Affiliations of authors: M. M. Lee, S. S. Lin, M. R.Wrensch (Department of Epidemiology and Biostatistics), S. R. Adler (Division of Medical Anthropology Program), University of California, San Francisco; D. Eisenberg, Center for Alternative Medicine Research, Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA.
Correspondence to: Marion M. Lee, Ph.D., Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94143-0560 (e-mail: mlee{at}epi.ucsf.edu).
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ABSTRACT |
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INTRODUCTION |
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This study presents the prevalence and patterns of use of conventional and alternative therapies chosen by black, Chinese, Latino, and white women in San Francisco, CA, who were diagnosed with breast cancer from 1990 through 1992. It further examines factors associated with the use of different therapies.
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SUBJECTS AND METHODS |
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Women under age 70 years and living in San Francisco at the time of diagnosis of primary breast cancer (carcinoma in situ or invasive) were identified by ethnicity through the regional tumor registry, operated by the Northern California Cancer Center. A total of 163 blacks, 160 Chinese, 141 Latino women, and a 10% random sample of 141 non-Hispanic whites diagnosed from January 1990 through December 1992 were sent a letter explaining the study after obtaining consent from their physicians. Subjects were assigned an appropriate bilingual interviewer and contacted by phone. All interviews were conducted from 1995 through 1996 in the language of the subject's preference. The Institutional Review Board of the University of California, San Francisco, granted approval to the study.
Questionnaire
The questionnaire included questions on demographics; cultural variables, such as language use, birthplace, and acculturation; the type, frequency, and length of use of various therapies; social support; general attitude toward life, such as satisfaction about life before breast cancer diagnosis and participation in religious, social, professional, and charity groups; smoking; alcohol consumption; exercise habits; support groups attended or counseling received; and pregnancy and health history. The interviewer also asked about conventional breast cancer therapies, including surgery, chemotherapy, and radiation and hormonal therapies, as well as alternative therapies, including macrobiotic diet, megavitamin therapy, and other dietary methods (i.e., low-fat or vegetarian diets, homeopathy, herbal remedies, and psychologic methods, such as meditation or imagery; faith and spiritual healing; and physical methods, including massage, relaxation, acupressure, and acupuncture). A complete list and description of the therapies in the survey are included in the "Appendix" section. Categories of alternative therapies were developed based on the prevalence of use reported in previous studies (6,8). The study questionnaire was translated from English into Chinese (both Cantonese and Mandarin) and Spanish.
In addition, clinical factors, such as stage of cancer and lymph node involvement, were abstracted from medical records. Early stage at diagnosis refers to localized lesions, and late stage refers to regional or distant lesions.
Statistical Analysis
Interview data were edited and key entered twice into a personal computer. All inconsistencies were checked and corrected through an edit-range check program written specifically for the questions asked. Outcomes examined were having ever used versus never having used alternative therapies for breast cancer or having ever used versus never having used specific therapies for breast cancer.
Because research on factors associated with alternative therapy use among patients with breast cancer is limited, this cross-sectional study was designed to explore any factor that might be related to therapy choices. Variables included in our analyses were based on those previously found to be associated with alternative therapy use (such as age, socioeconomic status, and educational level), as well as on other factors that we hypothesized to be related to use (i.e., social support, belonging to a church or community group, having attended support groups, having received any type of counseling, comorbid conditions, and other lifestyle factors). Predictor variables (except ethnicity) were dichotomized to allow ease in interpretation. Continuous variables, such as age and educational level, were dichotomized at their approximate median values.
Chi-squared tests were used for comparisons of users of alternative therapy with nonusers. Multivariate logistic regression equations were developed to include any variable with odds ratios (ORs) of 2 or greater or 0.5 or less in univariate analyses to determine the relative importance of factors associated with use of alternative breast cancer therapies. ORs adjusted for other factors in the models and their 95% confidence intervals (CIs) were estimated by multivariate logistic regression. For example, a positive OR is interpreted as an increased likelihood of ever using alternative therapies for breast cancer or ever using a specific therapy for breast cancer given a particular characteristic. Since an OR is only a statistical estimation of the probability of observing the particular association in this population, the 95% CI represents the relative precision of the OR measure. Goodness of fit for the multivariate logistic models was assessed by use of the Hosmer-Lemeshow chi-squared test (12). This method calculates a chi-squared statistic on the basis of the expected versus observed values for the outcome given the factors in the model. Fit for all models presented exceeded P = .7, indicating good fit (12). The multivariate logistic models giving the best fit are presented. All statistical analyses were performed with Statistical Analysis Software (SAS Institute, Inc., Cary, NC). All P values were two-sided.
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RESULTS |
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The mean age of participants at diagnosis was 56 years. Within each ethnicity, alternative
therapy users tended to be younger, more educated, have more private insurance, and at a later
stage at diagnosis of breast cancer than nonusers (Table 1). With the
exception of Chinese women, the majority were of the Christian faith. About 19% of the
women had a mother, sister, daughter, or granddaughter with breast cancer.
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Overall, 48% of our subjects used at least one type of alternative therapy, and about one third used two types of therapies after breast cancer diagnosis. In general, women did not report using the therapies for very long; the majority used the therapies for the duration of 3-6 months after diagnosis. Spiritual healing was practiced on average for more than 2 years among non-Chinese women. Among users of alternative therapies, one half reported discussing use of these therapies with their physicians. More than 90% found the alternative therapies to be helpful, and with the exception of homeopathy, they would recommend these therapies to friends.
Table 3 shows variables associated with the use of alternative
therapies after multivariate adjustments. Ethnicity remained an important factor in alternative
therapy use. Black women were less likely than women of the other three ethnicities to use dietary
and physical therapies, while Latino women were more likely to use mental, physical, and herbal
therapies. Chinese women were less likely to use dietary and mental therapies, but they were two
times more likely to use herbal therapies.
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Table 4 shows that the factors associated with using any alternative
therapies differed by ethnicity. Belonging to community groups, attending support groups,
engaging in exercise, or having a higher income emerged as the statistically significant factor for
blacks, Chinese, Latino women, and whites, respectively. Stage at diagnosis was not a confounder
in any logistic regression model stratified by ethnicity.
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DISCUSSION |
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In this study, because women with late-stage breast cancer were more likely than those with early-stage cancer to report using any alternative therapy and because most of our participants had early-stage cancer at diagnosis, the prevalence estimates of use of alternative therapy reported here probably are conservative. It seems reasonable to speculate that those with even worse survival would have been more likely to try alternative therapies, but a prospective study would be needed to verify this possibility.
Since women were asked to recall their use of various therapies 3-5 years before interviews, problems with recall are possible. Moreover, we do not know if a woman's current health status would influence her recall of using alternative therapies. We might expect that women who are more "health conscious" are more likely than less health-conscious women to recall uses of alternative therapies. That women who were nonsmokers and who engaged in regular exercise were more likely to use one of the alternative therapies partially supports this claim. However, our results also indicate that perceived health was not associated with reported therapies, which suggest that differential recall bias may be minimal.
Because of heterogeneity in acculturation and differences in countries of origin of Latino women and Chinese in various regions of the United States, our study population is not representative of the rest of the country. It would be of value if our findings were replicated in other cities with comparable ethnic populations.
Consistent with previous studies (2,3,6,10,13-16), our findings suggest that use of alternative therapies was associated with higher educational level among blacks, Latino women, and whites, younger age among whites and Chinese, and type of insurance among blacks and Latino women. A recently published study (10) that examined predictors of alternative therapy use among the general U.S. population found that users were more likely to subscribe to a set of values characterized by an interest in spirituality and personal growth. Our observation that women who reported attending a support group or belonging to a church or community group were more likely to use certain types of alternative therapies supports this finding.
Physical activity may be a protective factor in the etiology of breast cancer by reducing exposure to endogenous estrogen, reducing body fat, or increasing immune function (17-21). Because physical activity also can influence psychosocial well-being, its effects during the course of cancer recovery may be as important as those found in primary prevention (22-26). It is notable that women who engaged in regular exercise were twice as likely to use alternative therapy as women who reported not engaging in regular exercise; Latino women who regularly exercised were three times more likely to use alternative therapies than Latino women who did not regularly exercise. This finding that regular exercise is related to use of alternative therapies suggests that women who are either more health conscious or more active may be more likely to try different therapies. A prospective study would be needed to verify this hypothesis.
This study found that Chinese women had higher rates of radical mastectomies and lower rates of surgical reconstruction. This may reflect cultural beliefs of wanting to be rid of the disease completely, with less focus on body image compared with overall health and well-being. Moreover, physicians may offer different treatment options to women of different ethnic groups. We did not ask why the women chose the specific conventional treatments; thus, we have no data to speculate about the reasons for ethnic differences in therapies. The most reasonable explanations would seem to be ethnic difference in choices either by the women themselves or by their providers. Further research is needed to understand these differences.
Our results show that use of alternative therapies is a very complicated issue and has been described by other investigators as "multidimensional" (27). Not only do therapy choices vary among ethnic groups but also factors influencing choices of treatments vary by type of therapy and ethnicity. Our data provide no explanation of clear reasons for these ethnic differences but suggest that research is needed to understand cultural origins of different therapy choices and options, both for conventional and alternative therapies. We may, however, speculate on the reasons for the ethnic differences in alternative therapy use. The fact that Chinese are more likely to use herbal therapies than whites or blacks may be due to a more prevalent use of herbal therapies by Chinese in general, such as in traditional Chinese medicine. The importance of spirituality and religious faith among blacks is seen in the finding that belonging to a church or community group is statistically significantly associated with using any alternative therapy, an association that is not seen in the other three ethnic groups. Because usage patterns differed so dramatically across ethnic groups, it is imperative that future research examine detailed patterns of use, access, and avoidance as well as factors associated with these patterns within each ethnic group. In the absence of such ethnic-specific surveys, we will be unable to responsibly advise individual ethnic populations regarding choices of therapies (11).
Our research confirms the report by Schimpff (28) regarding the use and acceptance of alternative therapies among women with breast cancer that the majority of women do not report their use of alternative therapies to their physicians. An open discussion between physicians and their patients about the role of alternative therapy is needed (29-31). Because safety and efficacy of these practices remain largely unknown, advising patients who seek alternative therapies presents a professional challenge (30-33). A recent pilot survey (32) among oncologists and primary care physicians indicates that physicians perceive that alternative cancer therapies have little proven benefits and that it is a poor use of their time to discuss the issue with patients. It is important for medical practitioners (and the public) to realize that a treatment with proven lack of benefit is not logically equivalent to a therapy whose benefit is not known. Because of the growing interest in such therapies, Eisenberg (30) proposed that strategies should involve a formal discussion of patients' preferences and expectations, the maintenance of symptom diaries, and monitoring by follow-up visits. Such an approach is to be guided by the evidence or lack thereof to support the use or avoidance of individual alternative therapies. Fortunately, residents and medical students are increasingly exposed to alternative medicine practitioners and lectures during their training, and the majority of medical schools in the United States now offer courses in complementary and alternative medicine (34). Given the high prevalence of use of alternative medicine found in this study, the introduction of such course work is well-timed.
Large-scale short- and long-term outcome studies to follow-up women with cancer who have and have not used any alternative therapies are needed. A recent longitudinal study (14) showed that, among women with early-stage breast cancer, users of complementary therapies reported worse general mental health, worse depression scores, greater fear of recurrence, and a greater number and higher severity of symptoms at 3 months after surgery compared with women who did not use complementary therapies. More studies like this for specific therapies among well-defined cohorts are needed. If better outcomes (improving quality of life, reducing recurrence, and improving survival) are associated with any type of alternative therapy, then well-defined clinical trials on specific therapies would be an appropriate next step. In conjunction with such trials, any adverse effects and/or diminished survival associated with specific alternative therapies could also be investigated. Clearly, patients of all ethnic groups will benefit from this line of inquiry.
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APPENDIX |
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Dietary Therapies
Special diets include the very low-fat diet, vegetarian diet, and the elimination of foods that are thought to trigger the onset of symptoms or chronic illness. Virtually all of these interventions focus on eating more fresh and freshly prepared vegetables, fruits, and whole grains. Studies have found that certain dietary lifestyles, such as the vegetarian diet of Seventh-day Adventists, the macrobiotic diet (which consists largely of whole grains, beans, and vegetables), and certain cultural eating styles, such as the Asian and Mediterranean diets, can lower risk factors for heart disease and certain forms of cancer. In traditional Eastern medicine, proper nutrition has always been a key element in maintaining health and wellness. Megadoses of vitamins, plant extracts, antioxidants, and other supplements are used to prevent or control symptoms of disease. Megadoses are much larger doses, often 100-1000 times larger than the recommended dose.
Herbal Therapies
Herbal and botanical treatments, many of which have been used by some cultures for hundreds of years, are today the source of 25% of the Western pharmaceutical drugs. In Chinese medicine, for example, individual or mixtures of plants and herbs are generally prescribed to restore balance and increase or decrease energy, or chi. Herbal combinations are a vital part of traditional Chinese medicine. Common herbs and botanical treatments used in the United States include garlic oil for the treatment of mild hypertension, echinacea for improving the immune system, and herbs for controlling symptoms related to menopause and pregnancy.
Homeopathy was founded in the late 1800s by a German physician, Samuel Hahnemann, who found that "a substance that produces a certain set of symptoms in a healthy person has the power to cure a sick person manifesting those same symptoms" (37). In essence, homeopathic medicines are very diluted doses of plant, animal, or mineral substances that seek to cure symptoms of health problems by stimulating the body's immune system to combat the illness.
Mental Therapies
Meditation and relaxation techniques are psychologic methods that are used to calm the body and mind by focusing attention on different objects, a repeated word or mantra, an image, or by body and breathing exercises. These techniques have been shown to produce distinct biochemical changes in the body, including the lowering of blood pressure, pulse rates, and levels of stress hormones in the blood.
Guided imagery and visualization are psychologic methods that involve creating a mental image or process to represent bodily functions to give individuals a sense of control over their illness. It has been used in treating various chronic diseases, including cancer. Spiegel (39) found that patients with breast cancer who used guided imagery and other counseling techniques had a survival time that was twice that of control subjects who did not receive any such therapies.
Hypnosis is a psychologic method that involves the induction of a positive mental state of healing and the use of therapeutic suggestion. Sometimes patients are taught self-hypnosis to apply to themselves when the problem recurs. It has been shown to be helpful in treating stress-related disorders and in helping people stop smoking.
Biofeedback is a psychologic method that involves using a variety of monitoring machines that provide feedback to the patient about how the body is responding to mental control. It has been used to treat conditions related to stress and hypertension, including insomnia, asthma, menstrual cramping, sphincteric incontinence, symptoms of pain, schizophrenia, and depression.
Spiritual healing is a form of meditation in which one directs entreaties to a Supreme Being, a Universal Power, or God. This practice involves a state of prayerfulness, a feeling of genuine caring, compassion, love, or empathy with the target system or a feeling that the individual is "one" with the Supreme Being.
Physical Therapies
Acupuncture involves the placing of tiny needles at certain points on the body meridian to direct the flow of energy, or chi, to certain organs in an attempt to restore health. Acupuncturists help patients balance the chi energy within and between the five major organ systems: the heart, lungs, liver, spleen, and kidneys. It is a method used in traditional Chinese medicine and is often used in combination with herbal treatments.
Acupressure is a form of acupuncture that involves applying pressure with the fingers and thumbs, rather than needles, to chi points on the surface of the body. The idea is that this technique relieves muscular tension and enables oxygen and nutrients to be distributed to tissues throughout the body. Similarly, reflexology involves applying pressure to specific chi points on the bottom of the feet.
Massage therapy, in the West, involves applying pressure with the fingers and hands to various parts of the body to relax muscle tension and reduce stress. However, the Chinese use this therapy to treat chronic illness.
Body work includes different techniques, such as the Feldenkreis Method, Somatics, Rolfing, the Alexander Technique, Rosen Body Work, and kinesiology. Each approach has its own specific aims and methods, but, in general, the idea is to help patients improve their mental and physical health by learning how to use their bodies in more healthful ways.
Yoga, which in Sanskrit means "union," originated in India and involves stretching, breathing, and physical exercise to promote the flow of energy and to generate healing processes within the body. Tai Chi and Chi Gong, also part of traditional Chinese medicine, involve similar components.
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NOTES |
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We thank Cindy Sterns, Jackie Chan, Florence Lee, Martha Miranda, Amy Yu, Julie Lang, Peter Bacchetti,Yfei Ma, Jessica Watson, Bradley Jacobs, and Christine Choy for their assistance in various stages of the study.
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Manuscript received February 19, 1999; revised October 25, 1999; accepted November 2, 1999.
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