Abstract

Objectives: The use of alternative forms of medicine is well known in India, especially amongst cancer patients but there are very few studies that have investigated its usage and benefits. A study was conducted to determine the prevalence of the use of Traditional medicine, Complementary and Alternative Medicine (CAM) by cancer patients visiting a cancer care center. This study laid an emphasis on the predictors of use of CAM. Materials and Methods: This is an observational study conducted from March 2017 to May 2017 at a tertiary cancer care center. After obtaining informed consent, patients were handed a questionnaire and their responses were analyzed. Data analysis tools of Microsoft Office Excel 2007 were used for statistics. Results: A total of 407 patients took part in the study. The prevalence of traditional medicine and CAM was found to be 23.5% (96 patients). The mean duration of CAM use was 4.8 months (0.25 months–48 months). About 77% of the users had an education level below the upper primary level, of which 30.02% were illiterate. About 62.5% of the users were below poverty line. Nearly, 41.7% of the patients had not received any allopathic treatment before starting traditional medicine and CAM and did so for a mean duration of 4 months. About 53% of the patients who received some form of traditional medicine and CAM claim to have experienced some symptomatic benefits from its use. Nearly, 68.75% of the users were simultaneously receiving conventional anticancer therapy. Traditional medicine and CAM use was disclosed to the treating physician by 55% of the patients. Conclusion: Traditional medicine and CAM use have been shown to have a high prevalence 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. physicians have to acknowledge the increasing incidence of traditional medicine and CAM use in the population and actively inquire and educate the patients on its use.

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.

1.  World Health Organization. WHO Traditional Medicine Strategy 2014-2023. 1st ed. World Health Organization; 2017. http://www.apps.who.int/iris/bitstream/10665/92455/1/9789241506090_eng.pdf?ua=1 Available from: [Last accessed on 2017 Jan 12]
2.  Chang KH, Brodie R, Choong MA, Sweeney KJ, Kerin MJ. Complementary and alternative medicine use in oncology: A questionnaire survey of patients and health care professionals. BMC Cancer 2011; 11: 196
3.  Hyodo I, Amano N, Eguchi K, Narabayashi M, Imanishi J, Hirai M. et al. Nationwide survey on complementary and alternative medicine in cancer patients in Japan. J Clin Oncol 2005; 23: 2645-54
4.  Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000; 18: 2505-14
5.  Boon H, Stewart M, Kennard MA, Gray R, Sawka C, Brown JB. et al. Use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J Clin Oncol 2000; 18: 2515-21
6.  Mathijssen RH, Verweij J, de Bruijn P, Loos WJ, Sparreboom A. Effects of st. John's wort on irinotecan metabolism. J Natl Cancer Inst 2002; 94: 1247-9
7.  Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: A review of qualitative and quantitative studies. Complement Ther Med 2004; 12: 90-8
8.  Broom A, Nayar K, Tovey P, Shirali R, Thakur R, Seth T. et al. Indian cancer patients' use of traditional, complementary and alternative medicine (TCAM) and delays in presentation to hospital. Oman Med J 2009; 24: 99-102
9.  Ezzo J, Vickers A, Richardson MA, Allen C, Dibble SL, Issell B. et al. Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. J Clin Oncol 2005; 23: 7188-98
10.  Taixiang W, Munro AJ, Guanjian L. Chinese medical herbs for chemotherapy side effects in colorectal cancer patients. Cochrane Database Syst Rev 2005; 1: CD004540
11.  Rahmani AH, Al Zohairy MA, Aly SM, Khan MA. Curcumin: A potential candidate in prevention of cancer via modulation of molecular pathways. Biomed Res Int 2014; 2014: 761608

1.  World Health Organization. WHO Traditional Medicine Strategy 2014-2023. 1st ed. World Health Organization; 2017. http://www.apps.who.int/iris/bitstream/10665/92455/1/9789241506090_eng.pdf?ua=1 Available from: [Last accessed on 2017 Jan 12]
2.  Chang KH, Brodie R, Choong MA, Sweeney KJ, Kerin MJ. Complementary and alternative medicine use in oncology: A questionnaire survey of patients and health care professionals. BMC Cancer 2011; 11: 196
3.  Hyodo I, Amano N, Eguchi K, Narabayashi M, Imanishi J, Hirai M. et al. Nationwide survey on complementary and alternative medicine in cancer patients in Japan. J Clin Oncol 2005; 23: 2645-54
4.  Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 2000; 18: 2505-14
5.  Boon H, Stewart M, Kennard MA, Gray R, Sawka C, Brown JB. et al. Use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J Clin Oncol 2000; 18: 2515-21
6.  Mathijssen RH, Verweij J, de Bruijn P, Loos WJ, Sparreboom A. Effects of st. John's wort on irinotecan metabolism. J Natl Cancer Inst 2002; 94: 1247-9
7.  Robinson A, McGrail MR. Disclosure of CAM use to medical practitioners: A review of qualitative and quantitative studies. Complement Ther Med 2004; 12: 90-8
8.  Broom A, Nayar K, Tovey P, Shirali R, Thakur R, Seth T. et al. Indian cancer patients' use of traditional, complementary and alternative medicine (TCAM) and delays in presentation to hospital. Oman Med J 2009; 24: 99-102
9.  Ezzo J, Vickers A, Richardson MA, Allen C, Dibble SL, Issell B. et al. Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. J Clin Oncol 2005; 23: 7188-98
10.  Taixiang W, Munro AJ, Guanjian L. Chinese medical herbs for chemotherapy side effects in colorectal cancer patients. Cochrane Database Syst Rev 2005; 1: CD004540
11.  Rahmani AH, Al Zohairy MA, Aly SM, Khan MA. Curcumin: A potential candidate in prevention of cancer via modulation of molecular pathways. Biomed Res Int 2014; 2014: 761608