Prevalence of Complementary/Alternative Medicine use in Cancer Patients in a Tertiary Hospital in Puerto Rico.
CAM use has become a global phenomenon, with reports showing increasing numbers of patients utilizing it in some way. Previous studies have estimated that 25% of United Kingdom residents (1), 50% of German (1), French (1), and Australians utilize some form of CAM with or without simultaneous conventional treatment (2) while in USA, the numbers range from 42% to 69%. Between 1990 and 1997, the prevalence of CAM use in USA increased from 33.8% to 42.1% and visits to CAM practitioners also increased from 427 million to 629 million (3).
A summary of 26 surveys across 13 countries concluded that total CAM use among cancer patients was 31.4% (4) but currently there are no equivalent data regarding CAM utilization in Puerto Rico. Information about the prevalence of CAM in cancer patients is potentially useful knowledge for oncologists because some of those treatments, particularly antioxidants, can interfere with the activity of chemotherapy and radiotherapy (5).
CAM therapies can be divided into three main categories: special diet, movement/physical therapies/mind/body, vitamins/herbs, as well as other forms of CAM not specified in these categories. The main goals of our study are: 1- to determine the prevalence of CAM utilization in outpatients seen in a cancer center in Puerto Rico 2- to determine if there are any differences in CAM utilization between Puerto Rico as compared to other countries. 3- explore the correlations between use of CAM with certain demographic and clinical features described below.
Spanish speaking residents of Puerto Rico > 18 years of age who had been diagnosed with any form of cancer at the Auxilio Cancer Center which is part of Auxilio Mutuo Hospital were considered eligible to participate in the study. After patients arrived at the outpatient clinic, a research assistant introduced the study. Patients were required to sign a consent form before proceeding to fill out an IRB approved questionnaire which inquired about the use of CAM therapy and specifically which modalities were utilized.
CAM therapies were divided into five main groups: special diet, movement/physical therapies, mind/body, natural therapies, and any other therapies not specified in the previous categories. For each category, the patient had to check off the specific therapies they had utilized after their official diagnosis. If applicable, the questionnaire asked whether the patient had consulted with their oncologist regarding their CAM use and also about the expectations of their CAM therapy. The study protocol as well as the consent form were approved by the Auxilio Mutuo Hospital Institutional Review Board (IRB).
The null hypothesis set for the study was that patients in our cancer center do not use CAM frequently (defined as less than 20%). Expectations were that the null hypothesis would be rejected. Given a sample size of 200 patients, if 55 answered that they were CAM users, then the 95% confidence interval would range from 21.4%-34.2%; consequently if at least 55 patients responded positively to the question about CAM usage, the null hypothesis would be rejected.
We analyzed the following factors for their correlation with use of CAM: gender, age, educational level, area of residence, tumor type, and tumor stage.
Two-sided chi square test was used to analyze the statistical significance of those factors associated with CAM use. Multivariate analysis, specifically logistic regression, was used to determine the contribution of those factors that were significant in the univariate analysis. A generalized linear model was used to accomplish this task.
A total of 215 patients were approached over the course of the study and 200 of these signed the consent and participated in the study, while 15 did not wish to participate. The demographic characteristics of the study population is shown in table 1. Area of residence was divided into metropolitan and non-metropolitan municipalities. The metropolitan area is composed of Bayamon, Caguas, Carolina, Catano, Dorado, Guaynabo, San Juan, Toa Baja, and Trujillo Alto.
A total of 95 of 200 patients (47.5%) responded that they utilized at least one CAM treatment or therapy. Table 1 shows the demographic and clinical factors analyzed and their corresponding frequency. In order to determine their association with CAM usage, the six factors shown in table 1 were then subjected to statistical analysis.
Table 2 depicts the six factors analyzed with their respective p values in regards to their association with the use of CAM and the two other factors not associated with CAM use.
Table 3 depicts the results of the multivariate logistic regression analysis which revealed that all three factors identified in the univariate analysis: age, area of residence, and educational level were independent variables associated with more frequent use of CAM. Residence in a non-metropolitan area, younger age and high educational level were associated with more frequent use of CAM.
The number of patients using a specific type of CAM treatment is shown in table 4. Note that 23 patients (11.5%) stated that they utilized other forms of alternative therapies not listed above, such as transfer factor. The most commonly used were vitamins, fruits and relaxation therapies.
The total number of CAM therapies per patient who responded "yes" to using CAM was also recorded. The median was 5 treatments per patient (range 1-15).
We also asked whether the patient had informed their oncologist regarding their CAM use. Three patients refused to answer the question. A total of 51 of the 92 (55.4 %) who had responded that they utilized CAM, answered that they had informed their oncologist while 41 patients (44.6 %) reported they had not (table 5).
Information about patient's expectations regarding their use of CAM are shown in table 5. The most common expectation was that the treatment would help boost their immune system.
Comparison with other CAM studies
Overall, our results and demographics are similar to other global CAM studies with some differences. A study conducted in Australia by Maclennan et al (2) revealed similar results to ours. A total of 48.5% of patients reported to have used alternative medicine, very close to 47.5% in our study. Molassiotis et al. (6) reported CAM use in 14 European countries. Overall CAM use and study population varied highly among all countries, with the lowest reported being Greece (14.8%) and the highest Italy (73.1%). The latter study covered CAM use, before and after diagnosis as well as current use.
We compared our results to the percentage of patients currently using alternative medicine in Molassiotis study. Herbal medicine proved to be the most popular treatment (12.1 %), one that was less common in our study population (8.0%). Vitamins were the second most used (5.1%), although percentage-wise it is very low when compared to our population (31.0%).
Their data also showed similar trends to ours, with younger patients, females, and better educated patients the most likely to utilize at least one CAM treatment, a trend also reflected in our results, although in our case the association with gender did not reach statistical significance.
Eisenberg et al. (3) also showed that women were more prone to use alternative medicine than men (48.9% vs 37.8%, P = .001). In Molassiotis' study, women as well as those with a higher educational level were more likely to utilize alternative medicine. However, in Eisenberg's study the frequency of CAM usage according to age was contrary to our experience, with older patients utilizing alternative medicine more commonly. Since our study showed an inverse correlation between age and educational level, it is likely that the younger age of our frequent CAM users could correspond to a higher educational level. However, in our multivariate analysis these two factors were independent, each contributing on their own. Our results are consistent with other studies which have concluded that age is significantly associated with CAM use.
We inferred that the popularity of CAM is associated with ignorance and poor education. Contrary to this, our findings indicate that the most educated patients are the ones that utilized CAM the most. This finding is in keeping with other studies. In both Eisenberg's and Molassiotis' studies, educational level was associated with more frequent use, like our experience.
We hypothesized that patients who live in metropolitan areas would use CAM more frequently than those living in rural areas. Our hypothesis was based on the idea that metropolitan area residents have a higher purchasing power that allows them to pay for expensive non-reimbursable treatments. Our results proved to be contrary to our hypothesis, as patients living in metropolitan areas were the least likely to use CAM. No previous studies have investigated this association between CAM use and area of residence.
The study by Eisenberg et al showed that relaxation techniques, although not extremely common, still are among the most popular among Americans in 1990 and 1997 (3) (13.1% and 16.3%, respectively). Our study similarly showed that relaxation techniques were utilized by 11.5%.
We couldn't find any correlation between use of CAM with type of cancer or stage. Other studies have also failed to show any association with these two features (1-4).
Consultation with Oncologist and Expectations
We considered that it was important to investigate if patients had consulted with their oncologist because of the potential of interference with the delivery of some types of treatments such as chemotherapy and radiotherapy. Although expectations were that most patients would report that they did not consult their oncologist regarding their CAM use, results showed the contrary. Of the patients who reported to have used at least one alternative medical treatment or therapy, most of them stated that they had consulted their oncologist regarding their CAM use (55.4%). Note that this does not reflect whether they have consulted their oncologist regarding each of their treatments. The opinion or recommendations from their oncologists was not recorded.
Patient's expectations regarding use of CAM
Expectations regarding patient's use of CAM varied. Most patients expect their treatments to boost their immune system (49.5%). Patients boosting their immune system tend to be the ones choosing vitamins and other supplements. The second most common expectation was between helping with symptoms and having hope that the treatment will help in some way. Note that many patients chose more than one expectation for their treatment, thus, the number of patients for each choice does not reflect the number of patients with only that expectation. A small percentage of patients expect that the treatment(s) will cure their cancer (17.5%).
Similar results regarding expectations were reported in a study carried out by Richardson et al (7). In that study, the most common reason reported for using CAM was a desire to feel optimistic and hopeful (73.0%), other reasons being that they thought these approaches are nontoxic (48.9%) and that they wanted more control over their medical decisions (43.8%). Most patients expected CAM to improve their quality of life (76.7%), boost their immune system (71.1%), extend their life duration (62.5%), or relieve symptoms (44.0%). About one third of the patients expected that CAM could cure their disease (37.5%).
Types of CAM used
Vitamins seemed to be the most common CAM used in the Australian study (37.6%), a trend also observed in our study population (31.0%). Most alternative medical treatments reported by Maclennan et al. (2) correspond to herbs and other natural treatments. No special diets, physical therapies nor mind / body therapies were reported by any patient.
In our study, two of the most popular alternative medicines belong under the category of vitamins (31.0 %) and herbs (25.5 %). Although studies have suggested that vitamin D has anticancer properties, (8-10) in our study ironically most patients who use vitamins report that they use vitamin C which has not been associated with proven anti-cancer activity in humans. In fact, only 4 patients (6.5 %) reported that they utilized vitamin D.
Under the category of fruits, most patients utilized Graviola (soursop or guanabana) in some way, ranging from tea prepared from the leave to drinking soursop juice or taking Graviola pills. Most patients who consume Graviola are middle-aged, while younger ones do not use it as much.
A systematic literature search was carried out by Ortiz et al. (11), compiling different sources of data from studies that focused on CAM use by several Hispanic populations. While the studies listed mostly cover all spectra in the medical field, ranging from populations with chronic conditions to some populations with a specific disease, we need to highlight two of these studies listed. The first, carried out in 2001 by Factor-Litvak (12), revealed that CAM users utilized vitamins very commonly, a finding similar to ours. The second, by Raji in 2005 (13), similarly reported the frequent use of vitamins.
In summary, our overall results are consistent with other studies carried out around the world with the most notable differences being the lack of a statistically significant difference between gender and frequency of CAM utilization in our study. In spite of this, we did observe a non-statistically significant trend for females to use more CAM than males (table 2) consistent with other reports. Regarding the type of CAM used, our data point out that vitamins and fruits are two of the most popular treatments, specifically vitamin C and Graviola (soursop), the latter being a finding different from other studies outside of Puerto Rico.
Most patients have reported that they consult their CAM use with their oncologist. However, almost half of patients fail to mention it and the use of some of these modalities, such as antioxidant vitamins, potentially could interfere with the mechanism of action of chemotherapy and radiotherapy (9). The finding underscores the need for clinicians to inquire about use of CAM since we can't rely on all of them reporting it spontaneously.
Ironically, in our study, the most common CAM modality used was vitamin C which has not shown any definitive antitumor activity in clinical trials while vitamin D, which does have activity in reducing the risk of cancer in randomized trials was one of the less commonly used vitamins by our patients (8-10).
A frequent misconception in our medical community is that CAM use is linked with ignorance and low educational level. In this regard, the findings in our study that a higher educational level is associated with more frequent use of CAM is surprising and counterintuitive. However, this has been described before in other studies (2, 3).
To the best of our knowledge this is the first study of the use of CAM in cancer patients in Puerto Rico. It would be convenient to have our data confirmed independently since the patient population in our hospital, which is a tertiary care center, might not necessarily reflect the average population in our island. It is possible that our population is biased towards a higher education level. However, we do see patients from all parts of the island and they all belong to different educational backgrounds. In these regards, it is important to point out that the use of CAM in our population is different between the higher and lower education level, with use favoring higher education level. Also, in our experience, our patients from the metropolitan area tend to use it more than the rest of the island.
We want to thank the entire staff in the Auxilio Mutuo Cancer Center for making this study possible. A special thanks goes to Idalia Liboy for assisting with the approval of the study protocol. Thanks to all the nurses and front desk staff in the cancer center for helping with the registration of the patients available for participation.
(1.) Fischer PF, Ward AW.; Medicine in Europe: Complementary medicine in Europe; BMJ 1994;309(6947):107-11.
(2.) MacLennan AH, Wilson DH, Taylor AW; Prevalence and cost of alternative medicine in Australia; The Lancet 1996;347(9001):569-73.
(3.) Eisenberg DM, Davis RB, Ettner SL et al.; Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey. JAMA 1998;280(18):1569-75.
(4.) Ernst EE; The prevalence of complementary/Alternative medicine in cancer: A systematic review. Cancer 1998;83(4):777-82.
(5.) DAndrea GM; Use of Antioxidants During Chemotherapy and Radiotherapy Should Be Avoided; CA: A Cancer Journal for Clinicians 2005;55(5):319-21.
(6.) Molassiotis AM, Fernandez-Ortega PF, Pud DP et al.; Use of complementary and alternative medicine in cancer patients: a European survey; Ann Oncol 2005;16(4):655-63.
(7.) Richardson MA, Sanders TS, Palmer JL et al.; Complementary/Alternative Medicine Use in a Comprehensive Cancer Center and the Implications for Oncology. J Clin Oncol 2000;18(13):2505-1.
(8.) Garland CF, Garland FC, Gorham ED et al.; The Role of Vitamin D in Cancer Prevention. Am J Public Health 2006;96(2):252-61.
(9.) Lappe JM, Travers-Gustafson DT, Davies KM et al.; Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. ASCN 2007;85(6):1586-91.
(10.) Ng K, Sayed H, Jackson, N et al.; Randomized double-blind phase II trial of vitamin D supplementation in patients with previously untreated metastatic colorectal cancer. Jpn J Clin Oncol 2017;35, no. 15_sup-pl:3506-3506.
(11.) Ortiz BI, Shields KM, Clauson KA et al.; Complementary and Alternative Medicine Use Among Hispanics in the United States; Ann Pharmacother 2007;41(6):994-1004.
(12.) Factor-Litvak P, Cushman LF, Kronenburg FK et al.; Use of complementary and alternative medicine among women in New York City: a pilot study. J Altern Complement Med 2001;7:659-66.
(13.) Raji MA, Kuo Y-F, Snih SA et al.; Ethnic differences in herb and vitamin/mineral use in the elderly; Ann Pharmacother. 2005;39:1019-23.
Este cuestionario tiene el proposito de investigar el uso de tratamientos de medicina alternativa en pacientes con cancer en Puerto Rico. Marca la respuesta o respuestas que aplica a usted. Si no se siente comodo contestando una pregunta, puede omitirla.
Parte A: Informacion sobre usted
2) ?Cual es su edad?______________
3) Sexo: * Masculino * Femenino
4) ?Que grado has completado?
* No termine escuela superior.
* Me gradue de la escuela superior.
* Empece universidad o instituto, pero no termine.
* Me gradue de la universidad o instituto.
* Estudio post graduado (maestria, doctorado)
* Otro POR FAVOR ESPECIFIQUE:_______________
Parte B: Terapias de medicina alternativa que ha utilizado
Tratamientos de medicina alternativa son tratamientos de bajo riesgo para el cancer que se usan en lugar de los convencionales (estandar). Se puede utilizar junto con tratamientos convencionales.
1) iUsted ha o esta utilizado por lo menos un tratamiento de medicina alternativa?
* Si, he utilizado por lo menos un tratamiento de medicina alternativa.
* No, nunca he utilizado ningun tratamiento de medicina alternativa.
Si usted contesto que no ha utilizado tratamiento de medicina alternativa, por favor notifique al asistente del estudio para que recoja el cuestionario. Gracias.
2) Por favor marque los tratamientos de medicina alternativa que usted esta utilizando o ha utilizado:
1. Dieta especial:
* Vegano (no carne roja, productos lacteos, o huevos)
* Otro POR FAVOR ESPECIFIQUE:_____________
2. Terapia fisica
* Tai chi o chi gong
3. Cuerpo / mente
* Energia curativa / Toque terapeutico
* Terapia de musica
* Otro POR FAVOR ESPECIFIQUE:______________
4. Vitaminas / hierbas para tratar o mejorar el cancer
* Vitaminas / suplementos
* Vitamina C por boca
* Vitamina C por vena
* Vitamina B-17 (laetrile)
* Terapia de hierbas
* Cartilago de tiburon
* Frutas (moringa, guanabana, etc.) POR FAVOR ESPECIFIQUE:
* Cama de imanes
* Remedios ayurdevicos
* Remedios caseros
5. Otro tipo de terapia
* POR FAVOR ESPECIFIQUE:____________________
arte C: Informacion sobre uso de medicina alternativa
1 ?Usted ha discutido su uso de medicina alternativa con su oncologo?
* Si, he mencionado el uso de medicina alternativa a mi oncologo.
* No, no he mencionado el uso de medicina alternativa a mi oncologo.
2) ?Cuales son sus expectativas de su tratamiento(s) de medicina alternativa?
* El tratamiento(s) me va a curar el cancer.
* El tratamiento(s) me va a ayudar con los sintomas que presento debido al cancer.
* Tengo esperanza que el tratamiento(s) me va ayudar con el cancer de alguna forma.
* El tratamiento(s) no es toxico.
* El tratamiento(s) me va a mejorar el sistema inmunologico.
* Otro POR FAVOR ESPECIFIQUE:____________________
Por favor notifique al asistente del estudio para que recoja el cuestionario. Gracias.
Daniel Torres-Vega (*), Fernando Cabanillas ([dagger]), Noridza Rivera ([double dagger]), Pedro Sollivan ([paragraph]), Wandaly Pardo ([paragraph]), Caroline Rivera ([paragraph]), Muay Hernandez ([section])
(*) Undergraduate student at Dartmouth College; ([dagger]) Director at Auxilio Mutuo Cancer Center and Professor of Medicine at University of Puerto Rico Medical Science Campus, San Juan, Puerto Rico; ([double dagger]) Auxilio Mutuo Cancer Center and Assistant Professor of Medicine at Universty of Puerto Rico Medical Science Campus, San Juan, Puerto Rico; ([paragraph]) Auxilio Mutuo Cancer Center; ([section]) Oncology Fellow at University of Puerto Rico Medical Science Campus, San Juan, Puerto Rico
The authors have no conflict of interest to disclose.
Address correspondence to: Hospital Espanol Auxilio Mutuo, Avenida Juan Ponce de Leon, Hato Rey, Puerto Rico 00919. Email: firstname.lastname@example.org
Table 1. Study population characteristics Number of patients N (%) Gender Male 79 (39.5) Female 121 (60.5) Age group 18-64 yrs 115 (57.5) 65[+ or -] yrs 85 (42.5) Median age 61 Education level (*) High school or lower 44 (22.1) University, college, or post graduate studies 154 (77.9) Area of residence (**) Metropolitan area 109 (54.8) Non-metropolitan area 90 (45.2) Tumor type Solid tumor 115 (57.5) Lymphoid tumor 85 (42.5) Tumor stage Localized 96 (48.0) Advanced 104 (52.0) (*) Two patients declined to answer the question regarding education level. (**) One patient declined to answer the question regarding area of residence Table 2. Factors associated with CAM use Category Use CAM Do not Total P-value use CAM Gender Male 35 (44.3) 44 (55.7) 79 (39.5) 0.46 Female 60 (49.6) 61 (50.4) 121 (60.5) Age Group 18-64 yrs 66 (57.4) 49 (42.6) 115 (57.5) 0.0011 65[+ or -] yrs 29 (34.1) 56 (65.9) 85 (42.5) Education level 198 High school or lower 15 (34.1) 28 (65.9) 43 (22.0) 0.050 University, college, or post graduate studies 80 (51.4) 75 (48.6) 155 (77.5) Area of residence 197 Metropolitan area 47 (39.4) 71 (60.6) 118 (54.8) 0.011 Non-metropolitan area 46 (56.7) 33 (43.3) 79 (45.2) Tumor type 200 Solid tumor 54 (46.9) 61 (53.1) 115 (57.5) 0.731 Lymphoid tumor 42 (49.4) 43 (50.6) 85 (42.5) Tumor stage Localized 46 (47.9) 50 (52.1) 96 (48.0) 0.909 Advanced 49 (47.1) 55 (52.9) 104 (52.0) Table 3. Multivariate analysis of factors significant in univariate analysis Category Odds ratio Standard error Z-value P value 95% confidence interval Age .4405682 .1360368 -2.65 0.008 .2405375 .8069442 Area of residence .3922528 .1245696 -2.95 0.003 .210497 .7309474 Education level .4302832 .1700501 -2.13 0.033 .1983148 .9335845 Table 4. Frequency of CAM modalities used Category Number of patients N (%) Special diet 35 (17.5) Vegetarian 11 (5.5) Vegan 6 (3.0) Macrobiotic 2 (1.0) Other special diet 20 (10.0) Any relaxation (mind / body) or movement /physical therapy 51 (25.5) Yoga 9 (4.5) Tai Chi or Chi Gong 2 (1.0) Massage 20 (10.0) Hypnosis 1 (0.5) Meditation 17 (8.5) Curative energy / therapeutic touch 7 (3.5) Music therapy 8 (4.0) Other form of therapy 14 (7.0) Any natural (vitamins / herbs) and other therapies 205 (102.5) Vitamins 62 (31.0) Vitamin C oral 46 (23.0) Vitamin C (intravenous) 6 (3.0) Vitamin D 4 (2.0) Vitamin B-12 2 (1.0) Vitamin B-17 (laetrile) 9 (4.5) Multivitamins 6 (3.0) Melatonin 12 (6.0) Chinese herb therapy 16 (8.0) Shark cartilage 4 (2.0) Fruits 51 (25.5) Soursop 45 (22.5) Moringa 2 (1.0) Other fruits 10 (5.0) Turmeric 26 (13.0) Homeopathy 2 (1.0) Magnet bed 1 (0.5) Ayurvedic remedies 1 (0.5) Cannabis 20 (10.0) Table 5. Treatment expectations Expectations regarding their CAM use Number of patients N(%) Treatment will cure my cancer 16 (17.5) Treatment will help with symptoms 40 (43.9) I have hope that the treatment will help in some way 40 (43.9) Treatment is not toxic 24 (26.4) Treatment will help improve my immune system 45 (49.5) Other reason 9 (9.9) Total 91