Use of alternative medicine by patients with cancer in a rural area of Switzerland

Alternative therapies are very popular among patients suffering from cancer and many patients use them in addition to conventional cancer treatment. In a systematic review of 21 studies from 13 countries, Ernst and Cassileth [1] found a mean prevalence of 31.4% (range 7% to 64%) for patients using alternative treatments. Earlier studies carried out in urban areas of Switzerland showed a prevalence of between 25% and 52% [2–4], while more recent surveys done in the USA found prevalence rates of as high as 80% [5, 6]. Against this background, we investigated the prevalence and the types of alternative therapy used by cancer patients in a rural area of Switzerland. The main focus of our study was the underlying motivation of the patients. We know that alternative practitioners are often described as being more caring, taking more time and listening better to their patients [7–9]. For this reason, we also looked at the question of whether users of alternative therapies have a greater need than non-users to discuss with their physician health-related quality-of-life issues, such as emotional concerns, social functioning and relations towards their partner and family. This might be a reason for seeking help from alternative treatment. It was not the purpose of this study to investigate the effects of various alternative therapies on survival or quality of life. Background: Many cancer patients use alternative therapies in addition to conventional treatment. In a survey among such patients, we assessed the prevalence of and the motivation for alternative therapy use in a rural area of Switzerland. Methods: From 1st February to 30th November 2001, we interviewed 108 patients treated in the oncology outpatient clinic of the Langenthal District General Hospital, Switzerland, using a structured questionnaire. 77% of the patients were female. 49% of the patients (i.e., 64% of the female patients) suffered from breast cancer. Results: 42 (39%) of all patients had used an alternative therapy in addition to conventional treatment at least once. Mistletoe preparations were by far the most popular with a prevalence of 74%. Homeopathy (24%) and cancer diets (12%) were used less often. 79% of the patients seeking help from alternative treatment informed their treating oncologist and/or medical practitioner accordingly. 57% of the doctors encouraged their patients to continue the alternative treatment, none discouraged the patient to do so. The main reasons for the use of alternative therapy were: the desire to feel more hopeful (83%); “to do as much as possible myself to cure the disease” (83%); and to harness mental energy (62%). Only 19% of the patients hoped to be cured of cancer by alternative therapy. Conclusions: The motivation to seek help from alternative treatment is not based on a distrust of conventional care. Maintaining hope and taking an active role in self-care are the main stimuli for using alternative medicine.

We know that alternative practitioners are often described as being more caring, taking more time and listening better to their patients [7][8][9].For this reason, we also looked at the question of whether users of alternative therapies have a greater need than non-users to discuss with their physician health-related quality-of-life issues, such as emotional concerns, social functioning and relations towards their partner and family.This might be a reason for seeking help from alternative treatment.
It was not the purpose of this study to investigate the effects of various alternative therapies on survival or quality of life.
Background: Many cancer patients use alternative therapies in addition to conventional treatment.In a survey among such patients, we assessed the prevalence of and the motivation for alternative therapy use in a rural area of Switzerland.
Methods: From 1st February to 30th November 2001, we interviewed 108 patients treated in the oncology outpatient clinic of the Langenthal District General Hospital, Switzerland, using a structured questionnaire.77% of the patients were female.49% of the patients (i.e., 64% of the female patients) suffered from breast cancer.
Results: 42 (39%) of all patients had used an alternative therapy in addition to conventional treatment at least once.Mistletoe preparations were by far the most popular with a prevalence of 74%.Homeopathy (24%) and cancer diets (12%) were used less often.79% of the patients seeking help from alternative treatment informed their treating oncologist and/or medical practitioner accordingly.57% of the doctors encouraged their patients to continue the alternative treatment, none discouraged the patient to do so.The main reasons for the use of alternative therapy were: the desire to feel more hopeful (83%); "to do as much as possible myself to cure the disease" (83%); and to harness mental energy (62%).Only 19% of the patients hoped to be cured of cancer by alternative therapy.
Conclusions: The motivation to seek help from alternative treatment is not based on a distrust of conventional care.Maintaining hope and taking an active role in self-care are the main stimuli for using alternative medicine.
From 1st February to 30th November 2001, all patients referred to the oncology outpatient clinic of the District General Hospital, Langenthal, Switzerland, were asked to participate in this study.
Exclusion criteria were an age below 18 years and an inability to understand the German language.To allow them time to become acquainted with the new hospital environment, patients were not recruited at their first clinic visit.
All patients were interviewed by the same physician (FvdW), for approximately 30 minutes each, using a structured questionnaire.All data thus acquired were kept strictly anonymous.

Questionnaire
The questionnaire had a multiple-choice structure designed to assess demographic characteristics, questions on lifestyle, health consciousness, the disease itself, and experiences with conventional cancer treatment.Questions relating to the subjective conception of a correlation between the origin of the disease and lifestyle issues were formulated according to Berger et al. [10], and those on the subjective conception of conventional cancer treatment according to Obrist et al. [4].The questionnaire devised by Detmar et al. [11] was used to ask patients about their preferences in disclosing personal information (including psychosocial issues) to their doctor.
A list of recognised alternative therapies was compiled, based on a brochure issued by the Swiss Cancer League [12], as well as the publications of Richardson et al. [5] and Morant et al. [3].This included the following categories: herbal medicine; traditional and folk remedies; diet and nutrition; relaxation methods; manual healing methods and spiritual healing methods.We did not in-clude purely psychotherapeutic or religious activities, such as prayer.Patients were asked about their reasons for using alternative therapies with questions formulated as in the above-mentioned studies [3,5].

Definition of alternative medicine
In the literature, the terms alternative medicine, complementary medicine and unproven, unconventional methods are often used interchangeably.However, Ernst et al. [13] gave a definition of complementary medicine which closely suits our view of the subject: "Complementary medicine is diagnosis, treatment and/or prevention, which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine."

Statistical methods
Most statistical analyses were performed with respect to the "user" variable.A patient was defined as a "user" if he or she indicated that any alternative treatment was explicitly undertaken because of the cancer.Statistical significance was determined using a two-sided test with rejection levels of 5% and 10%.P values for multivariate parameters (Table 1) have been computed using a bootstrap chi-square test with 100'000 samples.Two-sided 95% confidence intervals (Tables 2, 4) of user percentages have been computed using bootstrap sampling.The twosided 95% confidence interval for the odds-ratio (OR) (Tables 5, 6, 7) have also been computed using bootstrap sampling.P values in Tables 5 and 6 have been computed exactly, the "user" percentage being described by a binomial distribution.

Patient characteristics
During the study period, 94 new patients were referred to the clinic; 77 patients agreed to be in-terviewed, 10 refused, and 7 did not answer our written request.Within this time, we additionally recruited 31 patients newly referred to the gynae- cological oncology clinic of the same hospital, bringing the final number of participants to 108.77% of the patients were female (table 1).42 (39%) of the 108 patients had used an alternative therapy for cancer treatment in addition to conventional therapy, at least once.Women were significantly more often users of alternative therapies than men (p = 0.028).Only 10% of the patients older than 71 years used alternative therapies.
The types of malignant disease in our patients are listed in table 1. Patients with breast cancer have a significantly higher user percentage as compared to patients with other malignant diseases (p = 0.035).
The prevalence of alternative therapy use among those who had known their diagnosis for less than 1 year was lower than among the other patients, but this did not reach statistical significance.
Educational level and profession were similar in both groups.23% of the patients had only primary education, most (66%) had completed vocational training, 9% had a college degree, and 2% had a university degree.
44% of the female patients were full-time housewives, 33% were working part-time; 12% were full-time employees, 11% were self-employed or had a managerial position.Of the last group, only 8% used alternative therapies, a significantly lower figure than in the other professional groups (p <0.03).
81% of the users had heard about their chosen alternative therapy through family or friends, 45% from other cancer patients, while 29% had read about it in books.Newspapers and the internet were mentioned as information sources by only 4 and 3 patients, respectively.

Forms of alternative therapies
Of the 42 patients who had used an alternative cancer therapy at least once, 30 (71%) used only one alternative treatment, 4 (10%) used two different types, and 8 (19%) three or more types.
The various alternative treatments used are listed in table 2. With a prevalence rate of 74% (95% confidence interval [C.I.]: 59.5% to 85.7%), mistletoe preparations (Iscador ® ) were by far the most popular alternative drugs.
Table 3 shows the distribution of alternative methods used by our study group compared with three other investigations carried out in Switzerland.

Reasons for the use of alternative therapies and expectations
The most common reasons for using alternative therapy at the same time as conventional treatment were the desire "to feel more hopeful" (83%; 95% C.I.: 71.4% to 92.2%) and "to do as much as possible myself to cure the disease" (83%; 95% C.I.: 71.4% to 92.2%), as can be seen in table 4.
Only 10% of the users were "disappointed by conventional treatment" and 10% thought that "conventional treatment cannot help me any The sum of the percentages exceeds 100%, because many patients used more than one type of alternative treatment.more".14% used alternative therapies because they had "heard that my disease is not curable".81% of the users expected to boost their immune system with the help of alternative therapy, 67% wanted to improve their quality of life, and 29% expected to prolong their life.However, only 19% expected alternative therapy to cure the disease.

Disclosure of alternative therapy use to the oncologist/physician
79% of all users discussed the use of alternative therapy with their treating oncologist and/or medical practitioner.57% of the doctors encouraged their patients to continue this treatment, 36% were neutral about this issue but none told the patient to stop the therapy.7% of these patients did not report on the way their doctor reacted.

Former use of alternative medicine for other diseases
45 (42%) of the 108 patients (36% of the nonusers and 50% of the users) had previously used alternative therapies for diseases other than cancer.They were slightly, though not significantly, more likely to use alternative therapies for their malignant disease as well (p = 0.08).

Preferences for disclosing physical and psychosocial health issues
Patients were asked which physical and psychosocial health issues they wanted to discuss with their physician and whether they would raise these issues themselves or expected the physician to start the discussion.
98% of the patients of both groups wanted to discuss their physical condition with their physician, 86% wanted to discuss their feelings about the disease, 74% wanted to talk about the implica- The sum of the percentages exceeds 100%, because many patients indicated more than one reason.tions of the disease on their social contacts and 81% about the implications of the disease on their relations with partner and family.Most patients (88%) indicated that they would start the discussion on health issues themselves.However one-quarter to one-third of all patients expected their physician to raise issues like social contacts and relations with partner and family.
67% of the women indicated that they would initiate discussion of their feelings in relation to their disease and16% would like their physician to start this discussion.For men, the corresponding figures are 36% and 36% (p <0.03).There was no significant difference in disclosing health issues between users and non-users of alternative treatments.

Subjective conception of disease
Patients were asked what they believed was the cause of their disease (table 5).More non-users than users indicated that they did not know the origin (p = 0.06).More users believed stress to be a possible cause of their disease (p = 0.11) and emotional disharmony a possible risk factor (p = 0.15).Not a single user assigned a causative role to his/her smoking habit.In the non-user group, 9% suspected smoking to be a causative factor of their cancer.

Perception of effect of conventional treatment
Patients were asked what effects they thought conventional treatment had on their disease (table 6).Users had a slightly more positive attitude in this respect; more often than non-users they believed that chemotherapy had prevented metastases occurring (p = 0.07) and had made the tumour regress, although this difference did not reach statistical significance.

Lifestyle
Patients were asked about their lifestyle (smoking, sports, relaxation, and nutrition) before and after the diagnosis of their cancer (table 7).
Before cancer diagnosis, users smoked significantly less than non-users (odds ratio [OR] 0.383; 95% C.I.: 0.100 to 0.977).There were no significant differences in nutritional behaviour and relaxation (95% C.I. of OR includes unity).Nonusers tended to do more sports than users, but this difference was not significant either.
Of those patients, who smoked at diagnosis, significantly more users than non-users stopped (OR 8.0; 95% C.I.: 1.167 to 108.0).Similarly, of the patients who had not put special emphasis on healthy nutrition, more users than non-users tried to eat in a more healthy fashion after diagnosis (OR 4.909; 95% C.I.: 1.607 to 26.00).Also, more users than non-users reduced their consumption of meat (OR 1.888), however, this difference does not reach statistical significance (95% C.I. of OR: 0.844 to 4.352, ie, including unity).No statistical differences could be identified with regard to regular relaxation and sports.Lifestyle before and after the diagnosis of cancer.
In our study, significantly more women than men used alternative therapies.This finding corresponds to several other investigations [6,[14][15][16][17] but differs from the studies of Berger et al. [10] and Morant et al. [3], which both found no correlation between gender and alternative therapy use.With increasing age, fewer patients used alternative therapies, which agrees with earlier results [6,8,14,15,17,18].As in other investigations [14,19] most patients in both groups were married.We were unable to confirm the findings of several studies that users of alternative medicine are better educated [7,8,16,18,[20][21][22].On the contrary, in our investigation, patients with a high level of education or a managerial position tended to use alternative treatment even less often.Patients with breast cancer were more likely to use alternative therapies than patients with other malignant diseases.This study shows that a significant number of oncology outpatients use alternative therapies along with conventional cancer treatment also in a rural area of Switzerland.Many patients even try several different alternative therapies simultaneously, a fact found by other authors as well [5,6,23].
Table 3 shows that the prevalence of alternative medicine use in our investigation is comparable to that found in earlier Swiss studies carried out in urban areas [2-4, 10, 24].Some of the differences may be due to the definitions of alternative treatment.Morant et al. [3] reported a prevalence rate of 52%, with herbal teas and beetroot juice being the substances most commonly used.We did not include these two methods in our study.American publications [5,6] showed prevalence rates of up to 80% for users of alternative treatment for cancer.These figures may also result partly from a broader definition of alternative medicine.
As Ernst and co-workers stated in their review [1], one problem in comparing prevalences between studies is that definitions of alternative or complementary therapies vary so much.They often include home remedies, wellness centres, and self-help groups.The definition of "alternative" has been broadened in the last few years [25,26] to include even religious sentiments, personal philosophies and relaxation methods.
In the present study, the definition of alternative treatment tended to be more conservative than in other investigations.
The alternative therapy most often used in our study was Iscador ® , a mistletoe preparation (74%).Homeopathy and special cancer diets were used by 24% and 12% of users, respectively.These results are similar to many other European studies [2,4,8,19].Comparison of the Swiss studies, however, shows that very different prevalences for the same therapies are found even in one small country.This reflects the importance of factors such as the availability of a particular therapy in a certain region, tradition and cultural background, as well as underlying social trends and values which certainly influence a patient's choice [27][28][29][30].Mistletoe therapy, for example, is almost unknown in the United States [19].
Compared to the very high prevalence (74%) of mistletoe use in our study, other Swiss investigators found rates of only 34% [2], 21% [4], and 15.6% [3].In Germany, the prevalence of mistletoe therapy is high as well; Grothey et al. [19] found 45% users of Iscador ® .In a survey among German gynaecologists by Kalder et al. [31], more than 50% of the providers of alternative therapies prescribed mistletoe preparations.Münstedt et al. [32] found that 44% of those medical doctors who prescribe alternative treatments mainly use mistletoe preparations.
One reason for the high prevalence in our study may be the geographical proximity of our hospital to the "Lukasklinik" in Arlesheim, a hospital specialising in anthroposophical cancer treatment.
Feeling more hopeful, doing everything possible against the disease oneself, and harnessing mental energy, are the reasons most often mentioned for using an alternative therapy.Patients expect to boost their immune system and improve their quality of life with the help of alternative treatment.These findings confirm the results of other studies [3-5, 7, 10, 19, 23, 33, 34].
Only 19% of the users expected the alternative therapy to cure their disease, but 29% hoped that alternative treatment would help them to prolong their life, findings comparable with other investigations [14,21,35].In the study conducted by Richardson et al. [5], however, 37.5% of the users of alternative treatment expected the alternative therapy to cure their disease while 62.5% hoped that the therapy would help to prolong life.
Regarding the reasons found in our study for using alternative therapies to treat cancer, we can say that hope seems to be an important, perhaps the most important, issue [1, 5,14,23,25].From research in this field, we know that any belief which increases the hope of cure will improve a patient's quality of life and this may contribute to the decision to seek help from alternative therapies [36].
Another important stimulus to seek alternative care is clearly the wish of cancer patients to take an active role in their own care and to be able to make their own decisions concerning therapy [9,19] a desire often not adequately met by the conventional health system.In a recent study by Paltiel et al. [37] "unmet needs" were strongly associated with the use of alternative treatment.Providers of alternative care seem to be more aware of cancer patients' needs in maintaining hope and being involved in their own care.
However, the literature indicates that there is little reason to believe that patients are choosing Discussion alternative treatment instead of standard oncological care [17,25,39,40].Patients choose alternative therapies as a complement rather than as an alternative to conventional treatment.
Most of our patients using alternative treatment informed their physician of this.The majority of physicians reacted positively or neutrally and not one discouraged the patient.In contrast, Richardson et al. [5] found that 60.6% of the users did not in fact tell their physician about the alternative therapy and disclosure was found to be low by other investigators as well [8,23,33,35,41,42].
Physicians' knowledge of alternative therapies was not investigated in our study, although we know from the literature that it is generally rather limited [4,39,43].
There was a significant difference between users and non-users of alternative therapies in the subjective conception of the cause of their disease, Non-users more often did not have their own hypothesis about the origin of the disease.Users frequently believed that stress and emotional disharmony could possibly be causes of their disease.These findings correspond with previous research [8,21,38].The belief that there is a preventable cause of disease could explain the use of alternative care; by changing lifestyle (diet, stress reduction) the patient tries to influence the outcome of his/her disease.
Users of alternative treatment tended to have a slightly more positive view on the effect of conventional care than non-users.Many of them believed that it had prevented metastases and made the tumour regress.Users, however, more often reported feeling worse after treatment.The finding that users more often report side-effects of conventional care corresponds to the study by Obrist et al. [4].Studying women with breast cancer, Boon et al. [9] found that users of alternative treatments more often thought that conventional therapies weakened the body's natural reserves and had serious side effects.
Users of alternative therapies were more health conscious than non-users after the diagnosis of their cancer.The difference was most obvious regarding changes in smoking and nutritional behaviour; more users than non-users stopped smoking after the diagnosis of cancer.Several investigations confirm that users of alternative therapies are more health conscious [10,29] and, according to Berger et al. [10], they are so inclined even before their cancer is diagnosed.
This difference in health consciousness between users and non-users again reflects the desire of users to fight against the disease as much as possible themselves, to influence their own health by means of nutrition, relaxation etc. From the findings of this study we can draw the following conclusions: -First of all, it is most important for oncologists and physicians treating cancer patients to be aware of the needs and characteristics of patients seeking alternative care.Physicians can help patients to feel they are receiving the best possible care by establishing good communication, addressing feelings like hopelessness and fear, discussing possible emotional and social distress and talking about issues like nutrition and stress reduction, as well as offering supportive services.-Secondly, as stated by Downer et al. [14], physicians should "be prepared to accept that for some cancer patients complementary therapies fulfil an important psychological need".
In the face of a potentially life-threatening disease, many patients understandably try to do anything possible to fight for their recovery.-Thirdly, physicians are often not sufficiently well-informed about alternative therapies and whether these therapies are potentially harmful.They cannot therefore recommend a particular therapy or warn patients about side-effects or interactions with conventional treatment.Physicians should acquaint themselves with the therapies their patients use and help in making decisions.In Switzerland, a good source of primary information is the Swiss Cancer League, which provides information brochures on a variety of alternative therapies [44].It may then be useful to contact providers of alternative care to obtain more information about a specific therapy, and in some cases there will be the possibility of working together.The patient will appreciate the fact that the physician takes his/her needs seriously.
We are indepted to Peter de Haan, PhD for statistical help and to Meryl Clarke, PhD for linguistic improvement of the manuscript.

Table 2
Types of alternative treatment used by patients (N = 42).

Table 4
Reasons for the use of alternative therapies for cancer treatment (N = 42).

Table 5
Perceived causes of cancer.