Complementary and Alternative Medicine Use Among Patients With Cancer

Invited Commentary

Invited Commentary

Complementary and Alternative Medicine Use

Among Patients With Cancer
A Challenge in the Oncologist-Patient Relationship
Robert Zachariae, DMSc

Numerous large trials involving more than 100 000 patients

have documented that adjuvant chemotherapy (AC) leads to
considerable reductions in breast cancerrelated mortality.1
Despite the well-documented
survival benefits, a proporRelated article
tion of women for whom AC
is indicated may delay or
completely fail to initiate AC. This is a cause for considerable
concern, as supported by the results of a systematic review and
meta-analysis of 7 studies involving more than 34 000 women
treated surgically for breast cancer, indicating that overall and
disease-free survival is reduced by 15% and 16%, respectively, for every 4-week delay in initiation of AC.2 It is therefore of urgent interest to determine the factors associated with
noninitiation of AC. With respect to patient decisions to delay or ultimately reject AC all together, a complex interaction
of sociodemographic, clinical, and psychosocial patient characteristics, as well as oncologist factors, are likely to be at play.
In this issue of JAMA Oncology, Greenlee et al3 explore the
possible role of patients use of complementary and alternative medicine (CAM) in noninitiation of AC in a cohort of 685
women with nonmetastatic, invasive breast cancer. Selfreport data collected 12 months after baseline indicated that
11% of the women for whom AC was indicated according to National Comprehensive Cancer Network guidelines did not initiate AC. A considerable proportion of the participants (87%)
reported use of 1 or several types of CAM, and, after adjusting
for a number of demographic and clinical variables, the higher
the number of CAM modalities used, the more likely the women
were to have noninitiated AC. Among the strengths of the study
is that not only did the authors prospectively investigate the
association of overall CAM use with noninitiation, but they also
explored the use of several CAM modalities. Users of dietary
supplements seemed to be particularly at risk of not initiating AC, whereas use of various mind-body practices (eg, yoga,
meditation, and acupuncture) seemed to be unrelated to AC
initiation.
Greenlee and colleagues3 did not explore patients motivations or their perceptions of CAM efficacy, but they do discuss the possibility that the benefits patients hope to obtain
differ between these 2 categories of CAM. This finds support
in a study4 of CAM use in a nationwide prospective cohort of
3343 Danish women treated for primary breast cancer. A
considerable proportion of CAM users (23.7%) were absolutely or relatively certain that the CAM used would have a
beneficial effect on their breast cancer, and, when exploring
differences between use of various types of CAM, women
who used herbal medicines or dietary and/or exercise counjamaoncology.com

seling emerged as more likely than women who used various

mind-body practices to perceive the CAM used as effective
in treating their cancer. It thus seems quite possible that
similar differences in perceived efficacy could explain the
findings of the Greenlee et al3 study that users of dietary
supplements were less likely to initiate AC and underscores
the necessity to investigate the various characteristics associated with use of different CAM modalities rather than
treating CAM use as one homogenous category.
Additional findings from the cohort of Danish women
treated for breast cancer could indicate that this particular
group of CAM users may be particularly vulnerable.5 The CAM
users thus reported more depressive symptoms than nonusers at both 3 and 15 months after surgery, with further analyses showing that having used CAM during the 12-month
follow-up period was associated with higher levels of depressive symptoms at follow-up, even after adjusting for baseline
depressive symptoms and sociodemographic, diseaserelated, and treatment-related variables, including comorbidity and previous psychiatric history. When comparing different CAM modalities, the use of dietary supplements emerged
as the only independent predictor of experiencing more
depressive symptoms at both time points.
The results described by Greenlee et al3 and others emphasize the need to improve our understanding of the decisionmaking process of patients with cancer in their choice of conventional or alternative treatments. A recent systematic review6
of 35 studies suggests that CAM-related decision-making by
patients with cancer occurs as a complex, nonlinear, dynamic process of information-seeking and evaluation. The results suggest a wide range of motivations behind the choice
to use various types of CAM as patients move through the different phases of cancer treatment and recovery. In the early
phase, when patients receive their initial cancer diagnosis, the
choice to use CAM seems to be particularly associated with the
need to cope with the sense of loss of control. In later phases,
the use of CAM seems to be directed toward perceived ends,
such as maintaining well-being, controlling the spread of cancer cells, boosting the immune system, and preventing or
delaying recurrence.
To provide the best evidence-based decision support regarding CAM useincluding whether to use CAM as a complementary or alternative treatment to AConcologists need to
be actively involved in discussing CAM use with their patients. Only by acknowledging that communication about CAM
use is an important part of cancer care will oncologists be able
to help patients to make sufficiently informed choices about
CAM use. However, as shown in a systematic review of the
(Reprinted) JAMA Oncology Published online May 12, 2016

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Invited Commentary

Complementary and Alternative Medicine Use Among Patients With Cancer

available literature,7 a considerable proportion (20%-77%) of

patients with cancer who use CAM do not disclose their CAM
use, the main reasons for nondisclosure being the physicians
lack of inquiry; the patients anticipation of the physicians disapproval, disinterest, or inability to help; and the patients perception that disclosure of CAM use is irrelevant to his or her
conventional care. Furthermore, there seems to be evidence
to suggest that patient-physician communication about CAM
use is associated with a better patient-physician relationship
and higher patient satisfaction.
ARTICLE INFORMATION
Author Affiliations: Unit for Psycho-oncology and
Health Psychology, Department of Oncology,
Aarhus University Hospital, Aarhus, Denmark;
Department of Psychology, Aarhus University,
Aarhus, Denmark.
Corresponding Author: Robert Zachariae, DMSc,
Unit for Psycho-oncology and Health Psychology,
Department of Oncology, Aarhus University
Hospital, Bartholins Alle 9, Building 1340, Aarhus,
8000C, Denmark (bzach@aarhus.rm.dk).
Published Online: May 12, 2016.
doi:10.1001/jamaoncol.2016.0713.
Conflict of Interest Disclosures: None reported.
REFERENCES
1. Peto R, Davies C, Godwin J, et al; Early Breast
Cancer Trialists Collaborative Group (EBCTCG).

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Taken together, the available studies, including the important addition to the literature by Greenlee and colleagues3 in the
present issue of JAMA Oncology showing that CAM use may be
associated with noninitiation of potentially life-saving adjuvant treatment, highlight the urgent need to train oncologists
to enhance their ability to improve patient disclosure of CAM.
This can best be done in a patient-centered manner by respectfully exploring patients preferences and beliefs about CAM
and by providing the best evidence-based information about
treatment options in a nonjudgmental fashion.

Comparisons between different polychemotherapy

regimens for early breast cancer: meta-analyses of
long-term outcome among 100,000 women in 123
randomised trials. Lancet. 2012;379(9814):432-444.
2. Yu KD, Huang S, Zhang JX, Liu GY, Shao ZM.
Association between delayed initiation of adjuvant
CMF or anthracycline-based chemotherapy and
survival in breast cancer: a systematic review and
meta-analysis. BMC Cancer. 2013;13:240.
3. Greenlee H, Neugut AI, Falci L, et al. Association
between complementary and alternative medicine
use and breast cancer chemotherapy initiation: the
Breast Cancer Quality of Care (BQUAL) study
[published online May 12, 2016]. JAMA Oncol.
doi:10.1001/jamaoncol.2016.0685.
4. Pedersen CG, Christensen S, Jensen AB,
Zachariae R. Prevalence, socio-demographic and
clinical predictors of post-diagnostic utilisation of
different types of complementary and alternative

medicine (CAM) in a nationwide cohort of Danish

women treated for primary breast cancer. Eur J
Cancer. 2009;45(18):3172-3181.
5. Pedersen CG, Christensen S, Jensen AB,
Zachariae R. Use of complementary and alternative
medicine (CAM) and changes in depressive
symptoms from 3 to 15 months after surgery for
primary breast cancer: results from a nationwide
cohort study. Breast Cancer Res Treat. 2013;141(2):
277-285.
6. Weeks L, Balneaves LG, Paterson C, Verhoef M.
Decision-making about complementary and
alternative medicine by cancer patients: integrative
literature review. Open Med. 2014;8(2):e54-e66.
7. Davis EL, Oh B, Butow PN, Mullan BA, Clarke S.
Cancer patient disclosure and patient-doctor
communication of complementary and alternative
medicine use: a systematic review. Oncologist.
2012;17(11):1475-1481.

JAMA Oncology Published online May 12, 2016 (Reprinted)

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