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The use of complementary therapies in radiation therapy departments throughout Australia.

Introduction: While both radiation therapy patient use of complementary and alternative medicine (CAM) and the oncologist's perspective of CAM have been surveyed in Australia and reported in the literature, actual radiation therapy department practice and endorsement of CAM is yet to be reported. This investigation aimed to provide an overview of current practice and adoption of CAM in radiation therapy departments across Australia.

Methodology: This investigation was a survey of current department endorsed CAM practice in all 45 radiation therapy centres in Australia. The study design employed a self administered questionnaire, ensuring participant anonymity.

Results: While only 27.7% of radiation therapy departments employed staff with training in CAM, CAM is recommended or endorsed by 66.7% of departments. Relaxation and meditation are the most common CAM therapies and the principal reasons for CAM use in radiation therapy departments is to cope with the emotional aspects of radiation therapy and to improve quality of life. Only 44.4% of radiation therapy departments (8/18) obtain details of CAM use of which only 37.5% actually account for it in therapy planning.

Conclusion: CAM is widely endorsed in Australian radiation therapy departments, predominantly to aid in management of psychosocial issues and to boost quality of life. Consequently, relaxation and meditation are the mainstays of CAM in radiation therapy.

Key words: complementary therapy, radiation therapy, cancer, quality of life

Introduction

Approximately 34% of cancer patients (including Australians) use complementary and alternative medicine (CAM) and many do not inform their oncologist of the CAM use (Ernst 2001). Many conventional health care professionals remain sceptical because of a lack of evidence and flawed methodology in some research (Ernst 2003). From the perspective of the radiation oncology patient, improved treatment outcomes resulting from earlier detection and better treatment options may have added breadth to issues of post treatment morbidity, quality of life (QOL) and side effects.

A cancer patient survey in Australia reported that while 85.6% of patients believed at the start of treatment that conventional treatment would cure them or prolong their lives, only 63.0% felt that after the treatment they had either been cured or had their life prolonged (Begbie 1996).

After conventional treatment, 8.2% of patients felt the treatment had no benefit or had made them worse (Begbie 1996). While only 21.9% of patients indicated that they were using alternative therapies, 73% of cancer patients using CAM expect them to cure their cancer or to prolong their lives (Begbie 1996). The main CAMs used by cancer patients (40.1% had radiation therapy) were relaxation and meditation, diet therapy, megavitamins, positive imagery and faith/spiritual healing (Begbie 1996).

Despite continued resistance to CAM from conventional health care practitioners, patients are integrating CAM with conventional therapies at an increasing rate, including with radiation therapy. Fortunately, given the tendency to withhold information about CAM use from the patient's oncologist, the most popular CAMs tend to be psychosocial (meditation, relaxation therapy etc) so tend not to interfere with radiation therapy (Newell 2000). There are a number of other commonly used CAMs however that may interfere with radiation therapy (e.g. herbal therapies, dietary therapies) (Newell 2000).

This investigation aimed to provide an overview of current practice and adoption of CAM in radiation therapy departments across Australia. While both radiation therapy patient use of CAM and the oncologists perspective of CAM have been surveyed in Australia and reported in the literature (Begbie 1996, Newell 2000) actual radiation therapy department practice and endorsement of CAM is yet to be reported. The information might provide a useful tool to guide decision making with regard to CAM training and research in radiation oncology.

Methodology

This investigation was a survey of current department endorsed CAM practice in radiation therapy centres throughout Australia. The study design employed a self administered questionnaire ensuring participant anonymity. The sampling frame included all 45 Australian Radiation therapy departments (figure 1) identified by the Department of Health and Aging as radiation therapy treatment facilities (Dept Health & Aging 2006). Surveys were sent to the Chief Radiotherapist in each department. All data was collected in 2006. A reply paid envelope was included for the return of the completed questionnaire.

The questionnaire requested demographic data regarding each department's sector (public versus private), location (metropolitan, regional or rural) and staff training in CAM. The questionnaire provided a detailed checklist of standards for management of acute radiation skin toxicity, recommended/endorsed CAM use in radiotherapy patients, reasons for recommending/endorsing CAM use and opinion on the contribution of CAM. The questionnaire also asked for information regarding if and how CAM use is incorporated or accounted for in radiation therapy planning.

The statistical significance was calculated using Chi square analysis for nominal data and student's t test for continuous data. The F test analysis of variances was used to determine statistically significant differences within grouped data. A P value less than 0.05 was considered significant. The difference between independent means and proportions was calculated with a 95% confidence interval (CI).

Results

The collection period saw 18 of the 45 questionnaires returned giving a response rate of 40.0%. Responder compliance of 40% for a self administered postal questionnaire was considered a good response. With respect to department location, metropolitan departments represented 61.1% of respondents (11/18), regional 33.3% (6/18) and rural 5.5% (1/18) (figure 2). For department type, the public sector represented 72.2% of the respondents (13/18) while the private sector represented 27.7% (5/18) (figure 2). This translated to response rates of 44.8% and 31.3% for the public and private sectors respectively. Trans Tasman Radiation Oncology Group member departments represented 88.9% of the respondents.

Only 27.7% of radiation therapy departments (5/18) employed staff with training in CAM. No statistically significant correlations were demonstrated between departments with staff trained in CAM versus those without staff trained with respect to department location (P=0.226) or type (P=0.823). Specifically four departments had staff who had completed CAM workshops, two of which had staff who had also completed post graduate university qualifications. The fifth department had staff with post graduate university qualifications. One of the five departments had staff completing workshops, post graduate qualifications and overseas training in CAM.

CAM is recommended or endorsed in 66.7% of departments (12/18) (table 1). It is clear that psychosocial methods are favoured with relaxation and meditation being the CAM of predominance. Only 22.2% (4/18) of departments offered any CAM other than meditation and relaxation, three of which had staff with CAM training.

While no statistically significant correlation was noted for CAM endorsement versus department location (P=0.316) or type (P=0.524), there was a statistically significant difference noted with respect to those departments with staff trained in CAM versus those without (P=0.038) (table 2).

The principal reasons for CAM in radiation therapy departments were to cope with the emotional aspects of radiation therapy (55.6%: 10/18) and to improve QOL (50%: 9/18).

Of the 38.9% (7/18) of departments that indicated there was no reason to use CAM in radiation therapy patients, all had no staff with CAM training and two (28.6%: 2/7) actually endorsed CAM use.

Other reasons for recommending CAM in radiation therapy departments included; to improve patient compliance with radiation therapy (16.7%: 3/18), to address the acute side effects of radiation therapy (16.7%: 3/18), to cope with the late effects of radiation therapy (5.6%: 1/18) and to improve the efficacy of radiation therapy (5.6%: 1/18).

Irrespective of the use of CAM indicated above, departments were invited to indicate their general view of the role CAM plays in patient health. Only one (5.9%) department indicated that CAM serves no purpose at all and not surprisingly corresponded to a department that neither endorses CAM use in radiation therapy nor has staff trained in CAM. The principal view of CAM was an ability to improve QOL (table 3). Interestingly 61.1% (11/18) of departments indicated that the aims of endorsed use of CAM in radiation therapy were broader than the actual beliefs of CAM capability. Aims and beliefs were matched in 27.8% (5/18) departments and the remaining 11.1% (2/18) had broader beliefs than use.

Only 44.4% of radiation therapy departments (8/18) obtain details of CAM use during patient consultation and planning. Not surprisingly, a statistically significant difference was noted between departments taking a CAM history versus those that do not with respect to departments indicating a role for CAM in radiation therapy (P=0.019) (table 4). Only 37.5 (3/8) of departments who take a CAM history actually account for CAM use in therapy planning.

Specific information was gleaned regarding management of acute radiation skin toxicity. Management of acute radiation skin toxicity was varied (table 5) and perhaps reflects lack of consensus on best practice.

A general consensus would appear to include avoiding irritants, avoiding sun and wind exposure, washing with a mild soap, keeping dry, the use of corticosteroid creams and from CAM perspective application of aloe vera.

Discussion

An Australian survey of 161 oncologists including 60 radiation oncologists revealed that meditation, relaxation and visual imagery were the CAMs for which they had the greatest understanding (Newell 2000). They reported that oncologists consider psychosocial therapies helpful for cancer patients. Not surprisingly this investigation indicated that meditation and relaxation were the most commonly employed CAMs in Australian radiation therapy departments.

This finding is also concordant with previously published CAM use by cancer patients (40.1% radiation therapy) which listed relaxation / meditation, diet therapy, megavitamins, positive imagery and faith / spiritual healing as the main CAMs (Begbie). What has not been reported previously in the literature is the emerging role of herbal therapies in cancer patients. This survey reported that 17% of Australian radiation therapy departments endorse the use of herbal therapies in cancer patients. Given the relative scepticism of conventional health care practitioners (including those in radiation therapy) experienced anecdotally by these investigators, it was somewhat surprising that CAM was so widely endorsed in Australian radiation therapy departments.

While the survey indicated that 67% of Australian radiation therapy centres endorse or recommend the use of CAM by patients, this figure may be artificially elevated if departments not endorsing CAM were more likely not to respond to the questionnaire. None the less, a worst case scenario where all those non respondents do not endorse CAM use would still offer 27% (12/45) of Australian radiation therapy centres endorsing CAM use.

In radiation therapy departments CAMs are not 'prescribed' but might be 'suggested' as an option for some patients and are more often endorsed by the nursing staff and radiation therapists than by the radiation oncologists.

It is important to offer the distinction between the reasons a radiation therapy centre might endorse CAM and the reason cancer patients are drawn to them. No radiation therapy centre supported a curative role for CAM. Typically CAMs are employed to assist distressed or anxious patients and to manage co-morbidity or side effects of radiation therapy. This is reflected in both the principle CAM used being relaxation and meditation, and in the principle use being to cope with the emotional aspects of radiation therapy and to improve QOL.

CAM does offer an important supportive role in curative therapy. Improved efficacy of conventional therapy is a perceived role for CAM in 33% of Australian departments (table 3) despite only 6% of departments using CAM for this specific purpose. One suspects that this reflects an indirect improvement in efficacy by addressing psychosocial needs of patients, thus improving compliance with radiation therapy itself and increasing the likelihood of a cure.

A variety of topical preparations has been employed for the care of acute radiation skin toxicity although supporting empirical evidence is sparse. Schreck et al (2002) indicate that the underlying pathological process is not influenced by topical agents. Patients may however gain some soothing benefit from several topical creams. Not surprisingly those creams identified in this survey are widely reported and evaluated in the literature.

The relatively wide acceptance and prescription of CAM to radiation therapy patients highlights the need for further investigation and education to:

* Assess possible interactions and complications in radiation therapy, particularly herbal therapies.

* Assess efficacy of CAM for specific purposes.

* Develop and formalise an integrated therapy protocol where CAMs complement radiation therapy.

* Provide patients with evidence based informed judgment on the CAM choices available.

All of the above should be transparently integrated vertically and horizontally within departments to ensure all stakeholders are informed.

Conclusion

CAM is widely endorsed in Australian radiation therapy departments, predominantly to aid in management of psychosocial issues and to boost QOL. Consequently relaxation and meditation are the mainstays of CAM use in radiation therapy although herbal therapies have an emerging role. The impact of CAM use on patient compliance and thus radiation therapy efficacy appears to be a primary motivator for endorsing CAM in radiation oncology patients.

Despite the widespread use of CAM in radiation therapy departments there is a need to increase the number of staff trained in CAM and to include CAM history in the patient workup and therapy planning.

References

Ernst E. 2001. A primer of complementary and alternative medicine commonly used by cancer patients. MJA 174;88-92.

Ernst E. 2003. Obstacles to research in complementary and alternative medicine. MJA 179:6;279-80.

Begbie S, Kerestes Z, Bell D. 1996. Patterns of alternative medicine use by cancer patients. MJA 165;545-8.

Newell S, Sanson-Fisher R. 2000. Australian oncologists' self reported knowledge and attitudes about nontraditional therapies used by cancer patients. MJA 172;110-13.

Department of Health and Aging, Radiation therapy treatment facilities. 2006. Department of Health and Aging viewed 25 May 2006 <http://www.health.gov.au>.

Schrek U, Paulsen F, Bamberg M, Budach W. 2002. Intraindividual comparison of two different skin care conceptions in patients undergoing radiotherapy of the head-and-neck region. Creme or powder? Strahlenther Onkol 178:6;321-9.

Porock D, Nikoletti S, Kristjanson L. 1999. Management of radiation skin reactions: literature review and clinical application. Plast Surg Nurs 19:4;185-92.

Janelle Wheat, B AppSci M MedRadSc, DHlthSc

Geoff Currie, M MedRadSc, M AppMngt

School of Biomedical Sciences, Charles Sturt University, Wagga Wagga

Correspondence Janelle Wheat, School of Biomedical, Locked Bag 588 Charles Sturt University, Wagga Wagga Australia 2678 Ph: 612 6933 2750 Fax: 612 6933 2866 Email: jwheat@csu.edu.au
Table 1
Types of CAM endorsed for use in radiation therapy
departments in Australia and the percentage of
departments endorsing each CAM

Types of CAM % use

Relaxation 66.7
Meditation 61.1
Aromatherapy 16.7
Herbal medicine 16.7
Homeopathy 11.1
Acupuncture 11.1
Reflexology 11.1
Naturopathy 5.6
Reiki 5.6
Alexander Technique 5.6
Chiropractic 5.6
Traditional Chinese 5.6

Table 2
CAM endorsement in radiation therapy departments versus departments
with staff trained in CAMs. The 'endorse CAM use' data is further
stratified as 'meditation/relaxation' and 'other' since table 1
revealed the former to represent the bulk of CAM use.

 Staff with No staff with
 CAM training CAM training

Endorse CAM use 27.6% (5/18) 38.9% (7/18)

Do not endorse CAM use 0 33.3% (6/18)

No CAM 0 33.3% (6/18)

Meditation/Relaxation 11.1% (2/18) 33.3% (6/18)

 Other 16.7% (3/18) 5.6% (1/18)

Table 3
Perceived roles for CAM

Role View

Improves QOL 88.9% (16/18)
Only relieves symptoms 55.6% (10/18)
Has only limited use 38.9% (7/18)
Can decrease the side effects of conventional therapy 33.3% (6/18)
Can improve efficacy of therapy 33.3% (6/18)
Gives hope to patients when conventional therapy fails 27.8% (5/18)
Can reduce morbidity following conventional therapy 22.2% (4/18)
Psychological conditioning 11.1% (1/18)
Serves no purpose at all 11.1% (1/18)
Can cure disease 0
Safer than conventional therapy 0

Table 4
CAM endorsement in radiation therapy versus
departments actually taking a CAM history

 CAM history No CAM
 history

Endorse CAM 38.9% (7/18) 5.6% (1/18)
use

Do not endorse 27.8% (5/18) 27.8% (5/18)
CAM use

Table 5
Management of acute radiation skin toxicity

Intervention % use

Corticosteroid cream 77.8

Avoid irritants 77.8

Avoid sun and wind 77.8

Wash with mild soap 72.2

Aloe vera 55.6

Keep dry 44.4

Sorbelene cream 27.8

Cease skin washing 22.2

Vitamin E 16.7

Bepanthan 16.7

Solugel 16.7

Intrasite gel dressing 11.1

Relaxation therapy, Solosite, Duoderm 5.6
gel, Lipiderm & Sucralfate each

Figure 1

Demographics of the sampling frame for radiation therapy department
state of origin (left) and ownership (right).

New South Wales 35%
Victoria 29%
Queensland 16%
South Australia 7%
Western Australia 7%
Tasmania 4%
Australian Capital 2%

Private 36%
Public 64%

Note: Table made from pie chart.

Figure 2

Demographics of the respondents for radiation therapy department
Location (left) and ownership (right).

Metropolitan 61%
Regional 33%
Rural 6%

Public 72%
Private 28%

Note: Table made from pie chart.
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Article Details
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Author:Wheat, Janelle; Currie, Geoff
Publication:Australian Journal of Medical Herbalism
Article Type:Survey
Geographic Code:8AUST
Date:Sep 22, 2007
Words:2869
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