Use of Complementary and Alternative Medicine by Patients with Cancer in Saudi Arabia

Abstract

Background:

The use of complementary and alternative medicine (CAM) is common among patients with cancer. However, the issue is not well-studied among the Saudi patient population. Our study aimed at determining the patterns of CAM use among patients with cancer in Saudi Arabia.

Methods:

A cross-sectional study using interview-administered questionnaire was conducted in patients with cancer in the Oncology Department of King Abdulaziz Medical City for National Guards, Riyadh, Kingdom of Saudi Arabia. Patients were asked about CAM use including dietary supplement (DS) and non-DS remedies. Univariate and multivariate analyses were conducted to identify predicting factors for CAM use.

Results:

A total of 453 adult patients were enrolled in the study, with a median age of 53.5 years (14.7–94.6), and the ratio of females to males was 271/182 (59.8%/40.2%). Of those, 410 patients (90.5%) used some type of CAM remedy. Non-DS remedies were used by 399 patients (88%) and were mainly of a religious nature including reciting the Quran (74.8%), prayer (16%), supplication (13%), and others (3.7%). However, 386 patients (85.2%) used DS including: Zamzam water (59.8%), honey (54.3%), black seed (35.1%), water with the Quran recited over it (29.8%), and other remedies. The majority of patients (90%) used CAM as a cancer treatment and the rest used it for various reasons, such as symptom control or supportive treatment. Only 18% of the patients discussed CAM use with their physicians, compared to 68% discussing it with religious clergypeople (Sheikhs).The univariate analysis revealed that only female gender is a predictor of CAM use, which remained significant in a multivariate analysis, in addition to current employment.

Conclusions:

The use of complementary therapies among Saudi patients with cancer is highly prevalent, with a predominance of interventions of religious background, indicating the strong influence of religion on peoples' lives, especially when people are faced with life-threatening illnesses.

Introduction

T he use of complementary and alternative medicine (CAM) is common among healthy people as well as among patients with various medical problems—especially in patients with life-threatening diseases, such as cancer.^1
–3 However, little is known about the safety, efficacy, mechanisms of action, and cost-effectiveness of most CAM therapies.⁴ Use of CAM by patients with cancer has been reported exhaustively, especially among Western or Far Eastern populations. Although there are few reports from the Kingdom of Saudi Arabia about the use of CAM among the general population and among patients with various illnesses, the use of CAM in patients with cancer has not been not well-described or studied.^5

–10 Given that cancer is a major health problem, it is imperative that more research be conducted on CAM use in patients with cancer to determine the prevalence of this use and the potential risk–benefit of such therapies. Studying CAM use in the Saudi population is important, as it will reflect the impact of psychosocial, cultural, and religious influence on health behaviors. Because of influence of their faith, Muslims believe that whatever goes on in their lives is under the full control of Allah (God), including their health and illnesses. Although Muslims may have different views about the causes of their diseases—including scientific and cultural causes—all Muslims believe that health and illness are under Allah's divine will. Most importantly, Muslims believe that cures will not be attained in any fashion but through Allah's divine will.^11,12

Therefore, this belief can be expected to affect the approach of these patients in seeking help for cures. This fact is evident during patients' visits and discussions, during which the statement “God's Willing” is repeated carefully and meticulously when discussing treatment or expected outcome of any intervention. The same statement is used for anything related to future events.

Therefore, determining the prevalence and type of CAM use in Saudis is important because of the social, cultural, and religious characteristics of this population.

The aim of this study was to determine the patterns of CAM use among patients with cancer in the Kingdom of Saudi Arabia.

Patients and Methods

This was a cross-sectional descriptive study, which was conducted in the Oncology department at King Abdulaziz Medical City for National Guards, Riyadh, Kingdom of Saudi Arabia. Institutional review board approval was obtained. This study aimed at determining the use of CAM in patients with cancer, as well as examining the relationships between CAM use and specific characteristics of interest, including demographic and disease variables, in this population at the time of survey administration.

Inclusion criteria allowed enrollment of any patient with a diagnosis of cancer, who was willing to participate in the study.

The questionnaire was administered by a clinical research coordinator to participants in oncology clinics, after explaining what the study was about and obtaining the patient consent.

The survey was translated into Arabic and modified from questionnaires used in similar studies in the United States.¹³

As the Arabic version of the survey was used for the first time, evaluation of its applicability to the Saudi participant population was assessed in the first 20 participants. The survey was modified to clarify any ambiguity and address any concerns raised by participants or the research coordinator.

Data were entered into a database using Microsoft Access software. Data was verified by a second person for accuracy.

Variables and survey components

The survey contains questions to capture descriptive data regarding the use of CAM. Participants who forgot the name, doses, or ingredients of their CAM supplements were asked for permission to call them at home to obtain missing information. This survey included questions about the following issues:

Demographic Information—age, gender, marital status, educational level, employment status, and annual income

Disease profile—diagnosis, stage and extent of disease, and treatment received

Use of CAM—name of product, start date, reasons for use, source of supplement, dosage/frequency, and cost.

Communication with physicians and clergypeople—regarding CAM and the patient's perception of physician's reaction.

The questionnaire was written in a simple fashion, and a research coordinator administered the survey in to ensure that participants were able to complete the survey without any difficulties and to ensure consistency.

CAM was divided into dietary supplement (DS) and non–dietary supplement (non-DS) categories. DS was defined as any substance that a patient ingests that is not a nutritional substitute.

Statistical methods

All enrolled patients' data were used for analysis. Descriptive statistics were analyzed for all variables. Prevalence and type of CAM used were calculated for each of the demographic and clinical categories.

The chi-square test was used to compare use of CAM with each of the following patient characteristics: gender; marital status; nationality; employment; education level; type of malignancy; cancer stage at diagnosis; and type of treatment.

The association between use of CAM and continuous patient characteristics (age, body mass index, and time since cancer diagnosis) was examined using Student's t-test.

Step-wise multiple logistic regression analyses were carried out to identify predictors of CAM use (DS or non-DS). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A p-value<0.05 was considered to indicate statistical significance. Statistical Analysis Software (SAS) was used for data management and analyses.

Results

Between September 2006 and October 2008 a total of 453 patients participated in this study, including 271 females (59.8%) and 182 (40.2%) males, with a median age of 53.5 years (14.7–94.6). The patients' characteristics are summarized in Table 1. The patients had various malignant diseases in different stages with gastrointestinal cancer, breast cancer, lymphoma, and leukemia being the most common malignancies.

Table 1.

Participants' Characteristics (N=453)

Characteristics		n (%)
Gender	Female	271 (59.8%)
	Male	182 (40.2%)
Age (yrs), median (range)		53.1 (14.7–94.6)
Time since cancer diagnosis, median (range)		0.4 (0.1–19.0)
Marital status	Married	330 (74.0%)
	Single/divorced/widowed/separated	116 (26.0%)
Nationality	Saudi	426 (94.0%)
	Non-Saudi	27 (6.0%)
BMI, median (range)		26.2 (14.0–76.5)
Level of education	Uneducated	185 (41.7%)
	Elementary/middle school	122 (27.5%)
	High school	64 (14.4%)
	Diploma/University	73 (16.4%)
Employment	Part-time	68 (17.0%)
	Full-time	10 (2.5%)
	Unemployed	322 (80.5%)
Type of malignancy	Gastrointestinal	128 (28.3%)
	Lymphoma/Leukemias	119 (26.3%)
	Breast	105 (23.2%)
	Genitourinary	62 (13.7%)
	Lung	18 (4.0%)
	Other	21 (4.6%)
Stage of cancer	Metastatic	201 (46.3%)
	Limited to organ	151 (34.8%)
	Regional	82 (18.9%)

yrs, years; BMI, body mass index.

The majority of patients (410; 90.5%) used some type of CAM remedy, including DS and non-DS remedies. The following sections offer details of these findings.

Non–dietary supplement use

The results of the 399 patients (88%) who used non-DS remedies are presented in Table 2. Most of the patients recited the Quran (74.8%), followed by prayer (16.1%), supplication (12.6%), and other remedies (3%). In a univariate analysis, gender and age were associated with the use of non-DS; however, multiple regression analysis revealed that female gender and current employment were the only predictors of their use (Tables 3 and 4).

Table 2.

Type and Frequency of CAM Use

Variables	# of patients n (%)
Total CAM users (DS & Non-DS)	410 (90.5%)
Total DS users	386 (85.2%)
Type of DS used
Zamzam water	271 (59.8%)
Honey (Hel Millis)	246 (54.3%)
Black seed (Nigella Sativa)	159 (35.1%)
Olive Oil (Olea Europaea)	156 (34.4%)
Quran read over water	135 (29.8%)
Herbs	66 (14.6%)
Milk (Lacteus)	54 (11.9%)
Myrrh (Commiphora Myrrha)	42 (9.3%)
Urine of Arabian Camel	39 (8.6%)
Garlic (Allium Sativum)	38 (8.4%)
Sedar (Frangula Alnus)	21 (4.6%)
Safron (Crocus Sativus)	15 (3.3%)
Helteet (Ferula Assafodida)	14 (3.1%)
Hulbah (Trigonella Foenum-Graceum)	9 (2.0%)
Vitamin	8 (1.8%)
Other (different kinds of herbs)	29 (6.4%)
Monthly cost (SR), median (range)	280.0 (0–7000)
Total DS users	377 (83.2%)
Type of Non-DS used
Holy Quran	339 (74.8%)
Supplication	57 (12.6%)
Prayer	73 (16.1%)
Other (cupping, massage, acupuncture, etc.)	12 (2.7%)
Monthly cost (SAR), median (range)	300.0 (0–25000)

CAM, complementary and alternative medicine; DS, dietary supplement; SAR, Saudi Riyals ($1 USD=3.75 SAR).

Table 3.

Association Between Use of DS and Non-DS by Demographic and Clinical Factors

Use of DS		Yes n (%)	No n (%)	p-Value
Gender	Male	145 (37.6%)	37 (55.2%)	0.0065
	Female	241 (62.4%)	30 (44.8%)
Age (yrs), mean (SD)		52.6 (16.6)	56.0 (18.1)	0.13

Use of Non-DS		Yes n (%)	No n (%)	p-Value
Gender	Male	141 (37.4%)	41 (54.0%)	0.0073
	Female	236 (62.6%)	35 (46.1%)
Age (yrs), mean (SD)		52.0 (17.0)	58.7 (15.1)	0.0015

The univariate analysis revealed that gender was the only predictor for use of DS and non-DS. All other variables were not significant. A t-test analysis revealed that age was the only significant factors for using non-DS.

DS, dietary supplement; yrs, years; SD, standard deviation.

Table 4.

Multivariate Logistic Regression Analysis for the Use of CAM (DS and Non-DS)

Characteristics		Odds ratio	95% CI	p-Value
DS	Female gender	2.05	1.09–3.86	0.03
	Currently working	2.30	1.01–5.22	0.05
Non-DS	Female Gender	2.60	1.38–4.90	0.0030
	Currently working	3.00	1.26–7.14	0.01
Honey	Educational level	1.23	0.99–1.54	0.06
Black seed	Currently working	1.76	1.06–2.92	0.03
Zamzam water	Age at diagnosis	0.99	0.97–1.00	0.04
	Surgery	0.61	0.39–0.97	0.04
Oil	Age at diagnosis	0.97	0.96–0.99	0.0002
	Non-Saudi	0.08	0.01–0.57	0.01
Quran read over water	Female gender	1.60	0.95–2.70	0.08
	Non-Saudi	0.26	0.08–0.93	0.04
	Surgery	1.90	1.13–3.17	0.01
Quran	Age diagnosis	0.99	0.97–1.00	0.08
	Female gender	1.68	0.95–2.98	0.08
	Non-Saudi	0.30	0.11–0.77	0.01
	Currently working	2.68	1.28–5.62	0.0090
	Hormonal	0.38	0.14–1.04	0.06
Supplication	Stage	0.63	0.43–0.93	0.02
Prayer	Female gender	1.97	0.97–4.02	0.06
	Non-Saudi	3.15	1.17–8.46	0.02
	Currently working	0.43	0.18–1.03	0.06
Milk	Female gender	0.26	0.13–0.54	0.0003
	Time since cancer diagnosis	1.13	0.99–1.30	0.07
	BMI	1.05	0.99–1.10	0.09
Camel urine	Female gender	0.23	0.10–0.55	0.0008

CAM, complementary and alternative medicine; DS, dietary supplement; CI, confidence interval; BMI, body mass index.

Dietary supplement use

Another group, consisting of 386 patients (85.2%), used different types of DS remedies. Drinking Zamzam water was the most common type of DS used (59.8%), followed by honey (54.3%), black seeds (35.1%), oil (34.4%), water with the Quran recited over it (29.8%), in addition to other products. Zamzam water is water that flows from a spring near Kaaba in the Holy Mosque in Mecca and considered to be blessed by Muslims. Some Muslims believe that reciting the Quran over the drinking water may transfer healing power to the water.

Multivariate analysis revealed that female gender and current employment were the only predictors of DS use.

Reasons for use and perceived benefit

The majority of patients (90%) used CAM as a type of treatment for cancer. Other reasons for use were to improve immunity and to improve appetite (information not presented).

Sources of CAM and costs

CAM therapy costs were, on average, 300 SAR (0-25000) for non-DS remedies. The average cost of DS remedies was 290 SAR (0-7000). Note: $1 USD=3.75 SAR.

Discussions with physicians and clergypeople

Only 80 patients (18%) informed their physicians about the use of CAM. Physician response was perceived as supportive by 35.7% of patients, negative by 34.7%, and neutral by 30.7%.

There were 279 patients (67.7%) who informed or consulted a clergyperson about the use of CAM.

Discussion

The current study represents the first study addressing the use of CAM among patients with cancer in the Kingdom of Saudi Arabia.

The reported prevalence of CAM use among patients with cancer varies widely.^14,15 In a survey of 13 countries by Ernst and Cassilieth, the prevalence of CAM use was 31.4% (7%–64%).¹⁶ The prevalence of CAM use in the Saudi patient population is one of the highest reported in the literature.

It is very intriguing to notice that almost all CAM remedies used have religious elements incorporated into them, including both DS and non-DS remedies.

Use of such remedies reflects the importance of religion in the lives of the Saudi patient population. The use of spiritual support has been described in different populations including other Muslim groups,^17,18 but the rate appears to be much higher in the Saudi patient population.

The low reporting rate of CAM use to physicians is well-known and has many contributing factors, including the belief that physicians may not be interested in this information nor supportive of the idea, or for other reasons.^19
–21

The impact of religion is also notable by the higher percentage of patients who discussed the use of CAM with clergypeople, compared to patients who disclosed this information to physicians. Clergypeople comprise a predominant component of traditional healers who are not unique to Saudi culture, as this is a well-known phenomenon in many societies. Traditional healers in Saudi Arabia include a spectrum of individuals with different educational and social backgrounds. They include religious scholars and clergypersons, as well as laypersons with no formal education. The healers provide various services, including counseling and advice; spiritual support; reciting the Quran; supplications to the patient directly or to foods or drinks that patient consumes, such as honey or water; prescribing herbs and supplements with the Quran recited on them; prescribing traditional herbs; cupping; and cauterization.²²

The overwhelming common factor among traditional healers is the use of faith and religion as base for intervention in pursuit of healing. There are sayings of the Prophet Mohammed (peace be upon him) about using the Quran, Zamzam water, honey, and black seed as healing agents.²³

These services are different than the psychologist interventions in conventional biomedicine, as psychology is used to mainly provide emotional support to the patient, while religious interventions are directed toward healing of the disease. However, although patients may attain emotional strength and support from psychology. Unfortunately, most traditional healers work in isolation from the conventional medical system, and there are rare communications between the two groups, although religious affairs services exist in many hospitals and function in a way similar to chaplain services in the U.S. hospitals. These staff may offer religious counseling, recite the Quran, or perform supplications, but, usually, they do not give DS.

Our patients share with other patients' populations the same skepticism, doubts, or dissatisfaction with mainstream medicine, leading them to seek help outside the conventional health care system. The firm belief that only Allah holds a cure for any ailment makes Saudi patients seek faith-based remedies for cure, not just for comfort and support.

The finding that females are more likely to use CAM is also consistent with other reports in which females were more likely to use these remedies.²⁴

The perceptions of patients about self and disease may be different between men and women, and the responses and coping mechanisms may also vary, which may explain, at least in part, the reasons why more females use CAM. ²⁵ The spirituality and faith perception differences between males and females deserve further evaluation in future studies.

Use of CAM is not risk-free, as some remedies can interact with cancer therapies or other medications, or some CAMs may have their own inherent risks, including toxic effects or development of infectious. Of 247 samples of herbal remedies used in the Kingdom of Saudi Arabia that were analyzed, more than 30% were found to have heavy-metal contents, bacterial contamination, or toxic organic substances.²⁶

This raises major concerns about the use of these remedies, which are usually not regulated the same way all over the world.

Another health risk that requires further study is delaying definitive treatment that may be curative, to pursue CAM treatment that can be detrimental to a patient's health. Unfortunately, this phenomenon is encountered in the current authors' practices sporadically and requires further evaluation and proper educational intervention.

Conclusions

This study revealed a very high prevalence of CAM use among patients with cancer in the Kingdom of Saudi Arabia. The religious and spiritual nature of these CAM was very predominant.

Further research is required to understand the reasons for use and the potential risks and benefits of these remedies.²⁷ It is imperative that physicians inquire about the use of CAM and provide counseling as appropriate.²⁸

Footnotes

Disclosure Statement

No financial conflicts exist.

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