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© 2002 American Society for Clinical Oncology
Complementary and Alternative Medicine Use Among Women With Breast CancerByFrom Dana-Farber Cancer Institute, Boston, MA. Address reprint requests to Lisa M. DiGianni, PhD, Dana-Farber Cancer Institute, 44 Binney St SM204, Boston, MA 02115; email: lisa_digianni{at}dfci.harvard.edu
Abstract: Complementary and alternative medicine (CAM) use has increased in recent years, with at least 42% of individuals in the United States using some form of CAM in 1997. CAM includes a variety of modalities, ranging from nutritionally based interventions to behavioral techniques. This article reviews the status of CAM use among women with breast cancer. Patients are increasingly incorporating CAM into cancer prevention and treatment regimens. The prevalence of CAM use by breast cancer patients varies; however, it is typically higher than among individuals in the general population. Commonly used CAMs among women with breast cancer include nutritional/dietary supplements, relaxation strategies, and various types of social support groups. Apart from psychosocial interventions, little scientific evidence exists regarding the efficacy of CAM use for breast cancer patients. A common theme seen in many studies is that CAM use in women with breast cancer is highly correlated with increased psychosocial distress.
COMPLEMENTARY AND alternative medicine (CAM) is broadly defined as medical practices that are generally not taught in medical schools and are not widely available in United States hospitals.1 CAM includes a wide array of healing philosophies, therapies, and approaches.2 A distinction between alternative and complementary medicine is debated in the literature.3-5 The National Institutes of Health classify complementary therapies as those used in addition to conventional treatment, whereas alternative treatments are used instead of standard care.6 Depending on utilization techniques, some approaches may be considered either complementary or alternative. This article reviews the status of CAM use among women with breast cancer. CAM is becoming more integrated into the medical and political mainstream. In 1992 an Office of Alternative Medicine was established at the National Institutes of Health by congressional mandate, and in 1995 the First Annual International Congress on Alternative and Complementary Medicine in the United States was held.5 At least 27 United States medical schools have established complementary medicine training programs.4 Harvard Medical School recently established the Division for Research and Education in Complementary and Integrative Medical Therapies, with more than 60 Harvard-affiliated faculty members expressing interest in participation.7 CAM has gained a major presence in the industrialized world in recent years. The prevalence of CAM use is largely dependent on what approaches are considered CAM.3,8 The National Institutes of Health categorize CAM into five major domains: (1) alternative medical systems (ie, methods focused on restoring innate harmony); (2) mind-body interventions (ie, meditation and hypnosis); (3) biologically based therapies (ie, herbal remedies and special diet); (4) manipulative and body-based methods (ie, chiropractic treatments); and (5) energy therapies (ie, Qi gong).6 Annual visits to CAM practitioners are estimated to far exceed visits to traditional primary care physicians by as much as 243 million visits.3 The most frequently cited study on the prevalence of CAM use in the general population reports that use of at least one of 16 CAM interventions in the preceding year increased from 34% to 42% between 1990 and 1997.1 In the same study, the likelihood that any individual would visit a CAM practitioner increased from 36% to 46% during this time period. Other studies report varying CAM prevalence rates, with 10% to 40% of general population cohorts reporting some form of CAM use.9,10 Characteristics that consistently predict CAM use include female sex, younger age, and higher income and educational levels.1,11,12 A confounding factor is that women tend to seek out health care services more often than men.13 CAM services are typically not reimbursed by health insurance coverage, with as many as 58% of individuals paying entirely out-of-pocket.1
CAM use is more common among patients with cancer than among individuals in the general population. The prevalence of CAM use by breast cancer patients varies,12,14-16 with reports indicating that 63%17 to 83%18 of breast cancer patients use at least one type of CAM (Table 1). However, women with breast cancer tend to use more CAM than individuals with other types of malignancy.19 This finding may be confounded by the fact that more women than men use CAM.1 Given the interest in the possible relationship between dietary factors and breast cancer risk,20,21 it is not surprising that several studies report a high proportion of breast cancer patients use some form of vitamins or herbs as part of their CAM regimen.12,22,23 Other types of CAMs used by breast cancer patients include massage (53%),19 relaxation techniques (20%),14 and self-help groups (15%).14
The prevalence of CAM use by ethnicity has been studied. In a San Francisco–based study, CAM use was consistently high across four different ethnic groups, though the type of CAM used varied to some degree by ethnicity.24 This study found that African-American women used spiritual healing more frequently than other types of CAM (36%), Chinese women most often reported using herbal remedies (22%), and Latino women used dietary therapies (30%) and spiritual healing (26%). This study also reports significant predictors of CAM use for African-American, Chinese, Latino, and white women: higher income, engaging in exercise, and membership in community or support groups. Alferi et al25 report that of 231 breast cancer patients, more black women used herbal therapies and spiritual healing than did Hispanic or non-Hispanic white patients. A qualitative study used focus group data to compare CAM use between African-American and Hispanic women.26 The authors report higher CAM use among older women of both groups, with younger Hispanic women indicating the most distrust toward the effectiveness of CAM techniques. Breast cancer patients report varying reasons for incorporating CAM into their health care practices. Boon et al12 queried a random sample of Canadian breast cancer survivors to understand the motivation behind CAM use. Women indicated that they sought to boost the immune system (63%), increase quality of life (53%), prevent a cancer recurrence (42%), provide a feeling of control over life (38%), and aid conventional medical treatment (38%).12 Richardson et al18 report similar expectations from CAM treatments in a group of mixed cancer patients at a major cancer center. Patients hoped to improve quality of life (77%), boost immune system (71%), and prolong life (62%). A cohort of Italian breast cancer survivors cited their main reasons for using CAM as physical distress (61%) and psychological distress (21%).11
Few studies provide definitive evidence of the effectiveness of CAM interventions in women with breast cancer. It has been suggested that the true appeal of CAM may be the sense of self-control experienced by the patient.18 A patient’s perceptions and understanding of his/her illness is an evolving process that may have an influence on quality of life.27 Jacobson et al28 reviewed English-language articles published between 1980 and 1997 that reported results of clinical trial research on CAM treatments for breast cancer patients. Of more than 1,000 retrieved citations, only 17 reports consisted of randomized clinical trials, 7 were observational studies, and the remainder were phase I or II clinical trials. The authors conclude that patients interested in exploring CAM for cancer treatment are left with little scientific evidence on which to base their decisions. Because of the limited scientific data on the effectiveness of CAM for cancer treatment, patients may have no alternative but to rely on anecdotal evidence. Gotay and Dumitriu29 report on the role played by health food stores in educating cancer patients on the efficacy of CAM treatments; they indicate that shark cartilage is the most frequent recommendation for breast cancer treatment. Other resources for cancer patients on CAM’s effectiveness include family/friends, the media, and traditional health care providers.30 Many early CAM studies have focused on the effectiveness of behavioral interventions on cancer patients. There is little evidence that these approaches have a direct impact on a patient’s cancer or change overall survival.28 However, several studies have suggested that certain types of CAMs, such as relaxation therapy, may help to reduce distress frequently experienced by patients undergoing chemotherapy or other invasive treatment31,32 and may also aid in increasing cancer patients’ overall quality of life.9 Guided imagery is another tool that may be beneficial for cancer patients coping with pain management issues.33 Other behavioral modalities have also been studied, such as massage and body therapy, and have been found to provide some physical and emotional benefits for cancer patients.34,35 Some cancer support groups have also been found to be useful in enhancing breast cancer patients’ physical and emotional quality of life.36 Spiegel et al37 have conducted several studies exploring the effect of supportive-expressive group therapy (a unique intervention designed to encourage terminally ill patients to explore their feelings about the effect their illness has on their lives) on women with metastatic breast cancer. Preliminary results from this trial reported that women who received the supportive intervention lived a mean of 18 months longer than the control group.38 However, additional studies using supportive-expressive group therapy report that this intervention does not prolong survival, yet does provide psychosocial benefits for metastatic breast cancer patients, particularly for patients with elevated levels of distress.39,40 Although behavioral and supportive interventions do not extend survival, these studies support the suggestion that CAM may promote an increased quality of life for women with breast cancer. Communication between patients and their health care providers is critical in exploring CAM’s role in cancer treatment.15 For many years, the high prevalence of CAM use in the United States was unrecognized, largely because physicians never asked their patients whether they were using CAM.41 This situation is slowly changing, with recent studies indicating that almost one half of cancer survivors discuss CAM with their physicians.12,42 Adler and Fosket15 cite reasons reported by breast cancer patients for not reporting CAM use to their physicians: fear of doctors’ disinterest, negative response, or inability to contribute useful information in the area. In addition, there was a perception among this cohort that CAM therapies might be perceived as not relevant to the traditional cancer treatment course. These exploratory studies indicate that patients’ communication with their health care providers is an important factor in examining the role played by CAM in health monitoring.
Several studies have explored the relationship of psychosocial factors to CAM use. In general, these studies demonstrate a common theme: breast cancer patients who use CAM tend to have higher levels of psychosocial distress. Burstein et al14 explored the relationship between depression level, fear of cancer recurrence, and sexual satisfaction among 480 patients with early-stage breast cancer. Among this cohort, only 11% had used CAM before breast cancer diagnosis; however, 28% initiated CAM use after diagnosis. Younger age and higher education levels were significantly correlated with new CAM use for this group. The authors found that patients used CAM in conjunction with standard care: those with stage II disease and who received chemotherapy were significantly more likely to use CAM, whereas women who received tamoxifen were significantly less likely to use complementary modalities. In addition, women who had been treated with standard therapies and who were new CAM users reported more distress and a worse quality of life than nonusers of CAM or those whose CAM use predated their breast cancer diagnosis. Several other recent studies have further investigated the correlation between psychosocial factors and CAM use for women with breast cancer. Ganz et al,22 who explored the relationship of herbal remedy use to psychological functioning, found significantly poorer distress scores among users compared with nonusers of St John’s Wort. The authors postulate that because St John’s Wort is an herbal remedy frequently used for the treatment of depression, these women were self-medicating for subjective symptoms that may have been undetected by traditional health care providers. Carlsson et al43 explored quality of life and coping among a cohort of 120 Swedish women with breast cancer. Half of the sample chose conventional cancer treatment and half chose anthroposophic therapy, which is a complementary modality characterized by use of holistic care and natural products. Women who chose the CAM intervention perceived more anxiety and a lower quality of life than women who selected traditional cancer treatment. Edgar et al30 explored psychosocial issues among 156 women completing breast cancer treatment. This cohort experienced high problem-solving scores; however, women who used CAM were somewhat more psychologically distressed, and did not feel a strong sense of personal control, compared with CAM nonusers. Moschen et al44 also explored the correlation of CAM use with psychosocial factors among 117 women with breast cancer. They found that CAM users were more spiritually involved and attempted to gain a deeper holistic view of their illness than nonusers of CAM. In addition, women who used more than three types of CAM tended to adopt a more depressive coping style than women who used three or fewer CAMs. The authors conclude that CAM appears to fulfill a vital psychological need for cancer patients. In summary, multiple studies demonstrate the association between increased distress and CAM use in women with breast cancer. There is little rigorous evidence that CAM relieves psychological distress, but the consistency of this finding suggests that women with breast cancer may perceive CAM as supportive in nature and may hope that CAM use will improve their quality of life. Clinicians should be alert to the association of CAM use and psychological distress. Women with significant psychological distress should be referred to appropriate mental health providers for further evaluation and treatment. Research focusing on CAM use by women with breast cancer is a relatively new field of study. The scientific efficacy of most CAM interventions is unknown.28 A patient’s perceptions and understanding of his/her illness is an evolving process that may have an influence on quality of life and health behavior choices.27 Distress levels seem higher among women who choose CAM as part of their health surveillance regimen, perhaps indicating that this group is seeking additional coping mechanisms. It has also been suggested that the true appeal in CAM may be the sense of hope and self-control felt by the patient who chooses CAM modalities.18 It remains to be discovered whether this feeling of empowerment actually provides any true medical benefit.8 Additional clinical trial research using CAM interventions is critical in understanding the value of these commonly used interventions in women with breast cancer.28 As new information about CAM becomes available, it will be important to provide education to physicians and other health care providers who respond on an ongoing basis to the needs of their patient population.18
1. Eisenberg D, Davis R, Ettner S, et al: Trends in alternative medicine use in the United States, 1990-1997. JAMA 280: 1569-1575, 1998 2. National Institutes of Health: Use of Complementary or Alternative Medicine Practices by Women at Increased Risk for Breast Cancer. NIH Clinical Trials Database. Bethesda MD, National Institutes of Health, 2000
3. Eisenberg D, Kessler R, Foster C, et al: Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med 328: 246-252, 1993 4. Spiegel D, Stroud P, Fyfe A: Complementary medicine. West J Med 168: 241-247, 1998[Medline] 5. Cassileth B, Chapman C: Alternative and complementary cancer therapies. Cancer 77: 1026-1034, 1996[CrossRef][Medline] 6. National Center for Complementary and Alternative Medicine: Expanding Horizons of Healthcare: Five-Year Strategic Plan 2001-2005. Bethesda MD, Department of Health and Human Services and National Institutes of Health, 2000 7. Harvard Medical School On-Line Web Site: www.harvard.edu, 2000, accessed April 23, 2001
8. Kaptchuk TJ, Eisenberg DM: The persuasive appeal of alternative medicine. Ann Intern Med 129: 1061-1065, 1998 9. Paramore L: Use of alternative therapies: Estimates from the 1994 Robert Wood Johnson Foundation National Access to Care Survey. J Pain Symptom Manage 13: 83-89, 1997[CrossRef][Medline]
10. Astin J: Why patients use alternative medicine: Results of a national study. JAMA 279: 1548-1553, 1998 11. Crocetti E, Crotti N, Feltrin A, et al: The use of complementary therapies by breast cancer patients attending conventional treatment. Eur J Cancer 34: 324-328, 1998
12. Boon H, Stewart M, Kennard MA, et al: Use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J Clin Oncol 18: 2515-2521, 2000 13. Wootton J, Sparber A: Surveys of complementary and alternative medicine, Part I: General trends and demographic groups. J Altern Complement Med 7: 195-208, 2001[CrossRef][Medline]
14. Burstein HJ, Gelber S, Guadagnoli E, et al: Use of alternative medicine by women with early-stage breast cancer. N Engl J Med 340: 1733-1739, 1999 15. Adler SR, Fosket JR: Disclosing complementary and alternative medicine use in the medical encounter: A qualitative study in women with breast cancer. J Fam Pract 48: 453-458, 1999[Medline] 16. VandeCreek L, Rogers E, Lester J: Use of alternative therapies among breast cancer outpatients compared with the general population. Altern Ther Health Med 5: 71-76, 1999[Medline] 17. Sparber A, Bauer L, Curt G, et al: Use of complementary medicine by adult patients participating in cancer clinical trials. Oncol Nurse Forum 27: 623-630, 2000[Medline]
18. Richardson MA, Sanders T, Palmer JL, et al: Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol 18: 2505-2514, 2000 19. Morris K, Johnson N, Homer L, et al: A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites. Am J Surg 179: 407-411, 2000[CrossRef][Medline] 20. Persky V, Van Horn L: Epidemiology of soy and cancer: Perspectives and directions. J Nutr 125: 709S-712S, 1995
21. Willett W: Diet and cancer: One view at the start of the millennium. Cancer Epidemiol Biomarkers Prev 10: 3-8, 2001
22. Ganz P, Desmond K, Leedham B, et al: Quality of life in long-term, disease-free survivors of breast cancer: A follow-up study. J Natl Cancer Inst 94: 39-49, 2002 23. Newman V, Rock C, Faerber S, et al: Dietary supplement use by women at risk for breast cancer recurrence. The Women’s Healthy Eating and Living Study Group. J Am Diet Assoc 98: 285-292, 1998[CrossRef][Medline]
24. Lee MM, Lin SS, Wrensch MR, et al: Alternative therapies used by women with breast cancer in four ethnic populations. J Natl Cancer Inst 92: 42-47, 2000 25. Alferi S, Antoni M, Ironson G, et al: Factors predicting the use of complementary therapies in a multi-ethnic sample of early-stage breast cancer patients. J Am Med Womens Assoc 56: 120-123, 2001 26. Cushman L, Wade C, Factor-Litvak P, et al: Use of complementary and alternative medicine among African-American and Hispanic women in New York City: a pilot study. J Am Med Womens Assoc 54: 193-195, 1999 27. Brown PJ, Carney PA: Health beliefs and alternative medicine: A qualitative study of breast cancer patients. J Cancer Educ 11: 226-229, 1996[Medline]
28. Jacobson JS, Workman SB, Kronenberg F: Research on complementary/alternative medicine for patients with breast cancer: A review of the biomedical literature. J Clin Oncol 18: 668-683, 2000
29. Gotay C, Dumitriu D: Health food store recommendations for breast cancer patients. Arch Fam Med 9: 692-698, 2000 30. Edgar L, Remmer J, Rosberger Z, Fournier M: Resource use in women completing treatment for breast cancer. Psychooncology 9: 428-438, 2000[CrossRef][Medline]
31. Redd W, Montgomery G, DuHamel K: Behavioral intervention for cancer treatment side effects. J Natl Cancer Inst 93: 810-823, 2001 32. Bridge L, Benson P: Relaxation and imagery in the treatment of breast cancer. BMJ 297: 1169-1172, 1988 33. Moore R, Spiegel D: Uses of guided imagery for pain control by African-American and white women with metastatic breast cancer. Integr Med March 21: 115-126, 2000 34. Billhult A, Dahlberg K: A meaningful relief from suffering experiences of massage in cancer care. Cancer Nurs 24: 180-184, 2001[CrossRef][Medline] 35. Kullmer U, Stenger K, Milch W, et al: Self-concept, body image and use of unconventional therapies in patients with gynaecological malignancies in the state of complete remission and recurrence. Eur J Obstet Gynecol Reprod Biol 82: 101-106, 1999[CrossRef][Medline] 36. Coward D: Facilitation of self-transcendence in a breast cancer support group. Oncol Nurs Forum 25: 75-84, 1998[Medline] 37. Spiegel D, Bloom J, Kraemer H, et al: Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 2: 888-891, 1989[CrossRef][Medline]
38. Spiegel D, Bloom J, Yalom I: Group support for patients with metastatic cancer: A randomized outcome study. Arch Gen Psychiatry 38: 527-533, 1981
39. Classen C, Butler L, Koopman C, et al: Supportive-expressive group therapy and distress in patients with metastatic breast cancer: A randomized clinical intervention trial. Arch Gen Psychiatry 58: 494-501, 2001
40. Goodwin P, Leszcz M, Ennis M, et al: The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med 345: 1719-1726, 2001
41. Penson R, Castro C, Seiden M, et al: Complementary, alternative, integrative, or unconventional medicine? Oncologist 6: 463-473, 2001 42. Balneaves L, Kristjanson L, Tataryn D: Beyond convention: Describing complementary therapy use by women living with breast cancer. Patient Educ Couns 38: 143-153, 1999[CrossRef][Medline] 43. Carlsson M, Arman M, Backman M, et al: Perceived quality of life and coping for Swedish women with breast cancer who choose complementary medicine. Cancer Nurs 24: 395-401, 2001[CrossRef][Medline] 44. Moschen R, Kemmler G, Schweigkofler H, et al: Use of alternative/complementary therapy in breast cancer patients: A psychological perspective. Support Care Cancer 9: 267-274, 2001[CrossRef][Medline] Submitted July 30, 2002; accepted July 30, 2002.
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
