Abstract
Background
Complementary and alternative medicine (CAM) encompasses healthcare practices beyond conventional medical care. Despite advancements in oncology treatment, CAM use remains prevalent among patients with cancer. In Jordan, while CAM usage is common, particularly involving herbalists and spiritual healers, data on its patterns among patients with cancer are limited. This study compared CAM use among cancer patients in Jordan between 2013 and 2022, aiming to identify changing trends, associated factors, and implications for clinical practice and patient education.
Methods
A cross-sectional survey was administered to adult cancer patients in Jordan in 2013 and 2022. In 2013, participants were recruited from four facilities, including the King Hussein Cancer Center (KHCC), whereas in 2022, recruitment was exclusively at KHCC. Patients completed a validated semi-structured questionnaire covering sociodemographic information, CAM usage patterns, communication with healthcare providers, and perceptions of CAM.
Results
The prevalence of CAM use has decreased from 49.4% (n = 400) in 2013 to 32.8% (n = 124) in 2022. Natural health products such as herbs, vitamins, and special foods remained the most commonly used CAM therapies in both surveys. Despite the overall decrease in CAM usage, the frequency among users increased, with daily use reported by 65.9% in 2022 compared to 55.3% in 2013. The perceived benefits of CAM have significantly declined from 86.6% in 2013 to 31.9% in 2022. Communication about CAM use with healthcare providers remains low, although it slightly improves from 35.2% in 2013 to 46.3% in 2022. In 2013, younger age at diagnosis and treatment completion were independently associated with higher CAM use. In contrast, 2022 data identified lack of health insurance as the sole independent predictor of CAM use (Adjusted Odds Ratio = 1.820, 95% CI: 1.007–3.289).
Conclusion
Over the past decade, CAM use among Jordanian patients with cancer has significantly decreased, although current users engage more intensively. The decline in perceived benefits and the persistent communication gap with healthcare providers underscores the necessity for educational programs targeting both patients and clinicians. Such interventions could enhance dialogue regarding CAM, ensure safer integration with conventional treatments, and potentially improve patient outcomes by preventing harmful interactions.
Keywords: Trends in CAM use, Cancer patients, Jordan, Patient-Healthcare communication
Introduction
According to the National Center for Complementary and Integrative Health (NCCIH), health care approaches that are not typically part of conventional medical care or that may have origins outside of usual Western practice are referred to as complementary and alternative medicine (CAM) [1]. The words “alternative” and “complementary” are often used interchangeably, although the two terms refer to different concepts. If a nonmainstream practice is used together with conventional medicine, it is considered “complementary”, whereas if a nonmainstream practice is used in place of conventional medicine, it is considered “alternative”. Most people who use nonconventional approaches also use mainstream medical interventions. The definitions include spiritual or religious rituals and folk medicine; the use of special foods and diets; herbal remedies and supplements; and acupuncture, massage and physical therapy, among others.
Despite significant advancements in conventional cancer therapies, the utilization of CAM remains widespread globally, with prevalence estimates ranging from 9.8 to 76%. This variation is primarily due to heterogeneous study designs, differences in the cancer populations sampled, and the lack of a standardized, universally accepted definition of CAM [2–4]. This variation in prevalence was also observed in the age, sex, and socioeconomic status of CAM users [5, 6]. In the United States (US), 38% of adults reported using CAM; women, people with higher education and people with high income were the most common users [7]. In European countries, CAM use varies between 0.3% and 86%, and female gender again is associated with increased use [8]. In Middle Eastern countries such as Jordan, the availability of shops that sell herbs and other products of CAM is common under the name of spice trading, and people who visit clerics seeking treatment via herbal remedies, prayers or nutritional supplements are usually encountered. The healthcare system in Jordan is well established, and most patients have the option of seeking conventional medical treatment in primary, secondary and tertiary care facilities. Nevertheless, considering CAM as a treatment option is common in the population [9]. The increasing popularity of CAM has been driven by a variety of factors, including patient dissatisfaction with traditional healthcare, rising healthcare costs, and a desire for a holistic and preventative approach to health [10–12]. CAM use has been widely studied from different perspectives, and the perception of CAM benefits and risks is an area of interest. Positive perceptions often revolve around the holistic nature of CAM, its ability to prevent disease, and its perception of natural safety [2]. However, concerns arise from potential side effects, interactions with conventional medicines, and a lack of scientific evidence supporting the effectiveness of CAM [13, 14]. Communication between patients and healthcare providers regarding CAM usage is an area of concern. Studies have reported a gap in this communication, with a significant number of CAM users not disclosing their usage to healthcare professionals [15–17]. Such nondisclosure could result in potentially harmful interactions between CAM and conventional medicine [18]. Therefore, investigating the extent of this communication gap, the reasons behind it, and its implications is essential. The literature on CAM usage also highlights the changing trends over time. For example, the use of CAM among cancer patients has been shown to fluctuate, indicating changes in perceptions and beliefs regarding CAM effectiveness [19, 20]. Additionally, the sources of information on CAM have a significant effect on CAM usage patterns. Friends, family, and the internet have been identified as primary sources of information on CAM, raising concerns about the credibility of information guiding healthcare decisions [21].
In Jordan, a number of studies have surveyed the ethnopharmacological and ethnobotanical use of common herbs and explored folk toxic plants in different regions [22–26]. These studies revealed that the use of CAM is common among the public and that people are unaware of the possible harm associated with its use. At the same time, information regarding herbs and their effects is obtained mainly from herbalists, who gain their knowledge primarily through experience, with no formal education or training [27, 28]. Other studies focused on CAM use in patients with chronic diseases such as diabetes [29, 30], coronary artery diseases [31] and reproductive system disorders in both males and females [15, 32, 33] and reported a high prevalence of CAM use, but little is known about its negative effects. In a previous study, we investigated the perceptions and attitudes of Jordanian physicians toward CAM use for cancer patients and reported that physicians have little knowledge of CAM use in oncology but are highly interested in it [15]. Very few studies have investigated CAM use patterns among Jordanian cancer patients [34–37]. In pediatric cancer patients, a study revealed a tendency to use CAM by parents to treat their children; however, parents were hesitant to disclose the use of CAM to healthcare providers [34]. In adult cancer patients, a study at King Hussein Cancer Center in 2010 revealed that 35.5% (404/1,138) of interviewed patients reported using botanical-based CAM [35]. Akhu-Zaheya and Alkhasawneh (2012) investigated CAM use among 123 Muslim cancer patients and reported that 100% of participants (123/123) used one or more CAM therapies, mainly to reduce the side effects of chemotherapy [36]. Al-Momani and Al-Tawalbeh (2015) conducted a cross-sectional study on 200 cancer patients from only two hospitals in Jordan and concluded that the majority of cancer patients use CAM without discussing it with their oncologists [17].
Understanding the patterns of CAM use among cancer patients is crucial, as it can affect patient outcomes, quality of life, and the effectiveness of conventional treatments. This study aimed to present a comprehensive comparison of CAM use among cancer patients in Jordan between 2013 and 2022, identifying changing trends, associated factors, and implications for clinical practice and patient education.
Materials and methods
Setting
This was a cross-sectional survey of adult cancer patients in Jordan conducted in 2013 at four different facilities, including King Hussein Cancer Center (KHCC), Royal Medical Services (RMS), King Abdullah University Hospital (KAUH), and the Ministry of Health Hospitals (MoH). In 2022, another sample was recruited at KHCC to compare trends and predictors of use over 10 years. The sample size for each survey was determined through a power calculation, assuming a 95% confidence level and a 5% margin of error. Consequently, a minimum sample size of 384 was calculated for each period. The study obtained 828 responses in 2013 and 378 in 2022, thereby exceeding this requirement. A semi-structured and validated questionnaire adapted from a previous study was used [34]. The questionnaire was originally in English and translated into Arabic by a bilingual expert. A back-translation was performed to ensure accuracy. The Arabic version was used in both surveys. Patients were consecutively recruited during their routine outpatient visits and data collection was conducted through in-person interviews by trained research assistants at outpatient clinics.
Study subjects
The study population included adult cancer patients who were at least 18 years of age with a confirmed cancer diagnosis and were seen at the outpatient clinics of one of the four participating sites. The participants were invited to enroll in the study by the research team and asked to complete the study questionnaire. Pediatric cancer patients younger than 18 years were excluded from the study.
Data collection tool
Data were collected via a semistructured questionnaire adapted from a previous study [34]. The tool included a cover letter that introduced the study and explained its objectives. The tool consists of four sections: sociodemographic information (i.e., gender, age, educational level, cancer-specific health insurance, place of residency, monthly income, cancer diagnosis, time since diagnosis, and treatments received), CAM use (i.e., type of therapies, reasons for use, benefit of CAM use, frequency of use and cost), communication with healthcare providers on CAM use, and patients’ perceptions of CAM. If the participant was not a CAM user, they were only asked to complete the section related to their perception of CAM in addition to their sociodemographic information (i.e., the first and last sections of the questionnaire).
Ethical considerations
This study was approved by the Institutional Review Board at KHCC, under reference number 21KHCC164. The participants were fully informed about the study’s purpose, and completing the study questionnaire was considered voluntary consent to participate.
Statistical analysis
Statistical Package for the Social Sciences software for Windows version 28.0 (IBM SPSS Statistics for Windows, Armonk, NY, USA) was used for statistical analysis. Descriptive statistics were used to categorize the sociodemographic data and patient characteristics. Associations between sociodemographic factors and CAM use-related factors were determined via chi-square tests, Fisher’s exact tests, or ANOVA. Missing values were excluded. Multivariate logistic regression analysis was performed to identify independent factors associated with CAM usage. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated to measure the strength of these associations. A P value of < 0.05 was considered to indicate statistical significance.
Results
This research study encapsulates the outcomes of two surveys conducted almost a decade apart, in 2013 and 2022. The objective was to analyze the use of complementary and alternative medicine (CAM) among two distinct samples of individuals.
Sample characteristics and factors associated with CAM use
Among CAM users, females were slightly more prevalent than males in both the 2013 survey (59.6% vs. 40.4%) and the 2022 survey (61.3% vs. 38.7%). However, this difference was not statistically significant in either survey (P = 0.297 in 2013 and P = 0.226 in 2022). Compared with nonusers, a significantly greater proportion of CAM users were aged between 18 and 59 years at diagnosis in both the 2013 and 2022 surveys (P < 0.001 in 2013). Although the distribution of educational attainment between users and non-users of CAM appears similar, notable variations are evident. For instance, there is a higher percentage of diploma holders among CAM users in 2013 compared to 2022 (19.5% versus 12.9%).
In both surveys, a greater proportion of CAM users than nonusers had received their diagnosis more than 25 months prior. Nevertheless, the difference was not statistically significant (P = 0.487 in 2013 and P = 0.142 in 2022). While the place of residence (city, village, or rural) did not achieve statistical significance, there were notable differences between the samples from 2013 to 2022. CAM use did not seem to be significantly associated with income level in either survey. Other characteristics and associations are listed in Table 1.
Table 1.
Sample characteristics and factors associated with CAM use
| Characteristics | Levels | 2013 Survey results. n = 828 | P | 2022 Survey results. n = 378 | P | ||
|---|---|---|---|---|---|---|---|
| CAM users 413 (49.9%) | CAM nonusers 415 (50.1%) | CAM users 124 (32.8%) | CAM nonusers 254 (67.2%) | ||||
| n (%) | n (%) | n (%) | n (%) | ||||
| Gender | Male | 161 (40.4) | 179(44) | 0.297 | 48 (38.7) | 115 (45.3) | 0.226 |
| Female | 238 (59.6) | 228 (56) | 76 (61.3) | 139 (54.7) | |||
| Age at Diagnosis | 18–39 Years | 146 (38.4) | 133 (35.5) | < 0.001* | 22 (17.7) | 49 (19.5) | 0.184 |
| 40–59 Years | 183 (48.2) | 151 (40.3) | 65 (52.4) | 107 (42.6) | |||
| ≥ 60 Years | 51 (13.4) | 91 (24.3) | 37 (29.8) | 95 (37.8) | |||
| Education | Secondary or less | 74 (18.5) | 79 (19.7) | 0.968 | 22 (17.7) | 60 (23.6) | 0.367 |
| High school | 105 (26.3) | 105 (26.1) | 35 (28.2) | 66 (26) | |||
| Diploma | 78 (19.5) | 72 (17.9) | 16 (12.9) | 28 (11) | |||
| Undergraduate | 115 (28.7) | 115 (28.6) | 38 (30.6) | 85 (33.5) | |||
| Graduate | 28 (7) | 31 (7.7) | 13 (10.5) | 15 (5.9) | |||
| Time Since Diagnosis | Less than 6 months | 113 (28.7) | 133 (32.7) | 0.487 | 30 (24.4) | 84 (33.1) | 0.142 |
| 7–12 months | 88 (22.3) | 98 (24.1) | 22 (17.9) | 46 (18.1) | |||
| 13–24 months | 67 (17) | 58 (14.3) | 5 (4.1) | 17 (6.7) | |||
| More than 25 months | 126 (32) | 118 (29) | 66 (53.7) | 107 (42.1) | |||
| Place of Residence | City | 306 (77.1) | 303 (74.8) | 0.437 | 107 (87.7) | 224 (88.2) | 0.639 |
| Village | 76 (19.1) | 88 (21.7) | 12 (9.8) | 27 (10.6) | |||
| Rural | 15 (3.8) | 14 (3.5) | 3 (2.5) | 3 (1.2) | |||
| Monthly income | Less than 500 JD | 220 (55.1) | 244 (59.7) | 0.428 | 21 (40.4) | 53 (44.9) | 0.350 |
| 500–1000 JD | 138 (34.6) | 128 (31.3) | 27 (51.9) | 49 (41.5) | |||
| More than 1000 JD | 41 (10.3) | 37 (9) | 4 (7.7) | 16 (13.6) | |||
| Health insurance | Yes | 271 (72.5) | 256 (65.8) | 0.047 | 96 (77.4) | 221 (87) | 0.017 |
| No | 103 (27.5) | 133 (34.2) | 28 (22.6) | 33 (13) | |||
| Diagnosis | Other Type | 25 (6.3) | 25 (6.2) | 0.903 | 10 (8.2) | 19 (7.5) | 0.077 |
| Bladder | 4 (1) | 4 (1) | 1 (0.8) | 6 (2.4) | |||
| Bone | 8 (2) | 4 (1) | 0 (0) | 5 (2) | |||
| Brain tumor | 17 (4.3) | 19 (4.7) | 3 (2.5) | 1 (0.4) | |||
| Breast cancer | 133 (33.5) | 130 (32.1) | 30 (24.6) | 61 (24.1) | |||
| Colorectal Cancer | 33 (8.3) | 38 (9.4) | 17 (13.9) | 22 (8.7) | |||
| Head and Neck | 10 (2.5) | 18 (4.4) | 0 (0) | 6 (2.4) | |||
| Kidney | 0 (0) | 0 (0) | 0 (0) | 4 (1.6) | |||
| Leukemia | 23 (5.8) | 31 (7.7) | 5 (4.1) | 16 (6.3) | |||
| Liver | 0 (0) | 0 (0) | 2 (1.6) | 5 (2) | |||
| Lung cancer | 26 6.5) | 25 (6.2) | 7 (5.7) | 21 (8.3) | |||
| Lymphoma | 47 (11.8) | 41 (10.1) | 31 (25.4) | 48 (19) | |||
| Multiple Myeloma | 0 (0) | 0 (0) | 1 (0.8) | 3 (1.2) | |||
| Naso-pharynx | 7 (1.8) | 4 (1) | 0 (0) | 0(0) | |||
| Ovarian | 6 (1.5) | 4 (1) | 0 (0) | 0(0) | |||
| Prostate | 2 (0.5) | 6 (1.5) | 0 (0) | 10 (4) | |||
| Sarcoma | 13 (3.3) | 13 (3.2) | 1 (0.8) | 5 (2) | |||
| Stomach cancer | 16 (4) | 14 (3.5) | 8 (6.6) | 7 (2.8) | |||
| Testicular cancer | 3 (0.8) | 6 (1.5) | 0 (0) | 0(0) | |||
| Thyroid | 2 (0.5) | 2 (0.5) | 1 (0.8) | 4 (1.6) | |||
| Uterus cancer | 22 (5.5) | 21 (5.2) | 5 (4.1) | 10 (4) | |||
| Treatment Phase | Newly diagnosed, did not start treatment yet | 27 (6.8) | 46 (11.3) | 0.016 | 6 (4.8) | 21 (8.3) | 0.232 |
| On treatment | 299 (75.3) | 309 (76.1) | 92 (74.2) | 198 (78) | |||
| Finished treatment | 71 (17.9) | 51 (12.6) | 20 (16.1) | 28 (11) | |||
| On Palliative care | 0 (0) | 0 (0) | 6 (4.8) | 7 (2.8) | |||
CAM usage and uharacteristics: 2013 vs. 2022
The 2013 study revealed that the prevalence of CAM use was 49.4%. Nearly a decade later, in 2022, the prevalence decreased to 32.8%.
A comparative analysis of the two studies indicated that a consistent proportion of current CAM users reported CAM use prior to their cancer diagnosis. This figure was 38.4% in 2013 and slightly decreased to 33.1% in 2022. The CAM types predominantly used in both studies were natural health products, including herbs, vitamins, and special foods. Usage was high in both studies, at 89.8% in 2013, increasing further to 97.6% in 2022. The frequency of CAM use exhibited some variability among the participants. A notable majority reported daily use, accounting for 55.3% in 2013 and 65.9% in 2022. In terms of the reasons for CAM usage, participants from both studies primarily mentioned treatment (46.5% in 2013 and 54% in 2022) and improving the immune system (45.5% in 2013 and 36.3% in 2022).
Notably, dialog regarding CAM usage with healthcare teams was low in both studies, at 35.2% in 2013 and slightly higher at 46.3% in 2022. A similar trend was noted for physician inquiries about CAM use, which was 27.8% in 2013 and 38.7% in 2022. Other trends are presented in Table 2.
Table 2.
Trends in using CAM among cancer patients users between 2013 & 2022
| Characteristics | Levels | CAM users in 2013 n = 400 (49.4%) | CAM users in 2022 n = 124 (32.8%) |
|---|---|---|---|
| n(%) | n(%) | ||
| Using CAM before diagnosis | Yes | 146(38.4) | 41(33.1) |
| No | 234(61.6) | 85(669) | |
| CAM type | Natural health products (herbs, vitamins or special foods) | 359(89.8) | 121(97.6) |
| Spiritual | 150(37.5) | 23(18.7) | |
| Physical movement | 123(30.8) | 13(10.6) | |
| Frequency | Daily | 214(55.3) | 81(65.9) |
| Weekly | 64(16.5) | 3(2.4) | |
| Monthly | 21(5.4) | 3(2.4) | |
| Yearly | 4(1.0) | 3(2.4) | |
| When needed | 84(21.7) | 33(26.8) | |
| Reasons for using CAM | For Treatment | 186(46.5) | 67(54) |
| To prevent recurrence | 91(22.8) | 12(9.7) | |
| Decrease pain | 59(14.8) | 14(11.3) | |
| Decrease side effects | 78(19.5) | 10(8.1) | |
| Improve immune system | 182(45.5) | 45(36.3) | |
| Improve appetite | 39(9.8) | 1(0.8) | |
| Decrease stress | 67(16.8) | 4(3.2) | |
| Not convinced with conventional treatment | 14(3.5) | 1(0.8) | |
| Improve general health | 7(1.75) | 6(4.8) | |
| Followed a recommendation from others | 4(1) | 0(0) | |
| Enhance treatment | 4(1) | 0(0) | |
| For just experience | 2(0.5) | 0(0) | |
| Discussion of CAM use with your healthcare team | Yes | 140(35.2) | 57(46.3) |
| No | 258(64.8) | 66(53.7) | |
| Did your physician ask about CAM use | Yes | 109(27.8) | 36(38.7) |
| No | 283(72.2) | 57(61.3) | |
| Do you want to know more about CAM use in oncology | Yes | 344(86.9) | 102(87.9) |
| No | 52(13.1) | 14(12.1) | |
| Postponed conventional treatment to use CAM | Yes | 57(14.4) | 55(45.1) |
| No | 339(85.6) | 67(54.9) | |
| Perceived benefit from using CAM | Yes | 317(86.6) | 37(31.9) |
| No | 49(14.4) | 79(68.1) | |
| Type of perceived benefit | Higher energy level | 208(52) | 41(49.4) |
| Decrease pain | 71(17.8) | 7(8.4) | |
| Decrease side effects of medications | 76(19) | 10(12.1) | |
| Better response to conventional treatment | 68(17) | 18(21.7) | |
| Others: Improve psychology | 21(5.3) | 2(2.4) | |
| Others: Immunity Improvement | 8(2) | 5(6) | |
| Stopped using CAM | Yes | 114(30.3) | 67(58.3) |
| No | 262(69.7) | 48(41.7) | |
| Sources of CAM info | Friends and relatives | 221(55.3) | 83(66.9) |
| Media | 147(36.8) | 34(27.4) | |
| Herbalists | 50(12.5) | 5(4.1) | |
| Healthcare team | 7(1.8) | 0(0) | |
| Specialist in complementary medicine | 41(10.3) | 4(3.2) | |
| Other patients experiences | 158(39.5) | 13(10.5) | |
| Other sources | 35(8.8) | 3(2.4) |
Perceived benefits and CAM Source
The perceived benefits of CAM usage were considerably high in 2013, with 86.6% of CAM users reporting some form of benefit. The key perceived benefits included increased energy levels (52%), decreased pain (17.8%), and reduced side effects from medication (19%). The 2022 survey, however, revealed a stark decrease in the perceived benefits of CAM usage, dropping to 31.9%.
In regard to information sources about CAM, both surveys revealed friends and relatives as the leading source (55.3% in 2013, 66.9% in 2022), followed by media outlets (36.8% in 2013, and 27.4% in 2022). Other trends are presented in Table 2.
Independent factors associated with CAM use
Multivariate logistic regression analysis in the 2013 survey further revealed that young and middle-aged adults aged 18–39 years (Adjusted OR 2.113, 95% CI 1.375–3.247), 40–59 years (Adjusted OR 2.160, 95% CI 1.419–3.288) and patients who finished their treatment (Adjusted OR 2.140, 95% CI 1.139–4.020) were independent predictors of CAM usage. These findings are presented in Table 3.
Table 3.
Independent factors associated with CAM use in 2013
| Factors retained in backward logistic regression analysis | Adjusted OR (95%CI) | Adjusted P value |
|---|---|---|
| Age at Diagnosis | ||
| ≥ 60 Years(Ref) | 1 | |
| 18–39 Years | 2.113 (1.375-3.247) | < 0.001 |
| 40–59 Years | 2.160 (1.419–3.288) | < 0.001 |
| Current Treatment Phase | ||
| Newly diagnosed, did not start treatment yet(Ref) | 1 | |
| On treatment | 1.636 (0.964–2.779) | 0.061 |
| Finished treatment | 2.140 (1.139–4.020) | 0.018 |
In the 2022 survey, multivariate logistic regression analysis further demonstrated that the absence of health insurance was independently associated with CAM use (Adjusted OR 1.820, 95% CI 1.007–3.289). These results are detailed in Table 4.
Table 4.
Independent factors associated with CAM use in 2022
| Factors retained in backward logistic regression analysis | Adjusted OR (95%CI) | Adjusted P value |
|---|---|---|
| Insurance | ||
| Yes(Ref) | 1 | |
| No | 1.820 (1.007–3.289) | 0.047 |
Discussion
The research conducted in these two surveys provides a comprehensive assessment of the evolving patterns of complementary and alternative medicine (CAM) usage among cancer patients in Jordan between 2013 and 2022. This decennial snapshot reveals important trends and shifts in attitudes toward CAM, shedding light on the changing perceptions and utilization of CAM.
One of the most striking findings from our research is the reduction in the overall prevalence of CAM usage among cancer patients, from 49.4% in 2013 to 32.8% in 2022. Such findings were reported recently from a regional study in Saudi Arabia by Jazieh et al. [38] This marked decrease might be reflective of several factors. First, it could suggest increased trust in conventional therapies, especially with advancements in medical treatments and pharmacology over the past decade [39]. Alternatively, it might also be indicative of growing awareness regarding the limitations and potential risks associated with some CAM therapies, leading to a more judicious usage pattern [40].
Interestingly, while the overall usage of CAM has decreased, the frequency of usage among CAM users has increased, with more patients reporting using CAM on a daily basis in 2022 than in 2013. Unfortunately, reports on the frequency of CAM use among cancer patients are scarce [41]. This means that, while fewer cancer patients opt for CAM, those who use it more intensively. Therefore, further research should aim to understand the motivations and beliefs that guide this intensive usage.
One of the salient findings from our study was the predominant use of natural health products for treatment and immune enhancement. This finding is consistent with other previously reported studies [42, 43]. This finding indicates a continued belief in the therapeutic properties of these products, regardless of the decreased overall usage of CAM. Future research should focus on understanding the perceived benefits and effectiveness of these natural health products in comparison with conventional medicines.
A critical area of concern highlighted by both surveys is the ongoing communication gap between patients and healthcare providers regarding CAM usage. This lack of communication was observed and reported in several previous studies [15–17, 44]. While there was a marginal improvement in patient-healthcare provider communication about CAM use from 2013 to 2022, over half of the respondents in both surveys did not discuss their CAM use with their doctors. This lack of disclosure raises the potential for harmful interactions with conventional therapies and adverse health outcomes. This underlines the urgent need for an open dialog between patients and healthcare providers about CAM usage, thereby encouraging safe and effective CAM use.
Comparing the two surveys, we found significant differences in the associations between certain demographic and treatment factors and CAM usage. In 2013, age at diagnosis and current treatment phase were associated with CAM use, but this association was not found in 2022. However, having no insurance emerged as a significant factor associated with CAM use in 2022. Such changes in trends were reported previously among cancer patients [20, 38]. This suggests a shift in the factors influencing CAM usage over time, hinting at the fluid nature of CAM acceptance and the influence of evolving societal, cultural, and personal factors, in addition to the significant impact of economic status on CAM use trends.
In terms of the perceived benefits of CAM, findings from this study revealed a sharp decrease from 2013 to 2022. This might suggest that the initial high expectations or hopes related to CAM therapies may not be sustained over time for various reasons, such as a lack of desired outcomes, side effects, or changes in health beliefs.
The predominant sources of information about CAM are friends, relatives, and media outlets, as indicated by our study, which raises questions about the quality, credibility, and accuracy of information influencing healthcare decisions. This result is supported by a recent report by Källman et al., who reported that the most common sources of information about CAM were family and friends [45], emphasizing the need to disseminate reliable, evidence-based information about CAM to individuals considering these therapies, which can play a critical role in informed decision-making and safe usage of CAM.
The reporting of CAM use trends among cancer patients over a ten-year period is a notable strength of this study. This allowed for an in-depth evaluation of trends and changes in CAM usage over time, thereby providing a comprehensive overview of the evolving landscape of CAM. Another strength lies in the large sample size, which increases the generalizability of the findings. However, several limitations need to be acknowledged. First, this research relies on self-reported data, which are susceptible to recall bias and may not accurately represent actual CAM usage. Second, owing to the inherent nature of surveys, we were unable to explore in depth the motivations, perceptions, and beliefs associated with CAM usage, which might offer valuable insights. Additionally, we did not account for the differences between the results of both studies in our statistical analysis, which might have affected the conclusions drawn in this study. Finally, the unequal gender distribution in both surveys, with a greater number of female respondents, might have introduced a gender bias in the results.
Conclusion
This study offers valuable insights into the changing dynamics of CAM usage over a decade among cancer patients in Jordan, revealing critical areas of concern and potential avenues for future research. The findings from this study revealed a considerable reduction in the overall prevalence of CAM usage among cancer patients. Furthermore, these findings also suggest that, while fewer cancer patients opt for CAM, those who use it more intensively.
There is a clear communication gap between physicians and patients in terms of CAM use, highlighting the need to understand the factors influencing CAM acceptance and perceived benefits and calling for the provision of accurate and reliable information about CAM use among cancer patients. Therefore, an educational program targeting both cancer patients and healthcare providers may help close this communication gap and may help prevent potentially harmful interactions that may result from concurrent use with conventional cancer treatment. Recently, a lack of health insurance has been identified as an important factor that influences CAM use among cancer patients, unlike previous significant factors such as age at diagnosis and the current treatment phase. The findings from this study can contribute to the development of effective strategies and interventions for the safe and effective use of CAM in patients with cancer.
Acknowledgments
Clinical trial number
21KHCC164.
Abbreviations
- CAM
Complementary and Alternative Medicine
- RMS
Royal Medical Services
- KAUH
King Abdullah University Hospital
- MoH
Ministry of Health Hospitals
- KHCC
King Hussein Cancer Center
Authors’ contributions
NA: Conception, design, data analysis, data acquisition, interpretation of data, manuscript writing. AA: Conception and design, data acquisition. MQ: Review original manuscript. IA: Review original manuscript. NK: Review original manuscript. KA: Data coding, review original manuscript. All the authors critically revised the manuscript for important intellectual content. All the authors approved the final version for publication.
Funding
There was no Funding for this study.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
The study was approved by and conducted in accordance with the guidelines of the Institutional Review Board (IRB) at KHCC.
Competing interests
The authors declare no competing interests.
Conflict of interest
The authors declare that they have no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.NCCIH. CAM Basics. 2010. Available from: https://www.apdaparkinson.org/. https://www.apdaparkinson.org/uploads/files/CAM-Basics-HG0.pdf.
- 2.Harris PE, Cooper KL, Relton C, Thomas KJ. Prevalence of complementary and alternative medicine (CAM) use by the general population: a systematic review and update. Int J Clin Pract. 2012. 10.1111/j.1742-1241.2012.02945.x. [DOI] [PubMed] [Google Scholar]
- 3.Meier-Girard D, Lüthi E, Rodondi PY, Wolf U. Prevalence, specific and non-specific determinants of complementary medicine use in Switzerland: data from the 2017 Swiss health survey. PLoS One. 2022. 10.1371/journal.pone.0274334. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Abusanad A, Ujaimi R, Alotaibi MA, Alharbi LA, Alatawi N, Algarni AA et al. Exploring Integrative Approaches: Insights Into Complementary Medicine Practices Among Breast Cancer Survivors in Saudi Arabia. Cureus. 2024;16(1):e52282. 10.7759/cureus.52282. [DOI] [PMC free article] [PubMed]
- 5.Alwhaibi M, Sambamoorthi U. Sex differences in the use of complementary and alternative medicine among adults with multiple chronic conditions. Evidence-Based Complementary and Alternative Medicine. 2016. 10.1155/2016/2067095. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kristoffersen AE, Stub T, Salamonsen A, Musial F, Hamberg K. Gender differences in prevalence and associations for use of CAM in a large population study. BMC Complement Altern Med. 2014. 10.1186/1472-6882-14-463. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.According to a New Government Survey, 38% of Adults and 12% of Children Use Complementary and Alternative Medicine. 2008. Available from: https://www.nih.gov/news-events/news-releases/according-new-government-survey-38-percent-adults-12-percent-children-use-complementary-alternative-medicine.
- 8.Eardley S, Bishop FL, Prescott P, Cardini F, Brinkhaus B, Santos-Rey K, et al. A systematic literature review of complementary and alternative medicine prevalence in EU. Forsch Komplementmed. 2012. 10.1159/000342708. [DOI] [PubMed] [Google Scholar]
- 9.European Commission. Complementary medicine popular across Europe. 2012. Available from: https://cordis.europa.eu/article/id/35388-complementary-medicine-popular-across-europe.
- 10.Astin JA. Why patients use alternative medicine: results of a national study. J Am Med Assoc. 1998. 10.1001/jama.279.19.1548. [DOI] [PubMed] [Google Scholar]
- 11.Dufter SA, Hübner J, Ahmadi E, Zomorodbakhsch B. Traits of cancer patients and CAM usage. J Cancer Res Clin Oncol. 2021;147(12):3685-3692. 10.1007/s00432-021-03605-7. [DOI] [PMC free article] [PubMed]
- 12.Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States -- prevalence, costs, and patterns of use. N Engl J Med. 1993. 10.1056/NEJM199301283280406. [DOI] [PubMed] [Google Scholar]
- 13.Ventola CL. Current issues regarding complementary and alternative medicine (CAM) in the united States - Part 1: the widespread use of CAM and the need for better-informed health care professionals to provide patient counseling. P T. 2010;35(8):461–8. [PMC free article] [PubMed]
- 14.Bellanger RA, Seeger CM, Smith HE. Safety of complementary and alternative medicine (CAM) treatments and practices. Side Eff Drugs Annu. 2017;39:503–12. [Google Scholar]
- 15.Al-Omari A, Al-Qudimat M, Abu Hmaidan A, Zaru L. Perception and attitude of Jordanian physicians towards complementary and alternative medicine (CAM) use in oncology. Complement Ther Clin Pract. 2013. 10.1016/j.ctcp.2013.01.002. [DOI] [PubMed] [Google Scholar]
- 16.Abuelgasim KA, Alsharhan Y, Alenzi T, Alhazzani A, Ali YZ, Jazieh AR. The use of complementary and alternative medicine by patients with cancer: aF cross-sectional survey in Saudi Arabia. BMC Complement Altern Med. 2018. 10.1186/s12906-018-2150-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Al-momani shraq N, Al-tawalbeh DM. Usage of complementary and alternative medicine among cancer patients in Jordan. Glob J Medical, Phys Heal Educ [Internet]. 2015 Dec 20 [cited 2023 May 24];3(6):152–9. Available from: https://www.globalscienceresearchjournals.org/abstract/usage-of-complementary-and-alternative-medicine-among-cancer-patients-in-jordan-46607.html.
- 18.Posadzki P, Watson LK, Ernst E. Adverse effects of herbal medicines: an overview of systematic reviews. Clin Med Lond. 2013. 10.7861/clinmedicine.13-1-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V et al. Use of complementary and alternative medicine in cancer patients: A European survey. Ann Oncol. 2005;16(4):655–63. 10.1093/annonc/mdi110. [DOI] [PubMed]
- 20.Zuniga KB, Zhao S, Kenfield SA, Cedars B, Cowan JE, van Blarigan EL et al. Trends in complementary and alternative medicine use among patients with prostate cancer. J Urol. 2019;202(4):689–695. 10.1097/JU.0000000000000336. [DOI] [PMC free article] [PubMed]
- 21.B KAJC, H SB, K K, C C-S. S. M. Practices, attitudes, and beliefs associated with complementary and alternative medicine (CAM) use among cancer patients. Integr Cancer Ther. 2012;11(3):232–42 . 10.1177/1534735411433832. [DOI] [PMC free article] [PubMed]
- 22.Alzweiri M, Sarhan A, Al, Mansi K, Hudaib M, Aburjai T. Ethnopharmacological survey of medicinal herbs in Jordan, the Northern Badia region. J Ethnopharmacol. 2011;137(1):27–35. Available from: https://pubmed.ncbi.nlm.nih.gov/21335083/. Cited 2023 May 24. [DOI] [PubMed]
- 23.Aburjai T, Hudaib M, Tayyem R, Yousef M, Qishawi M. Ethnopharmacological survey of medicinal herbs in Jordan, the Ajloun heights region. J Ethnopharmacol. 2007. 10.1016/j.jep.2006.09.031. [DOI] [PubMed] [Google Scholar]
- 24.Al Khalidi K, Shudfat M, Al Tabaini R, Nawash O. Ethnobotanical study of medicinal plants used by local Bedwins in the badia region of Jordan. Planta Med. 2011;77(12). 10.1055/s-0031-1282411.
- 25.Al-Qura’n S. Ethnopharmacological survey of wild medicinal plants in showbak, Jordan. J Ethnopharmacol. 2009. 10.1016/j.jep.2009.02.031. [DOI] [PubMed] [Google Scholar]
- 26.Al-Qura’n S. Ethnobotanical survey of folk toxic plants in southern part of Jordan. Toxicon. 2005;46(2):119–29. Available from: https://pubmed.ncbi.nlm.nih.gov/15964044/. Cited 2023 May 24. [DOI] [PubMed]
- 27.Khader Y, Sawair FA, Ayoub A, Ayoub N, Burgan SZ, Amarin Z. Knowledge and attitudes of lay public, pharmacists, and physicians toward the use of herbal products in North Jordan. J Altern Complement Med. 2008;14(10):1186–7. 10.1089/acm.2008.0282. [DOI] [PubMed] [Google Scholar]
- 28.Issa RA, Basheti IA. Herbal medicine use by people in Jordan: exploring believes and knowledge of herbalists and their customers. J Biol Sci. 2017. 10.3923/tmr.2017.55.64. [Google Scholar]
- 29.Wazaify M, Alawwa I, Yasein N, Al-Saleh A, Afifi FU. Complementary and alternative medicine (CAM) use among Jordanian patients with chronic diseases. Complement Ther Clin Pract. 2013. 10.1016/j.ctcp.2013.03.001. [DOI] [PubMed] [Google Scholar]
- 30.Otoom SA, Al-Safi SA, Kerem ZK, Alkofahi A. The use of medicinal herbs by diabetic Jordanian patients. J Herb Pharmacother. 2006. 10.1080/J157v06n02_03. [PubMed] [Google Scholar]
- 31.Omeish AF, Abbadi W, Ghanma IM, Drabaa Z, Botoosh FA, Seif A et al. Hospital-based study on the use of herbal medicine in patients with coronary artery disease in Jordan. J Pak Med Assoc. 2011;61(7):683–7. https://www.archive.jpma.org.pk/PdfDownload/2868. [PubMed]
- 32.Akour A, Kasabri V, Afifi FU, Bulatova N. The use of medicinal herbs in gynecological and pregnancy-related disorders by Jordanian women: a review of folkloric practice vs. evidence-based pharmacology. Pharm Biol. 2016;54(9):1901–18. Available from: https://pubmed.ncbi.nlm.nih.gov/26911517/. Cited 2023 May 24. [DOI] [PubMed]
- 33.Bardaweel SK. Alternative and antioxidant therapies used by a sample of infertile males in Jordan: a cross-sectional survey. BMC Complement Altern Med. 2014. 10.1186/1472-6882-14-244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Al-Qudimat MR, Rozmus CL, Farhan N. Family strategies for managing childhood cancer: using complementary and alternative medicine in Jordan. J Adv Nurs. 2011;67(3):591–7. 10.1111/j.1365-2648.2010.05517.x. [DOI] [PubMed]
- 35.Afifi FU, Wazaify M, Jabr M, Treish E. The use of herbal preparations as complementary and alternative medicine (CAM) in a sample of patients with cancer in Jordan. Complement Ther Clin Pract. 2010. 10.1016/j.ctcp.2010.05.001. [DOI] [PubMed] [Google Scholar]
- 36.Akhu-Zaheya LM, Alkhasawneh EM. Complementary alternative medicine use among a sample of Muslim Jordanian oncology patients. Complement Ther Clin Pract. 2012. 10.1016/j.ctcp.2011.10.003. [DOI] [PubMed] [Google Scholar]
- 37.Hamash K. Use of complementary and alternative medicine among breast cancer women in Jordan. Online J Complement Altern Med. 2020;4(5). 10.33552/OJCAM.2020.04.000600.
- 38.Jazieh AR, Abuelgasim KA, Ardah HI, Alkaiyat M, Da’ar OB. The trends of complementary alternative medicine use among cancer patients. BMC Complement Med Ther. 2021. 10.1186/s12906-021-03338-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 39.Tangkiatkumjai M, Boardman H, Walker DM. Potential factors that influence usage of complementary and alternative medicine worldwide: a systematic review. BMC Complement Med Ther. 2020. 10.1186/s12906-020-03157-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.October 31 NCI. 2024. 2024. Complementary and Alternative Medicine. Available from: https://www.cancer.gov/about-cancer/treatment/cam. Cited 2025 May 25.
- 41.Lo-Fo-Wong DNN, Ranchor AV, de Haes HCJM, Sprangers MAG, Henselmans I. Complementary and alternative medicine use of women with breast cancer: self-help CAM attracts other women than guided CAM therapies. Patient Educ Couns. 2012. 10.1016/j.pec.2012.02.019. [DOI] [PubMed] [Google Scholar]
- 42.Wode K, Henriksson R, Sharp L, Stoltenberg A, Hök Nordberg J. Cancer patients’ use of complementary and alternative medicine in Sweden: a cross-sectional study. BMC Complement Altern Med. 2019. 10.1186/s12906-019-2452-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Knecht K, Kinder D, Stockert A. Biologically-based complementary and alternative medicine (CAM) use in cancer patients: the good, the bad, the misunderstood. Front Nutr. 2020. 10.3389/fnut.2019.00196. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Sait KH, Anfinan NM, Eldeek B, Al-Ahmadi J, Al-Attas M, Sait HK, et al. Perception of patients with cancer towards support management services and use of complementary alternative medicine - a single institution hospital-based study in Saudi Arabia. Asian Pac J Cancer Prev. 2014. 10.7314/APJCP.2014.15.6.2547. [DOI] [PubMed] [Google Scholar]
- 45.Källman M, Bergström S, Carlsson T, Järås J, Holgersson G, Nordberg JH et al. Use of CAM among cancer patients. BMC Complement Med Ther. 2023;23(1):51. 10.1186/s12906-023-03876-2. [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.