Cancer Impact,Complementary/Alternative Medicine Beliefs,and Quality of Life in Cancer Patients

Abstract

Objectives:

The purpose of this study was to explore the relationships among cancer impact, belief in complementary and alternative medicine (CAM), CAM use, and quality of life (QOL).

Design:

The study used a cross-sectional, descriptive correlational design with convenience sampling. A total of 122 cancer patients participated. Data were collected at a medical center in Chunghua, Taiwan. The questionnaires included the Chinese version of the Cancer Problem in Living Scale (CPILS), Complementary and Alternative Medicine Belief Inventory (CAMBI), Complementary and Alternative Medicine scale, and Chinese versions of QOL scales, including the Functional Assessment of Cancer Therapy-General (FACT-G).

Results:

The mean age was 56.5 years, and most participants were male (n = 69, 56.6%), had completed high school or above (n = 56, 45.9%), and were married (n = 109, 89.3%). The most common type of cancer was oral (n = 17, 13.9%), followed by esophageal (n = 15, 12.3%) and colorectal (n = 13, 10.7%). Cancer patients, on average, use one or two types of CAM. The impact of cancer is significantly related to age (F = 7.12, p < 0.05), and income is related to QOL (F = 3.61, p < 0.05). Pearson correlations showed that the use of CAM was positively associated with belief in CAM (CAMBI) (r = 0.26, p = 0.01), and the impact of cancer was highly negatively associated with QOL (r = −0.71, p = 0.001). The predictors of QOL were the impact of cancer and use of CAM, and the impact of cancer accounted for 51% of the variance in QOL.

Conclusion:

This study supports research on the impact of cancer, belief in CAM, and use of CAM as related to QOL in cancer patients. These results can be used to provide options to clinicians and cancer patients.

Introduction

Cancer is the leading cause of death worldwide, and 1,310 thousand people will die from cancer in 2030, according to World Health Organization (WHO) estimates.¹ In Taiwan, 46,095 people died from cancer in 2014, which is 28.3% of total deaths, as based on Ministry of Health and Welfare data.² Cancer diagnosis and treatment affect not only patients' physical health but also their emotional and social lives.³

In regard to the physical aspects, cancer patients undergo one or more of the following treatments: chemotherapy, surgical treatment, radiation treatment, and hormone therapy, which affect their physical status and results in fatigue, chronic pain, and sleep disorders.^4
–6 In regard to the emotional aspects, cancer patients become distressed once they receive a diagnosis.⁷ Furthermore, long-term cancer treatment can lead to changes in body image as well as emotional manifestations, such as anxiety and pessimism, as well as a loss of control when there is unexpected disease progression. In addition, the patients' role function can change if they lack a support system, and they can experience loneliness due to reduced interaction with others and a loss of self-confidence due to changes in self-worth. Finally, they might experience guilt over their inability to take care of their family. All of these emotions can result in a sense of hopelessness.^8

–14

Work performance in cancer patients suffers due to fatigue and a self-perception of weakness.¹⁵ Wu et al. also found that salary was affected by a cancer diagnosis, which results in cancer patients' concern about financial issues.¹⁵ Cancer patients also may need to miss work (and social activities) due to treatments.^16
–18

Cancer patients may seek alternative therapy to help them overcome their discomfort.^19,20 Esther et al. conducted a system review to disclose cancer patients' complementary and alternative medicine (CAM) use.²¹ This study reported that 11%–95% of cancer survivors use CAM and 20%–70% of these patients did not disclose their CAM use.²¹ According to National Institutes of Health (NIH), CAM includes five categories: (1) an alternative medical system that includes homeopathy, naturopathy, Ayurveda, and traditional Oriental/Chinese medicine; (2) mind–body interventions, such as meditation; (3) biological-based treatments, such as herbal medicine or nutritional supplements; (4) manipulative and body-based methods, such as touch therapies or chiropractic treatment; and (5) energy therapies, which involve a belief in energy balance.^19
–21

Quality of life (QOL) has received increasing attention in the past three decades and has found to be a strong predictor of survival.^22,23 The concept of QOL in cancer patients encompasses five aspects: (1) biological or physiological: assessment of body functioning, such as blood sugar, blood pressure, and other objective parameters; (2) symptoms: patients' subjective perceptions of physical changes from the disease or treatment, such as a toxic response to a certain medication: (3) functioning: competency in performing specific tasks or roles, such as a social role function, which can be assessed by patients themselves, healthcare providers, or primary care providers; (4) general health perception: global perception of patients' health condition, including symptoms or functional impairments that patients experience; and (5) overall QOL: measurements of life satisfaction that are not directly related to health, but to financial status, employment status, family situation, and environment.^22,23

QOL is an important outcome indicator among cancer patients, and cancer impact and CAM belief and use potentially influence QOL.^{6,11,12,19

–23} As such, the purpose of this study was to explore the relationships among cancer impact, CAM belief, CAM use, and QOL. Predictors of QOL in cancer patients also are identified.

Materials and Methods

The study used a cross-sectional, descriptive correlational design with convenience sampling. A total of 122 cancer patients participated in the study. Data were collected at the oncology outpatient clinic in a medical center in Chunghua, Taiwan. After gaining Institutional Review Board approval and agreement from patients, the researcher conducted the study from August 2014 to March 2015. We recruited the participants in person and explained that they can withdraw anytime without any consequence after gain agreement from their primary physicians.

Patient inclusion criteria were as follows: (1) diagnosed with cancer, (2) age 20 years and older, (3) clear consciousness, (4) able to communicate in Mandarin or Taiwanese, and (5) having been treated for at least 6 months. Patients who had psychiatric problems or who were not notified of the diagnosis of cancer were excluded.

Data were analyzed by IBM SPSS 22.0 software. Descriptive analysis was used to present the demographic data and to determine the mean score of cancer impact, CAM belief, CAM use, and QOL. Pearson's correlations were used to examine the relationships among the main variables. Finally, multiple regression was used to identify the predictors of QOL.

Measures

Cancer Problem in Living Scale

This instrument is used to measure cancer impact and identify the problems associated with cancer. Cancer Problem in Living Scale (CPILS) includes 29 statements that identify problems that cancer survivors are likely to experience and include four areas: physical distress, mental distress, employee/financial status, and worry about disease recurrence. For each problem statement, the responses are phrased in terms of three levels of severity (0 = not a problem for me, 1 = somewhat a problem for me, and 2 = a severe problem for me).²⁴ Cronbach's αs range from 0.78 to 0.97 with overall good internal reliability.²⁵

Complementary and Alternative Medicine Belief Inventory

This scale is used to measure beliefs about CAM. The Complementary and Alternative Medicine Belief Inventory (CAMBI) is a 20-item instrument that includes three domains: the perceived value of natural treatments, preferences for participation in treatment, and orientation toward holistic health. Items are addressed on a 7-point Likert scale: 1 = strongly disagree, 4 = neither agree nor disagree, and 7 = strongly agree. Cronbach's αs were 0.75, 0.68, and 0.73, respectively, for the three domains, and modest-to-moderate intercorrelations among summary measures of the three domains (rs ranged from 0.18 to 0.47) were reported. Items 9, 11, 14, 17, and 19 were reverse scored.²⁶

Complementary and Alternative Medicine Scale

This scale, developed by Wang and Chung, is used to measure the use of CAM.²⁷ This scale includes 38 questions focused on the types of CAM that patients use and the frequency of use. It was used first for breast cancer patients, for whom the Cronbach's α was 0.88. Participants are asked to indicate the frequency of CAM use.²⁷ The items are addressed on a 5-point scale: 1 = never or very few times (annually or once in a few years), 2 = not often (once in a few weeks), 3 = sometimes (once a week), 4 = often (one to two times a week), and 5 = always (five times or above per week). Scores range from 38 to 190, with higher scores' indicating more frequent use of CAM.²⁷

Functional Assessment of Chronic Illness Therapy

Functional Assessment of Chronic Illness Therapy (FACIT) is used to measure QOL in patients with any type of cancer or chronic disease, such as HIV, multiple sclerosis, or Parkinson's, as well as in the general population. A scale that is part of the FACIT measurement system, the Functional Assessment of Cancer Therapy-General (FACT-G), Version 4, has 27 general questions, categorized into four subscales: Physical Well-Being (PWB), Social/Family Well-Being (SWB), Emotional Well-Being (EWB), and Functional Well-Being (FWB). Items are addressed on a 6-point Likert scale, ranging from 0 to 5, for which 0 = not at all and 5 = very much, in regard to the severity of participants' condition. The total FACT-G score is obtained by summing individual subscale scores (PWB+SWB+EWB+FWB), yielding a range of 0 to 108, with higher scores' indicating better QOL.^28

–31 This instrument has been widely used clinically, and the average Cronbach's α is 0.89.

Results

As seen in Table 1, all four instruments have good reliability, which ranges from 0.706 to 0.972.

Table 1.

Reliability

Instrument	n	Cronbach's α
CPILS	31	0.927
CAMBI	17	0.706
CAM	38	0.812
FACT-G	27	0.895

CAM, complementary and alternative medicine; CAMBI, Complementary and Alternative Medicine Beliefs Inventory; CPILS, Cancer Problem in Living Scale; FACT-G, Functional Assessment of Cancer Therapy-General.

Table 2 presents the demographic data. The mean age was 56.5 years, and over half of the participants were male (56.6%). A variety of cancers were seen in the patients (Table 3).

Table 2.

Demographics (N = 122)

Variable	n (%)
Gender
Male	69 (56.6)
Female	53 (43.4)
Age
20–35	5 (4.1)
36–50	28 (23.0)
51–65	68 (55.7)
66 and over	21 (17.2)
M ± SD	56.5 ± 11.12
Education
None	11 (9.0)
Junior high school	55 (45.1)
High school or above	56 (45.9)
Religion
No	17 (13.9)
Yes	105 (86.1)
Employment status
Unemployed	26 (21.3)
Employed	96 (78.7)
Marital status
Single/divorced/widowed	13 (10.7)
Married	109 (89.3)
Salary
$0 USD	5 (4.1)
$1–$1.000 USD	70 (57.4)
$1.001–$2.300 USD	33 (27.0)
Above $2.301 USD	14 (11.5)

Table 3.

Cancer Distribution (N = 122)

Type	n (%)	Rank
Oral	17 (13.9)	1
Esophageal	15 (12.3)	2
Colon	13 (10.7)	3
Lung	12 (9.8)	4
Nasopharyngeal	12 (9.8)	5
Breast	7 (5.7)	5
Leukemia	7 (5.7)	7
Gastric	5 (4.1)	8
Ovarian	5 (4.1)	9
Liver	4 (3.3)	10
Hypopharyngeal	4 (3.3)	11
Cervical	3 (2.5)	12
Lymphoma	3 (2.5)	13
Pancreatic	3 (2.5)	14
Rhabdomyosarcoma	3 (2.5)	15
Tongue	2 (1.6)	16
Anal	2 (1.6)	17
Multiple myeloma	1 (0.8)	18
Lipoma	1 (0.8)	19
Fallopian tube	1 (0.8)	20
Uterine fibroma	1 (0.8)	21
Salivary gland	1 (0.8)	22

Table 4 showed the descriptive information of cancer impact, CAM belief, and QOL. The CPILS indicated that the top three problems that affected patients were fatigue/loss of energy, sleep disturbance, and concern about recurrence. Among four subscales embraced, physical distress, emotional distress, employment/financial issues, and worry about disease recurrence, emotional distress had the highest score. In regard to CAM beliefs, the mean score was 83.56 (SD = 10.70), which indicated that participants held positive CAM beliefs. The highest score, which indicates the strongest belief, which is the perceived value of natural treatments. For the FACT-G, the mean score was 78.36 (SD = 16.49), which indicated moderate-to-high QOL among participants. The rank order, from high-to-low, of the four subscales was PWB, SWB, EWB, and FWB. The most cited QOL statement was, “I feel hopeless to overcome my disease.”

Table 4.

Descriptive Data of Cancer Impact, Complementary and Alternative Medicine Belief, and Quality of Life

	Range	Mean	SD
Cancer impact	0–43	11.61	9.61
Physical distress	0–10	3.43	2.41
Mental distress	0–18	4.23	3.99
Employee/financial status	0–10	1.49	2.35
Worry about disease recurrence	0–11	2.47	2.78
CAM belief	42–109	83.56	10.70
Perceived value of natural therapy	6–24	33.64	6.82
Preference of participation in Tx	9–30	21.41	3.48
Orientation toward holistic health	18–40	28.51	4.59
Quality of life	32–106	78.36	16.49
Physical well-being	3–28	20.39	6.39
Social/family well-being	2–28	20.97	5.73
Emotion well-being	6–24	18.69	4.09
Function well-being	3–28	18.32	5.81

Tx, treatment.

In regard to CAM use, the range score was 38–89, which indicates that the frequency of CAM use was moderate-to-low. The most frequent CAM use involved praying, music therapy, and gardening therapy.

Table 5 presents the relationships among cancer impact, CAM belief, CAM use, and QOL. QOL was negatively associated with cancer impact and positively associated with CAM use. In addition, CAM use was positively associated with CAM beliefs.

Table 5.

Relationships Between Cancer Impact, Complementary and Alternative Medicine Belief, Complementary and Alternative Medicine Use, and Quality of Life (N = 122)

	Cancer impact	CAM belief	CAM use	QOL
Cancer impact	1
CAM belief	0.04	1
CAM use	−0.12	0.26^*	1
QOL	−0.71^*	0.10	0.21^*	1

p < 0.05.

The results in Table 6 demonstrate that cancer impact accounts for 51% of better QOL. In addition, cancer impact and CAM use together account for 52% of better QOL.

Table 6.

Predictors of Quality of Life (N = 122)

	Unstandardized		Standardized
Model	B	Error	β	R²	Adj. R²	F
1	−1.23	0.11	−0.71	0.51	0.51	0.000
2	0.21	0.10	0.13	0.53	0.52	0.040

Model 1: Cancer impact. Model 2: Cancer impact, CAM use.

Discussion

According to statistical data of the Health Promotion Administration of Taiwan, in 2012, males accounted for 55.4% of the cancer population, which is similar to the results in our study (55.6%). Data from 2007 indicate that the majority of cancer patients are 65 years or older.² In our study, however, the majority of cancer patients were between 55 and 59 years old. In our study, the mean age of cancer patients was 56.5, which is in keeping with data from the Taiwanese government. Overall, the demographic findings in our study were similar to those of the Health Promotion Administration.

Cancer patients experience a variety of symptoms, including acute/chronic pain, loss of appetite, nausea/vomiting, sleep disturbance, and fatigue.^32,33 Baró et al. reported that fatigue is the most often-cited problem, which is consistent with the results of our study.³⁴ We also found that concern about recurrence is one of the top three cancer impacts, which previous studies did not report as a major concern.³⁴ This might be due to the use different patient populations, and future investigation is needed to clarify this different finding.³⁴

CAM beliefs are similar between our study and previous studies from the West.^35,36 Hirai et al. found that cancer patients use CAM to relieve physical symptoms, indicating a positive believe about CAM.³⁵ In addition, previous studies found that cancer patients wanted to achieve a balance among the physical, mental and spiritual, which is in keeping with the results of our study that cancer patients believe the perceived value of natural treatments.³⁶

Previous research indicates that 40% of cancer patients use CAM.^37,38 In Taiwan, Chang et al. reported that about 30% of the general population uses CAM for musculoskeletal and respiratory problems.³⁹ Chang et al. found that Chinese herbs account for 25.4% of CAM use, while, in our study, praying was the most frequent use of CAM.³⁹ It may be that cancer patients might worry about Chinese herbs interacting with Western treatments. Many Western studies also show that praying is the most frequent use of CAM.⁴⁰

Patients who suffer from cancer impacts seek CAM to reduce the discomfort and promote better physical and mental health.^41

–45 As expected, we found that cancer impact and CAM use are predictors of better QOL. We validated the relationships among cancer impact, CAM use, and QOL. The findings from this study contribute to our understanding of cancer impact and CAM use on QOL.

There are several limitations of this study. First, the participants were from one medical center in the middle of Taiwan with convenient sampling and might not be able to represent the entire cancer population. A potential selection bias may exist, which may result in further bias in data interpretation. Second, there were 21 kinds of cancer represented in our study, and each type of cancer had different number of participants. Notably, the cancer type might affect the study results. In addition, we used a cross-sectional design, and changes in QOL over time could not be examined.

Conclusions

The results indicated that the level of cancer impact was moderate-to-low and that emotional distress had the highest impact. CAM belief was positive, and the frequency of CAM use was moderate-to-low. The average QOL in our study was moderate-to-high. In regard to QOL, “I feel hopeless to overcome my disease” (emotional well-being) was the most endorsed item, which draws attention to emotional well-being as very important to QOL. The healthcare provider can use these findings to identify the factors that influence patients' outcome. In addition, the results can increase the clinicians' knowledge about CAM belief and CAM use in cancer patients as well as cancer impact and CAM use are predictors of better quality of life among cancer patients.

Footnotes

Acknowledgment

I would like to show my deep appreciation to all the participants and Changhua Christian Hospital.

Author Disclosure Statement

No competing financial interests exist.

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