Eur Arch Otorhinolaryngol DOI 10.1007/s00405-010-1223-1
HEAD AND NECK
Complementary medicine use in patients with head and neck cancer in Ireland Mohamed Amin · F. Glynn · S. Rowley · G. O’Leary · T. O’Dwyer · C. Timon · J. Kinsella
Received: 4 November 2009 / Accepted: 18 February 2010 © Springer-Verlag 2010
Abstract The objectives of the study were: Wrst, to determine the prevalence of traditional medicine (TM) and complementary and alternative medicine (CAM) use in head and neck cancer patients in Ireland; second, to educate ourselves on the plethora of CAM/TM options available to patients outside the dominion of conventional medicine. The study design consisted of a cross-sectional survey carried out in three head and neck cancer centres. Self-administered questionnaires were distributed to 110 head and neck cancer patients attending the three cancer centres and data were collected for statistical analysis. A total of 106 patients completed the questionnaire; 21.7% of the participants used CAM/TM since their diagnosis with head and neck cancer. CAM/TM usage was higher in female (34.3%) than in male patients (16.2%). CAM/TM use was more common in the 41–50-year age group, in patients with
Poster presentation at the Joint Anglo-American Otolaryngology Meeting, July 2008, Dublin, Ireland. M. Amin · F. Glynn · C. Timon · J. Kinsella Department of Otolaryngology, Head and Neck Cancer, St. James’s Hospital, Dublin, Ireland S. Rowley Cancer Audit Program, St. James’s Hospital, Dublin, Ireland G. O’Leary Department of Otolaryngology, Head and Neck Cancer, South InWrmary Hospital, Cork, Ireland T. O’Dwyer Department of Otolaryngology, Head and Neck Cancer, The Mater Hospital, Dublin, Ireland M. Amin (&) 22, Gainsborough Lawn, Malahide, Dublin, Ireland e-mail:
[email protected]
higher educational levels and those holding strong religious beliefs, and also in married than single patients. The most common types of CAM/TM used were spiritual and laying on of hands. The most common reasons reported for using CAM/TM were to counteract the ill eVects of treatment and increase the body’s ability to Wght cancer. Sources of information on CAM/TM were friends (65%), family (48%) and media (21%). This survey reveals a high prevalence of CAM/TM use in head and neck cancer patients, hence emphasising the need for otolaryngologists to educate themselves on the various therapies available to be able to provide informative advice. There is an urgent need for evidence-based investigation of various CAM/TM therapies currently oVered to patients. Keywords Head and neck cancer · Complementary and alternative medicine · Survey
Introduction The use of traditional medicine and complementary and alternative medicine (CAM) in head and neck cancer patients has received limited attention in literature despite reports of its growing use in cancer patients in general. A signiWcant number of cancer patients use CAM as adjunct therapies to their cancer treatment [1, 2], whilst Eisenberg et al. [3] reported that one-third of the US population used some form of unconventional medicine and 75% of patients did not inform their physicians of this practice. The National Centre of Complementary Medicine in 2007 estimated that around 38% of adults and 12% of children in the USA have used some form of complementary medicine [4], spending more than $34 billion per year on CAM therapies [5].
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Health-care professionals and the public alike face a dilemma regarding the eYcacy and safety of CAM and TM largely due to the lack of rigorously conducted scientiWc tests of eYcacy based on accepted rules of evidence [6]. Treatment delay associated with alternative medicine use in head and neck cancer patients has previously been demonstrated, sometimes with catastrophic results [7, 8]. Hence, the need for a national survey with a primary outcome measure to determine the prevalence of CAM/TM use in head and neck cancer patients in Ireland and to obtain a proWle of users in this particular group, and with a secondary outcome measure to educate ourselves on the plethora of CAM/TM options available to our patients outside the realm of conventional medicine. Such information would enable us to engage with them in more open dialogue and provide informative advice regarding their use of CAM/ TM.
Patients and methods Ethical considerations The study was approved by the research and ethics committee in the participating hospitals prior to commencing the survey. Methods The present study design was a cross-sectional survey carried out in three head and neck cancer centres in Ireland. Eligibility for the study included adult patients with a conWrmed diagnosis of head and neck cancer, who were aware of their diagnosis and who had received or were currently receiving conventional treatment for the same. An anonymous validated self-administered questionnaire based on that of Swisher et al. [9] was modiWed with permission to the needs of this study. The questionnaire consisted of 22 items. Its Wrst part enquired about medical data and sociodemographic characteristics, following which patients were asked whether they used CAM after the diagnosis of cancer. If they responded positively, a number of questions followed enquiring about the type(s) of CAM used, the reasons for using CAM, expenditure on CAM and sources of information about CAM. A four-point scale (ranging from not at all satisWed to completely satisWed) was used to assess satisfaction with the CAM used. Patients were requested to tick all that applied regarding the beneWts they had actually experienced to assess the perceived eVectiveness of the CAM used. The questionnaire was administered to 110 patients attending the three participating cancer centres: St. James’s Hospital, Dublin, the Mater Hospital, Dublin,
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and South InWrmary Hospital, Cork. Over a 3-month period between February and April 2008, 106 patients completed the questionnaire. Four patients did not complete the questionnaire and therefore were excluded from the study. An information leaXet was given to the patients explaining the purpose of the survey, emphasising its anonymity and stating that we neither promoted nor prohibited the use of CAM/TM. A head and neck oncology liaison nurse specialist was available in the outpatient clinics to answer any patient queries arising from the questionnaire. The questionnaires were returned in a sealed envelope. Data analysis Power analysis study indicated that 110 patients would be required for a study with 80% power, with p < 0.05. Data were coded and analysed using the Statistical Package for the Social Sciences (SPSS) v.17.0 (SPSS inc. Chicago, IL, USA). Descriptive statistics were used and non-parametric tests were performed using Pearson’s Chi-square test and Fisher’s exact test.
Results Out of 110 participants, 106 completed the questionnaire (96%). A total of 23 patients (21.7%) used CAM/TM since they were diagnosed with head and neck cancer. Of the 32 females participating in the survey, 11 used CAM/TM (34.3%) in comparison to 12 male patients (16.2%) out of a total of 74 male participants in this study. Five patients (4.7%) considered using CAM/TM since their diagnosis with cancer. The age of the respondents ranged between 20 and 79 years. The use of CAM was more common in the age group ranging from 41 to 50 years (p = 0.017), followed by the age group ranging from 61 to 70 years and was more common in patients with higher levels of education, as 26% of CAM/TM users held a college degree or higher in comparison to 10.8% of non-CAM/TM users. People with strong religious beliefs were more common in the CAM/ TM user group (87%) compared to 76.5% in the non-user group. CAM/TM use was also more common in married patients (60%) than in single patients (Table 1). The various CAM/TM therapies used were divided into four categories for the purposes of statistical analysis: spiritual/faith healing (including laying on of hands and healing touch), ingested therapy (including vitamins, herbal medicine, medicinal tea and juicing), body technique (including aromatherapy, reXexology, acupuncture and massage) and psychic therapy (including homeopathy, meditation, relaxation technique and hypnotherapy).
Eur Arch Otorhinolaryngol Table 1 Patient demographics Parameter
CAM user (n = 23)
Non-CAM user (n = 83)
p Value
Previous Med Tx
23
75
0.122
Previous Sx
16
60
0.797
Previous RT
17
45
0.090
Previous CT/RT
3
5
0.236
Current Tx
3
8
0.636
Treatment
Current Sx
2
6
0.533
Current RT
1
3
0.630
Current RT/CT
0
0
Sex Male
12
62
Female
11
21
0.037
17
74
0.129
6
9
0.063
Retired
4
36
0.018
Business professional
6
7
0.022
Education Leaving certiWcate College degree or higher Profession
The most common types of CAM/TM used were spiritual/faith healing (56%, p = 0.01), followed by body technique and psychic therapy (47%) and ingested therapy (34%). When asked for the reasons they used CAM/TM, 82% sought to counteract the ill eVects of treatment and to increase the body’s ability to Wght cancer, whilst 65% held a “might help, can’t hurt” attitude. Only three patients cited a desire to directly Wght cancer. The most common reported beneWts from CAM/TM were an increase in the body’s ability to Wght cancer (86%, p = 0.01), followed by decreased side eVects of medical treatment (82%) and improvement in physical well-being (43%) (Fig. 1). Monthly expenditure on CAM/TM ranged from 100– 500 D, with 48% spending 100 D per month, 30% spending between 100 and 300 D and three people spending more than 300 D per month. Sources of information on CAM/TM were mainly friends (65%) and family (48%) followed by media (21%) (Table 2). The most common cancer site associated with CAM/TM use was the oral cavity (43%, p = 0.036) followed by laryngeal cancer (26%) (Table 1). No patient reported any ill eVects from using CAM/TM.
Housewife
6
12
0.189
Manual work
5
12
0.291
Clerical staV
0
3
0.476
Unemployed
0
3
0.612
Others
2
10
0.492
CAM/TM: the deWnitions
2
16
0.192
Married
14
47
0.641
Divorced
1
3
0.630
Separated
3
5
0.236
Widowed
3
12
0.584
20
62
0.219
5
20
0.528
Voice box
6
27
0.555
Neck
5
23
0.565
10
18
0.036
0
3
0.476
In a recent World Health Organisation strategy statement [10], the term “traditional medicine” (TM) was deWned as diverse health practices, approaches and beliefs incorporating plant, animal and spiritual therapies used to maintain the well-being as well as to treat and diagnose illnesses. The term “complementary and alternative medicine” (CAM) was deWned as referring to a broad set of healthcare practices that are not part of a country’s own tradition or not integrated into its dominant health-care system. Thus, Chinese medicine, Indian Ayurveda and Arabic Unani medicine are considered as traditional medicine, but many European countries deWne them as CAM as they do not form part of their own health-care tradition.
Discussion
Marital status Single
Religious beliefs Strong religious beliefs Living alone Tumour site
Oral cavity Pharynx Nasopharynx
1
3
0.630
Sinus
0
3
0.452
Ear
0
3
0.476
Others
1
3
0.630
1
2
0.524 0.630
Age 20–30 31–40
1
3
41–50
10
16
0.017
51–60
1
11
0.233
61–70
7
36
0.263
>70
3
14
0.469
Health-care systems and CAM/TM Ireland has what is considered to be a tolerant system, whereby the national health-care system is based entirely on conventional orthodox medicine, while some CAM/TM practices are tolerated by law. This is in contrast to an integrative system whereby CAM/TM is oYcially recognised and incorporated into all areas of health-care provision such as in China, Korea and Vietnam. An inclusive system also exists where recognition of CAM/TM has not yet been fully integrated into all aspects of health care. Countries operating
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Fig. 1 Reported beneWts of CAM/TM use
Integrated health-care system
Table 2 Source of information on CAM/TM The media (TV, magazines, newspapers, internet)
5
Friends
15
Family
11
Practitioners of alternative therapy
2
Advice by medical personnel
2
Medical professionals
4
an inclusive system include developing countries such as Nigeria and Mali, which have a national CAM/TM policy, but little or no regulation of CAM/TM products, and developed countries such as Canada and the UK, which do not oVer signiWcant university-level education in CAM/TM, but are making concerted eVorts to ensure the quality and safety of the same. It is estimated that 7,770 CAM therapists, who are members and associate members of various organisations, are in operation in Ireland. In response to the diversity of CAM therapies available, the Irish Government established a National Working Group to report on the regulation of complementary therapists and this report was published in May 2006 [11]. The group reported that CAM practice in Ireland was a very disparate one with a broad range of expertise, training and level of association with other practitioners and/or international organisations. The Wndings of the group showed that Ireland was in the early stages of forming solid frameworks of associations and federations with which to link and govern the sector, and that Ireland favoured the international trend towards self-regulation with some limited statutory regulation or registration being considered.
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With CAM/TM becoming ever more popular, it is little wonder that a number of studies have shown that some forms of CAM/TM therapies may be considered cost-eVective in a number of conditions such as acupuncture for chronic headache [12] and stress management for cancer patients undergoing chemotherapy [13]. The idea of costeVectiveness has helped to develop the concept of integrated health care, which is a fast growing area of medicine whereby complementary therapies are available and integrated within a conventional health-care setting and with conventional health-care funding. A prime example is the Prince’s Foundation for Integrated Health in the UK and the ongoing initiative in Northern Ireland to oVer patient access to CAM/TM through GPs and local health boards. In the USA, most medical schools oVer courses on CAM/TM and fellowships in CAM are available in some university centres. Integrated health care is being oVered in many medical centres in the USA, whilst the National Institute of Health has a national centre for complementary and alternative medicine funding research in CAM [14]. Interest in CAM has led the American Academy of Otolaryngology Head and Neck Surgery to establish a committee on alternative medicine to serve as a resource for information regarding CAM practices, which relate to otolaryngology, and to make this information available to its members. Herbal medicine is a long established CAM/TM therapy. Some herbs have medicinal beneWts and the traditional approach is to use their active ingredients as a source for therapeutic medication. However, possible adverse side eVects and interaction of traditional herbal medicine with other medications has previously been shown [15]. Ginkgo
Eur Arch Otorhinolaryngol Table 3 Literature review Author
Head and neck patients surveyed (n)
Talmi et al. [19]
143
6.3
75
22.7
65
14
Molassiotis et al. [17] Shakeel et al. [18] Amin et al. [This study]
110
CAM users (%)
21.7
biloba, ginseng and garlic have anti-platelet eVects and may cause bleeding problems, thus emphasising that natural is not synonymous with safe, and there is a potential risk that a herbal remedy with no demonstrated eYcacy may compromise, delay or even replace an eVective form of conventional treatment [15]. Traditional herbal medicine has been given special attention by the European Union and a directive on traditional herbal medicine products was published in 2004 aiming to provide a framework for placing herbal medicine products on the market in the European community [16]. This directive has now been transported into Irish law. Until recently, research in the area of eYcacy and safety of CAM/TM therapies was questionable; in fact, research in this area could be described as non-existent or at best of poor quality. However, increased use of CAM/TM in the worldwide population has ignited the need for good quality research. In fact, the UK and USA have established funded research bodies, namely the Foundation for Integrated Health and the National Centre for Complementary and Alternative Medicine. These centres award research grants, aid in establishing centres of learning, share information and coordinate trials amongst themselves. However, given the small size of the Irish population, it is unlikely that large randomized control trials will be carried out here, but we are certain to beneWt from international trials and research. Our data in comparison to other studies Our survey data indicate a high rate (21.7%) of CAM/TM use in head and neck cancer patients in Ireland. Our Wndings and those of Molassiotis et al. [17], Shakeel et al. [18] and Talmi et al. [19] are illustrated in Table 3. Our Wgures are understandably lower than the mean rate of 36.4% in a larger European survey of CAM use in cancer patients in general [20] and is also lower than those published by Ernst [21] in a systematic review of 12 surveys on the use of CAM in patients with cancer where the prevalence of use ranged from 9 to 65%, whilst Bernstein and Grasso [22] reported that the prevalence of CAM use was as high as 80%. Our proWling data shows that women are 2.1 times more likely to use CAM/TM than men. Also, patients with higher levels of education are 2.4 times more likely to use CAM/
TM than those with just primary education; these Wgures are in accordance with Bernstein and Grasso [22] Richardson et al. [23], and Patterson et al. [24]. Although literature favours a higher incidence of CAM use in women, which may be attributed to the larger series conducted on breast cancer patients [17], it was surprising to Wnd that females are still more likely to use CAM in a head and neck sample where cancer is predominantly in the male population. The use of CAM/TM was more common in the age group ranging from 41 to 50 years and in people holding strong religious beliefs, although the latter Wnding was not found to be statistically signiWcant. CAM/TM was also more common in married than single patients. Friends, family and media were the main sources of information on CAM/TM, conWrming previous Wndings by Molassiotis et al. [17, 25] and Shen et al. [26]. This unregulated and word of mouth information is based on testimonials and old wives tales, which generally lack credible scientiWc evidence. How to address CAM/TM use with patients The need to educate ourselves on the variety of CAM/TM therapies available to patients cannot be overemphasised. As orthodox clinicians, we may Wnd it diYcult to openly discuss such therapies, but as patient advocates it is our role to provide knowledgeable non-biased advice on these modalities, whilst being mindful of patient’s choices and beliefs. On addressing CAM issues with patients, it is helpful to adopt the approach proposed by Weiger et al. [27] that CAM is no magic wand and is more for relieving associated symptoms than slowing cancer progression. CAM therapies can then be discussed with the patient on two fronts, those that may reasonably be accepted and those that should be discouraged and avoided. Eisenberg [28] also devised an approach for advising patients based on the importance of shared decision-making, patient documentation of symptoms and monitoring for adverse eVects of CAM. Health professionals should recognise that trivialising CAM merely denies them the chance to provide patients with accurate information to assist in making an informed decision [25]. It is likely that patients’ expectations of therapy were met as our data indicated that 74% of CAM/TM users believed that they obtained good value for money by achieving what they considered to be an increase in the body’s ability to Wght cancer and a subjective decrease in the side eVects of treatment. All CAM/TM users in this survey did so in conjunction with conventional treatment. Why do patients use CAM/TM? In many developed countries, increased use of CAM may be attributed to rising concerns about the adverse eVects of
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chemical drugs, questioning of the approaches and assumptions of conventional medicine, greater public access to health information and reduced tolerance to paternalism [29]. In a systematic review of 94 articles, Bishop et al. [30] concluded that there was evidence to suggest that CAM users were likely to have active coping styles, believe that psychological factors and lifestyle aVect their illness and hold a holistic, non-toxic, approach to health. Others suggested that push and pull factors [31] were behind the ever growing popularity of CAM. Push factor refers to patient dissatisfaction with some aspects of conventional medicine and the pull factor represents patients’ belief in mind–body connection, natural medicine and participation in treatment. Our survey did not investigate push and pull factors, although two participants cited delay in hospital appointments as their reason for using CAM/TM. This survey has identiWed oral and laryngeal cancer as the subgroup of head and neck cancer patients more likely to seek CAM/TM therapy, thereby enhancing the proWle of CAM users. This may be due to the fact that oral cancer represents 30% of all head and neck cancers and the overall 5-year survival rate for this disease remains at 50% and has not signiWcantly improved in the last two decades [32]. Also, laryngeal cancer is the second most common malignancy of the head and neck and loss of laryngeal function aVects speech, swallowing and some of the senses, which allow us to enjoy the world [33]. Thus, these patients face greater debilitation due to the anatomical nature of their disease. Future work should address this subgroup with a specially tailored questionnaire in an attempt to identify the CAM/TM therapy that is in particular use by this subgroup and the beneWt, if any, observed. Key Wndings in our study • It was surprising to Wnd that females were 2.1 times more likely to use CAM/TM than men in a head and neck sample where cancer was predominantly in the male population. • This survey has identiWed oral and laryngeal cancer as the subgroup of head and neck cancer patients more likely to seek CAM/TM therapy, thus adding to the proWle of CAM users. • In this study, 74% of patients reported that their expectations of CAM/TM were met, an important point to remember when discussing CAM/TM with patients. Strength and limitations of this study We believe that this survey is an accurate representation of the use of CAM/TM in head and neck cancer patients in Ireland, as it was conducted in the three main referral centres. No research is without limitations and this survey is no
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exception. The most apparent limitation of the current study is that the original survey was not tailored for head and neck cancer patients; instead, it was modiWed to cater to this particular group. Nevertheless, it is important to obtain an indication of the prevalence of CAM/TM use amongst these patients, so we can develop more suitable questionnaires for further studies. Another limitation of the survey in general was the constraint on the information gathered and this was imposed by the questionnaire itself.
Conclusion This survey reveals a high prevalence of CAM/TM use in head and neck cancer patients, thus emphasising the need for otolaryngologists to educate themselves on the various therapies available. Such information would enable us to openly discuss CAM/TM with patients, whilst providing informative advice regarding its use. There is an urgent need for evidence-based investigation of various CAM/TM therapies currently oVered to patients. This study is of relevance to head and neck surgeons and enhances our knowledge of the rising popularity of various therapies available to patients outside the realm of conventional medicine, here and elsewhere in the world. Acknowledgments We wish to acknowledge Dr. Elizabeth M. Swisher, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Washington University, St. Louis, Missouri for her kind permission to use her survey for the purpose of this study. We also wish to acknowledge Ms. Margaret McGrath, Head and Neck Oncology Liaison nurse, Mater Hospital, Dublin, for her assistance in coordinating the distribution and collection of the survey. ConXict of interest statement
None declared.
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