Abstract
Background
Complementary and Alternative Medication (CAM) is commonly used among women with breast cancer to improve their quality of life (QoL). However, few studies examine the prevalence of CAM and its’ relation to the patients’ QoL among women with breast cancer.
Methods
A cross-sectional study was conducted among 95 women with breast cancer at a tertiary hospital in Saudi Arabia. The outcome measure of interest was the QoL. The correlation was used to assess the association between CAM use and QoL. Bivariate and multivariate analyses were used to examine the factors that affect the use of CAM. The data was analysed using Statistical Package for the Social Sciences (SPSS) version 24.0.
Results
CAM use was reported by 81.1% of the study participants. The most commonly used CAM therapy was spiritual therapy 70.5%, followed by honey 36.8%, olive oil 24.2% and 23.2% herbal therapy. We found that those who were undergoing cancer treatment had a significantly higher percentage of CAM usage as compared to those not undergoing cancer therapy (72.6% vs. 8.4%, P=0.008). With regards to QoL, there was a statistically significant difference between CAM users and non-CAM users in global health status (73.2% vs. 64.8%, P = 0.049).
Conclusions
CAM therapy was commonly used among women in our study sample which was correlated with higher overall global QoL. As CAM is widely used, health care providers may need to discuss the use of CAM with breast cancer women and be up to date on the benefits and risk of CAM use through well-equipped training programs and workshops.
Keywords: Breast Cancer, Women, Complementary and Alternative Medicine, Quality of Life, Saudi Arabia
1. Introduction
Cancer is a highly prevalent chronic condition that is one of the leading causes of morbidity and mortality worldwide (Globocan., 2012, Laronga, 2016). However, mortality rates have declined due to early diagnosis, enhanced surgical and radiotherapy techniques and improved systemic therapies (Laronga, 2016). Aside from these developments, breast cancer is still the second most common cause of death from cancer in women (Yeo et al., 2014). In Saudi Arabia, breast cancer is the most common cancer type among women; accounting for 27.3% of cancer cases among women (Laronga, 2016, Saudi, 2012, Cancer.org., 2016). Cancer diagnosis and treatment has shown to exhibit substantial impact on women’s functional, mental and emotional well-being and overall quality of life (Almutairi et al., 2015). Women with breast cancer commonly use complementary and alternative medicine (CAM); an estimated 44.7% of women with breast cancer reported using CAM (Molassiotis et al., 2005a, Molassiotis et al., 2005b). CAM is defined by the National Centre for Complementary and Alternative Medicine (NCCAM) as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” (Ernst, 2015).
There is an increasing demand for complementary therapies by cancer patients during their disease to reduce the side-effects of cancer therapy (Rossi et al., 2017). Women with breast cancer use CAM to boost their immunity (Almousa et al., 2015), prevent disease progression (Hwang et al., 2015), cure cancer (Oyunchimeg et al., 2017), or improve their quality of life (Naja et al., 2015). The Quality of Life (QoL) may be described as the sense of well-being involving physical, mental, social and spiritual characteristics of an individual (Almutairi et al., 2015). There is mixed evidence regarding the association between CAM and QoL. A Lebanese study reported no significant relation between CAM consumption and the patient’s QoL (Naja et al., 2015) that was consistent with the findings of a Malaysian study published in the same year (Chui et al., 2015). On the other hand, a Korean study found a significant relationship between high CAM consumption and low QoL in breast cancer patients (Hwang et al., 2015).
The most common types of CAM used among women with breast cancer include spiritual therapy, a study using the National Health Interview Survey (NHIS) documented that yoga, chiropractic, and osteopathic manipulation are the most common CAM therapies used by cancer patients (NCCIH, 2015). In Saudi Arabia, a cross-sectional study among 1,408 individuals reported that 62.5% of the participants used the Holy Quran (Al-Rowais et al., 2010). Another was conducted among 518 participants, were prayers accounted for almost 54.0% of CAM, Hijama (wet cupping) 35.7% and cauterization or massage therapy 22% (Elolemy and Albedah, 2012).
There are few studies conducted in Saudi Arabia concerning CAM use among cancer patients (Elolemy and Albedah, 2012, Sait et al., 2014, Aldahash and Marwa, 2012). In addition, there are no studies that examined the association between CAM and QoL among women with breast cancer in Saudi Arabia. Therefore, the purpose of this study was to examine the prevalence of CAM use and its’ relation to the patients’ quality of life among breast cancer women at a tertiary hospital in Saudi Arabia.
2. Methods
2.1. Study Design
A cross-sectional study was conducted among 140 women with breast cancer; 95 of women completed the questionnaire (Response rate 68%); 10 women did not complete the questionnaire, and 35 refused to participate.
2.2. Study Setting
The study was conducted in the females’ Oncology ward among patients who attend their therapy from July 1st to December 30th, 2016 at the Oncology Unit at a tertiary hospital in Saud Arabia.
2.3. Participants
Women who participated in this study had the following inclusion criteria: females, eighteen years or older, diagnosed with breast cancer, and willing to take part in the study.
2.4. Procedures
A structured questionnaire was developed to measure CAM use and the factors that affect CAM use based on various studies (Hwang et al., 2015, Naja et al., 2015, Chui et al., 2015, Molassiotis et al., 2005a, Molassiotis et al., 2005b). The questionnaire was composed of three main sections (socio-demographic data, CAM use, and QoL). The questionnaire was approved by the Institutional Review Board (Ref.No. 16/0328/IRB). After receiving the IRB approval, the research assistant approached the eligible participants and began to explain the purpose of the study, reassured them about the flexibility of withdrawing and then obtained consent to start the interview. The interviewer then conducted a one to one interview using a structured questionnaire by reading the questions one by one and recording the participants’ response.
2.5. Sample size
Based on previous studies (Almutairi et al., 2015, Gerber et al., 2014, Saibul et al., 2012) we calculated the required sample size to be 76 patients through Jacob Cohens’ table (Jacob Cohen, 1992) with an estimated power of 0.8, an alpha error of 0.05 and a medium effect size.
3. Measures
3.1. Dependent variable
The dependent variable was CAM use since breast cancer diagnosis. Since diagnosis is described as the period from cancer diagnosis until the current date (Molassiotis et al., 2005a, Molassiotis et al., 2005b). If patients did not use CAM, they were asked about the possible reasons for not using CAM. Patients who reported CAM use were asked about the reasons for CAM use, the frequency of CAM use, benefits and risks of CAM used, the cost of CAM, and the source of information about CAM. Participants were also asked if they have consulted their health care provider before using CAM, and the reasons for not consulting their healthcare provider.
3.2. Independent Variables
Independent variables include socio-demographic data (e.g. age, gender, marital status, occupation, education, and income level), Clinical data (e.g. ongoing cancer treatments), and Quality of life (QoL). QoL was assessed using a validated (Huijer et al., 2013, Alawadhi and Ohaeri, 2010, Awad et al., 2008) Arabic version of the European Organization for Research and Treatment of Cancer (EORTC) (Aaronson et al., 1993). We used the generic EORTC-QLQ-C30 and cancer specific EORTC QLQ-BR23 QoL questionnaires. The generic QoL scale consists of 30-items that contain both multi and single-item scales that measure the cancer patient’s QoL (Aaronson et al., 1993). The breast cancer QoL scale, on the other hand, consists of 23 items that measure the breast cancer patient’s QoL using five subscales (treatment side effects, arm symptoms, breast symptoms, body image, and sexual function).
The EORTC questionnaire scale scores range from 0 to 100; greater scores in the functional scale and QoL indicate a superior degree of performance and QoL. However, greater scores on a symptom scale refer to a critical degree of symptoms (Aaronson et al., 1993).
4. Analysis Plan
Descriptive and inferential statistics were used to describe our sample. The correlation was used to assess the association between CAM use and QoL. Adjusted binary logistic regression was used to examine the factors affecting CAM use. Statistical Package for the Social Sciences (SPSS) version 24.0 was used for the analysis.
5. Results
5.1. Description of the study sample
The characteristics of the study participants are summarized in Table 1. All participants were women; almost half of the study sample was between 40-59 years of age. The majority of the patients were Saudi, 70% resided in Riyadh, 76% were married, 84% were unemployed, and 57% reported low income (i.e., income level below 5000 Saudi Riyals). Furthermore, 89% of study participants were undergoing cancer treatment.
Table 1.
Description of the study sample.
| N | % | |
|---|---|---|
| Age | ||
| 25-39 | 25 | 26.3 |
| 40-59 | 45 | 47.4 |
| 60 and above | 25 | 26.3 |
| Nationality | ||
| Saudi | 77 | 81.1 |
| None-Saudi | 18 | 18.9 |
| Residence | ||
| Riyadh | 67 | 70.5 |
| Other | 28 | 29.5 |
| Level of education | ||
| Uneducated | 19 | 20.0 |
| <High school level | 49 | 51.6 |
| >High school level | 27 | 28.4 |
| Social status | ||
| Married | 72 | 75.8 |
| Unmarried | 23 | 24.2 |
| Job Status | ||
| Employed | 15 | 15.8 |
| Unemployed | 80 | 84.2 |
| Average monthly income | ||
| < 5000 SR | 55 | 57.9 |
| 5000-10000 SR | 24 | 25.3 |
| >10000 SR | 16 | 16.8 |
| Ongoing cancer treatment | ||
| Yes | 85 | 89.5 |
| No | 10 | 10.5 |
Note: Based on 95 Women, 18 years and above with breast cancer.
N: Number,%: Percentage.
5.2. Description of the study sample by CAM use
Current CAM use was reported by 81.1% of study participants (Table 2). Our study found that there is a statistically significant difference between CAM users and non-users in employment. A significantly higher percentage of CAM users were employed as compared to non-CAM users (80% vs. 20%). We did not find statistically significant differences between CAM users and non-CAM users in age, nationality, residence, educational status and other variables. We found that women who underwent cancer treatment had a significantly higher percentage of CAM use as compared to those who did not undergo cancer therapy (72.6% vs. 8.4%, p=0.008).
Table 2.
Description of the study sample by CAM use.
| CAM Use | No CAM Use | |||||
|---|---|---|---|---|---|---|
| N | % | N | % | Sig | ||
| Total | 95 | 77 | 81.1 | 18 | 18.9 | |
| Age | ||||||
| 25-39 | 25 | 20 | 80.0 | 5 | 20.0 | 0.192 |
| 40-59 | 45 | 36 | 80.0 | 9 | 20.0 | |
| 60 and above | 25 | 21 | 84.0 | 4 | 16.0 | |
| Nationality | ||||||
| Saudi | 77 | 64 | 83.1 | 13 | 16.9 | 1.128 |
| None-Saudi | 18 | 13 | 72.2 | 5 | 27.8 | |
| Residence | ||||||
| Riyadh | 67 | 53 | 79.1 | 14 | 20.9 | 0.562 |
| Other | 28 | 24 | 85.7 | 4 | 14.3 | |
| Which area | ||||||
| Middle | 30 | 27 | 90.0 | 3 | 10.0 | 2.286 |
| Other regions | 65 | 50 | 76.9 | 15 | 23.1 | |
| Level of education | ||||||
| Uneducated | 19 | 16 | 84.2 | 3 | 15.8 | 0.323 |
| <high school level | 49 | 40 | 81.6 | 9 | 18.4 | |
| >high school level | 27 | 21 | 77.8 | 6 | 22.2 | |
| Social status | ||||||
| Married | 72 | 57 | 79.2 | 15 | 20.8 | 0.689 |
| Single / Divorced / Widowed | 23 | 20 | 87.0 | 3 | 13.0 | |
| Job Status | ||||||
| Employed | 15 | 12 | 80.0 | 3 | 20.0 | 0.013** |
| Unemployed | 80 | 65 | 81.3 | 15 | 18.8 | |
| Average monthly income | ||||||
| < 5000 SR | 55 | 45 | 81.8 | 10 | 18.2 | 0.077** |
| 5000-10000 SR | 24 | 19 | 79.2 | 5 | 20.8 | |
| >10000 SR | 16 | 13 | 81.3 | 3 | 18.8 | |
| Ongoing cancer treatment | ||||||
| Yes | 85 | 69 | 72.6 | 16 | 16.8 | 0.008** |
| No | 10 | 8 | 8.40 | 2 | 2.1 |
Note: Based on 95 Women, 18 years and above with breast cancer.
N: Number,%: Percentage, Sig: Significance, CAM: Complementary Alternative Medicine.
5.3. Factors that affect CAM Use
Table 3 displays the reasons for CAM use among study participants. The commonly reported source of information about CAM was family and friends (54.7%) followed by the Media (20%). Around 42% of the participant’s self-chosen their CAM and 37.9% chose it according to the recommendations of family or friends. Family and friends were reported to be the common CAM providers (45.3%). CAM usage was reported to be more than once per month (65.3%), and 78.9% of the consumers spent approximately less than 500 SR per month on CAM.
Table 3.
Prevalence and characteristics of CAM use.
| N | % | |
|---|---|---|
| CAM use since diagnosis | ||
| Yes | 77 | 81.1 |
| No | 18 | 18.9 |
| Source of Information about CAM | ||
| No one | 6 | 6.3 |
| Media | 19 | 20.0 |
| Internet | 18 | 18.9 |
| Family / Friends | 52 | 54.7 |
| Doctor | 1 | 1.1 |
| Other | 11 | 11.6 |
| How CAM was chosen | ||
| Self-choice | 40 | 42.1 |
| Family / Friends | 36 | 37.9 |
| Health Specialist | 6 | 6.3 |
| Social media | 11 | 11.6 |
| Frequency of CAM use | ||
| Once a month | 15 | 15.8 |
| > Once month | 62 | 65.3 |
| CAM provider | ||
| No one | 22 | 23.2 |
| Doctor | 3 | 3.2 |
| Family / Friends | 43 | 45.3 |
| Other | 10 | 10.5 |
| Approximate cost per month | ||
| <500 SR | 75 | 78.9 |
| >500 SR | 20 | 21.1 |
| Reason for CAM use after diagnosis | ||
| Directly eliminate cancer | 28 | 29.5 |
| Increase immunity | 35 | 36.8 |
| Improve physical & psychological well being | 37 | 38.9 |
| Benefit and no harm | 24 | 25.3 |
| Do everything they can to fight cancer | 35 | 36.8 |
| Benefits acquired from CAM usage | ||
| No benefit | 13 | 13.7 |
| Direct decrease in cancer cells | 17 | 17.9 |
| Increased immunity | 21 | 22.1 |
| Improved physical & psychological well being | 56 | 58.9 |
| Decrease in treatment side effects | 16 | 16.8 |
| Other | 1 | 1.1 |
| CAM side effects | ||
| Yes | 8 | 8.4 |
| No | 69 | 72.6 |
| Satisfaction with CAM | ||
| Satisfied | 36 | 37.9 |
| Average | 33 | 34.7 |
| Dissatisfied | 8 | 8.4 |
| Extent of CAM effectiveness | ||
| Effective | 43 | 45.3 |
| Average | 28 | 29.5 |
| Not effective | 6 | 6.3 |
| Consult Doctor about CAM use | ||
| Yes | 33 | 34.7 |
| No | 44 | 46.3 |
| Reason for not consulting the doctor | ||
| Did not think it was important | 32 | 33.7 |
| Fear of receiving negative input | 4 | 4.2 |
| Other | 8 | 8.4 |
Note: Based on 95 Women, 18 years and above with breast cancer.
N: Number,%: Percentage, CAM: Complementary Alternative Medicine.
The frequently cited reasons for using CAM was to improve physical & psychological well-being (38.9%), strengthen the immune system (36.8%) and directly eliminate cancer (29.5%). The benefits reported from CAM usage were to improve physical & psychological well-being (58.9%) and increase immunity (22.1%).
The majority of CAM users (72.6%) did not experience side effects, 37.9% stated that they were satisfied with their CAM use and 45.3% reported CAM to be effective. Higher proportions (46.3%) of CAM users did not discuss their use of CAM with their physicians. The main reason for not discussing CAM consumption with their physicians was because they did not think it was important to consult their physician (33.7%), and others feared to receive negative input (4.2%). Table 4 illustrated the most common types of CAM used after cancer diagnosis as follow: Spiritual therapy 70.5%, followed by Honey 36.8%, Olive oil 24.2% and 23.2% used Herbal therapy.
Table 4.
Type of CAM use after diagnosis.
| N | % | |
|---|---|---|
| None | 1 | 1.1 |
| Spiritual therapy | 67 | 70.5 |
| Herbal Therapy | 22 | 23.2 |
| Hojama | 11 | 11.6 |
| Black seed | 16 | 16.8 |
| Honey | 35 | 36.8 |
| Olive oil | 23 | 24.2 |
| Other | 22 | 23.2 |
Note: Based on 95 Women, 18 years and above with breast cancer.
N: Number,%: Percentage, CAM: Complementary Alternative Medicine.
6. Association between CAM Use and Quality of Life
Table 5, Table 6 display the mean value for each subscale of both the EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires. In the EORTC QLQ-C30, statistical differences were found between CAM users and non-CAM users in the mean global health status (73.16 vs. 64.82, p-value 0.049), physical function (68.05 vs. 63.33, p-value 0.055), role function (78.14 vs. 62.96, p-value 0.002) and social function (83.33 vs. 72.22, p-value 0.047). Furthermore, only constipation (29.01 vs. 14.81, p-value 0.005) from the symptoms scale was significantly different between CAM users and non-CAM users.
Table 5.
Association between CAM Use and Quality of Life EORTC QLQ-C30.
| CAM Users | Non-CAM Users | ||
|---|---|---|---|
| EORTC QLQ-C30 | Mean ± SD | Mean ± SD | P-value |
| Global health status QoL | 73.16 ± 20.26 | 64.82 ± 32.79 | 0.049** |
| Functional Scale | |||
| Physical | 68.05 ± 21.72 | 63.33 ± 28.02 | 0.055** |
| Role | 78.14 ± 29.28 | 62.96 ± 42.23 | 0.002** |
| Emotional | 70.78 ± 29.54 | 67.14 ± 32.39 | 0.733 |
| Cognitive | 79.22 ± 24.05 | 83.33 ± 25.56 | 0.934 |
| Social | 83.33 ± 26.35 | 72.22 ± 33.82 | 0.047** |
| Symptom Scale | |||
| Fatigue | 33.62 ± 29.13 | 41.97 ± 30.39 | 0.729 |
| Nausea & Vomiting | 19.70 ± 30.55 | 12.04 ± 26.07 | 0.200 |
| Pain | 33.99 ± 31.46 | 50.92 ± 28.85 | 0.424 |
| Dyspnea | 25.11 ± 30.19 | 24.07 ± 29.83 | 0.614 |
| Insomnia | 48.06 ± 41.01 | 40.74 ± 46.52 | 0.249 |
| Appetite Loss | 31.60 ± 34.59 | 29.63 ± 41.05 | 0.151 |
| Constipation | 29.01 ± 39.13 | 14.81 ± 28.52 | 0.005** |
| Diarrhea | 12.99 ± 28.69 | 18.52 ± 38.30 | 0.133 |
| Financial difficulties | 13.42 ± 29.25 | 20.37 ± 34.56 | 0.264 |
Note: Based on 95 Women, 18 years and above with breast cancer.
EORTC QLQ-C30: The generic European Organization for Research and Treatment of Cancer questionnaire, SD: Standard Deviation, CAM: Complementary Alternative Medicine.
Table 6.
Association between CAM Use and Quality of Life EORTC QLQ-BR23.
| CAM Users | Non-CAM Users | ||
|---|---|---|---|
| EORTC QLQ-BR23 | Mean ± SD | Mean ± SD | P-value |
| Functional Scale | |||
| Body Image | 80.63 ± 23.40 | 66.67 ± 34.78 | 0.005** |
| Sexual Functioning | 19.26 ± 25.23 | 25.93 ± 31.43 | 0.213 |
| Sexual Enjoyment | 21.33 ± 28.81 | 24.08 ± 33.94 | 0.211 |
| Future Perspective | 64.07 ± 38.53 | 55.55 ± 41.23 | 0.541 |
| Symptom Scale | |||
| Systemic therapy Side Effects | 25.98 ± 19.67 | 26.14 ± 27.41 | 0.119 |
| Breast Symptoms | 22.73 ± 21.62 | 23.15 ± 23.33 | 1.000 |
| Arm Symptoms | 37.36 ± 28.39 | 36.42 ± 29.97 | 0.760 |
| Upset by hair loss | 34.85 ± 41.89 | 51.86 ± 44.45 | 0.790 |
Note: Based on 95 Women, 18 years and above with breast cancer.
EORTC QLQ-BR23: Cancer specific European Organization for Research and Treatment of Cancer questionnaire, SD: Standard Deviation, CAM: Complementary Alternative Medicine.
For the EORTC QLQ-BR23 subscales, we only observed a significant variation between CAM users and non-CAM users in body image (80.63 vs. 66.67, p-value 0.049), as for the rest of the questionnaire subscales, there were no significant differences found.
7. Sociodemographic and cancer related factors affecting CAM use
Table 7 displays the adjusted analysis of CAM use. The sociodemographic factors have not been found to affect the patient’s CAM consumption.
Table 7.
Sociodemographic and cancer related factors affecting CAM use.
| B | S.E. | Sig. | 95% C.I. | ||
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Age | 0.01 | 0.46 | 0.98 | 0.41 | 2.48 |
| Nationality | 0.08 | 0.72 | 0.91 | 0.27 | 4.42 |
| Residence | -0.60 | 0.69 | 0.39 | 0.14 | 2.16 |
| Level of education | 0.05 | 0.52 | 0.93 | 0.38 | 2.92 |
| Social status | -0.45 | 0.75 | 0.55 | 0.15 | 2.78 |
| Job Status | -0.07 | 0.87 | 0.94 | 0.17 | 5.15 |
| Average monthly income | -0.01 | 0.41 | 0.98 | 0.44 | 2.21 |
| Ongoing cancer therapy | -0.05 | 0.89 | 0.90 | 0.17 | 5.43 |
Note: Based on of 95 Women, 18 years and above with breast cancer
CAM: Complementary Alternative Medicine, B: Beta coefficient, S.E: Standard Error, Sig: Significance, C.I: Confidence Interval.
8. Discussion
In this cross-sectional study, breast cancer women from various backgrounds were examined for their CAM use and its’ relation to the patients’ QoL. The higher rate of CAM use among women with breast cancer in our study sample (81%) is consistent with other studies conducted in Korea 67% (Hwang et al., 2015), Saudi Arabia 74% (AlBedah et al., 2013), and Ethiopia 79% (Erku, 2016). Other studies have reported a lower rate of CAM use, 40% in a Lebanese study (Naja et al., 2015), 51% in Malaysian study (Saibul et al., 2012) and approximately 57% in a Turkish study (Yildiz et al., 2013).
CAM use in our study population was affected by many factors such as employment, average monthly income, and ongoing anti-cancer therapy. These findings are consistent with published studies in the wider literature (Gerber et al., 2014, AlBedah et al., 2013, Chui et al., 2014, Al-momani and Al-tawalbeh, 2015). The high prevalence of CAM usage found in our study could be justified by the strong religious and cultural beliefs among our population. Also, many women in this study reported using CAM to improve their physical & psychological wellbeing, and immune function were the commonly listed reasons, which was in agreement with other studies conducted by Almousa et al. (Hwang et al., 2015) and Saibul et al. (Saibul et al., 2012). Other studies reported other reasons for using CAM such as perceived benefits of CAM (Erku, 2016), to improve their functional and emotional well-being (Chui et al., 2014).
Furthermore, women in this study may have used CAM to improve their QoL. In fact, this study found that CAM users have a higher QoL as compared to non-users. The study findings displayed significantly enhanced physical, role and social functions among CAM users, yet, they were more likely to suffer from constipation and were found to be more concerned about their body image as compared to non-CAM users. In earlier studies (Yildiz et al., 2013), significant differences were only noted in terms of role and emotional functioning in addition to dyspnea and appetite loss. However, studies conducted in Ethiopia, Turkey, and Malaysia found no difference in QoL between CAM users and non-users (Chui et al., 2015, Erku, 2016, Yildiz et al., 2013).
The commonly reported source of information about CAM was “family and friends”, which was consistent with various studies (Almousa et al., 2015, Hwang et al., 2015, Erku, 2016, Al-momani and Al-tawalbeh, 2015). CAM users in our study did not experience side effects of CAM (Almousa et al., 2015, Naja et al., 2015, Erku, 2016, Al-momani and Al-tawalbeh, 2015), and CAM users were satisfied with their CAM use (Almousa et al., 2015, Naja et al., 2015, Yildiz et al., 2013). As mentioned in earlier findings (Hwang et al., 2015, Naja et al., 2015, Erku, 2016, Bahall, 2017), higher proportions of CAM users in our study did not discuss CAM use with their physicians mainly because they “did not think it was important” (Hwang et al., 2015) and others feared to receive negative input (Erku, 2016). Roter et al. have found that the majority of CAM discussion in the oncology setting is initiated by the patients rather than physicians (Roter et al., 2016). In this study, the most common type of CAM used was Spiritual therapy 70.5% (Chui et al., 2014). This high percentage could be explained by the strong religious beliefs of participants who are Muslim. In addition, the other modalities of CAM such as Honey (36.8%), Olive oil (24.2%) and herbal therapy (23.2%) were also used among the study population. Nevertheless, herbal therapy took the lead in previously conducted studies from various locations (Al-Rowais et al., 2010, Elolemy and Albedah, 2012, Yildiz et al., 2013, Al-momani and Al-tawalbeh, 2015, Posadzki et al., 2013, Ben-Arye et al., 2014). In Saudi Arabia (Al-Rowais et al., 2010, Elolemy and Albedah, 2012), Jordan (Al-momani and Al-tawalbeh, 2015), and similarly in the UK (Posadzki et al., 2013), herbal medicine were among the highest percentages of most common type of CAM consumed. Natural products are readily available and often sold as dietary supplements. They include a range of herbs, vitamins, minerals, and probiotics (NCCIH, 2015). Although the benefits of many natural products have been documented, there is still a lot to be learned about their effects on the human body, their safety and potential interactions with medicines and other natural products (Mohiuddin et al., 2010, Ji et al., 2009).
9. Strengths and limitations
This study was the first to investigate the association of CAM utilization with QoL amongst women with breast cancer in Saudi Arabia. However, this study has some limitations. All measures in the study were self-reported and hence subject to recall bias. Also, this study was conducted among women with breast cancer in a tertiary hospital in Saudi Arabia in an oncology clinic; therefore, our findings cannot be generalizable to other settings or other types of cancer.
10. Conclusion
CAM therapy commonly used among women in our study sample was correlated with higher overall global QoL, better physical, role and social functions and had a greater concern about their body images as compared to non-CAM users. Employment status and average monthly income, as well as ongoing anti-cancer therapy, had a significant relationship with CAM use. Since CAM is commonly widely used nowadays, the healthcare team may need to discuss the use of CAM with breast cancer women and be up to date on the benefits and risk of CAM use through well-equipped training programs and workshops. Also, future studies may need to explore the factors behind the patients’ CAM utilization.
Conflict of interests
The authors declare that there is no conflict of interests regarding the publication of this paper
Contributor Information
Hadeel Albabtain, Email: hadeel.albabtain@gmail.com.
Monira Alwhaibi, Email: malwhaibi@ksu.edu.sa.
Khalid Alburaikan, Email: kalburikan@ksu.edu.sa.
Yousif Asiri, Email: yasiri@ksu.edu.sa.
References
- Aaronson N.K., Ahmedzai S., Bergman B., Bullinger M., Cull A., Duez N.J. The European Organization for Research and Treatment of Cancer QLQ-C30: A Quality-of-Life Instrument for Use in International Clinical Trials in Oncology. J Natl Cancer Inst. 1993;85:365–376. doi: 10.1093/jnci/85.5.365. [DOI] [PubMed] [Google Scholar]
- Al-momani Ishraq N, Al-tawalbeh Deniz M. Usage of Complementary and Alternative Medicine among Cancer Patients in Jordan. Global Journal of Medical, Physical and Health Education. 2015;3(6):152–159. [Google Scholar]
- Al-Rowais, Norah, Eiad Al-Faris, Ashry Gad Mohammad, Mohammad Al-Rukban, and Hamza Mohammad Abdulghani. 2010. “Traditional Healers in Riyadh Region: Reasons and Health Problems for Seeking Their Advice. A Household Survey.” Journal of Alternative and Complementary Medicine (New York, N.Y.) 16 (2): 199–204. doi:10.1089/acm.2009.0283. [DOI] [PMC free article] [PubMed]
- AlBedah Abdullah M N, Khalil Mohamed K M, Elolemy Ahmed T., Al Abdullah A., Mudaiheem Sulaiman Al, Eidi Omar A., Al-Yahia Saleh A., Al-Gabbany, Yousef Henary Basem. The Use of and out-of-Pocket Spending on Complementary and Alternative Medicine in Qassim Province, Saudi Arabia. Annals of Saudi Medicine. 2013;33(3):282–289. doi: 10.5144/0256-4947.2013.282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Aldahash F.D., Marwa A.M.K. Attitude towards the Use of Complementary and Alternative Medicine by Patients in Saudi Arabia. Biomedica. 2012;28:1–6. [Google Scholar]
- Almousa H., Rabie Faten M, Alsamghan Awad S. Prevalence, Types and Determinants of Complementary and Alternative Medications among Health Clinic Clients. Journal of Education and Practice. 2015;6(18):51–59. [Google Scholar]
- Almutairi K.M., Alhelih E., Al-Ajlan A.S., Vinluan J.M. A Cross-Sectional Assessment of Quality of Life of Colorectal Cancer Patients in Saudi Arabia. Elsevier Ltd. 2015;1–9 doi: 10.1007/s12094-015-1346-3. [DOI] [PubMed] [Google Scholar]
- Awad M.A., Denic S., El Taji H. Validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires for Arabic-Speaking Populations. Ann N Y Acad Sci. 2008;1138:146–154. doi: 10.1196/annals.1414.021. [DOI] [PubMed] [Google Scholar]
- Bahall Mandreker. “Prevalence, Patterns, and Perceived Value of Complementary and Alternative Medicine among Cancer Patients : A Cross-Sectional, Descriptive Study”. BMC Complementary and Alternative Medicine 17 (1) BMC Complementary and Alternative Medicine. 2017;345 doi: 10.1186/s12906-017-1853-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yeo Belinda, Turner Nicholas C, Jones Alison. Anupdate on the Medical Management of Breast Cancer. BMJ. 2014;348:1–7. doi: 10.1136/bmj.g3608. [DOI] [PubMed] [Google Scholar]
- Ben-Arye Eran, Massalha E., Bar-Sela G., Silbermann M., Agbarya A., Saad B., Lev E., Schiff E. Stepping from Traditional to Integrative Medicine: Perspectives of Israeli-Arab Patients on Complementary Medicine’s Role in Cancer Care. Annals of Oncology. 2014;25(2):476–480. doi: 10.1093/annonc/mdt554. [DOI] [PubMed] [Google Scholar]
- Cancer.org. 2016. “Chemotherapy for Breast Cancer.” American Cancer Society. http://www.cancer.org/acs/groups/cid/documents/webcontent/003090-pdf.pdf.
- Chui Ping Lei, Abdullah Khatijah Lim, Wong Li Ping, Taib Nur Aishah. Prayer-for-Health and Complementary Alternative Medicine Use among Malaysian Breast Cancer Patients during Chemotherapy. BMC Complementary and Alternative Medicine. 2014;14:425. doi: 10.1186/1472-6882-14-425. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Chui P.L., Abdullah K.L., Wong L.P., Taib N.A. Quality of Life in CAM and Non-CAM Users among Breast Cancer Patients during Chemotherapy in Malaysia. PLoS ONE. 2015;10(10):1–17. doi: 10.1371/journal.pone.0139952. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Elolemy A.T., Albedah A.M.N. Public Knowledge, Attitude and Practice of Complementary and Alternative Medicine in Riyadh Region, Saudi Arabia. Oman Medical Journal. 2012;27(1):20–26. doi: 10.5001/omj.2012.04. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Erku, Daniel Asfaw. 2016. “Complementary and Alternative Medicine Use and Its Association with Quality of Life among Cancer Patients Receiving Chemotherapy in Ethiopia: A Cross-Sectional Study.” Evidence-Based Complementary and AlternativeMedicine. [DOI] [PMC free article] [PubMed]
- Ernst, Edzard. 2015. “Complementary and Alternative Medicine Treatments (CAM) for Cancer.” UpToDate. http://www.uptodate.com/contents/complementary-and-alternative-medicine-treatments-cam-for-cancer-beyond-the-basics.
- Gerber L.M., Mamtani R., Chilu Y.L., Bener A., Murphy M., Cheema S., Verjee M. Use of Complementary and Alternative Medicine among Midlife Arab Women Living in Qatar. Eastern Mediterranean Health Journal. 2014;20(9):554–560. [PMC free article] [PubMed] [Google Scholar]
- Globocan. 2012. “Estimated Incidence, Mortality and Prevalence Worldwide in 2012.” World Health Organization. http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx.
- Huijer H.A., Sagherian K., Tamim H. Validation of the Arabic Version of the EORTC Quality of Life Questionnaire among Cancer Patients in Lebanon. Qual Life Res. 2013;22(6):1473–1481. doi: 10.1007/s11136-012-0261-0. [DOI] [PubMed] [Google Scholar]
- Hwang, Jung Hye, Woon-yong Kim, Mansoor Ahmed, Soojeung Choi, Jiwoo Kim, and Dong Woon Han. 2015. “The Use of Complementary and Alternative Medicine by Korean Breast Cancer Women : Is It Associated with Severity of Symptoms ?” Evidence-Based Complementary and Alternative Medicine 2015. [DOI] [PMC free article] [PubMed]
- Cohen Jacob. Statistical Power Analysis. Current Directions in Psychological Science. 1992;1(3):98–101. [Google Scholar]
- Ji Hong-Fang, Li Xue-Juan, Zhang Hong-Yu. Natural Products and Drug Discovery. Can Thousands of Years of Ancient Medical Knowledge Lead Us to New and Powerful Drug Combinations in the Fight against Cancer and Dementia? EMBO Reports. 2009;10(3):194–200. doi: 10.1038/embor.2009.12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Laronga C. 2016. “No Breast Cancer Guide to Diagnosis and Treatment.” UpToDate.
- Mohiuddin E., Asif M., Sciences Allied. “Curcuma Longa and Curcumin : A Review Article”. Rom. J. Biol. –. Plant Biol. 2010;55(2):65–70. [Google Scholar]
- Molassiotis A., Fernadez-Ortega P., Pud D., Ozden G., Scott J., Panteli V., Margulies A. European Survey. Annals of Oncology. 2005;16(February):655–663. doi: 10.1093/annonc/mdi110. [DOI] [PubMed] [Google Scholar]
- Molassiotis A., Pud D., Ozden G., Scott J.A., Panteli V., Margulies A., Browall M. Original Article Use of Complementary and Alternative Medicine in Cancer Patients : A European Survey. Annals of Oncology, 2005;16:655–663. doi: 10.1093/annonc/mdi110. [DOI] [PubMed] [Google Scholar]
- Naja, Farah, Romy Abi Fadel, Mohamad Alameddine, Yasmin Aridi, Aya Zarif, Dania Hariri, Anas Mugharbel, Maya Khalil, Zeina Nahleh, and Arafat Tfayli. 2015. “Complementary and Alternative Medicine Use and Its Association with Quality of Life among Lebanese Breast Cancer Patients: A Cross-Sectional Study.” BMC Complementary and Alternative Medicine 15 (444). BMC Complementary and Alternative Medicine: 1–10. doi:10.1186/s12906-015-0969-9. [DOI] [PMC free article] [PubMed]
- NCCIH. 2015. “Complementary, Alternative, or Integrative Health: What’s In a Name?” NCCIH. https://nccih.nih.gov/health/integrative-health.
- Oyunchimeg, B, J H Hwang, M Ahmed, S Choi, and D Han. 2017. “Complementary and Alternative Medicine Use among Patients with Cancer in Mongolia: A National Hospital Survey.” BMC Complement Altern Med 17 (1). BMC Complementary and Alternative Medicine: 58. doi:10.1186/s12906-017-1576-8. [DOI] [PMC free article] [PubMed]
- Posadzki Paul, Watson Leala K., Alotaibi Amani, Ernst Edzard. “Prevalence of Use of Complementary and Alternative Medicine (Cam) by Patients/consumers in the Uk: Systematic Review of Surveys” Clinical Medicine. Journal of the Royal College of Physicians of London. 2013;13(2):126–131. doi: 10.7861/clinmedicine.13-2-126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rossi Elio, Di Stefano Mariella, Firenzuoli Fabio, Monechi Maria, Baccetti Sonia. Add-On Complementary Medicine in Cancer Care: Evidence in Literature and Experiences of Integration. Medicines. 2017;4(1):5. doi: 10.3390/medicines4010005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Roter, Debra L, Kathleen J Yost, Thomas O Byrne, Megan Branda, Aaron Leppin, Brittany Kimball, Cara Fernandez, et al. 2016. “Patient Education and Counseling Communication Predictors and Consequences of Complementary and Alternative Medicine (CAM) Discussions in Oncology Visits.” Patient Education and Counseling 99 (9). Elsevier Ireland Ltd: 1519–25. doi:10.1016/j.pec.2016.06.002. [DOI] [PMC free article] [PubMed]
- Saibul N., Shariff Z.M., Rahmat A., Sulaiman S., Yaw Y.H. Use of Complementary and Alternative Medicine among Breast Cancer Survivors. Asian Pac J Cancer Prev. 2012;13(8):4081–4086. doi: 10.7314/apjcp.2012.13.8.4081. [DOI] [PubMed] [Google Scholar]
- Sait Khalid Hussain, Anfinan Nisrin Mohammad, Eldeek Basem, Al-Ahmadi Jawher, Al-Attas Ma.ha., Sait Hesham Khalid, Basalamah Hussain Abdullah, Al-Ama Nabeel, El-Sayed Mohamed Eid. 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 Pacific Journal of Cancer Prevention : APJCP. 2014;15(6):2547–2554. doi: 10.7314/apjcp.2014.15.6.2547. [DOI] [PubMed] [Google Scholar]
- Saudi H. 2012. “Cancer Registry Reports.” Saudi Health Commission. http://www.chs.gov.sa/Ar/HealthCenters/NCC/CancerRegistry/CancerRegistryReports/2013.pdf.
- Alawadhi Shafika A., Ohaeri Jude U. Validity and Reliability of the European Organization for Research and Treatment in Cancer Quality of Life Questionnaire (EORTC QLQ): Experience from Kuwait Using a Sample of Women with Breast Cancer. Ann Saudi Med. 2010;30(5):390–396. doi: 10.4103/0256-4947.67083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yildiz Ibrahim, Ozguroglu Mustafa, Toptas Tayfur, Turna Hande, Sen Fatma, Yildiz Melek. Patterns of Complementary and Alternative Medicine Use among Turkish Cancer Patients. Journal of Palliative Medicine. 2013;16(4):383–390. doi: 10.1089/jpm.2012.0226. [DOI] [PubMed] [Google Scholar]