of CAM), and CAM consultation experience with a doctor (5 items). CAM types were categorized as follows for practical reasons, and each category has detailed examples frequently used in South Korea: Chinese medicine, health supplement, herb/folk remedy/dietary supplementation, imaginary therapy, and cell therapy, among others. Four medical oncologists, one radiational oncologist, and one oncology surgeon developed the questionnaire based on a literature review. Review, feedback, and revision of the questionnaire were conducted during investigator meetings. A paper self-report questionnaire was used for this survey with the support of clinical research coordinators to ensure proper data collection. Patients received a gift worth $5 on the day of survey participation.
Descriptive statistics, including the means, medians, percentages, quartiles, and standard deviations, were used to summarize the demographics and the survey responses. Student’s t test and the Mann-Whitney U test were used to determine the differences between the groups. A p-value of < 0.05 was considered statistically significant. IBM SPSS statistics ver. 24 (IBM Corp., Armonk, NY) was used for all statistical analyses. Graphs were produced using Excel software based on SPSS output data.
The study was approved by the Institutional Review Board at the Kangdong Sacred Heart Hospital (KANGDONG 2017-05-006), Soonchunhyang University Hospital Cheonan (SCHCA 2017-08-043), Seoul St. Mary's Hospital (KC19QEDI0218), Seoul National University Bundang Hospital (B-1709/423-304), Gyeongsang National University Hospital (GNUH 2017-09-008), Keimyung University Dongsan Medical Center (2017-09-017), Chungnam National University Hospital (CNUH 2017-09-003), Chonnam National University Hwasun Hospital (CNUHH-2017-135), Catholic Kwandong University International St. Mary's Hospital (IS17QIMI0053), and Severance Hospital, Yonsei Cancer Center (4-2017-0713). Written informed consent was obtained from all participants.
Between September 21 and October 31, 2017, 415 patients and family members were invited to participate in the survey. Four hundred patients agreed to take the survey among the 10 participating oncology clinics in South Korea: the response rate was 75% (310/415), and 283 patients completed the survey (
In total, 286 of 310 patients reported their attitudes toward CAM. Among 286 patients, 51 (17.8%) had strong beliefs in CAM, 156 (54.5%) had weak beliefs in CAM, and 79 (27.6%) had no beliefs in CAM. The analysis included 283 patients because three patients did not report the satisfaction of CAM.
The patients’ demographics are summarized in
A total of 106 patients (37%) had experienced a median of two CAM modalities (interquartile range [IQR], 1 to 3), and 60 of them continued to use CAM at the time of survey, with a median of one modality (IQR, 1 to 2). The median duration of each CAM modality was 4 months (IQR, 1 to 12). Patients who continued to use CAM reported belief in the efficacy of CAM (p < 0.001) and reported that they were actively receiving treatment (p=0.040). A total of 39% of the patients (41/106) reported that they started using CAM at the time of diagnosis, and 27% (29/106) reported that they started during chemotherapy. Herb/folk remedy/dietary supplementation was the most recognized CAM modality, followed by health supplementation, Chinese medicine, and imaginary therapy. The patients’ satisfaction score with imaginary therapy was relatively higher than their satisfaction with Chinese medicine, health supplementation, or herb/folk remedy/dietary supplementation (
Among the 283 patients, 106 experienced CAM and 60 used CAM at the time of the survey. Duration of disease and belief in CAM were significantly related to the experience of CAM. The odds ratios (ORs) of those two factors were still significant after controlling for age, sex, disease duration, and belief in CAM through a multivariable logistic model (disease duration: OR, 1.012; 95% confidence interval [CI], 1.004 to 1.020; belief in CAM: OR, 3.015; 95% CI, 1.611 to 5.640) (
Forty-three percent of patients (56/106) started CAM following recommendations from family, relatives, or friends. Twenty-four percent (25/106) received recommendations from other patients and their family members. Only 14% of patients (15/106) started CAM by themselves. Patients gathered their CAM information from various sources, with a median number of 3 (range, 1 to 11). The most common sources of CAM information were family, relatives or friends (200/634), followed by media (186/634), healthcare professionals (68/634), social networking sites (62/634), advertisements (45/634), etc. Media (34%), followed by family, relatives, or friends (22%), and health care professionals (20%) were regarded as reliable sources of information (
Only 25% (72/283) discussed CAM with their oncologists. In most cases (90%), patients or family members started the discussion about CAM, and only 10% of patients reported that the discussion about CAM was initiated by healthcare professionals. These conversations included discussions of efficacy (42%), side effects (28%), drug interactions with conventional treatments or other CAM (26%), the appropriate use of CAM (2%), and restrictions during chemotherapy (1%). Common reasons for not asking physicians in 211 patients were “not a matter to discuss with a doctor” (49%, 103/211), “physicians hate to discuss CAM” (23%, 48/211), and “physicians will stop my use of CAM (18%, 38/211), among others.
In our study population, positive attitudes regarding the safety and efficacy of CAM and duration of disease were associated with the experience of CAM. This result is similar to the results of a previous study that investigated the attitudes and beliefs related to CAM in cancer patients in the United States [
The prevalence of CAM use has increased in Western countries, and out-of-pocket costs for CAM modalities is enormous [
In addition to the paucity of scientific studies on CAM, patients’ attitudes about disclosing their use of CAM to their primary care physicians are concerning. In our study, only 25% (72/283) discussed using CAM with their physicians, and most of these discussions were initiated by patients or family members, not by physicians. Other studies have reported that less than 50% of patients disclose their use of CAM to their healthcare providers, and they do not disclose all types of CAM modalities [
Patients’ sources of information constitute another problem that remains to be solved. Physicians as well as patients need more information about CAM. In our study, 132 patients wanted information related to the scientific evidence of CAM efficacy, and 96 wanted to know about clinical trials on CAM. However, their sources of information were family, relatives, and friends (32%) and media and social networking sites (40%), with their most trusted source of information being media (34%). Another study reported that lay referral and media were also used by cancer patients to gather information about CAM [
The design of this cross-sectional study has some limitations in confirming the relationships between patients’ expectations of CAM efficacy and their feelings of effectiveness and satisfaction. Young age, chronic illness, including cancer, and level of education were reported to have impacts on the use of CAM or CAM experiences. Cancer type has also been associated with CAM-related behaviors. To validate our study, prospective observational studies are needed that control for confounding factors.
Supplementary materials are available at Cancer Research and Treatment website (
Conflict of interest relevant to this article was not reported.
This is a Planning Task of the General Affairs Committee of the Korean Cancer Association. The authors would like to express our appreciation to the secretariat members of the Korean Cancer Association, as well as to the patients and family members who participated in this study.
Study consort diagram. CAM, complementary and alternative medicine.
Satisfaction with complementary alternative medicine according to complementary and alternative medicine (CAM) modalities in 283 patients. (A) Number of patients who are aware of the types of CAM, those who have previously used CAM, and those who are current CAM users. (B) Satisfaction score (0-10) for each CAM modality in 106 patients. The median and quartile values are displayed; Q1-Q3, 1st quartile-3rd quartile. NA, not available.
Patients’ answers on multiple-choice questions regarding their expectations about complementary and alternative medicine (CAM) before use (left side) and met their expectancy after using CAM (right side).
Sources of information of complementary and alternative medicine (CAM): tree-map of various sources of information from all patients for multiple-choice questions on the left side (A) and the percentage of actual sources from multiple-choice questions and sources that were regarded as reliable by patients from single-choice questions on the right side (B).
Demographics according to CAM use
Characteristic | Total (n=283) | Not experienced (n=177) | Experienced (n=106) | p-value |
---|---|---|---|---|
60 (52-67) | 62 (52-67) | 60 (52-67) | 0.574 |
|
Male | 169 (59.7) | 113 (63.8) | 56 (52.8) | 0.068 |
Female | 114 (40.3) | 64 (36.2) | 50 (47.2) | |
Gastrointestinal tract | 109 (38.5) | 73 (41.2) | 36 (34.0) | 0.845 |
Thorax | 37 (13.1) | 22 (12.4) | 15 (14.2) | |
Hepatobiliary | 37 (13.1) | 24 (13.6) | 13 (12.3) | |
Breast | 36 (12.7) | 20 (11.3) | 16 (15.1) | |
GY/GU | 26 (9.2) | 14 (7.9) | 12 (11.3) | |
Sarcoma | 12 (4.2) | 7 (4.0) | 5 (4.7) | |
Head and neck | 10 (3.5) | 7 (4.0) | 3 (2.8) | |
Hematology | 8 (2.8) | 6 (3.4) | 2 (1.9) | |
Other | 8 (2.8) | 4 (2.3) | 4 (3.8) | |
12 (4-29) | 10 (3-22) | 20.5 (5-39) | < 0.001 |
|
Yes | 86 (30.4) | 59 (33.3) | 27 (25.5) | 0.379 |
No | 125 (44.2) | 75 (42.4) | 50 (47.2) | |
Missing | 72 (25.4) | 43 (24.3) | 29 (27.4) | |
Active treatment | 2 (0.7) | 2 (1.1) | 0 | 0.792 |
Palliative care | 278 (98.2) | 173 (97.7) | 105 (99.1) | |
Unknown | 3 (1.1) | 2 (1.1) | 1 (0.9) | |
Yes | 204 (72.1) | 115 (65.0) | 89 (84.0) | < 0.001 |
No | 79 (27.9) | 62 (35.0) | 17 (16.0) |
Values are presented as median (IQR) or number (%). CAM, complementary and alternative medicine; GY/GU, gynecological/genitourinary tumor; IQR, interquartile range.
Chi-square test,
Fisher exact test.
Probability of using CAM among patients (n=283)
Variable | cOR (95% CI) | aOR (95% CI) |
---|---|---|
0.995 (0.973-1.017) | 0.996 (0.972-1.020) | |
1.576 (0.966-2.572) | 1.375 (0.814-2.324) | |
Thorax vs. GI | 1.383 (0.641-2.980) | - |
HB vs. GI | 1.098 (0.501-2.406) | - |
Breast vs. GI | 1.622 (0.752-3.500) | - |
GY/GU vs. GI | 1.738 (0.729-4.141) | - |
Sarcoma vs. GI | 1.448 (0.430-4.882) | - |
HN vs. GI | 0.869 (0.212-3.560) | - |
Hematology vs. GI | 0.676 (0.130-3.519) | - |
Others vs. GI | 2.028 (0.479-8.578) | - |
Advanced disease vs. not | 1.457 (0.816-2.600) | - |
Unknown vs. not | 1.474 (0.765-2.837) | - |
Active treatment vs. palliative care | > 999.999 (< 0.001-> 999.999) | - |
Unknown vs. palliative care | > 999.999 (< 0.001-> 999.999) | - |
1.011 (1.003-1.019) | 1.012 (1.004-1.020) | |
2.823 (1.543-5.162) | 3.015 (1.611-5.640) |
CAM, complementary and alternative medicine; cOR, crude odds ratio; CI, confidence interval; aOR, adjusted odds ratio controlling for age, sex, disease duration, and belief in CAM; GI, gastrointestinal tumor; HB, hepatobiliary tumors; GY/GU, gynecological/genitourinary tumor; HN, head and neck cancer.
Probability of current use of CAM among patients (n=283)
Variable | cOR (95% CI) | aOR (95% CI) |
---|---|---|
1.007 (0.981-1.034) | 1.010 (0.982-1.039) | |
1.394 (0.785-2.476) | 1.360 (0.742-2.493) | |
Thorax vs. GI | 0.811 (0.300-2.194) | - |
HB vs. GI | 1.156 (0.462-2.889) | - |
Breast vs. GI | 1.197 (0.478-3.000) | - |
GY/GU vs. GI | 1.862 (0.714-4.861) | - |
Sarcoma vs. GI | 2.095 (0.576-7.620) | - |
HN vs. GI | 1.048 (0.207-5.299) | - |
Hematology vs. GI | 1.397 (0.263-7.417) | - |
Others vs. GI | 0.599 (0.070-5.132) | - |
Advanced disease vs. not | 1.304 (0.647-2.629) | - |
Unknown vs. not | 1.578 (0.730-3.412) | - |
Active treatment vs. palliative care | > 999.999 (< 0.001-> 999.999) | - |
Unknown vs. palliative care | > 999.999 (< 0.001-> 999.999) | - |
1.004 (0.996-1.012) | 1.004 (0.996-1.012) | |
3.609 (1.563-8.331) | 3.633 (1.567-8.424) |
CAM, complementary and alternative medicine; cOR, crude odds ratio; CI, confidence interval; aOR, adjusted odds ratio controlling for age, sex, disease duration, and belief in CAM; GI, gastrointestinal tumor; HB, hepatobiliary tumors; GY/GU, gynecological/genitourinary tumor; HN, head and neck cancer.