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Table 1.  Baseline Characteristics of 3118 Participants Stratified by CAM Use and Multivariable Adjusted Odds of Using CAM
Baseline Characteristics of 3118 Participants Stratified by CAM Use and Multivariable Adjusted Odds of Using CAM
Table 2.  CAM Modalities Used by 1023 Participants Stratified by Disclosure and Adjusted Odds of CAM Nondisclosure
CAM Modalities Used by 1023 Participants Stratified by Disclosure and Adjusted Odds of CAM Nondisclosure
1.
Dy  GK, Bekele  L, Hanson  LJ,  et al.  Complementary and alternative medicine use by patients enrolled onto phase I clinical trials.  J Clin Oncol. 2004;22(23):4810-4815. doi:10.1200/JCO.2004.03.121PubMedGoogle ScholarCrossref
2.
Johnson  SB, Park  HS, Gross  CP, Yu  JB.  Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers.  JAMA Oncol. 2018;4(10):1375-1381. doi:10.1001/jamaoncol.2018.2487PubMedGoogle ScholarCrossref
3.
Centers for Disease Control and Prevention. National Health Interview Survey: Methods. http://www.cdc.gov/nchs/nhis/methods.htm. Accessed July 1, 2018.
4.
Stussman  BJ, Bethell  CD, Gray  C, Nahin  RL.  Development of the adult and child complementary medicine questionnaires fielded on the National Health Interview Survey.  BMC Complement Altern Med. 2013;13:328. doi:10.1186/1472-6882-13-328PubMedGoogle ScholarCrossref
5.
Blewett  LA, Rivera Drew  JA, Griffin  R, King  ML, Williams  KCW.  IPUMS Health Surveys: National Health Interview Survey, Version 6.3. [dataset] Minneapolis, MN: IPUMS; 2018.
6.
Verhoef  MJ, Balneaves  LG, Boon  HS, Vroegindewey  A.  Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review.  Integr Cancer Ther. 2005;4(4):274-286. doi:10.1177/1534735405282361PubMedGoogle ScholarCrossref
Research Letter
April 11, 2019

Prevalence and Nondisclosure of Complementary and Alternative Medicine Use in Patients With Cancer and Cancer Survivors in the United States

Author Affiliations
  • 1Department of Radiation Oncology, University of Texas Southwestern, Dallas
  • 2Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
  • 3Harold Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
  • 4Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Massachusetts
  • 5Dana-Farber Cancer Institute McGraw/Patterson Center for Population Sciences, Boston, Massachusetts
JAMA Oncol. 2019;5(5):735-737. doi:10.1001/jamaoncol.2019.0349

Complementary and alternative medicines (CAMs), defined as therapies used in addition to or instead of conventional therapies, respectively, are frequently used in the United States by patients with cancer and cancer survivors; however, there is concern that these individuals may not disclose CAM use to their physicians.1 A recently published report from the National Cancer Database found that a small subset of patients who reported CAM use (n = 258; 0.01% of the study population) had worse survival than patients who did not use CAM; this finding appeared to be mediated by refusal of conventional cancer therapy.2 Given the potentially serious, adverse, and wide-reaching implications of CAM use (particularly use of alternative medicines) in patients with cancer, an accurate assessment of the prevalence of CAM use is needed. We used data from a comprehensive nationwide survey to conduct a cross-sectional study estimating the proportion of patients with cancer and cancer survivors using CAM and the associated rates of nondisclosure.

Methods

The National Health Interview Survey (NHIS) collects data annually on a range of health indicators for noninstitutionalized, civilian adults.3 In 2012, the NHIS included a supplement on CAM use, as defined by the National Center for Complementary and Alternative Medicine (renamed the National Center for Complementary and Integrative Health).4 Data on CAM use and on participant demographics among those reporting a cancer diagnosis were obtained through the Integrated Health Interview Series.5 Data analyses for this study were performed from October to December 2018.

Multivariable logistic regressions defined adjusted odds ratios (AORs) and associated 95% CIs for odds of using CAM. Among 1023 participants reporting CAM use, reasons for nondisclosure were reported. Factors associated with nondisclosure of CAM were assessed via multivariable logistic regression. As a sensitivity analysis, rates of CAM use and nondisclosure were reported for participants with a cancer diagnosis up to 2 years prior to survey administration (n = 812). Variables adjusted for in the models are described in Table 1 and Table 2, with weighted percentages reported in the Results section. Statistical testing was 2 sided, with α = .05. Analyses were performed with Stata software version SE 15.1 (StataCorp). The University of Texas Southwestern’s institutional review board deemed the study exempt, and patient written informed consent was not required for this study.

Results

Among 3118 participants reporting a history of cancer (1230 men and 1888 women; median age, 66 years [range, 18 to ≥85 years), 1023 (33.3%) used CAM in the past 12 months. The most commonly used CAM modality was herbal supplements (363 of 1023 participants, 35.8%), followed by chiropractic or osteopathic manipulation (256 of 1023, 25.4%), massage (129 of 1023, 14.1%), yoga/tai chi/qigong (85 of 1023, 7.6%), mantra/mindfulness/spiritual meditation (75 of 1023, 6.9%), special diets (29 of 1023, 2.9%), acupuncture (26 of 1023, 2.0%), homeopathy (15 of 1023, 1.5%), movement or exercise techniques (11 of 1023, 1.3%), naturopathy (7 of 1023, 0.6%), traditional healers (6 of 1023, 0.4%), energy healing therapy (5 of 1023, 0.6%), biofeedback (5 of 1023, 0.4%), hypnosis (4 of 1023, 0.5%), and craniosacral therapy (2 of 1023, 0.2%). Factors associated with CAM use included white race (AOR, 1.82; 95% CI, 1.28-2.58; P = .001), female sex (AOR, 1.55; 95% CI, 1.26-1.91; P < .001), non-Hispanic ethnicity (AOR, 1.64; 95% CI, 1.05-2.56; P = .03), and younger age (AOR, 1.02 per year; 95% CI, 1.01-1.02; P < .001) (Table 1). Among 1023 participants using CAM, 288 (29.3%) did not disclose CAM use to their physicians. The adjusted rates of nondisclosure for those using herbal supplements was 11.8% and 58.2% for those using mantra/mindfulness/spiritual meditation (Table 2). The most frequently reported reasons for nondisclosure were because the physician did not ask (n = 155 of 288; 57.4%) or participants did not think their physicians needed to know (n = 140 of 288; 47.4%). A smaller proportion of CAM users felt that their physician did not know as much about the therapy (n = 28 of 288; 8.5%), reported they were not given enough time to tell about therapy (n = 12 of 288; 5.7%), expressed concern about a negative reaction (n = 17 of 288; 3.9%), were worried that their physician would discourage use (n = 18 of 288; 3.6%), or reported that physicians discouraged use in the past (n = 11 of 288; 1.9%).

When the cohort was restricted to 812 patients with cancer diagnosed up to 2 years prior to survey administration, 271 (33.4%) reported CAM use, including 231 (28.5%) who did not disclose CAM use to their physician.

Discussion

In this comprehensive national study, 1023 of 3118 (33.3%) participants with a history of cancer reported CAM use in the past year, 288 (29.3%) of whom did not disclose use of CAM to their physician. Individuals diagnosed with cancer may have many motivations for seeking CAM, including persistent symptoms, psychological distress, or to gain a sense of control over their care.6 Given the high proportion of patients with cancer and cancer survivors reporting use of CAM in this nationally representative sample, the potential implications of CAM use on oncologic outcomes merits further study. Policy and guidelines should be established to encourage discussion of CAM. Data for this study were collected in 2012; however, this time frame is within those available from other nationwide databases. The NHIS is a US database, thus our results may not be generalizable to international populations. Additional research is needed to assess health outcomes, quality of life, and cost implications associated with CAM use in the oncology patient population.

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Article Information

Accepted for Publication: February 5, 2019.

Corresponding Author: Nina N. Sanford, MD, Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Rd, Dallas, TX 75390-9303 (nina.sanford@UTSouthwestern.edu).

Published Online: April 11, 2019. doi:10.1001/jamaoncol.2019.0349

Author Contributions: Dr Sanford and Dr Mahal had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sanford, Mahal.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Sanford, Mahal.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Conflict of Interest Disclosures: Dr Aizer reports grants from Varian Medical Systems outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Mahal reports funding from the American Society of Radiation Oncology and the Prostate Cancer Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Dy  GK, Bekele  L, Hanson  LJ,  et al.  Complementary and alternative medicine use by patients enrolled onto phase I clinical trials.  J Clin Oncol. 2004;22(23):4810-4815. doi:10.1200/JCO.2004.03.121PubMedGoogle ScholarCrossref
2.
Johnson  SB, Park  HS, Gross  CP, Yu  JB.  Complementary medicine, refusal of conventional cancer therapy, and survival among patients with curable cancers.  JAMA Oncol. 2018;4(10):1375-1381. doi:10.1001/jamaoncol.2018.2487PubMedGoogle ScholarCrossref
3.
Centers for Disease Control and Prevention. National Health Interview Survey: Methods. http://www.cdc.gov/nchs/nhis/methods.htm. Accessed July 1, 2018.
4.
Stussman  BJ, Bethell  CD, Gray  C, Nahin  RL.  Development of the adult and child complementary medicine questionnaires fielded on the National Health Interview Survey.  BMC Complement Altern Med. 2013;13:328. doi:10.1186/1472-6882-13-328PubMedGoogle ScholarCrossref
5.
Blewett  LA, Rivera Drew  JA, Griffin  R, King  ML, Williams  KCW.  IPUMS Health Surveys: National Health Interview Survey, Version 6.3. [dataset] Minneapolis, MN: IPUMS; 2018.
6.
Verhoef  MJ, Balneaves  LG, Boon  HS, Vroegindewey  A.  Reasons for and characteristics associated with complementary and alternative medicine use among adult cancer patients: a systematic review.  Integr Cancer Ther. 2005;4(4):274-286. doi:10.1177/1534735405282361PubMedGoogle ScholarCrossref
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