Complementary and Alternative Medicine Use in Cancer Patients in Rural Australia

Abstract

Aim. Numerous studies have demonstrated the high prevalence of complementary and alternative medicine (CAM) use in metropolitan cancer cohorts but few have been conducted in regional and remote populations. This study aimed to investigate the trends and regional variations in CAM use by cancer patients at a regional cancer care center in Toowoomba, South East Queensland, Australia. Methods. All English-speaking adult cancer patients attending the regional cancer care center were invited to participate. Eligible patients were provided a self-administered questionnaire that was developed based on published surveys. Ethics approval was obtained. Results. Overall 142 patients completed the questionnaire and 68% were currently or had previously used at least one form of CAM. CAM users and nonusers did not differ significantly by region, age, gender, time since diagnosis, income, town size, treatment intent, or metastases. CAM users were more likely to have a higher level of education. Concurrent CAM use with conventional treatment was reported by approximately half of respondents. The most common reason for CAM use was “to improve general physical well-being.” The most common sources of CAM information were family (31%) and friends (29%). Disclosure of CAM use to either the general practitioner or specialist was reported by 46% and 33% of patients, respectively. The most common reason for nondisclosure was “doctor never asked.” Conclusion. This study supports previous research that CAM use is as common in regional and remote areas as metropolitan areas. Nondisclosure of CAM use to health professionals was common. Future research needs to focus on strategies to improve communication between patients and health professionals about the use of CAM.

Keywords

complementary and alternative medicine CAM use regional and remote rural cancer chemotherapy Australia

Introduction

Complementary and alternative medicine (CAM) has been defined as “a group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine.”¹ CAM use is becoming increasingly prevalent among the cancer population.^2,3 A recent systematic review and meta-analysis reported an average prevalence of current or previous CAM use in 40% of cancer patients.² Individual studies have reported prevalence rates between 40% and 83% depending on the CAM modalities included, the study population, and the research technique.^2,4

Some CAM has evidence supporting efficacy in ameliorating symptoms or side effects of cancer or cancer treatment, such as ginger and acupuncture for acute chemotherapy-induced nausea⁵ and vomiting.⁶ The benefits of CAM may include improving quality of life and reducing depression.⁷ Many CAM, however, lack proven efficacy and may have serious sequelae when used as an alternative to conventional medicine. CAM may also affect the efficacy of conventional cancer treatment when used in combination.⁸ Both pharmacokinetic and pharmacodynamic interactions between CAM and chemotherapy have been reported,⁹ and CAM are not without adverse effects.¹⁰

Conservative beliefs and behaviors of rural populations such as avoidance or delay in attending health care,¹¹ along with a preference toward traditional health care,¹² have been proposed to reduce CAM use.¹³ To the contrary, previous surveys indicate that residents in rural areas frequently engage in the use of CAM,^13,14 and are in fact more likely to use CAM than their metropolitan counterparts.^13,15 The prevalence of CAM use by rural patients has been reported to range from 40% to 70% and consultation of CAM practitioners between 9% and 63%.¹⁴ Data from the southwest regional area of Western Australia found that approximately half of the health consults in a 12-month period were with a CAM practitioner.¹⁶ Suggested reasons for high CAM consumption in rural communities include lower availability and dissatisfaction with conventional health care services, as well as an increased interaction between CAM and conventional providers.¹⁴ One study found that 53% of CAM users at a rural health screening clinic had sourced their information from a doctor or pharmacist.¹⁷ Another study found approximately one quarter of rural general practitioners (GPs) referred to a chiropractor or osteopath at least once a month and 10.4% of GPs had performed manipulative therapies during the past month.¹⁸ In addition, limited access to social and health care services may lead rural patients to develop attributes such as resilience, stoicism, independence, and self-reliance, which may shape health seeking behavior and lead to self-management of disease including self-prescription of CAM.^14,19 A study investigating naturopaths’ perspectives on the demand for their services in the Darling Downs area also highlighted longer consultation times and a preference toward “local” rather than “foreign” health practitioners as drivers for CAM use in rural areas.¹⁹ Research in rural New South Wales found a similar pattern of distribution of general practitioners and CAM practitioners, which may suggest a proactive approach to seeking CAM by rural patients as opposed to a deferral to CAM when conventional services are not available.²⁰ Lack of local access to CAM practitioners does not appear to have an impact on CAM use by rural patients as they are often prepared to travel to access these services.¹³

Nondisclosure of CAM use to conventional health care providers is common in both rural and cancer populations.^10,21-25 This is of concern given the potential interactions between CAM and conventional cancer treatments. Common cited reasons for nondisclosure include the doctor not inquiring about CAM use, an anticipation of doctor disapproval, doctor disinterest or inability to provide information on CAM, and patient perception that CAM use is irrelevant to conventional treatment and is harmless.^10,22,24,26 Animosity from some conventional health care providers toward CAM use²⁷ may turn cancer patients toward less reliable sources of CAM information such as the media, the Internet, and word of mouth. This may be problematic as media reports are often skewed toward a positive view on CAM.²⁸

Limited studies have investigated the trend and reasons for high CAM use, whether there are regional variations in CAM use among rural cancer patients^25,29 and whether information seeking behavior and disclosure of CAM use is comparable to metropolitan cohorts.¹⁴ Improved awareness of trends in CAM use may assist health professionals engage rural cancer patients to disclose their CAM use and ensure patients are appropriately informed about how CAM use may have an impact, positively or negatively, on the efficacy or side effects of conventional cancer treatments.⁴

This study aimed to investigate the trends and any regional variation in CAM use by cancer patients at a regional cancer center located in Toowoomba, Queensland. The study also aimed to investigate where rural cancer patients sourced information regarding CAM treatment, whether they had discussed their CAM use with any member of the cancer care team, and what factors prompted them to use or not use CAM.

Method

All adult cancer patients (including oncology, hematology, and palliative care) attending a regional cancer care service in Toowoomba, in South East Queensland, Australia, were eligible to be included in the study. Exclusion criteria included inability to provide informed consent and inability to communicate in English. Daily clinic lists were used to identify eligible patients, who were then invited to participate in the study by the investigator while attending the cancer care clinic. If willing to participate, they signed a statement of informed consent and then were given a self-administered questionnaire. Assistance was provided to complete the questionnaire if required. Data were collected for 4 weeks between April 15 and May 10, 2013. Ethics approval was granted from the Toowoomba and Darling Downs Human Research Ethics Committee and the University of Tasmania Human Research Ethics Committee.

The Toowoomba cancer care service has a large catchment area extending from the Lockyer Valley west to the South Australian border, north to Murgon, and south into northern New South Wales. The estimated population of the area is 260 000 persons.³⁰ It is a predominantly agricultural area, however, there has been a recent growth in the resources sector with the coal-seam gas project in the Surat Basin. Manufacturing, health, education, and tourism sectors also provide employment in the area leading to a diverse demographic.³⁰ Toowoomba is the largest city in the area and is situated 132 km west of Brisbane.

In the absence of a standard questionnaire on the use of CAM, a questionnaire was developed based on published surveys investigating CAM use in cancer or rural populations.^13-15 The questionnaire asked patients to indicate CAM that they were currently or had previously used from a list commonly used by cancer patients.^26,31,32 The questionnaire had a particular focus on biologically based therapies that have the potential to influence the efficacy of conventional cancer treatments, but also included mind and body based practices commonly reported in the literature. The questionnaire also covered where CAM information was sourced, how much money each month was spent on CAM, whether CAM use had been discussed with any of the conventional health care team, and if not, the reasons for not discussing CAM use.^26,31 The questionnaire contained Likert-type statements to assess reasons for using or not using CAM.³³ Demographic data and cancer type and stage were obtained from patient medical records. The Australian Bureau of Statistics’ Australian Standard Geographic Classification remoteness areas structure was used to classify patient geographical location as inner regional (IR), outer regional, remote, and very remote.^34,35 It was planned to compare CAM usage between the 4 geographical classifications; however, insufficient patients were recruited in the outer regional, remote, and very remote groups so they were combined into an outer regional (OR) group for analysis.

The χ² test and Student’s t test were used to determine differences in CAM use between IR and OR participants for categorical and continuous variables respectively. A significance level of P < .05 was used. Statistical analysis was performed using R 3.0.1.³⁶

Results

A total of 142 patients participated in the study, while a further 64 patients were eligible to be included but either refused, were too unwell, or were not approached to complete the survey because of time constraints. Demographics were similar in both groups. The characteristics of IR and OR participants are shown in Table 1.

Table 1.

Characteristics of Inner Regional and Outer Regional Participants.

Variables	Inner Regional (N = 101)		Outer Regional (N = 41)		t	df	P
Variables	n	%	n	%	t	df	P
Average age (years)	62		61		0.46	85	.65
Average time since diagnosis (years)	3.7		3.1		0.63	118	.53

					χ²	df	P

Gender					0.00	1	.96
Male	49	48.5	19	46.3
Female	52	51.5	22	53.7
Income					2.52	2	.43
<$50 000	92	91.1	36	87.8
$50 000-100 000	9	8.9	4	9.8
>$100,000	0	0.0	1	2.4
Town size					47.91	3	<.001
>50 000	48	47.5	0	0.0
10 000-50 000	16	15.8	0	0.0
<10 000	32	31.7	33	80.5
Farm	5	5.0	8	19.5
Education					0.68	4	.97
Primary	26	25.7	10	24.4
Year 10	43	42.6	19	46.3
Year 12	13	12.9	6	14.6
Tertiary (nonuniversity)	14	13.9	5	12.2
University	5	5.0	1	2.4
Treatment type					4.08	7	.85
Chemotherapy (including combination treatment)	53	52.5	24	58.5
Hormonal	13	12.9	6	14.6
Monoclonal antibody	9	8.9	1	2.4
Bisphosphonate	1	1.0	0	0.0
Noncytotoxic antineoplastic	4	4.0	3	7.3
Octreotide	2	2.0	0	0.0
Radiotherapy	4	4.0	1	2.4
No treatment	15	14.9	6	14.6
Treatment intent					0.05	1	.83
Curative	26	30.2	12	34.3
Palliative	60	69.8	23	65.7
Metastases (for solid tumors)					0.02	1	.88
Yes	55	54.5	24	58.5
No	27	26.7	10	24.4

Characteristics of CAM Users and Nonusers

Overall, 97 of 142 respondents (68%) indicated that they were currently or had previously used at least one form of CAM (excluding prayer alone; see Table 2). The 2 patients who reported using prayer alone were not included as CAM users in subsequent analyses. CAM users and nonusers did not differ significantly by region, age, gender, time since diagnosis, income, town size, treatment intent, or metastases. CAM users were more likely to have a higher level of education (χ² = 16.7, df = 1, P = .002). Current CAM use was reported by 49% of respondents. There was no significant difference in current CAM use between IR and OR groups; however, OR respondents were more likely to have used CAM in the past (χ² = 3.91, df = 1, P = .048). Concurrent CAM use with conventional treatment was reported by 48% and 46% of IR and OR respondents, respectively. Five or more different types of CAM were used by 34% of CAM users. There was no significant difference in the number of CAM used between IR and OR groups (χ² = 7.09, df = 4, P = .15).

Table 2.

Comparison of Inner Regional and Outer Regional Complementary and Alternative Medicine (CAM) Use.

	Inner Regional (N = 101)		Outer Regional (N = 41)		χ²	df	P
	n	%	n	%	χ²	df	P
Current CAM use	51	50.5	18	43.9	0.28	1	.6
No current CAM use	50	49.5	23	56.1
Previous CAM use	54	53.5	30	73.2	3.91	1	.05
No previous CAM use	47	46.5	11	26.8
Current and/or previous CAM use (excluding prayer alone)	66	65.3	31	75.6	0.98	1	.32
No current and/or previous CAM use (excluding prayer alone)	35	34.7	10	24.4
Current and/or previous CAM use (including prayer alone)	67	66.3	32	78.0	1.38	1	.24
No current and/or previous CAM use (including prayer alone)	34	33.7	9	22.0

Types of CAM Used and Reasons for Using or Not Using CAM

Of the 97 CAM users, 87 (90%) reported using one or more biological CAM and 76 (78%) reported using one or more mind-body-based CAM. The most common CAM used was vitamin supplements; details are shown in Table 3.

Table 3.

Most Common Complementary and Alternative Medicine (CAM) Used: Current and Past Use.

Biologically Based CAM/Diets (N = 97)			Mind–Body CAM (N = 97)
	n	%		n	%
Vitamins	59	61	Acupuncture	31	32
Herbal tea	31	32	Chiropractic	29	30
Garlic	25	26	Prayer	27	28
Antioxidants	18	19	Therapeutic massage	19	20
Naturopathy	13	13	Deep breathing	18	19
Selenium	12	12	Meditation	14	14
Fish oil/krill oil	9	9	Yoga	7	7
Vegetarian diet	9	9	Tai chi	7	7
Ginseng	7	7	Reiki	7	7
St John’s wort	5	5	Aromatherapy	6	6
Gumbi Gumbi	5	5	Spiritual healers	4	4

Reasons for using CAM were explored both for individual CAM and across all CAM. Selenium (7%), antioxidants (5%), and herbal teas (4%) were the biological CAM most commonly used by patients to “treat” cancer. Prayer (12%), deep breathing (7%), meditation (6%), and spiritual healers (4%) were the most common mind–body CAM used to treat cancer. The most commonly used biological CAM to “boost the body or for side effects of cancer treatment” were vitamins (22%), antioxidants (6%), herbal tea (6%), and garlic (5%). Of the nonbiological CAM, deep breathing (12%), prayer (11%), and meditation (9%) were most commonly used. Patients reported the highest CAM use for “other” reasons not related to their cancer, for example, vitamins (37%), acupuncture (28%), chiropractic (27%), herbal tea (22%), garlic (21%), therapeutic massage (16%), prayer (14%), and antioxidants (9%).

Of the 97 respondents who reported currently or previously using CAM, 87 (90%) responded to the Likert-type statements regarding reasons for using CAM overall. The most common reason for using CAM was “to improve general physical well-being” (82%), followed by “might help, can’t hurt” (see Table 4). There was no significant difference in responses between IR and OR participants.

Table 4.

Reasons for Using Complementary and Alternative Medicine (CAM).

Reasons for Using CAM (N = 87)	Agree		Neutral		Disagree
Reasons for Using CAM (N = 87)	n	%	n	%	n	%
To improve general physical well-being	71	82	13	15	3	3
Might help/can’t hurt	49	56	27	31	11	13
To increase the body’s ability to fight the cancer	42	48	31	36	14	16
To do everything possible to fight the cancer	41	47	33	38	13	15
To improve emotional well-being	39	45	28	32	20	23
To treat or prevent side effects from cancer or its treatment	34	39	34	39	19	22
Family/friends want you to use complementary/alternative medicine	31	36	34	39	22	25
To directly fight the cancer	29	33	34	39	24	28
Conventional treatment was not successful	5	6	42	48	40	46

Fifty-three respondents (37%) completed the section concerning the reasons CAM was not used; the results are shown in Table 5. Interestingly, 10 respondents who had used at least one CAM still completed this question. Eighty-three percent of patients who completed this question agreed with the statement “I am happy with conventional treatment” and 77% agreed with the statement “I have never thought of using CAM.” A larger proportion of OR respondents agreed that “CAM are not available where I live” (38%) compared with IR respondents (8%) (χ² = 7.13, df = 2, P = .04).

Table 5.

Reasons for Not Using Complementary and Alternative Medicine (CAM).

Reasons for Not Using CAM (N = 53)	Agree		Neutral		Disagree
Reasons for Not Using CAM (N = 53)	n	%	n	%	n	%
I am happy with conventional treatment	44	83	8	15	1	2
I have never thought of using CAM	41	77	4	8	8	15
I am unable to afford CAM	13	25	10	19	30	57
I do not believe in CAM	9	17	37	70	17	32
CAM are not available where I live	9	17	7	13	37	70
Discouragement from conventional health care providers	5	9	8	15	40	75
I cannot access reliable information about CAM	3	6	12	23	38	72
Discouragement from family	0	0	10	19	43	81

Sources of CAM Information and CAM Cost

Eighty-seven (90%) CAM users responded to the questions about sources of CAM information, CAM cost, and discussion of CAM with health care professionals. The most common sources of CAM information were family (31%), friends (29%), a medical person (20%), the Internet (16%), and media (12%). The majority of patients (72%) reported spending less than $50 a month on CAM, 13% spent $50 to $100, and 5% spent more than $100 a month on CAM. There was no difference in information sources and money spent on CAM between IR and OR participants.

Discussion of CAM With Health Care Professionals

In this study, 46% of CAM users (40/87) reported discussing their CAM use with their GP and 33% with their oncologist or hematologist. The community pharmacist was consulted by 14% of patients followed by a naturopath or dietician (12% each), nurse (8%), and hospital pharmacist (7%). There was no difference in the rates of discussion with the various health care professionals between IR and OR participants. Overall, 41% of patients had not discussed their CAM use with either their GP or specialist, and 23% of patients had not discussed their CAM use with any health care professional. Table 6 shows the breakdown of the most common biologically based CAM being used, whether they were used in conjunction with conventional treatment or whether they had been discussed with a doctor. Of the 29 respondents who were using vitamins with conventional treatment, only 15 (51%) had discussed them with their doctor. In this study, only 5 respondents reported concurrently using antioxidants with conventional treatment; however, none of these respondents reported discussing their antioxidant use with their doctor. The question regarding reasons for not discussing CAM use with their doctor was answered by 25 participants. The most common reported reason was that “doctors never asked about other therapies” (32%), followed by “doctors would discourage/disapprove” (28%), “not important for my doctor to know” (28%), “doctor would not understand” (12%), and “already discussed with other members of the health care team” (12%).

Table 6.

Most Common Complementary and Alternative Medicine (CAM) Currently Used and Doctor Notified (N = 69).

	Current Users		Current Users Receiving Treatment		Current Users Receiving Treatment Who Discussed CAM With Doctor
	n	%	n	%	n	%
Vitamins	35	51	29	42	15	22
Herbal tea	21	30	19	28	2	3
Garlic	14	20	12	17	1	1
Antioxidants	8	12	5	7	0	0
Fish oil/krill oil	6	9	4	6	2	3
Selenium	5	7	4	6	0	0

Discussion

High CAM use has been previously reported in the general rural population, including Australia.^{3,13,15,25,37} This study did not find any regional variation in the number of patients currently using CAM between IR and OR areas. Patients from OR areas were more likely to have used CAM in the past. This result may reflect higher baseline CAM consumption (prior to cancer diagnosis) in OR patients; however, it is difficult to interpret as the current study did not define “previous CAM use” as before or after cancer diagnosis. Robinson and Chesters also found no difference in the use of various CAM modalities between patients in rural areas classified as highly accessible and less accessible using the ARIA rating scale,¹³ which was supported by the results of this study.

Overall, the number of patients using CAM in this study (68%) was comparable to recent Australian studies in predominantly metropolitan cancer populations which reported CAM use in 61% and 65% of participants, respectively,^31,38 but considerably higher than that reported in a similar regional population (38%).²⁵ This result supports previous Australian research that CAM use is as common in rural as metropolitan areas.¹³ The higher CAM use in the current study compared with previous studies may be because of the sample size and the broader definition of previous CAM use.

Previous studies have reported that CAM users in the cancer population are more likely to be younger,^38,39 female,³⁹ have a higher level of education,^31,38 have a higher income,³⁸ and be at a more advanced stage of disease.³¹ The trends in age, gender, income, and metastases were not observed in this study; however, participants with a higher level of education were more likely to use CAM as seen in previous studies. This may suggest that age, gender, and metastatic disease are not strong predictors of CAM use in cancer patients in regional areas. This study was conducted at a public hospital with most patients reporting an income less than $50 000; therefore, it is difficult to determine if income was a predictor of CAM use as there was no high-income group comparator.

Similar to recent Australian studies, vitamins were the most common biological CAM used.^25,38 Prayer was used by 28% of patients, which is also comparable to recent Australian studies^25,38; however, a limitation of the current study is that it did not clearly distinguish between therapeutic or healing prayer and routine prayer for religious beliefs. Higher rates of acupuncture (32%) and chiropractic use (30%) were seen in the current study,³⁸ which may reflect regional differences in the use of these practices but may also be a result of these services being subsidized through Medicare, as well as referral to and acceptance of these services by GPs.¹⁸ The Darling Downs region has been reported to have a high percentage of GPs who claim for acupuncture Medicare items,⁴⁰ which may also have affected this result. Differences in the definition of previous CAM use may also have influenced the results. Other studies have also identified variations in the type of CAM used between urban and rural populations. In the PUC-CAM study, rural respondents used significantly more self-prescribed supplements, chiropractic, and Bowen therapy.¹³ The PUC-CAM study proposed that there may be variations in the type of CAM used between different types of rural areas, for example, perimetropolitan, agricultural, and country towns with a large retiree population.¹³

Concurrent CAM use with conventional therapy (46% to 48%) was lower than reported previously (67% to 77%).²⁶ Despite this, there were still a large number of patients concurrently using CAM and conventional treatment. The concept that CAM is most commonly used as a “complement” rather than an alternative to conventional therapy is well supported in the literature.²⁶ One study reported that 79% of respondents agreed with the statement “using both conventional and alternative therapies is better than using either one alone.”⁴¹ Another study reported that 80% of patients believed CAM therapy can help the treatment of cancer even though efficacy has not been proven in studies.³⁸ The high use of multiple CAM modalities along with the high concurrent use of CAM with conventional treatment highlights the importance for health professionals to be able to assess how CAM may have an impact on the safety and efficacy of treatment and the need for further research in this area. Health professionals also need to be open-minded about the use of CAM and supportive of patients’ beliefs, values, and choices regarding CAM use, particularly if there is no known harm or there is a potential benefit from the CAM.

The most common reasons for CAM use from this study were “to improve general physical well-being” and “might help can’t hurt.” Unlike these findings, another study that used similar statements found the most common reason for CAM use was to “increase the body’s ability to fight the cancer.”³⁹ Previous research has highlighted “push factors” such as dissatisfaction with conventional treatment and “pull factors” such as desire to take control over ones health care as reasons for CAM use.³³ These results support the concept of patients using CAM in order to take control over their own health care. Interestingly, open-mindedness, independence, and preference for preventative health care by rural patients were also highlighted in a study investigating naturopaths’ perceptions on CAM use in the same geographical area.¹⁹ A third of the CAM users in this study agreed that they were using CAM to “directly fight the cancer.” A similar result has been reported previously where 37.5% of patients expected CAM therapies to cure their cancer.²⁶ This emphasizes the importance of conventional health care professionals engaging with patients to disclose their CAM use and to ensure they have been provided with appropriate information about the risks and benefits of CAM. Most patients disagreed that a reason for using CAM was “conventional treatment was not successful.” This supports the concept that CAM is not necessarily used as a last resort by terminally ill, desperate patients.²⁶ The major source of CAM information for participants was friends and family, which was similar to a previous study.³¹ The number of cancer patients that had consulted a medical professional for CAM information (20%) was slightly lower than reported in other studies (23% to 32%).^31,38 This observation may reflect cancer patients’ perception that medical professionals are not able to provide information about CAM²⁴ and represents an important barrier for conventional health professionals to overcome.

Nondisclosure of CAM use to health professionals is of concern because of the potential impact of CAM on the safety and efficacy of conventional treatment. A high nondisclosure rate of CAM use to medical practitioners has been reported previously.²⁴ Although almost half of patients in this study had not discussed their CAM use with the GP or specialist, when CAM discussion with any health professional was analyzed, only 23% of patients had not disclosed their CAM use. This highlights the role for all health professionals to initiate discussion about CAM use with cancer patients and the importance of communication between members of the multidisciplinary team. The most common reasons for nondisclosure of CAM use to a medical professional were “doctor never asked,” “doctor would discourage or disapprove,” and “not important for my doctor to know” and are consistent with those reported previously in the literature.⁴¹ This further stresses the importance for doctors and other health professionals to initiate discussion about CAM use and to remain open-minded about the potential role for CAM.²⁴ Schofield et al have published recommendations for effectively discussing CAM in an oncology consultation.⁴² Some of the recommended steps in this process include eliciting the patients’ understanding of their situation and their information preferences, asking questions about CAM use often and at crucial points in the illness trajectory, exploring the details of CAM use and actively listening, and discussing relevant concerns about CAM while respecting the patient’s beliefs.⁴² A limitation to effectively discussing CAM use in the busy oncology clinic may be time. Physicians have also reported feeling uncomfortable discussing CAM with patients because of a lack of knowledge about CAM.⁴³ The regular use of a screening tool such as the questionnaire used in this study may be a useful way to begin discussions about CAM. Although only one patient stated in the survey feedback that the survey prompted a discussion of CAM use with a health care professional, a question for future research is whether having a regular screening tool will prompt health professionals to initiate discussion with patients about CAM. Education for health professionals about commonly used CAM in cancer patients as well as communication skills training may also be beneficial to improve CAM discussions.

A study limitation was that only patients from regional and remote areas were included and there was no metropolitan subgroup for direct comparison. Also, it was conducted in a single health district; therefore, the results may not be generalizable to all rural areas. Another limitation was that the study was conducted at a regional cancer care center and did not capture patients that had chosen not to seek conventional cancer treatment. The results may also have been skewed by patients that choose not to, or were too unwell to participate in the study. The questionnaire design may also have limited the interpretation of the results as there was not a clear delineation between self-prescribed CAM and practitioner-led CAM. Finally, the results relied on self-reporting of CAM use, which may be limited by the accuracy of patient recall.

In conclusion, CAM use in the Toowoomba regional area was high, and the prevalence was similar to that seen in previous metropolitan studies. This supports previous research showing that CAM use is as common in regional and remote areas as metropolitan areas. There were many similarities in the types of CAM and the number of CAM used between patients from inner regional and outer regional areas in this study and metropolitan patients in previous studies. Concurrent use of CAM with conventional cancer treatment and nondisclosure of CAM use were common. This study has important implications for health professionals caring for cancer patients living in regional or remote areas. It emphasizes the need to discard misconceptions that rural patients are less likely to use CAM and to ensure that discussion about CAM are initiated routinely with all cancer patients. It also highlights the need for future research efforts to focus on strategies to improve communication between health professionals and cancer patients about CAM.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

National Center for Complementary and Integrative Health. What is complementary and alternative medicine. http://nccam.nih.gov/health/whatiscam. Accessed January 11, 2013.

Horneber

Bueschel

Dennert

Less

Ritter

Zwahlen

. How many cancer patients use complementary and alternative medicine: a systematic review and meta-analysis. Integr Cancer Ther. 2012;11:187-203.

MacLennan

Wilson

Taylor

. The escalating cost and prevalence of alternative medicine. Prev Med. 2002;35:166-173.

Arthur

Belliard

Hardin

Knecht

Chen

Montgomery

. Practices, attitudes, and beliefs associated with complementary and alternative medicine (CAM) use among cancer patients. Integr Cancer Ther. 2012;11:232-242.

Ryan

Heckler

Roscoe

. Ginger (Zingiber officinale) reduces acute chemotherapy-induced nausea: a URCC CCOP study of 576 patients. Support Care Cancer. 2012;20:1479-1489.

Ezzo

Richardson

Vickers

. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev. 2006;(2):CD002285.

Beatty

Adams

Sibbritt

Wade

. Evaluating the impact of cancer on complementary and alternative medicine use, distress and health related QoL among Australian women: a prospective longitudinal investigation. Complement Ther Med. 2012;20:61-69.

Lawenda

Kelly

Ladas

Sagar

Vickers

Blumberg

. Should supplemental antioxidant administration be avoided during chemotherapy and radiation therapy? J Natl Cancer Inst. 2008;100:773-783.

Meijerman

Beijnen

Schellens

. Herb-drug interactions in oncology: focus on mechanisms of induction. Oncologist. 2006;11:742-752.

10.

Smith

Clavarino

Long

Steadman

. Why do some cancer patients receiving chemotherapy choose to take complementary and alternative medicines and what are the risks? Asia Pac J Clin Oncol. 2014;10:1-10.

11.

Howat

Veitch

Cairns

. A descriptive study comparing health attitudes of urban and rural oncology patients. Rural Remote Health. 2006;6(4):3.

12.

Smith

Humphreys

Lenard

Jones

Prince

Han

. Still the doctor—by a country mile! Preferences for health services in two country towns in north-west New South Wales. Med J Aust. 2004;181:91-95.

13.

Robinson

Chesters

. Rural diversity in CAM usage: the relationship between rural diversity and the use of complementary and alternative medicine modalities. Rural Society. 2008;18(1):64-75.

14.

Wardle

Lui

Adams

. Complementary and alternative medicine in rural communities: current research and future directions. J Rural Health. 2012;28:101-112.

15.

Wilkinson

Simpson

. High use of complementary therapies in a New South Wales rural community. Aust J Rural Health. 2001;9:166-171.

16.

Sherwood

. Patterns of use of complementary health services in the south-west of Western Australia. Aust J Rural Health. 2000;8:194-200.

17.

Wilkinson

Jelinek

. Complementary medicine use among attendees at a rural health screening clinic. Complement Ther Clin Pract. 2009;15(2):80-84.

18.

Wardle

Sibbritt

Adams

. Referrals to chiropractors and osteopaths: a survey of general practitioners in rural and regional New South Wales, Australia. Chiropr Man Therap. 2013;21(1):21-25.

19.

Wardle

Adams

Lui

. A qualitative study of naturopathy in rural practice: a focus upon naturopaths’ experiences and perceptions of rural patients and demands for their services. BMC Health Serv Res. 2010;10:185.

20.

Wardle

Adams

Magalhaes

Sibbritt

. Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: a step towards explaining high CAM use in rural health? Aust J Rural Health. 2011;19:197-204.

21.

Dobos

Voiss

Schwidde

. Integrative oncology for breast cancer patients: introduction of an expert-based model. BMC Cancer. 2012;12:539.

22.

Herron

Glasser

. Use of and attitudes toward complementary and alternative medicine among family practice patients in small rural Illinois communities. J Rural Health. 2003;19:279-284.

23.

McLaughlin

Lui

Adams

. Complementary and alternative medicine use among older Australian women—a qualitative analysis. BMC Complement Altern Med. 2012;12:34.

24.

Davis

Butow

Mullan

Clarke

. Cancer patient disclosure and patient-doctor communication of complementary and alternative medicine use: a systematic review. Oncologist. 2012;17:1475-1481.

25.

Gillett

Ientile

Hiscock

Plank

Martin

. Complementary and alternative medicine use in radiotherapy: what are patients using? J Altern Complement Med. 2012;18:1014-1020.

26.

Richardson

Sanders

Palmer

Greisinger

Singletary

. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18:2505-2514.

27.

Juraskova

Hegedus

Butow

Smith

Schofield

. Discussing complementary therapy use with early-stage breast cancer patients: exploring the communication gap. Integr Cancer Ther. 2010;9:168-176.

28.

Mercurio

Eliott

. Trick or treat? Australian newspaper portrayal of complementary and alternative medicine for the treatment of cancer. Support Care Cancer. 2011;19:67-80.

29.

Butler

Owen-Smith

DiIorio

Goodman

Liff

Steenland

. Use of complementary and alternative medicine among men with prostate cancer in a rural setting. J Community Health. 2011;36:1004-1010.

30.

Regional Development Australia. Darling Downs and South West regional roadmap 2013/2014. http://www.rda-ddsw.org.au/. Accessed December 20, 2014.

31.

Klafke

Eliott

Wittert

Olver

. Prevalence and predictors of complementary and alternative medicine (CAM) use by men in Australian cancer outpatient services. Ann Oncol. 2012;23:1571-1578.

32.

Miller

Boyer

Butow

Gattellari

Dunn

Childs

. The use of unproven methods of treatment by cancer patients. Frequency, expectations and cost. Support Care Cancer. 1998;6:337-347.

33.

Sirois

. Motivations for consulting complementary and alternative medicine practitioners: a comparison of consumers from 1997-8 and 2005. BMC Complement Altern Med. 2008;8:16.

34.

Australian Standard Geographical Classification—Remoteness Area (ASGC-RA). http://www.health.gov.au/internet/otd/Publishing.nsf/Content/RA-intro. Accessed March 9, 2013.

35.

Australian Institute of Health and Welfare. Rural, regional and remote health: a guide to remoteness classifications. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459567. Accessed November 3, 2013.

36.

R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2013. http://www.R-project.org/. Accessed March 27, 2015.

37.

Adams

Sibbritt

Lui

. The urban-rural divide in complementary and alternative medicine use: a longitudinal study of 10,638 women. BMC Complement Altern Med. 2011;11:2.

38.

Butow

Mullan

. The use and perceived benefits resulting from the use of complementary and alternative medicine by cancer patients in Australia. Asia Pac J Clin Oncol. 2010;6:342-349.

39.

Molassiotis

Fernadez-Ortega

Pud

. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005;16:655-663.

40.

Wardle

Adams

Sibbritt

. Acupuncture in Australian general practice: trends in reimbursed acupuncture services from 1995 to 2011. Acupunct Med. 2013;31:45-50.

41.

Eisenberg

Kessler

Van Rompay

. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med. 2001;135:344-351.

42.

Schofield

Diggens

Charleson

Marigliani

Jefford

. Effectively discussing complementary and alternative medicine in a conventional oncology setting: communication recommendations for clinicians. Patient Educ Couns. 2010;79:143-151.

43.

Corbin Winslow

Shapiro

. Physicians want education about complementary and alternative medicine to enhance communication with their patients. Arch Intern Med. 2002;162:1176-1181.