Patterns of Complementary and Alternative Medicine Use among Turkish Cancer Patients

Abstract

Background:

The aim of this study was to determine the tendency to use complementary/alternative medicine (CAM) by patients with cancer in Turkey, and to compare sociodemographic and medical characteristics, perceptions, and quality of life of users and nonusers of CAM.

Methods:

A total of 1060 cancer patients were asked to complete a questionnaire about the use of CAM along with the European Organization for Research and Treatment of Cancer Life Quality Questionnaire C30 (EORTC QLQ-C30). Medical information was obtained from hospital chart records.

Results:

The response rate was 40.1% (425/1060). Use of at least one kind of CAM was identified in 57.4% of the patients. Herbal medications (95%), spiritual/religious affiliations (23.3%), multivitamins/antioxidants (18.4%), and transcendental meditation/yoga (8.6%) were the leading CAM methods. In multivariate analysis, CAM use was found to be associated with age (>60 years) only. Average expenditure on CAMs was 30 U.S. dollars (USD) per patient per month. The most common causes of CAM use were belief in their efficacy (41.3%) and intimate interaction with CAM users (37.2%). Only 41% of the users had informed their doctors that they used CAM. QLQ scores were similar between CAM users and nonusers. Of all participants, 15.5% had psychiatric support. Proportions of regular antidepressant and analgesic use were 16.4%, and 46.3%, respectively. CAM users had worse appetite scores. There was no difference in terms of other scales between the groups.

Conclusions:

This study showed that CAM use is widespread among Turkish cancer patients and CAM use does not improve QLQ scores. Physicians should be aware of high CAM utilization rate in patients with cancer and should better understand the factors directing the patients to such treatments.

Introduction

Complementary/alternative medicine (CAM) has been defined as any cancer treatment modality that is not regarded as biomedical. Notably, complementary medicine refers to practices that augment the action of conventional therapies, whereas alternative medicine refers to unconventional approaches that are intended to prevent, treat, or palliate a disease.¹

Being particularly effective among cancer patients, the worldwide popularity of CAM methods is increasing.² In many cases, CAM is being used as a complementary treatment and is not meant to replace conventional treatments.^3–5 A total of 26 surveys from 13 countries were retrieved; the use of CAM therapies in adult populations ranged from 7% to 64%, and the average prevalence was 31.4%.² As the incidence of cancer and survival periods increase, the population will likely require greater access to CAM.

CAM utilization varies according to the geographic location, ethnicity, educational level, socioeconomic factors, and religious beliefs in a country.^2,6,7 Patients use various herbal mixtures, vitamins, antioxidants, yoga, meditation, bioenergy, acupuncture, aromatherapy, and religious applications. Few of these modalities have been rigorously tested,⁸ but most remain unproven despite popular use.⁹

Because patients with cancer face a condition that is scarier and less controllable than other chronic and life-threatening diseases, they have been indicated to be more open to CAM utilization to increase their survival chance.¹⁰ In this respect, patients with advanced disease tend to use CAM application, for disease control, cure, increased survival, improved quality of life, and/or alleviation of symptoms, particularly if conventional treatments are unsuccessful.^11–13 It is, therefore, important for the medical community to understand the factors motivating patients to pursue CAM utilization.

Oncologists have only gradually acknowledged the utilization of CAM among their patients, although a few of them discuss these treatments with them.¹⁴ There has been concern that patients with cancer will withdraw potentially curative conventional therapies in favor of unproven methods.⁹ Other concerns include toxicities associated with nonconventional therapies for cancer¹⁵ or possible interactions with the chemotherapy.

The aims of this study were to determine the tendency to use CAM by patients with cancer in Turkey, and to compare sociodemographic and medical characteristics, perceptions, and quality of life of users and nonusers of CAM.

Methods

Participants

Patients who were diagnosed with cancer for at least 2 months and were being followed in the medical wards and the outpatient clinics at the Department of Medical Oncology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey, were consecutively included in the study between March 2005 and April 2007. All patients were at least 18 years old. The study protocol was approved by the local ethics review committee.

Patients were informed about the study and the questionnaire. They were told that they could quit the study at any time by refusing to complete forms or requesting that their questionnaires not be used for the final analysis. After providing written informed consent, they were asked to complete the CAM questionnaire.

Definition of CAM

We used the 2002 definition by the National Center for Complementary and Alternative Medicine or The Cochrane Complementary Medicine Field. According to that definition, the CAM therapies often have been classified into broad categories: (1) biologically based therapies: natural products, dietary supplements, including vegetarian, vegan, probiotics, vitamins, minerals, laetrile, shark or bovine cartilage, and other herbal medicine; (2) manipulative and body-based methods: movement and physical therapy, including exercise, yoga, chiropractic or osteopathic manipulation, and massage; (3) mind-body interventions: including chiropractic or osteopathic manipulation, imagery or visualization, hypnosis, meditation, journaling, music therapy, psychotherapy with a social worker, psychologist, psychiatrist, or support group, spiritual practices, including prayer for self and prayer/spiritual healing by others; (4) alternative medical systems: including homeopathic and naturopathic medicine, Ayurveda, acupuncture, and traditional Chinese folk remedies; and (5) energy therapies: including tai chi or qi gong, Reiki, biofeedback, energy healing or therapeutic touch, and bioelectromagnetic therapy.¹

Questionnaire

Through the questionnaire the following information was collected: sociodemographic data (age, gender, education level, job, place of birth, place of residence, condition of health coverage, actual working status, mode of transportation to hospital), medical history (diagnosis of the disease, date of diagnosis, stage at diagnosis, current stage, accompanying diseases, past and current treatment modalities, family history of cancer), awareness of the cancer diagnosis, any history of CAM utilization after the diagnosis of cancer and within 3 months prior to the study, CAM utilization method and dose/application frequency (if any), financial expenditure on CAM, relevant information resources, beliefs and expectations regarding CAM, reasons leading to CAM use, physician awareness of current CAM use, discussion of CAM use with the physician, utilization and application forms of herbal medications, disease period in which CAM was used, CAM utilization along with conventional treatment modalities, and the use of sleeping pills, antidepressants, and painkillers. As we did not have the ability to directly measure the average income of the patients, the form of transportation to the hospital was investigated as an indirect indicator of income (Appendix 1 can be found online at www.liebertonline.com/jpm).

The European Organization for Research and Treatment of Cancer Life Quality Questionnaire C30 (EORTC QLQ-C30; version 3.0) was used to assess quality of life.¹⁶

Statistical analysis

CAM users were defined as individuals using at least one type of CAM. Distribution of continuous variables was assessed by Shapiro-Wilk normality test. Comparison of skewed continuous variables was performed by means of Mann Whitney test. Relationships between the categorical variables were analyzed with χ² test. P values<0.05 were considered to be statistically significant (α=0.05). Chi-square or Mann Whitney tests used as a post hoc test for the comparison of multiple comparisons (n). Bonferroni corrected P value less than α/n was accepted as significance level in these comparisons. Sociodemographic and clinical features were potential predictors of CAM usage were compared in univariate analysis. Any variable with a P value<0.25 in χ² test was included into the multivariate analysis. The multiple logistic regression model was used to identify the variables that independently affect CAM utilization. Results of multiple logistic regression analysis were reported as odds ratios (OR) and 95% confidential intervals (95%CI). All statistical analyses were performed using the SPSS software program (Statistical Package for Social Sciences version 15, Chicago, IL).

Results

From a total of 1060 patient contacts, 425 (40.1%) questionnaires (male/female: 189/236, mean age of 50.6 ranging 18–80 years) were included in the final analysis; 254 (23.9 %) of the questionnaires collected were empty due to patients' reluctance to complete; 156 (14.7%) questionnaires were not returned by patients; 114 (10.8%) questionnaires were incomplete; 63 (5.9 %) were empty due to patients' inability to fill out the forms (because of illness or incapacity, etc.); 36 (3.4%) could not be completed due to language barriers; and 12 (1.0%) questionnaires were excluded due to uncertain cancer diagnosis.

The results showed that 244 of the 425 individuals (57.4%) used at least one kind of CAM subsequent to diagnosis with cancer. Patients who did not use CAM stated the reason for not using CAM as satisfaction with the treatment given, reliance on the physicians, and perception of CAM as useless or harmful. Most of the patients (64.2%) were middle aged (35–59 years of age), and 52.7% had an education level between 0 and 9 years.

Place of birth was typically the Marmara (36.5%) or Black Sea (22.9%) region; 74.2% were married (Table 1). The most frequently observed diagnoses among the patients were breast and gastrointestinal system cancer (Table 2). Results showed that 87.5% and 46.4% of the entire study population received chemo- and radiotherapy, respectively, during any period of the disease. A total of 15.5% of all patients had visited a psychiatrist, and 16.4% had received antidepressant treatment; 46.3% of patients utilized painkillers. Twenty percent of all patients were employed. Only 10 patients (2.4%) had no medical insurance.

Table 1.

Comparison of Sociodemographic Features of CAM Users and CAM Nonusers

		Users		Nonusers
Variables	Total N (%)	N	%	N	%	Unadjusted P value
Age (years)						0.0001^*
18–34	44 (10.4)	35	79.5	9	20.5
35–59	273 (64.2)	169	61.9	104	38.1
60–89	108 (25.4)	44	40.7	64	59.3
Sex						0.020
Male	189 (44.5)	122	64.6	67	35.4
Female	236 (55.5)	126	53.4	110	46.6
Place of birth^a						0.349
Black Sea	94 (22.9)	49	52.1	45	47.9
Marmara	150 (36.5)	96	64.0	54	36.0
Aegean	19 (4.6)	12	63.2	7	36.8
East and Southeast	64 (15.6)	38	59.4	26	40.6
Central	52 (12.7)	32	61.5	20	38.5
Mediterranean	16 (3.9)	7	43.8	9	56.2
Out of country	16 (3.9)	7	43.8	9	56.2
Education						0.001^**
0–9 years	222 (52.7)	117	52.7	105	47.3
10–12 years	105 (24.9)	59	56.2	46	43.8
+13 years	94 (22.3)	70	74.5	24	24.5
Marital status						0.391
Married	313 (74.2)	187	59.7	126	40.3
Not married	109 (25.8)	60	55.0	49	45.0
Cancer history in family						0.232
Yes	166 (45.0)	92	55.4	74	44.6
No	203 (55.0)	125	61.6	78	38.4
Working status						0.006
Working	86 (21.3)	63	73.3	23	26.7
Not working	317 (78.7)	180	56.8	137	43.2
Transportation						0.048
Car	140 (36.3)	94	67.1	46	32.9
Taxi-bus-other	246 (63.7)	140	56.9	106	43.1

18–34 years versus 35–59 years, p=0.036; 18–34 years versus 60–89 years, p=0.0001; 35–59 years versus 60–89 years, p=0.0001; χ² test (p significance level after Bonferroni correction <0.0167).

0–9 years versus 10–12 years, p=0.555; 0–9 years versus+13 years, p=0.0001; 10–12 years versus+13 years, p=0.007, χ² test (p significance level after Bonferroni correction <0.0167).

Southeastern Anatolia was excluded due to the low number of patients.

CAM denotes complementary/alternative medicine.

Table 2.

Comparison of Clinical Features of CAM Users and CAM Nonusers

		Users		Nonusers
Variables	Total N (%)	N	%	N	%	Unadjusted P value
Diagnosis^a						0.144
Breast	113 (30.6)	56	49.6	57	50.4
Gastrointestinal	108 (29.3)	68	63.0	40	37.0
Hematological	26 (7.0)	18	69.2	8	30.8
Gynecological	50 (13.6)	32	64.0	18	36.0
Lung	39 (10.5)	25	64.1	14	35.9
Bone-muscle	15 (4.1)	12	80.0	3	20.0
Genitourinary	18 (4.9)	11	61.1	7	38.9
Stage of disease						0.972
Early	116 (31.9)	69	59.5	47	40.5
Advanced	248 (68.1)	148	59.7	100	40.3
Duration of disease						0.174
≤6 months	79 (19.9)	45	57.0	34	43.0
7–12 months	113 (28.5)	58	51.3	55	48.7
1–5 years	85 (21.4)	57	67.1	28	52.9
≥5 years	120 (30.2)	70	58.3	50	41.7
Chemotherapy						0.790
Past use	105 (25.8)	65	61.9	40	38.1
Recent/current use	251 (61.7)	146	58.2	105	41.8
Never used	51 (12.5)	31	60.8	20	39.2
Radiotherapy						0.747
Past use	119 (31.4)	73	61.3	46	38.7
Recent/current use	57 (15.0)	32	56.1	25	43.9
Never used	203 (53.6)	125	60.7	78	39.3
Regular analgesic use						0.320
Yes	179 (46.3)	113	63.1	66	36.9
No	208 (53.7)	121	58.2	87	41.8
Antidepressant use						0.277
Yes	64 (16.4)	43	67.2	21	32.8
No	327 (83.6)	196	59.9	131	40.1
Psychiatric support						0.220
Yes	60 (15.5)	41	68.3	19	31.7
No	327 (84.5)	196	59.9	131	40.1

Diagnoses containing ≤10 patients were not included.

CAM denotes complementary/alternative medicine.

Characteristics of patients using CAM

The most frequently used CAM method was herbal treatments. Two hundred and thirty-two of 425 patients (54.2%) and 244 CAM users (95%) had used an herbal agent at some point during the disease. Forty-four percent of the patients who had used herbal medications were receiving these treatments per se; others used herbal medications in combination with other methods. The most common herbal medication, which was used by 70% of herb-users, was nettle (Urticae herba) and its seeds. The most frequently used nonherbal agents were found to be honey and royal jelly (Tables 3 and 4).

Table 3.

CAM Types and Features

	N	%
Type of CAM
Herbal medicine	232	95.1
Religious applications	57	23.3
Multivitamins/Antioxidants	45	18.4
Yoga	21	8.6
Nonherbal agents	47	19.2
CAM use encouraged by
Family, friends	101	41.4
Patients, patients' relatives	72	29.5
Media, TV, press	44	18.0
Herbalist, spice seller	39	15.9
Oncologist	17	6.9
Internet	14	5.7
Other doctors, nurses	3	1.2
Reasons for CAM use
Belief in the efficacy of CAM	84	41.3
Encouragement by friends and relatives	74	37.2
Feeling downcast and hopeless	21	10.5
Lack of confidence in chemotherapy	10	5.0
Chemotherapy-resistant disease	9	4.5
Changes in religious attitudes	3	1.5
CAM supply
Spice sellers	121	50.8
Nature	71	29.8
Pharmacy	27	11.3
Other	19	8.1
Expectations related to CAM use
Reinforcement of the immune system	53	22.4
Complementary to conventional therapies	75	31.6
Cure	64	27.0
Prevention of symptoms	26	11.0
Prevention of relapses	19	8.0
Time of initiation to CAM
By the time of diagnosis	120	63.4
Within the last 3 months	42	22.3
By the time of disease progression	27	14.3
CAM application during chemotherapy
Along with chemotherapy	93	52.0
After chemotherapy	59	33.0
Before chemotherapy	22	12.2
Only CAM	5	3.8
Consultation with a physician regarding CAM use
Generally	82	38.1
Sometimes	69	32.1
Never	64	29.8
Attitudes of physicians to CAM use
Not concerned	102	69.3
Not recommended	25	17.1
Recommended	20	13.6
Perceived beneficial effect of CAM use
Yes	86	50.5
No	84	49.5

CAM denotes complementary/alternative medicine.

Table 4.

CAM Used by Patients ^a

CAM	N	%
Herbal agents
Nettle (Urtica)	171	70.1
Linseed (Linum usitatissimum)	27	11.0
Bee pollen	25	10.2
Chinese tea (Camellia sinesis)	18	7.3
Thyme (Thymus vulgaris)	14	5.7
Grape seed (Vitis viniferae)	13	5.3
Broccoli (Brassica oleracea italica)	11	4.5
Rose-hip (Rosae canina)	9	3.6
French lavender (Lavendula stoechas)	9	3.6
Ginseng (Panax ginseng)	9	3.6
Turmeric (Curcuma longa)	9	3.6
Juniper (Juniperus)	8	3.3
Garlic (Allium sativum)	8	3.3
Blackberry (Rubus caesius)	8	3.3
Peppermint (Mentha piperita)	8	3.3
Senna (Cassia acutifolia)	7	2.9
Succory (Cichorium intybus)	7	2.9
Ginger (Zingiber officinalis)	6	2.4
Rosemary (Rosmarinus officinalis)	5	2.0
Daisy (Bellis perennis)	5	2.0
Nonherbal agents
Honey	23	9.4
Royal jelly	19	7.7
Omega-3 fish oil	6	2.4
Shark cartilage	5	2.0

Answers responded by fewer than 5 patients were not reported.

CAM denotes complementary/alternative medicine.

Of the users, 86.6% had taken the herbal agents orally; only a few patients had applied herbal agents to the tumor region. Half of the users applied these medications alone, and the other half used them as mixtures. We found that 52% of the patients used herbal remedies along with chemotherapy; 12.2% and 33% of the patients applied these before and after the completion of chemotherapy, respectively; 2.8% used only herbal remedies. The main sources that directed patients to use CAM were families (41.4%), and other patients and relatives (29.5%). Ingredients of CAM were generally provided by spice stores, nature, and rarely by pharmacies (Table 3). Average monthly expenditure on CAMs was found to be 30 USD (range: 5–135). We found that 78% of users used their own financial resources to obtain CAMs.

Among those surveyed, 59% had not informed their physician about current CAM use. Of patients who consulted their physician about the use of CAM, 69.3% were not given any advice. For 17.1% of the patients, CAMs were recommended by their physicians and 13.6% of patients were discouraged from the use of such treatments (Table 3).

CAM relieved the complaints in about half of the patients. Of the patients who experienced some benefit, 23% described this relief as disappearance of some symptoms only; 15% and 5% specified relief as a sense of physical refreshment and mental/psychological well-being, respectively.

The leading factors motivating the patients to utilize CAM were belief in the efficacy of alternative treatments (41.3%) and encouragement by close friends and relatives (37.2%). Other factors were the perception of CAM as natural, nontoxic, relatively safe and cheap, easy to get, and possibly preventive for chemotherapy toxicity and disease outcome (Table 3).

Univariate analysis

Considering sociodemographic variables for CAM use, young and middle age (p=0.0001), male sex (p=0.02), higher education level (p=0.001), employment (p=0.006) and private vehicle use (p=0.048) were associated with higher likelihood of CAM use (Table 1). Considering medical variables and the variables related to the disease, no significant relationship was determined between CAM use and diagnosis, stage of the disease at the time of diagnosis, disease duration, or use of chemotherapy, radiotherapy, painkillers, antidepressants, or psychiatric support (Table 2).

Multivariate analysis

In a logistic regression model based on the sociodemographic and medical parameters of the patients, only young and middle age were significant factors associated with less CAM use ([OR: 0.162, 95%CI 0.036 to 0.730, p=0.018] and [OR: 0.318, 95%CI 0.164 to 0.618, p=0.001] for 18–34 versus≥60 years and 35–39 versus≥60 years, respectively). Male gender, higher education level, working status, and transportation by private vehicle no longer had significant P values after adjustment by logistic regression analysis (P values: 0.106, 0.350, 0.602, 0.108, respectively) (Table 5).

Table 5.

Multivariate Logistic Regression Model of Sociodemographic and Clinical Parameters for CAM Use

Variables	Adjusted OR (95% CI)	Adjusted P value
Age
18–34 years	0.162 (0.036–0.730)	0.018
35–59 years	0.318 (0.164–0.618)	0.001
60–89 years	1
Sex
Male	0.525 (0.240–1.148)	0.106
Female	1
Education
0–9 years	1.443 (0.669–3.115)	0.350
10–12 years	1.306 (0.566–3.009)	0.531
+13 years	1
Cancer history in family
Yes	1.119 (0.625–2.004)	0.705
No	1
Working status
Employed	1.228 (0.568–2.653)	0.602
Unemployed	1
Transportation
Private car	0.613 (0.338–1.113)	0.108
Taxi-bus-other	1
Diagnosis
Breast	0.933 (0.243–3.571)	0.919
Gastrointestinal	0.776 (0.227–2.654)	0.686
Hematological	0.900 (0.197–4.100)	0.891
Gynecological	0.497 (0.119–2.083)	0.339
Lung	0.461 (0.099–2.155)	0.325
Bone-muscle	1.397 (0.194–10.066)	0.740
Genitourinary	1
Duration of disease
≤6 months	0.593 (0.250–1.405)	0.235
7–12 months	1.377 (0.677–2.802)	0.377
1–5 years	0.644 (0.288–1.444)	0.286
≥5 years	1
Psychiatric support
Yes	0.642 (0.282–1.460)	0.290
No	1

CAM denotes complement/alternative medicine; CI, confidence interval; OR, odds ratio.

Quality of life questionnaire (QLQ)

Among the symptom scales, only appetite loss score was higher in CAM users (p=0.0030). There was no difference in terms of other scales including global health status, functional, and financial impact scales among the groups (Table 6).

Table 6.

EORTC/QLQ C-30 Version 3.0 Scores

	Users			Nonusers
Scales/Items	No. of patients	Median (Range)	Mean (SEM)	No. of patients	Median (Range)	Mean (SEM)	P^*
Global health status/QoL^a
Global health status/QoL	196	58.33 (0–100)	55.53 (1.86)	140	58.33 (0–100)	56.78 (2.25)	0.652
Functional scales^a
Physical functioning	205	73.33 (0–100)	64.13 (1.79)	138	66.67 (0–100)	60.63 (2.24)	0.134
Role functioning	200	83.33 (0–100)	68.00 (2.36)	144	91.67 (0–100)	72.80 (2.93)	0.053
Emotional functioning	197	75.00 (0–100)	65.10 (1.98)	139	75.00 (0–100)	72.30 (2.03)	0.031
Cognitive functioning	198	83.33 (0–100)	77.19 (1.68)	137	83.33 (0–100)	78.47 (2.05)	0.547
Social functioning	194	66.67 (0–100)	65.12 (2.28)	138	75.00 (0–100)	70.77 (2.69)	0.073
Symptoms scales^b
Fatigue	199	44.44 (0–100)	50.75 (2.09)	145	44.44 (0–100)	48.74 (2.29)	0.568
Nausea/vomiting	203	16.67 (0–100)	26.60 (2.09)	148	16.67 (0–100)	20.95 (2.07)	0.107
Pain	200	33.33 (0–100)	36.25 (2.14)	143	33.33 (0–100)	37.00 (2.77)	0.895
Dyspnea	224	0.00 (0–100)	19.05 (1.90)	159	0.00 (0–100)	29.35 (2.95)	0.017
Insomnia	204	33.33 (0–100)	37.58 (2.60)	145	33.33 (0–100)	35.17 (2.65)	0.863
Appetite loss	203	33.33 (0–100)	33.50 (2.50)	146	0.00 (0–100)	23.29 (2.66)	0.003
Constipation	200	33.33 (0–100)	33.33 (2.37)	139	33.33 (0–100)	31.89 (2.72)	0.789
Diarrhea	201	0.00 (0–100)	20.73 (2.06)	141	0.00 (0–100)	15.37 (2.14)	0.084
Financial impact score^b	198	33.33 (0–100)	38.38 (2.43)	142	33.33 (0–100)	38.26 (2.86)	0.986

Mann-Whitney U test, p significance level after Bonferroni correction <0.0033.

Higher scores mean better QoL. Scores have a potential range between 1 and 100.

Higher scores mean increased symptoms. Scores have a potential range between 1 and 100.

EORTC/QLQ denotes European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; QoL, quality of life; SEM, standard error of the mean.

Discussion

In our study, 57.4% of patients were receiving at least one type of CAM. The frequency of CAM utilization ranges between 36.0% and 100% in nine Turkish survey studies (n≥100 on each) published between 2001 and 2011.¹⁷ Although methodological differences used to determine CAM usage and demographic variations across the studies might explain the wide ranges of CAM prevalence found in the various studies, our results are consistent with the overall prevalence of CAM usage in these studies (Supplementary Table 1 can be found online at www.liebertonline.com/jpm).^18–26 Overall CAM use is about 36% in European countries, 52% in Australia, 45% in Japan, and 98% in China.²⁷ CAM utilization frequency in Turkey seems to be similar to that observed in industrialized countries.

The most commonly used CAM modality in this study was herbal therapy, 70% of which was comprised by stinging nettle (Urtica dioica and Urtica urens), similar to reports by previous Turkish studies.^18–26 The nettle has a special position as a medicinal treatment in Turkey. Especially in recent years, there is a belief among Turkish people that stinging nettle or nettle leaves cure cancer. The traditional attitudes and beliefs of the people, the easy access to this plant, and the low cost can explain why stinging nettle is the most preferred herb among the Turkish population.

Other popular CAM methods were religious rituals, multivitamin and antioxidant treatments, and nonherbal agents. Certain Turkish studies reported that Western-type CAM modalities such as meditation, relaxation, special diets, and nonherbal animal products such as shark cartilage were almost absent.^18,22 Another recent study concluded that higher educational level is associated with less religious rituals and more mind-body practices.²⁵ The year in a which study was performed, the method of CAM determination in a survey, the area in which the survey was undertaken, educational level, income, and living in rural/urban areas may affect the preferred method of CAM across the studies.

Predictors of CAM usage reported by Turkish studies are conflicting.^18–26 Some of these studies did not report such information; some declared the results of univariate analysis only. Duration of disease, female gender, younger age, and cancer type have been found to be associated with CAM usage in various studies. However, there are also studies claiming an association with the opposite states of latter predictors or no associated predictors.^18–26 In the current study, the probability of being a CAM user was especially low among young and middle-aged patients. Our study added more information about the potential predictors of CAM usage. Heterogeneity in conclusions of studies evaluating Turkish cancer patients may be explained by methodological differences across the studies. This, in turn, can be translated, as more studies with appropriate methodology are needed to determine actual predictors of CAM use.

The main factors motivating patients to pursue alternative treatment methods were found to be belief in the effectiveness of the alternative treatments, the advice of close relatives, despair, and helplessness. Patient relatives and other patients were the most important sources of encouragement to pursue CAM. In Western societies, media and the Internet are the leading methods of knowledge acquisition.²⁸ Close family relationships and low socioeconomic status in Turkish cancer patients may be an explanation of this difference.

Psychological support is no longer considered to be complementary to conventional care but is now seen as an integral part of good cancer medicine.²⁹ We found that the rate of patients visiting a psychiatrist and utilization of antidepressants were determined to be low (15%).³⁰ Formal mental health services do exist in certain Turkish oncology centers providing treatment to cancer patients. However such services are not widespread. Lack of these facilities in many centers may impair patients' emotional psychological support and cause despair and helplessness. As a result, patients or their relatives may be prone to seek informal ways to achieve moral support. CAM practitioners generally present CAMs as positive and with optimism,³¹ and these operators allocate more time than the ones delivering conventional medical services,³² listen carefully, and provide emotional support.³³ Furthermore, whereas conventional treatments are toxic,³⁴ CAM treatments are deemed to be natural, nontoxic, and healthful.³⁵

More than 40% of the users believed in the efficiency of CAM. On the other hand, patients rarely report the use of CAM to their doctors.³ Although none of the participants had been informed about the potential harmful effects of CAM, there is a potential for harmful medication-herb-vitamin interactions.³⁶ These findings suggest the importance of more extensive communication with doctors and the delivery of more reliable information to patients.

Although cancer patients' approach CAM with the expectation of improving their quality of life,³³ we determined no evidence of improved QLQ scores among users of CAM.^4,9,25 CAM users had worse appetite scores. This may be because patients who have appetite loss may be prone to seeking alternative treatment options. Due to the cross-sectional design of our study, it was impossible to make a causal inference regarding quality of life and CAM use. These findings are important in terms of gaining knowledge about the presumed potential beneficial effects of CAM modalities preferred in Turkey.

Although half of the patients used herbal CAMs as mixtures, it is interesting that none of our patients mentioned the “traditional healers.” However, consulting a healer is quite common practice in Turkey. Traditional healers are called as “Lokman hekim,” which can be translated as “Doctor Lokman” in Turkey. Lokman hekim, a folkloric figure, is mentioned in folkloric tales and the Koran, Islam's holy book. It is believed that he is gifted and wise. He can cure any disease only by a mixture of natural herbs and plants. Lokman hekim activities are officially illegal in Turkey.

The most prominent limitation of our study was its relatively low response rate, which was about 40.1%. Questionnaires consisting of too much questions with many complicated answer options reduce the survey's response rate significantly, especially in such a suffering and frail population. We tried to keep the questionnaire as concise and simple as possible. Nevertheless, it is probable that the participants could have perceived the questionnaire as sophisticated and time-consuming. Anonymous questionnaires that contain no identifying information are more likely to produce honest responses than those identifying the respondent. Inclusion of confidential information about the participants in our questionnaire possibly led to the low response rate. It also had an adverse impact on the reliability of responses. For example, none of the respondents reported traditional healer activity despite its common practice.

In conclusion, CAM use is widespread among Turkish cancer patients and it does not improve QLQ scores. Physicians should be aware of high CAM utilization rates in patients with cancer and should better understand the factors directing patients to such treatments.

Footnotes

Acknowledgments

We thank all the patients and their families for their participation in this study and the investigators and their staff from the participating sites. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author Disclosure Statement

No competing financial interests exist.

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