Investigation of usage,attitudes toward complementary and alternative medicine among cancer patients in Turkey during the COVID-19 pandemic 1

Abstract

BACKGROUND:

Complementary and alternative medicines (CAM) are being uses more often with cancer patients.

OBJECTIVE:

This study aimed to investigate attitudes, use and influencing factors of CAM among cancer patients during the COVID-19 pandemic.

METHODS:

This descriptive, cross-sectional study was conducted on 407 cancer patients in Turkey. The study was conducted during July-September 2021 using a Questionnaire that included a Complementary, Alternative and Conventional Medicine Attitude Scale (CACMAS). Pearson’s Chi-Squared Test, Mann-Whitney U, Kruskal Wallis, and logistic regression were all utilized.

RESULTS:

The findings revealed that 76.2% of the participants stated that they used CAM methods while undergoing cancer treatment, and 65.2% of those who did so kept from sharing this information to medical professionals. Phytotherapy was the most common CAM method used by patients. The use of CAM was found to be significantly higher among those who were 55–64 years of age, married, secondary school graduates, non-smokers, CAM users before their cancer diagnosis, and who had a family history of cancer (p < 0.05). The participants’ average CACMAS scores were 112.20±16.53. Among those who used CAM during treatment, non-smoking, overweight-obese participants had higher CACMAS scores (p < 0.05).

CONCLUSION:

Due to the high prevalence of CAM usage among cancer patients and possible interaction effects with chemotherapy medications, it is important for healthcare professionals to assess and educate cancer patients regarding CAM use. Additional research is needed to determine potential interactions, as well as pros and cons of CAM use during cancer treatment.

Keywords

Attitude complementary therapies COVID-19 neoplasms patients phytotherapy traditional medicine

1 Introduction

Cancer is characterized by the excessive and unregulated growth of bodily cells [1]. Approximately 10 million deaths caused by cancer and 19 million newly diagnosed cases occurred globally in 2020 [2]. According to projections, by the year 2040, while the number of deaths related to cancer is forecast to reach 16 million, the incidence of cancer is anticipated to reach 28 million [3]. Cancer is the second most prevalent cause of mortality globally, following cardiovascular disorders, and its occurrence is on the rise [4]. The conventional approaches employed in the treatment of cancer include radiotherapy, chemotherapy, surgery, immunotherapy, hormone therapy, and targeted therapy [5]. These treatments may be administered singly or in combination, with the specific therapy modality being determined by the cancer diagnosis, individual attributes, and disease stage. An increasing number of patients with cancer are also choosing complementary and alternative medicine (CAM) for treating their cancer [6].

Complementary and alternative medicine refers to a comprehensive body of knowledge, skills, and practices that may or may not be scientifically explained. These practices are based on theories, beliefs, and experiences sometimes specific to different cultures. They are used for the purpose of preventing, diagnosing, and treating physical and psychological diseases, as well as maintaining overall health [7]. The utilization of CAM shows significant variations across countries and regions within the same country. CAM is widely used by both individuals who are in good health and those who have chronic conditions such arthritis, HIV/AIDS, and cardiovascular disorders [8]. One reason for increasing use of CAM is the simultaneous increase in life expectancy and prevalence of chronic illnesses [9]. The percentage of cancer patients who use CAM is 40% in Australia, 46% in Japan, 60% in Canada, 71.2% in Turkey, 70–83% in the USA, 85% in Tunisia, and 98% in Shanghai [10 –12].

Cancer patients who actively participate in their treatment may be inclined to try CAM [13]. Patients report using CAM to increase the efficacy of conventional treatments [13]. Many cancer patients report using CAM to improve their physical and emotional well-being and to cope with the negative effects of conventional treatment [9, 14]. CAM use has been found to alleviate patients’ treatment side effects and imrove their physical and mental conditions [13]. However, in many cases, patients do not use CAM as a complementary approach, but instead they use it as an alternative to traditional treatments, changing their main therapy to CAM, which can significantly worsen their prognosis [10]. Although CAM are used as an adjunct to conventional medicine in high-income countries, it is used as a primary healthcare service in low-income countries such as Chile, Brazil, and India [3]. Choosing to delay or decline conventional medical care owing to a belief in CAM can impact the chances of recovery for individuals with cancer [10].

In cancer patients, the use of CAM increases at the time of initial diagnosis, during increased stress, and upon receiving a poor prognosis [15]. In studies of cancer patients, CAM is used more by women, young people, and those with higher education levels [16, 17]. A number of cancer patients use CAM as a means to alleviate the adverse effects of chemotherapy and radiotherapy. Additionally, some individuals use CAM in order to proactively avoid disease, improve overall well-being, reduce symptoms, and strengthen their immune system [18]. Despite the common use of CAM by cancer patients, a significant number of them choose not to disclose their CAM usage to their healthcare professionals [19]. According to a study, 65.0% of cancer patients in Canada and 55.7% in Nepal preferred for CAM based on recommendations from their loved ones instead of seeking advice from a healthcare professionals [20].

Studies have shown that the combined use of chemotherapy and herbal products is more effective in suppressing tumors and reducing the number of remissions compared to chemotherapy alone [21]. In addition, chemotherapy drugs can cause many adverse reactions [22]. It has been reported that some herbs, especially in combination with some chemotherapy drugs, may reduce the effect of drugs and cause serious liver toxicity [21].

The global utilization of herbal products has shown a consistent rise, particularly from the 1990s till now. This growth can be attributed to reasons such as the simplicity of obtaining and affordability of these products, which have facilitated their widespread acceptance [23].

The purposes of this study were to examine: 1) self-reported use of CAM among cancer patients, 2) cancer patients attitudes toward CAM, and 3) relationships between CAM use and sociodemographic characteristics, cancer type, and prior COVID-19 history among cancer patients.

2 Methods

2.1 Study design

The population of this descriptive and cross-sectional study comprises all cancer patients who underwent outpatient and inpatient therapy at the Oncology Service and Oncology Day therapy Unit of Fırat University Faculty of Medicine in Elazığ, in a province in eastern Turkey, from July to September 2021. A number of patients treated; as of the date of the fieldwork of the study, it was 934. The sample size was calculated using the formula n = Nt²pq/d²(N-1)+t²pq [24].

N: Size of the universe (934)

n: Size of the sample (411)

p: The prevalence of CAM usage, which was approximated as 77.9% (68.6–87.2%) based on studies [25, 26]

q: Frequency of absence of the CAM (22.1%)

d: Confidence interval, which was accepted as 3%.

t: 1.96

The study sample was determined as 411 people with a 95% confidence interval and 3% margin of error. Inclusion criteria for the study; the individual’s willingness, being open to communication and cooperation, and giving consent. The exclusion criteria are those with impairments in hearing, vision, or cognition that impede communication, and anyone who decline to participate in the interview. In this study, 407 (99.0%) participants were reached. The researchers conducted a face-to-face survey technique in order to complete the two-part survey form. The average time for completing the questionnaire was 20 minutes for each participant.

2.2 Data collection tools

A questionnaire consisting of two parts was used to collect data in the study. Part I consisted of 14 questions regarding sociodemographic characteristics of the participants, 15 questions on the type of cancer, treatments, and medical characteristics, a prior history of COVID-19, and 24 questions on the use, type and associated factors of CAM use. The researchers created the survey (Part I) questionnaire using information from the literature [12 , 28]. Body mass index (BMI) estimates were calculated based on the participants’ self-reported estimated height and weight values.

Part II of the questionnaire consisted of the Complementary, Alternative and Conventional Medicine Attitude Scale (CACMAS). The scale was developed by McFadden et al. [29] to determine participants’ attitudes toward CAM. The scale, adapted into Turkish by Kose et al., [30] is in seven-point Likert type scale, with values ranging between “strongly disagree” (1) and “strongly agree” (7). The CACMAS consists of three sub-dimensions, which are, intellectual perspective on complementary medicine (1–56 points/eight items), dissatisfaction with modern medicine (1–70 points/ten items), and holistic view on health (1–63 points/nine items). The scale includes five items (1, 4, 8, 9, 26) that are reverse scored. A higher overall score indicates a more positive attitude towards CAM. The scale has a Cronbach Alpha values for the sub- sub-dimensions were as follows: 0.86 for the intellectual view of the alternative medicine sub-dimension, 0.80 for the unhappiness with contemporary medicine sub-dimension, and 0.68 for the holistic view of the health sub-dimension [30].

2.3 Statistical analysis

The statistical analyse were conducted using the IBM Statistical Package for Social Sciences (SPSS) version 22. The study presents descriptive data in the form of n, %, median (minimum-maximum), and mean±standard deviation (Mean±SD). The Pearson’s Chi-Squared Test was employed to compare categorical data across groups. The normality assumption of continuous variables was assessed using the Kolmogorov-Smirnov test. As the data did not follow a normal distribution, subsequent analyses were conducted using the Mann-Whitney U test, Kruskal Wallis test, Bonferroni test, and logistic regression analysis. A significance level of p < 0.05 was selected.

3 Results

The mean age of the participants was 60.09±14.67 (min:18, max:95). Females accounted for 50.4% (n = 205) of the participants, while 76.2% (n = 310) were married. Additionally, 38.8% had completed elementary school education. The majority (62.2%) resided in the city center. A total of 10.1% (n = 41) of the participants were self-employed, 32.4% (n = 132) were retired, and 9.1% (n = 37) were public servants; the remaining 48.4% (n = 197) were unemployed. The distribution of participants according to their sociodemographic characteristics is given in Table 1.

Table 1
Distribution of participants by sociodemographic characteristics

Sociodemographic n %

characteristics (n = 407)

Gender

Female 205 50.4

Male 202 49.6

Age

18–44 65 16.0

45–54 62 15.2

55–64 112 27.5

65–74 100 24.6

75–95 68 16.7

Marital status

Single 32 7.8

Married 310 76.2

Divorced/widow 65 16.0

Educational status

Literate 136 33.4

Primary school 158 38.8

Secondary school 39 9.6

High school 51 12.5

University 23 5.7

Family type

Extended 80 19.7

Nuclear 327 80.3

Place of residence

City center 253 62.2

County center 57 14.0

Village 97 23.8

Occupation

Unemployed 197 48.4

Worker 26 6.4

Retired 132 32.4

Government employee 11 2.7

Self-employment 41 10.1

Monthly income^*

≤2000 Turkish lira 175 43.0

2001–3000 Turkish lira 155 38.1

3001–4000 Turkish lira 44 10.8

≥4001 Turkish lira 33 8.1

Social insurance

Yes 299 73.4

No 108 26.6

Sociodemographic	n	%
Gender
Female	205	50.4
Male	202	49.6
Age
18–44	65	16.0
45–54	62	15.2
55–64	112	27.5
65–74	100	24.6
75–95	68	16.7
Marital status
Single	32	7.8
Married	310	76.2
Divorced/widow	65	16.0
Educational status
Literate	136	33.4
Primary school	158	38.8
Secondary school	39	9.6
High school	51	12.5
University	23	5.7
Family type
Extended	80	19.7
Nuclear	327	80.3
Place of residence
City center	253	62.2
County center	57	14.0
Village	97	23.8
Occupation
Unemployed	197	48.4
Worker	26	6.4
Retired	132	32.4
Government employee	11	2.7
Self-employment	41	10.1
Monthly income^*
≤2000 Turkish lira	175	43.0
2001–3000 Turkish lira	155	38.1
3001–4000 Turkish lira	44	10.8
≥4001 Turkish lira	33	8.1
Social insurance
Yes	299	73.4
No	108	26.6

^*The minimum wage amount at the date of the research is 2825,90 Turkish lira.

In this study, 18.7% (n = 76) of the participants had a history of COVID-19 and 48.9% (n = 199) were vaccinated against COVID-19. The most common cancer among the participants was gastrointestinal system cancers with 38.4% (n = 156). The most commonly used conventional treatment methods received by the participants were chemotherapy, surgery, and radiotherapy respectively.

Prior to their cancer diagnosis, 85.3% (n = 347) of participants reported using CAM. During their treatment, 76.2% (n = 310) continued using CAM. In 3.5% (n = 14) of participants, CAM was used in place of conventional therapy. The phytotherapy used most was black mulberry, garlic, and linden in that order.

The primary motivation of the participants in using CAM was to reduce symptoms. Out of the CAM users, 61.6% (n = 191) used it at least three times a week, and 65.2% (n = 202) did not inform their healthcare professional about their CAM usage (Table 2). Significantly higher use of CAM was observed in individuals aged 55–64, married, with secondary school education, non-smokers, with a family history of cancer, and those who had previously used CAM before their cancer diagnosis (p < 0.05, Table 3). Logistic regression analysis showed that individuals who took regularly prescription medication frequently had a 1.98 times higher (95% confidence interval [CI]: 1.45–6.97) of using complementary and alternative medicine (CAM). Furthermore, those who had been diagnosed with cancer for 1 year or longer had a 2.0 times higher (95% CI: 1.18–3.32) of using CAM. Additionally, individuals who had used CAM before their cancer diagnosis had a 2.16 times higher (95% CI: 1.12–4.18). The logistic regression analysis in Table 4 shows a comparison of participants’ use of CAM according to sociodemographic factors.

Table 2

Characteristics related to CAM

Variables	n	%
Treatment type^* (n = 407)
Chemotherapy	374	91.9
Surgical	212	52.1
Radiotherapy	115	28.3
Smart drug	77	18.9
Immunotherapy, hormone therapy	11	2.7
CAM method^* (n = 310)
Phytotherapy	292	94.2
Prayer-spiritual practices	223	71.9
Apitherapy	157	50.6
Vitamin supplement	104	33.5
Spa-hydrotherapy	25	8.1
Cup-hijama application	22	7.1
Physiotheraphy	13	4.2
Leech application	8	2.6
Massage	7	2.3
Psychotherapy	6	1.9
Donkey’s milk	5	1.6
Meditation	2	0.6
Music therapy	1	0.3
Chiropractic	1	0.3
Purpose of using CAM^* (n = 310)
Reduce symptoms	279	90.0
Strengthen the immune system	231	74.5
As a support for treatment	186	60.0
To do everything against the disease	145	46.8
To relax psychologically	120	38.7
Influence of my family	106	34.2
Instead of conventional treatment	11	3.5
CAM duration (n = 310)
≤3 months	163	52.6
4–7 months	66	21.3
8–12 months	54	17.4
≥12 months	27	8.7
Frequency of use of CAM (n = 310)
Once a week	62	20.0
Twice a week	57	18.4
Three or more times a week	191	61.6
Information about CAM^* (n = 310)
Family/Friend	227	73.2
Media/Internet	193	62.3
Health professional	72	23.2
Patient advice	59	19.0
CAM side effect status (n = 310)
Yes	18	5.8
No	292	94.2
The result from the use of CAM (n = 310)
Any benefit	45	14.5
Partially benefit	209	67.4
Completely benefit	56	18.1
Sharing the use of CAM with the health professional (n = 310)
Yes	108	34.8
No	202	65.2

^*One person answered more than once.

Table 3

Categorization of CAM usage scenarios according to sociodemographic characteristics

Sociodemographic characteristics (n = 407)	CAM users		CAM nonusers		Statistics^a
Gender	n	% ^*	n	% ^*
Female	153	74.6	52	25.4	χ² = 0.535
Male	157	77.7	45	22.3	p = 0.487
Age
< 45	49	75.4	16	24.6
45–54	47	75.8	15	24.2
55–64	94	83.9	18	16.1	χ² = 11.698
65–74	78	78.0	22	22.0	p = 0.020
≥75	42	61.8	26	38.2
Marital status
Single/divorced/widow	64	66.0	33	34.0	χ² = 7.281
Married	246	79.4	64	20.6	p = 0.009
Educational status
Literate	97	71.3	39	28.7
Primary school	117	74.1	41	25.9
Secondary school	36	92.3	3	7.7	χ² = 9.674
High school	43	84.3	8	15.7	p = 0.046
University	17	73.9	6	26.1
Social insurance
Yes	238	79.6	61	20.4	χ² = 7.309
No	72	66.7	36	33.3	p = 0.008
Smoking status
Yes	20	57.1	15	42.9	χ² = 7.635
No	290	78.0	82	22.0	p = 0.011
Regularly used prescription medications
Yes	200	80.0	50	20.0	χ² = 5.245
No	110	70.1	47	29.9	p = 0.024
The status of having COVID-19 in the past
Yes	59	77.6	17	22.4	χ² = 0.110
No	251	75.8	80	24.2	p = 0.881
Diagnosis time
< 1 years	139	69.5	61	30.5	χ² = 10.158
1–5 years	151	83.4	30	16.6	p = 0.006
v > 5 years	20	76.9	6	23.1
Family history of cancer
Yes	135	82.3	29	17.7	χ² = 5.723
No	175	72.0	68	28.0	p = 0.018
CAM usage status before diagnosis
Yes	272	78.4	75	21.6	χ² = 6.385
No	38	63.3	22	36.7	p = 0.014
Type of cancer
Gastrointestinal system	110	70.5	46	29.5
Breast	55	76.4	17	23.6
Genitourinary system	50	78.1	14	21.9	χ² = 7.535
Respiratory system	49	79.0	13	21.0	p = 0.274
Lymphoid/hematopoietic system	31	88.6	4	11.4
Central nervous system	10	90.9	1	9.1
Musculoskeletal system	5	71.4	2	28.6

^*Row percentage is used. ^aPearson chi square test

Table 4

Comparison of participants’ use of CAM according to sociodemographic factors with logistic regression analysis

Factor	Odds ratio	95% Confidence interval	p
Marital status
Single/divorced/widow	1
Married	1.962	1.129–3.409	0.017
Educational status
Literate	1
Primary school	2.227	1.118–4.435	0.023
Secondary school and above	2.899	1.391–6.043	0.005
Social insurance
Yes	1.447	0.842–2.488	0.181
No	1
Smoking status
Yes	1
No	3.182	1.451–6.977	0.004
Regularly used prescription medications
Yes	1.981	1.180–3.324	0.010
No	1
Diagnosis time
<1 years	1
1 years and above	2.053	1.248–3.377	0.005
Family history of cancer
Yes	1.486	0.878–2.513	0.140
No	1
CAM usage status before diagnosis
Yes	2.168	1.123–4.184	0.021
No	1

Complementary, Alternative and Conventional Medicine Attitude Scale total scores and subscale scores of the participants were as follows: CACMAS 112.20±16.53, intellectual perspective on complementary medicine 32.40±9.78, dissatisfaction with modern medicine 25.38±9.62, and holistic view on health was 54.42±5.44. Participants who were non-smokers, overweight/obese, and who used CAM during the treatment period showed higher CACMAS scores (p < 0.05). There was a significant association between the participants’ frequency of CAM usage and their scores on the CACMAS (p < 0.05, Table 5). Participants’ CACMAS scores did not change according to gender, age, marital status, and education level (p > 0.05).

Table 5

Distribution of CACMAS scores of participants according to various variables

Variables	n	CACMAS scores (Mean±SD)	CACMAS scores Median (min-max)	Statistics^*
BMI (n = 407)
Thin	29	110.45±17.43	111 (73–152)
Normal	193	109.41±16.14^**	107 (50–173)	χ² = 12.791
Overweight and obese	185	115.38±16.32^**	115 (85–177)	p = 0.002
Smoking status (n = 407)
Yes	35	104.06±18.24	101 (73–152)	U = 4339.00
No	372	112.97±16.18	112 (50–177)	p = 0.001
CAM usage status before diagnosis (n = 407)
Yes	347	112.58±15.47	112 (73–160)	U = 9179.50
No	60	110.00±21.70	107 (50–177)	p = 0.143
Status of using CAM during the treatment process (n = 407)
Yes	310	113.41±16.51	113 (50–177)	U = 12193.00
No	97	108.34±16.08	106 (73–152)	p = 0.005
Status of CAM recommendation by healthcare professional (n = 310)
Yes	70	107.71±14.83	109 (74–160)	U = 6278.00
No	240	115.07±16.64	113 (50–177)	p = 0.001
Sharing the use of CAM with the healthcare professional (n = 310)
Yes	108	111.03±16.08	110 (74–160)	U = 9434.00
No	202	114.68±16.64	113 (50–177)	p = 0.050
Status of receiving the CAM application from certified health professional (n = 310)
Yes	63	107.05±14.50	107 (74–138)	U = 5714.00
No	247	115.03±16.63	114 (50–177)	p = 0.001
Frequency of use of CAM (n = 310)
Once a week	62	108.23±15.67^**	106 (74–149)	χ² = 9.517
Twice a week	57	112.39±12.96	109 (86–151)	p = 0.009
Three or more times a week	191	115.39±17.38^**	115 (50–177)
The result from the use of CAM (n = 310)
Any benefit	45	111.51±16.55	108 (85–160)	χ² = 5.418
Partially benefit	209	112.77±16.28	112 (50–173)	p = 0.067
Completely benefit	56	117.30±17.03	119 (77–177)
The status of recommending CAM methods to other cancer patients (n = 310)
Yes	247	113.74±17.02	113 (50–177)	U = 7238.50
No	63	112.10±14.42	111 (88–160)	p = 0.393
Should conventional therapy be discontinued to use CAM? (n = 310)
Yes	8	126.25±23.38	122 (100–173)	U = 800.00
No	302	113.07±16.21	112 (50–177)	p = 0.103
CAM side effect status (n = 310)
Yes	18	114.83±16.38	117 (74–144)	U = 2320.00
No	292	113.32±16.55	112 (50–177)	p = 0.404
The state of thinking that there are people who abuse CAM (n = 310)
Yes	266	113.50±16.59	113 (50–177)	U = 5606.00
No	44	112.86±16.24	111 (87–152)	p = 0.655

^*The Mann-Whitney U test was used to compare two independent groups, and the Kruskal Wallis test was used for comparisons between more than two groups. ^**The groups from which the difference originates (Bonferroni test).

4 Discussion

4.1 Personal characteristics associated with cancer

The most common cancer types in this study were gastrointestinal system, breast, and genitourinary system cancers, respectively. These are among the five most prevalent types of cancer worldwide [10 , 31–34]. Examining types of cancer in Turkey, our results showing gastrointestinal cancer as most prevalent supported findings in three of the five of the studies [31 –33]. Poland had lung cancer as one of its’ top three and the top three in Nepal [20] were different than those found in this study [10]. Gastric cancer in Turkey appears to be associated with dietary habits. A case-control study showed that gastric cancer patients in Turkey consumed less fresh fruit, yellow-green vegetables, and meats, while consuming more salted food, condiments, compared with the control group [35].

4.2 Use of CAM during cancer treatment

During the treatment process, 76.2% of the participants used CAM. The prevalence of CAM among cancer patients was found to be 71.2% in Turkey [12], 69.9% in Saudi Arabia [36], 51% in U.S. [37] 46.7% in Poland [10], 31.6% in Nepal [20], 29.0% in Germany [38], 26.0% in Sweden [17], and 25.5% in Korea [6]. Our findings demonstrated a greater prevalence of CAM usage in comparison to other nations. Possible factors contributing to variations in outcomes include heterogeneity and changes in study designs. The use of CAM might vary throughout nations and communities, as well as within different cities or even among different facilities within the same country.

The patients frequently used CAM methods such as phytotherapy, prayer-spiritual practices, and apitherapy. Phytotherapy refers to the use of traditional herbal remedies and medicines derived from plants [39], while apitherapy involves the utilization of bee products such as honey, propolis, royal jelly, bee pollen, and bee venom for treating diseases [40]. The most commonly used CAM methods were; Ozkaya et al.’s study [41], phytotherapy, vitamin supplements, apitherapy, Toprak et al.’s study [27]; phytotherapy, spa, acupuncture, in the German study [42], vitamin/mineral supplements, homeopathy, yoga, in the Nepal study, ayurveda, yoga, phytotherapy [20], and in the Swedish study, vitamins/minerals, natural products, relaxation [17]. The cost-effectiveness and easy availability of phytotherapy may contribute to its extensive use in this study. Another crucial concern is the lack of oversight and absence of empirical support for these procedures. The primary issue with the use of herbal material, typically acquired from herbalists, lies in the combination of several metabolites that arise from photosynthesis in plants. The medicinal or harmful effect of any substance is dependent upon the dosage administered. Therefore, the idea that “it is harmless if it is natural” is extremely wrong [43 –45]. Prayer is a method used as a spiritual approach in Turkey, where the majority of the population is Muslim [46]. The fact that participants use prayer-spiritual practices as a CAM method can be explained by the fact that prayer has no side effects or costs.

The primary objectives of individuals using CAM were to alleviate symptoms and enhance/strengthen the immune system. The primary objectives of using CAM were to strengthen the immune system and alleviate pain, as demonstrated in a study conducted in Turkey [27]. Additionally, CAM usage was also aimed at improving overall health and alleviating symptoms, as seen by a study conducted in Australia [11].

The use of CAM was significantly more common in the participants who were diagnosed within 1–5 years (p < 0.05). The study conducted by Kucukoner et al. revealed a notable prevalence of CAM utilization among patients diagnosed during a period of 2–3 years [47]. As the duration since the cancer diagnosis progresses, the challenges faced by patients intensify. Consequently, there is a higher likelihood of utilizing CAM.

The use of CAM was found to be significantly more common in those with a family history of cancer (p < 0.05). Turan et al.’s [12] study was similar to our study. In the study of Dagtas Gulgun and Kaya, the use of CAM was significantly higher in those without a family history of cancer [48].

In this study, 65.2% of the participants using CAM did not share their use of CAM with the healthcare professional. In the literature, this frequency was between 33.0–65.0%. In the literature, patients stated that they did not share their use of CAM because of fear of disapproval by healthcare professionals, exclusion from clinical trials, or simply because no healthcare professionals asked [10]. Possible factors contributing to this condition include healthcare professionals’ failure to inquire about patients’ use of complementary and alternative medicine (CAM), patients’ inclination to conceal their CAM usage owing to apprehension of adverse reactions or criticism, and the worry stemming from the lack of endorsement by healthcare experts.

4.3 Use of CAM and sociodemographic characteristics

The use of CAM was more prevalent among males, although it did not reach statistical significance (p > 0.05). The studies accomplished in Turkey showed similarities to our findings [12, 47]. There were also studies [10 , 49] that found the prevalence of CAM use to be significantly higher among women than among the general population.

Participants aged 55–64 showed a considerably higher prevalence of CAM usage (p < 0.05). In the Swedish study found a significant rise in the use of CAM among participants between the ages of 50 and 69 [17]. Similarly, the Italian study, the use of CAM was significantly higher at the aged 70 and above population [50]. According to a study conducted in Germany, the use of CAM showed a notable decline as individuals became older [51]. In the study conducted in Iran, the use of CAM was frequent but not significant in the study conducted in participants aged 60 and above [52], as well as among individuals diagnosed with breast cancer [42]. Several studies in the literature have reported no significant difference between age and the usage of CAM [9 , 49]. This situation may be due to the differences in the samples of the region where the studies were carried out.

In this study, the use of CAM in married people was found to be statistically significantly more frequent (p < 0.05). The literature was consistent with our study [53, 54]. However, there were also studies in which no relationship was found between marital status and CAM use [36, 52]. Given the efficacy of family and friend guidance in using of CAM, it is possible that the prevalence of CAM usage is higher among individuals who are married.

The frequency of CAM use was significantly higher among people who completed secondary education (p < 0.05). In the study conducted by Dagtas Gulgun and Kaya, it was shown that the use of CAM among secondary school graduates was more prevalent, although the difference was not statistically significant [48]. The study conducted in Iran found that the use of CAM among secondary and high school graduates was high although it was not statistically significant [52]. The frequency of complementary and alternative medicine (CAM) use showed a considerable increase as the educational attainment of participants rose, as demonstrated by studies conducted in Italy [50], Germany [42], and Slovakia [55]. In addition, there were studies in the literature in which the use of CAM increased significantly as the level of education decreased [47, 56]. The use of CAM is on the rise in industrialized nations, paralleling the growth in educational attainment. This may be because the CAM method used is related to education level.

Participants with social insurance had a considerably higher frequency of CAM use (p < 0.05). The study of Can et al. was consistent with our study [57]. The study of Dagtas Gulgun and Kaya, the use of CAM by insured patients was frequent but not significant [48]. Given that conventional methods currently dominate cancer therapy and social security is available, it may be inferred that there is a greater inclination towards CAM in order to alleviate the adverse effects connected with these treatments.

Nonsmokers used CAM more frequently than in smokers, in this study (p < 0.05). Our findings were in-line-with those of Turan and colleagues [12]. However, our findings did not support those of Loquai and colleagues, who found no significant difference between smokers and non-smokers [51]. Individuals who do not smoke may prioritize their health and well-being more often than smokers, and use CAM more often.

4.4 CACMAS

The mean CACMAS score of the participants was 112.20±16.53. Participants showed a positive view toward CAM, as evidenced by the scores surpassing the mean score that could be achieved. This is similar to the mean CACMAS score for pediatric nurses (112.01±20.07) in [58], and midwifery students was (111.5±19.1) [[59]; lower than scores for patients attending an internal medicine outpatient clinic (115.78±18.81) [21]; and higher than that of patients attending a university hospital polyclinic (109.05±15.44) [53], and of medical school students (104.72±16.46) [60]. A higher score indicates the participant’s attitude towards CAM is more positive.

Of the sociodemographic scores examined in this study, only smoking was related to CACMAS scores. Non-smokers demonstrated significantly higher CACMAS scores (p < 0.05). Once again, this may be due to non-smokers’ having better awareness of their health and their seeking additional care with CAM.

As expected, participants who used CAM during the treatment period had significantly higher CACMAS scores (p < 0.05). However, in another study conducted with patients who applied to the internal medicine outpatient clinic, the scores of participants who did not use CAM were higher and not significant [21]. Our findings were anticipated, as higher CACMAS scores are associated with positive attitudes toward CAM and those wth a positive attitude toward CAM would be expected to use CAM more often than those with negative attitudes toward CAM.

The scores of the participants who recommended CAM methods to other cancer patients were high but not significantly different from those who did not recommend CAM to others (p > 0.05). A prior study conducted with pediatric nurses found, the scores of those recommending CAM to others were significantly higher than those who did not recommend CAM to others [58]. Benefiting from using CAM can trigger recommendations.

4.5 Limitations

This study used materials from a survey based on the participants’ self-reports. As some of the questions investigated past events, so recall bias might have influenced the results. Another limitation is that the present study utilized a cross-sectional methodology, and all individuals resided in a city in Turkey, thus limiting generalizability of the findings. Despite these limitations, this study sheds light on important aspects of CAM use among Turkish patients with cancer.

5 Conclusion

Two thirds of the cancer patients in this study, reported using CAM alongside their traditional cancer therapies. Phytotherapy was the most commonly used CAM method. Over half of the patients using CAM did not share their use of CAM with their healthcare professionals. These findings, coupled with potential interactions of phytotherapy with conventional drugs, suggest the importance of physician-patient communications regarding CAM. This study makes a valuable contribution to the field of cancer patient rehabilitation and therapy, as well as highlighting the significance of exploratory studies in suggesting future research requirements. These results also indicate the need for evidence-based outcome studies of traditional therapies coupled with CAM use, to give health care professionals the scientific information to share with their patients. That is, healthcare professionals should evaluate and inform cancer patients about the use of CAM. It may be beneficial to offer, CAM courses to the educational curricula in Medical and Health Care Educational Faculties, with upgrades occurring according to research findings. These courses may also be offered via continuing education classes for recquisite Continued Education Units. Since patients may obtain incorrect information about CAM from the media and the internet, it is important that doctors and other health care providers working in the field of oncology, be knowledgeable about the current literature on CAM. Sharing the results obtained with large-scale studies on the use of CAM will contribute to raising public awareness as to the benefits and disadvantages of different types of CAM use.

Ethical approval

Ethical approval for the research has been obtained from the Fırat University Non-Interventional Research Ethics Committee, with approval number 1918 dated April 27, 2021. Additionally, permission was obtained from the Chief Physician of Fırat University Hospital.

Informed consent

Informed consent was obtained from all participants included in the study.

Conflict of interest

The authors declare no conflicts of interest that may have influenced this work.

Footnotes

Acknowledgments

This article was derived from my doctoral thesis. I express my gratitude to the esteemed Faculty Members of the Department of Public Health at Fırat University, where I successfully completed my doctoral studies. We express our gratitude to all individuals who willingly took part in this study.

Funding

There was no funding for this study.

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Sociodemographic	n	%
characteristics (n = 407)
Gender
Female	205	50.4
Male	202	49.6
Age
18–44	65	16.0
45–54	62	15.2
55–64	112	27.5
65–74	100	24.6
75–95	68	16.7
Marital status
Single	32	7.8
Married	310	76.2
Divorced/widow	65	16.0
Educational status
Literate	136	33.4
Primary school	158	38.8
Secondary school	39	9.6
High school	51	12.5
University	23	5.7
Family type
Extended	80	19.7
Nuclear	327	80.3
Place of residence
City center	253	62.2
County center	57	14.0
Village	97	23.8
Occupation
Unemployed	197	48.4
Worker	26	6.4
Retired	132	32.4
Government employee	11	2.7
Self-employment	41	10.1
Monthly income^*
≤2000 Turkish lira	175	43.0
2001–3000 Turkish lira	155	38.1
3001–4000 Turkish lira	44	10.8
≥4001 Turkish lira	33	8.1
Social insurance
Yes	299	73.4
No	108	26.6