Prevalence of Traditional and Complementary Alternative Medicine’s Use among Cancer Patients in South Peninsular Malaysia

Globally, high mortality rates due to cancer have been reported with 20,100 deaths (2008) and 21,700 deaths (2012) [1]. Although many conventional therapies including chemotherapy or radiotherapy have been developed, they pose serious and debilitating adverse effects, which may contribute to non-compliance and/or resistance. As a result, many patients in Malaysia turn to non-traditional means as an alternative. Similarly, in the past years, there is a growing interest in complementary and Alternative Medicine (CAM) in Malaysia which is a multiracial country. CAM is defined as a group of diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and animal-based medicine, Abstract


Introduction
Globally, high mortality rates due to cancer have been reported with 20,100 deaths (2008) and 21,700 deaths (2012) [1]. Although many conventional therapies including chemotherapy or radiotherapy have been developed, they pose serious and debilitating adverse effects, which may contribute to non-compliance and/or resistance. As a result, many patients in Malaysia turn to non-traditional means as an alternative. Similarly, in the past years, there is a growing interest in complementary and Alternative Medicine (CAM) in Malaysia which is a multiracial country. CAM is defined as a group of diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and animal-based medicine, interactions or poor adherence to conventional treatments since many patients believe that CAM's treatment should be first line. In fact, a study revealed that approximately 13% of patients referred for post-surgical cancer treatment rejected all further conventional treatments while another 19% declined one treatment or another due to their strong beliefs in CAM's curatives effects [9]. Therefore, in this study, we explored the prevalence of CAM's use among cancer patients in Malaysia which include differences in CAM's used based on socio demographic and clinical factors, determination of the most common method for CAM's use, the purported reasons for use as well as the biggest factor influencing CAM's utilisation and patient satisfactions. It is hoped that this study can provide a better understanding on the expectation and pattern of CAM's use among Malaysian cancer patients and to identify the limitations of conventional treatment from patients' perspectives. The information gathered can be a good reflection of the preferences of Malaysian ethnicity and cultures to help better understand patients' preferences and for more successful therapies.

Study Design
This is a four-month cross-sectional study conducted in three government public hospitals in a southern state in Malaysia. It was a prevalence-based sample consisting of 240 cancer patients attending the oncology and visiting clinics in 1) Sultanah Fatimah Specialist Hospital (HPSF), Muar, 2) Sultanah Nora Ismail Hospital (HSNI), in Batu Pahat and 3) Sultan Ismail Hospital (HSI), Johor Bharu) ( Figure 1). The inclusion criteria included 1) cancer patients ageing more than 18 years old, with confirmed diagnosis of cancer regardless of tumour type for at least six months prior to the study (but not more than five years post diagnosis) and 2) able to understand the Malay and/ or English languages. A convenient sampling method was applied to obtain the samples. Ethical approval was obtained from the Medical Research Ethics Committee, Ministry of Health, Malaysia which complies with the Declaration of Helsinki.

Questionnaire
The patients were individually approached and written informed consents were obtained prior to conducting the interview and disseminating the questionnaires. A face-to-face interview was conducted by a single researcher dedicated to the study on consenting participants. A standardised, interviewer-administered questionnaire was used to collect the data on the socio-demographic and clinical characteristics, participants' understanding of their own diseases and utilisation of CAM, involving specifically 1) the type of CAM 2) used sources of information regarding CAM used 3) reasons for CAM used and 4) patient's satisfaction on CAM's utilisation.

Data analysis
PASW Statistics® 18 © 2009 Statistical Packages for Social Science (SPSS), version 16.0, IBM Corporation, (New York, USA) was used to analyse all data. Descriptive statistics was used to summarise the data while a Pearson Chi Square test was applied to identify the association among independent variables with CAM's utilisation. A p-value of < 0.05 is considered as statistically significant.

Socio-demographic and clinical characteristics
A total of 229 eligible cancer patients from the three different tertiary hospitals offering oncology services in the form of in-house and visiting clinics were involved. The mean age ± standard deviation of the participants was 57.7 ± 12.47 years. The majority of participants was female (79.9%), Malay (79.2%), Moslem (73.7%) and has secondary level of education (41.8%). The most frequent diagnosis was breast cancer (51.1%). Approximately

Use of CAM
Based on the 229 participants recruited, the majority (62.0%) had used CAM at any point of their disease to treat their condition. Participants from HSI showed the highest percentage of CAM use (40.7%), followed by HPSF (30.0%) and HSNI (29.3%) ( Table 1). The majority (80.7%) of CAM user was Malays although Johor consists of only 58.8% Malays (10). Among all the demographic variables, CAM's utilisation was significantly associated with hospital type (p=0.004), patients religion (p=0.001) and ethnicity (p=0.003).

Type and time of CAM use by study participant
Biological-based therapies such as herbs and dietary supplements (87.9%) were the most frequent type of CAM used by the patients ( Table 2). The majority (45.9%) of patients commenced CAM after completion of cancer treatments (Table 2). More than 50% of patients from all three hospitals reported were more likely to use CAM after they completed their treatments. HIS patients, on the other hand has the highest tendency (41.1%) to use CAM before conventional treatments were instituted (p = 0.002).

Factors influencing CAM's use and its satisfaction
Most patients chose CAM as they are believed to have fewer side effects (31.1%) as opposed to conventional treatments, can increase the quality of life (26.7%) and even cure cancer (20.7%). Others believed that CAM has multiple roles in treating cancer (17.8%) ( Table 3). Most patients heard about CAM from friends (37.9%), family (15.0%) and the internet (5.7%). However, a large number of patients heard about CAM from two or more sources (32.1%) while most (75.4%) were influenced by either family or friends who were also using CAM ( Table 3). The majority (60.1%) were satisfied with CAM with only a mere 17.4% reported not being satisfied with CAM's use (Table 3).

Discussion
To our knowledge, this is one of the first few studies to report on CAM's practises for amelioration cancer in Malaysia. Similar to other reported prevalence (14-62%) in Malaysia [8,[11][12], more than 50% of the investigated   Based on our findings, females tend to use CAM more than males which are similar with that reported in several previous studies [8][9][10][11][12][13]. Nevertheless, the finding may be gender-biased due to the high prevalence of breast cancer cases seen. Although breast cancer tend to be more common in the younger age groups in Malaysia (69.9% in the 2-40 years age category) [14], in this study, those in the older age groups (between 40 and 80 years old) tend to use CAM. McLauglin (2012) reported that the higher prevalence of CAM's use in the older age group is attributed by a "push" factor which include dissatisfaction with conventional health services and a "pull factor" that are related to positive traits of selection and self-care. Additionally, several studies have reported that a higher level of education and the female gender affect the preponderance towards CAM utilisation among cancer patients [15][16].
Ethnicity was significantly associated with CAM's use in the current study where similar to the study reported by Farooqui et al. (2016) and Zulkipli et al (2018), the Malay ethnicity to be amongst the highest user of CAM for cancer [8][9][10][11][12][13][14][15][16][17]. The finding is not surprising since it has been reported that in Malaysia, herbal medicines use are based on practical experiences, observations, and rituals derived from socio-religious beliefs passed from one generation to another [18] where the Malays are seen to have the strongest traditional beliefs. Moreover, although more and more patients tend to seek treatment in hospitals due to better access to the health care system, many of the Malays still have strong beliefs and practice that natural sources like plants and herbs have some healing properties and are not only as effective as conventional means but is also safer than conventional methods [19]. In fact, herbal medicine products which consist of either raw or processed elements from one or more medical plants, are always thought as healthy source of treatment by the Malay population [20]. Herbs like clinacanthus nutans ("sabah snake grass" or local name: belalai gajah), strobilanthes crispa (local name: pecah beling) and morinda citrifolia (local name: mengkudu) which are also easily planted and grow very fast in the tropical climate is widely available in almost every state in Malaysia and has been widely used not only to prevent many types of diseases but also as curative [21]. "Belalai Gajah" or its scientific name Clinacanthus nutans is a medicinal plant that is abundant and is readily available in many tropical countries including Thailand and Malaysia. It is widely used for many medicinal properties including antiviral [22], anti-inflammatory [23] and anti-hyperlipidaemic effects [24]. A study conducted by Teoh (2017) reported that the plant have some anti-cancer properties towards selective cancer cells by promoting apoptosis of cancer cells [25]. Although many manufacturers claim that it has some anti-cancer properties, to the best of our knowledge, no randomised controlled trials (RCTs) or quasi-RCT studies have been conducted to support the said claim.
Our study indicated that the highest CAM user were breast cancer patients followed by gynaecology and colorectal cancer patients. Again, the statistics corresponds with the type of cancer commonly affecting the female gender. Nevertheless, the association seen may be contributed by the fact that breast cancer is also among the top killer disease among Malaysian females [26][27]. Similar finding was also reported by Ezeome (2007), in which the distribution of cancer represented the typical spectrum of patients usually seen in oncology clinics that included breast and colorectal cancers [15]. Not surprisingly, CAM's use was highest among patients with advanced disease although the difference seen was statistically significant with age group but was not statistically significant in this study. It has been reported in the current study that patients who are at terminal stages are often desperate to survive and may try every possible methods available to combat their diseases [28].
Many studies reported that herbs, vitamins and health supplements are among the major treatment modalities among cancer patients. Overall, we have utilised the classification by the National Centre for Complementary and Alternative Medicine [29] in which CAM's practice is categorise into five groups. The first group is a whole medical system such as homeopathic, neuropathic medicine, and traditional Chinese medicines as well as herbs, yoga, massage, acupuncture and ayurveda. The second group is Mind Body Medicine such as patient support groups, cognitive-behaviour therapy, meditation, prayer, mental healing and therapies which utilises creative outlets including art, music or dance, while the third group is Biological-Based Practice such as herbs, food, vitamins and dietary supplements. The fourth group was Manipulative and Body Practice such as osteopathic manipulation, chiropractic medicine and naturopathy while the fifth group was Energy Medicine including bio-filled therapies, tai-chi, chi-qong, reiki and therapeutic touch. Similar to mostly reported studies across Asia and Europe, our patients tend to choose Biologically-Based Therapy as their favourite treatment modalities where two types of herb and a health supplement are frequently used.
Although it is unknown why there is a tendency towards Biological Based Practice among our patents, many patients believed that CAM generally can improve the quality of life with some patients even hoping that it could lead to a cure. The reason was similar in other studies which reported that many cancer patients believed CAM can improve quality of life by boosting the immune system and reducing the side effects of prescribed medications besides acting against cancers [30][31][32][33][34][35]. In addition, several studies have shown that cancer patients utilise CAM to alleviate their symptoms and relieve pain [36][37]. Although different types of herbs and multivitamins are popular choices among Asian and European patients, prayer and religious healing is the second most common modalities practised among our patients, which can be attributed to cultural and demographic influence which are strongly embedded in certain ethnic groups in Malaysia.
The pattern of CAM use among cancer patients has been a debate in recent years. Although many studies expressed concerns on using CAM for fear of interaction with conventional treatment, only several studies related CAM's use with the delay in initiating oncology treatment. A study conducted by Raja Lexshimi (2013) reported that 64% patients had utilised CAM before using any conventional treatment, 53% combined the use of CAM with conventional treatment while 98% continued to use CAM following completion of conventional treatment [38]. In our study, only 40% of patients utilised CAM after have completed their treatments, especially those in the advanced stage of their cancers with the belief that CAM pose fewer side effects and help to increase the quality of lives. Approximately 25% of the patients used CAM in combination with conventional medicine, which was very much lower than the study conducted by Al-Naggar also in Malaysia (2013) (at 85.5%) [36].
Physicians should be informed of CAM's used since unreported CAM's use may result in drug-drug interaction with either chemotherapy, targeted therapy and/or radiotherapy [39]. Mohd Mujar (2017) reported that CAM's use during conventional treatment has some influence to a certain extend on the non-adherence to conventional treatment [12]. They also pointed out that 35% delayed getting conventional treatment due to their trust on CAM's practices. Although our study reported similar figure (approximately 33% had used CAM after diagnosis, before treatment commencement), the time for initiation of conventional treatment may be delayed due to CAM's dependence. In fact, many patients expressed their reluctance to seek conventional treatment for fear of adverse effects, right after cancer diagnoses as the main cause of the delay seen.
As reported in many studies, friends and family members were the commonest source of information on CAM since this group of individuals are the closest to the patient and may therefore have the most influence on patient's decision making towards their treatments. Additionally, beliefs towards CAM's effectiveness strengthen the claims made by family members who may also have past prior experience of using CAM for many types of diseases on the other hand. Some patients relied on mass media and the internet for further information. The act may pose some risk since some websites may promote CAM without proper verification on the safety and efficacy data to increase their sales thus exposing patients to possible adverse event [40]. Due to this reason, physician plays important roles in conveying the right information about CAM's use and its possible role in cancer or conventional treatment although this fact was not explored in our study.
It has been reported that satisfaction tend to occur because when expectations were met [11]. Similar to the findings of other previous studies conducted in Malaysia  the majority of the patients were satisfied with CAM's use. Disappointment towards CAM's use is reported to be higher among Nigerian cancer patients, since the majority of the users from this country use them to cure cancer with ultimately unmet expectation [15] and some treatments offer some psychological satisfaction.
Overall, there is a higher prevalence of CAM users among cancer patients in HSI, which is situated in the capital of Johor in Johor Bahru which is one of the highest contributor to the GDP of Malaysia. Furthermore, HIS is an oncology-centred hospital with specialised oncology facilities and have experienced personnel at hand who may provide some advice on CAM as well as counselling. HSI is one of the Malaysia government hospitals, which provide not only conventional treatment but CAM services such as acupuncture, herbal treatment and massage as an adjunct therapy for cancer patients, which may have contributed to the higher preponderance towards CAM's utilisation seen. Recently, the Malaysian government has recently acknowledged the role of CAM in cancer treatment and has integrated herbal therapies within the government's healthcare system in some hospitals [41][42]. Such an integrated scheme indicates that a combination of CAM with conventional treatment is generally viewed as forthcoming in modern therapies [41].
Our study has some limitations. The convenient sampling method coupled with face-to-face interview may expose the patients to a selection bias where since our researchers were mostly Malay, other ethnic groups including the Chinese and Indians who may not be well versed in the language may have declined their participations due to some language barriers. In some occasions, the face-to-face interview may make participants uncomfortable to disclose certain information for fear of having a negative perception. In this study, although we reported some reasons for CAM use, since the focus was on three major government hospitals based in the urban area, it is unclear if similar findings will be yielded from patients coming from the rural areas. Further studies should explore on the perception of CAM's use among health professionals including doctors and nurses since the government has started establishing some registered CAM practices in some of the hospitals.
In conclusion, our study indicated that CAM is a popular alternative to conventional treatment among cancer patients admitted to the government hospitals in southern region of Malaysia. This is especially more among stage 4 cancer patients when patients have completed treatments with no further treatment options available. It is surprising to note however that many patients from a more urban site with greater facilities and specialities had a greater tendency to delay their treatment due CAM use. Although there were no data about the causes, it is hypothesized that the debilitating side effects of chemotherapy as well as influence from family members and friends may play important roles to this decision. Therefore, patient education is important where physicians should be informed on CAM's utilisation.