Heather Boon

Use of Complementary/Alternative Medicine by Breast Cancer Survivors in Ontario: Prevalence and Perceptions

PURPOSE To determine the prevalence of use of complementary/alternative medicine (CAM) by breast cancer survivors in Ontario, Canada, and to compare the characteristics of CAM users and CAM nonusers. PATIENTS AND METHODS A questionnaire was mailed to a random sample of Ontario women diagnosed with breast cancer in 1994 or 1995. RESULTS The response rate was 76.3%. Overall, 66.7% of the respondents reported using CAM, most often in an attempt to boost the immune system. CAM practitioners (most commonly chiropractors, herbalists, acupuncturists, traditional Chinese medicine practitioners, and/or naturopathic practitioners) were visited by 39.4% of the respondents. In addition, 62.0% reported use of CAM products (most frequently vitamins/minerals, herbal medicines, green tea, special foods, and essiac). Almost one half of the respondents informed their physicians of their use of CAM. Multiple logistic regression analysis determined that support group attendance was the only factor significantly associated with CAM use. CONCLUSION CAM use is common among Canadian breast cancer survivors, many of whom are discussing CAM therapy options with their physicians. Knowledge of CAM therapies is necessary for physicians and other health care practitioners to help patients make informed choices. CAM use may play a role in the positive benefits associated with support group attendance.

Reporting Randomized, Controlled Trials of Herbal Interventions: An Elaborated CONSORT Statement

Randomized, controlled trials (RCTs) of herbal interventions often inadequately describe important aspects of their methods (1-4). Although the quality of reporting of these trials may be improving with time, many still lack important information, particularly about the composition of the herbal intervention (4, 5). Crude herbal drugs are natural products and their chemical composition varies depending on several factors, such as geographic source of the plant material, climate in which it was grown, and time of harvest. Commercially available herbal medicinal products also vary in their content and concentration of chemical constituents from batch to batch and when products containing the same herbal ingredient are compared among manufacturers (6-14). Even when herbal products are standardized for content of known active or marker compounds to achieve more consistent pharmaceutical quality, there is variation in the concentrations of other constituents. These variations can result in differences in pharmacologic activity in vitro (15) and in bioavailability in humans (16). Mindful of these issues, we elaborated on the 22-item checklist of the Consolidated Standards of Reporting Trials (CONSORT) statement (17) to help authors and editors improve reporting of RCTs of herbal interventions. Methods We developed these reporting recommendations in 3 phases that included premeeting item generation, a consensus meeting, and postmeeting feedback. The individuals who participated are listed in the Appendix. To generate items, 1 investigator conducted telephone interviews of 16 participants with expertise in the method and reporting of RCTs (5 participants), pharmacognosy (4 participants), herbal medicinal products (5 participants), medical statistics (1 participant), and herbal product manufacturing (1 participant). The investigator asked participants to suggest revisions to existing CONSORT checklist items and also to additional items required for reporting trials of herbal interventions. He asked participants to nominate revisions or new items on the basis of empirical evidence that not reporting the item would bias estimates of treatment effect. When no empirical evidence was available, commonsense reasoning was acceptable. After completing all telephone calls, the investigator thematically grouped items and circulated them by e-mail to each participant for review. Fourteen participants attended the consensus meeting. The meeting began with a review of the premeeting checklist item suggestions. We emphasized minimizing item elaborations and additions and basing elaborations on evidence whenever possible. Each item suggestion was presented and followed by debate for its inclusion, deletion, or modification. This process was repeated until all items were reviewed and a consensus emerged. After the consensus meeting, we circulated a draft summary report to all participants to ensure that it accurately represented decisions made during the consensus meeting. We then circulated the report to the wider CONSORT Group for input and revised it on the basis of their suggestions. Ethical approval was obtained from The University of Toronto Health Sciences Ethics Review Committee on 23 January 2004. Financial support for the consensus meeting was provided by the Canadian Institutes of Health Research. The funding body had no role in the design, conduct, or analysis of this study and did not influence the decision to submit the manuscript for publication. All researchers are independent of the funders. Results The group did not recommend any new CONSORT checklist items or modifications in the CONSORT flow diagram. We did, however, elaborate on 9 of the 22 CONSORT checklist items to enhance their relevance to trials of herbal interventions (Table, Figure; Appendix Table), including minor recommendations for 8 items (item 1 [title and abstract], item 2 [background], item 3 [participants], item 6 [outcomes], item 15 [baseline data], item 20 [interpretation], item 21 [generalizability], and item 22 [overall evidence]) and detailed recommendations for 1 item (item 4 [interventions]). Table. Proposed Elaboration of CONSORT Checklist Item 4 for Reporting Randomized, Controlled Trials of Herbal Medicine Interventions Figure. The high-pressure liquid chromatography chemical fingerprint for the extract of Ginkgo biloba L Appendix Table. Proposed Elaborations of CONSORT Items for Randomized, Controlled Trials of Herbal Medicine Interventions The Table shows the detailed recommendations for item 4 and an example of good reporting related to each recommendation. These recommendations begin with the words where applicable to indicate that all information suggested may not be applicable to every type of herbal medicine intervention. For example, an herbal medicinal product comprising crude herbal material (for example, leaves and stems) simply prepared as a tea or decoction does not require description of the type and concentration of solvent used and the ratio of herbal drug to extract (item 4B.3). Also, not every herbal medicine intervention will have a finished product or extract name or manufacturer (item 4A.2), but instead may be made by the investigators specifically for the study. In such circumstances, all methods used in preparing and formulating the product must be reported. Similarly, item 4F is not required for herbal interventions when the practitioner is not a part of the intervention. With these exceptions, we recommend that all information shown in the Table be reported for all herbal interventions. Discussion We developed recommendations to be used in conjunction with the existing CONSORT checklist when reporting RCTs of herbal interventions. In particular, we thought it imperative that reports of RCTs provide clear and complete descriptions of the herbal intervention. We think that our recommendations might also be relevant for reporting herbal interventions in other research designs, whether preclinical (for example, in vivo or in vitro) or clinical (for example, N of 1 trials), and refer interested readers to a detailed explanatory document that further describes each of our recommendations and provides additional examples of good reporting (22). We hope that authors find our recommendations instructive and that journals will endorse their use and modify their instructions to authors accordingly.

Reasons for and Characteristics Associated With Complementary and Alternative Medicine Use Among Adult Cancer Patients: A Systematic Review

Purpose: To conduct a systematic review of reasons for and sociodemographic and disease characteristics associated with complementary and alternative medicine (CAM) use in cancer patients. Methods: Eligible studies were identified by searching the following databases: Alt Health Watch, AMED, CINAHL, CancerLit, PremMEDLINE, MEDLINE, Pub-Med, Ingenta, EMBASE, and Health Star, as well as reference lists in review articles. Only English-language articles published between 1994 and 2004 were included. Search terms included CAM and oncology/cancer , decision making and CAM and oncology/cancer , treatment decision making and CAM and oncology/cancer , and health care choices and CAM and oncology/cancer . Results: Fifty-two eligible studies were identified and summarized. These studies were conducted in 14 different countries, with the largest number of studies being completed in the United States (34.6%). A therapeutic response, wanting control, a strong belief in CAM, CAM as a last resort, and finding hope were the most commonly cited reasons for using CAM. Age, socioeconomic status, and gender were the dominant characteristics associated with CAM use. Conclusion: Reasons for and characteristics associated with CAM use among cancer patients have been studied extensively. Future CAM research among cancer patients should focus on identifying decision-making processes and building theoretical decision-making models. These can be used in the development of decisional aids for patients when confronted with the choice to use CAM as part of their cancer treatment.

Breast Cancer Survivors’ Perceptions of Complementary/Alternative Medicine (CAM): Making the Decision to Use or Not to Use

The study described in this article explored breast cancer survivors’ perceptions and experiences as they decided whether to use a variety of complementary/alternative therapies. Six focus groups were conducted composed of women who had been diagnosed with breast cancer. Each 2-hour session was audiotaped and transcribed verbatim. In this article, the process by which the participants made the decision to use or not to use complementary/alternative therapies, including their discovery and investigation of complementary/alternative medicine (CAM) and their experiences using or not using CAM, are described. Barriers to using CAM included cost, access, and time. Family and friends generally supported the decision to use CAM; however, the participants described health care practitioners’ reactions as mixed.

Use of complementary/alternative medicine by men diagnosed with prostate cancer: prevalence and characteristics☆

OBJECTIVES To ascertain the prevalence of the use of complementary/alternative medicine (CAM) among a random sample of Ontario (Canadian) men diagnosed with prostate cancer and to explore in what way users of CAM differ from nonusers. METHODS A questionnaire was mailed to a random sample of 696 men diagnosed with prostate cancer. RESULTS The final response rate was 78.8%. Almost one third (29.8%) reported using CAM for their prostate cancer care. Natural health products (most commonly vitamin E, saw palmetto, and selenium) were used by 26.5% of the respondents. CAM therapies were used by 17.0% of the men (most commonly dietary changes), and only 9.1% visited CAM practitioners. Three characteristics appear to differentiate CAM users from nonusers. Men who had attended support groups were much more likely to use CAM. Men who had more advanced disease, and those who believed in the efficacy of CAM, but were not concerned about potential adverse effects of CAM, were also more likely to use CAM. CAM use was not related to education, income, or geographic location. CONCLUSIONS The data suggest that CAM use is no longer a phenomenon restricted to a unique segment of the population that is highly educated and enjoys a high family income. CAM use appears to be more related to other factors such as support group attendance, disease characteristics, and beliefs about CAM. Our findings highlight the need for urologists to ask all their patients about their use of CAM.

Women's decision-making about their health care: views over the life cycle

This paper describes a compilation and further analysis of three qualitative studies, conducted independently, on womens health care decisions. Key areas regarding womens health, which span the life cycle, were examined including prenatal genetic screening, hormone replacement therapy and the use of complementary/alternative medicine in the treatment of breast cancer. Common themes were evident across all the focus groups in each of the three studies including: womens information seeking behavior; reliance on trusted information sources; the desire for information sharing; active involvement in the decision-making process; and accepting the consequences of the final decision. The findings have important implications for health care professionals as they engage women in the decision-making process about health concerns.

The use of CAM by women suffering from nausea and vomiting during pregnancy

BackgroundNausea and vomiting during pregnancy (NVP) affects two-thirds of pregnant women to varying degrees and over the years many modalities have been used to try to alleviate this often debilitating condition. There is a paucity of information in the literature about the use or efficacy of complementary and alternative medicine (CAM) for the treatment of this condition that affects so many women. Our primary objective was to examine the prevalence of CAM usage by women suffering from NVP. Our secondary objective was to ascertain if women had any supervision in the use of these treatments.MethodsWomen who called The Motherisk NVP helpline, were asked after the counseling session to complete a questionnaire, which included demographic data as well as information about their CAM use.ResultsSeventy women completed the questionnaire. 61% reported using CAM therapies, of which the three most popular were: ginger, vitamin B6 and acupressure. 21% of those who reported using CAM, had consulted CAM practitioners, 8% their physicians or pharmacists and 71% discussed the usage with family, friends and other allied health professionals. Women who did not use CAM stated they would probably use these modalities if there was more information about the safety in pregnancy.ConclusionPregnant women with NVP are mirroring the trend in the general population of the use of CAM. They are also using CAM therapies with little supervision from practitioners experienced in the use of these modalities.

Evaluating Complex Healthcare Systems: A Critique of Four Approaches

The purpose of this paper is to bring clarity to the emerging conceptual and methodological literature that focuses on understanding and evaluating complex or ‘whole’ systems of healthcare. An international working group reviewed literature from interdisciplinary or interprofessional groups describing approaches to the evaluation of complex systems of healthcare. The following four key approaches were identified: a framework from the MRC (UK), whole systems research, whole medical systems research described by NCCAM (USA) and a model from NAFKAM (Norway). Main areas of congruence include acknowledgment of the inherent complexity of many healthcare interventions and the need to find new ways to evaluate these; the need to describe and understand the components of complex interventions in context (as they are actually practiced); the necessity of using mixed methods including randomized clinical trials (RCTs) (explanatory and pragmatic) and qualitative approaches; the perceived benefits of a multidisciplinary team approach to research; and the understanding that methodological developments in this field can be applied to both complementary and alternative medicine (CAM) as well as conventional therapies. In contrast, the approaches differ in the following ways: terminology used, the extent to which the approach attempts to be applicable to both CAM and conventional medical interventions; the prioritization of research questions (in order of what should be done first) especially with respect to how the ‘definitive’ RCT fits into the process of assessing complex healthcare systems; and the need for a staged approach. There appears to be a growing international understanding of the need for a new perspective on assessing complex healthcare systems.

Men with Prostate Cancer: Making Decisions about Complementary/Alternative Medicine

Purpose. The purpose ofthis study was to explore prostate cancer patients’ perceptions, feelings, ideas, and experiences regarding making decisions to use (or not use) complementary/alternative medicine (CAM). Methods. Five focus groups were conducted with 29 men diagnosed with prostate cancer. Content analysis ofthe verbatim transcripts was used to identify key themes in the data. Findings. Decision making about CAM treatments appears to depend on both fixed (e.g., disease characteristics, demographic characteristics, and medical history) and flexible (e.g., perceptions of CAM and conventional-medicine, experiences with the health care system and health care practitioners, and perceptions about the need for control or action) decision factors. Conclusions. The participants in this study appeared more likely to be “pushed” toward using CAM by negative experiences with the health care system than to be “pulled” toward CAM by perceptions about its safety or congruence with their beliefs about health and illness.

Acupuncture as a promising treatment for below-level central neuropathic pain: a retrospective study.

Abstract Background/Objective: Below-level central neuropathic pain, a diffuse pain characterized by generalized burning, is commonly experienced by individuals with spinal cord injury (SCI) . The objective of this study was to investigate the effects of an electroacupuncture protocol for the treatment of below-level central neuropathic pain developed at the Toronto Rehabilitation Institute, Lyndhurst Center, Toronto, Ontario, Canada. Method: Retrospective chart review. Results: Thirty-six individuals with traumatic and nontraumatic SCI met the inclusion criteria. Of these, 24 showed improvement after treatment with the electroacupuncture protocol. Type of injury, level of injury, and duration of below-level central neuropathic pain was not correlated with improvement. However, individuals whose pain was described as bilateral (vs unilateral; P = 0 .01 4) or symmetric (vs non symmetric; P = 0.02 6) were more likely to improve after acupuncture treatment. Overall, patients whose burning pain was bilateral, symmetric, and constant (P = 0 .005) were the most likely to improve. Conclusion: This retrospective study suggests that the Lyndhurst Center Central Neuropathic Pain Acupuncture Protocol may be an effective treatment option for patients with SCI who are experiencing below-level central neuropathic pain. Additional prospective clinical studies are needed to confirm these findings. J Spinal Cord Med. 2003;26:21-26