Cancer-related correlates of Traditional and Complementary Medicine use among Norwegian cancer survivors: A cross-sectional study

DOI: https://doi.org/10.21203/rs.3.rs-1584706/v1

Abstract

Background

Cancer survivors are a diverse group with varying needs that are patient-, disease-, and/or treatment-specific. Cancer survivors have reported supplementing conventional anti-cancer treatment with Traditional and Complementary Medicine (T&CM) to combat the effects of the disease, as well as the adverse effects of conventional anti-cancer treatments, at different phases of their diagnosis. We aimed to study disease- and treatment-related correlates of T&CM use among Norwegian cancer survivors.

Methods

Data was collected from the seventh survey of the Tromsø Study, Tromsø 7, conducted in 2015-16 among residents of the Tromsø municipality aged 40 and above. Of the 32 591 inhabitants invited, 21 083 accepted the invitation leading to a response rate of 64.7%. The Tromsø study consists of a three-part questionnaire and a thorough clinical examination. In addition to data from the Tromsø study, data on cancer diagnosis and conventional anti-cancer treatment were collected from the Cancer Registry of Norway. Pearson chi-square test, Fisher’s exact tests and independent sample t-test were used to compare T&CM users with non-users. Statistical significance was set at the p-value of < 0.05. All statistical analyses were conducted using Statistical Package for Social Sciences (SPSS) version 28.0 for Windows.

Results

T&CM was used by 31.2% of the participants with natural remedies as the most reported modality of T&CM (18.2%, n = 238), followed by self-help practices of meditation, yoga, qigong, or tai chi, which was reported by 8.7% (n = 114). Provider-based T&CM were reported by 10.0%, where each (acupuncturists; traditional healers; and other CM providers) were reported by 4% of the participants, respectively. Users of T&CM were significantly younger and more likely to be female (p < .001) than the non-users, with higher use of T&CM among females with poor self-reported health, distant metastasis, and being 1–5 years post-diagnosis. Lower use was found among women who received a combination of surgery and hormonal therapy. Similar trends were seen in males, but not at a significant level. For both males and female, T&CM was most frequently used by those with only one cancer diagnosis (p = .046).

Conclusion

The findings suggest that there is a difference in clinical predictors for T&CM between female and male cancer survivors, with more clinical predictors among females.

Background

In Norway, about 35 000 new cancer cases are recorded annually, with an overall growing number of cancer survivors. More males (54%) are diagnosed than females (46%), and the country’s median age at diagnosis is 70 years for both sexes[1]. Cancer survivorship is broadly defined as a continuum from the time of diagnosis to the end of one’s life [2]. Although this implies a commonality, cancer survivors are a diverse group with varying needs due to factors such as cancer type [3], stage at diagnosis [4], age at first diagnosis [5, 6], racial differences [7, 8] and disparities [9], and anti-cancer treatment [10, 11]. Besides breast cancer being the most common cancer in females and prostate cancer being the second most common in males worldwide [12], sex also plays a role in cancer incidence and mortality beyond reproductive organs among survivors [13]. Due to the various differences, cancer survivors face adverse outcomes to varying degrees such as pain, fatigue, and gastrointestinal symptoms as a direct result of the disease [14]. Additionally, the most common conventional cancer treatment forms such as surgery, chemotherapy, radiation therapy, and hormonal therapy can have adverse effects [1517]. The risk can increase when these modalities are used in combination [18].

Some effects, known as late effects of treatment, appear months to years after treatment [19]. These effects range from pain, fatigue, cardiotoxicity, lymphedema, neurological complications to secondary cancers [20, 21]. In addition to these physical effects, cancer survivors face psychological distress such as fear of recurrence which can result in anxiety, fear of death, and cognitive challenges [22]. To combat these effects, many cancer survivors report using Traditional and Complementary Medicine (T&CM) modalities [2325].

T&CM can generally be defined as health practices not part of conventional medicine [12, 26]. Additionally, traditional medicine draws from the knowledge, beliefs, and century old experiences of indigenous peoples [27]. Other reasons given for the use of these modalities are to increase the body’s innate ability to fight the disease and to improve physical and mental well-being [28, 29]. Other reasons given are to improve prognosis and increase the chance of recovery [30]. All of which reflect the complex effects of cancer that survivors deal with, and possible insufficiencies in cancer survivorship care. Especially if symptoms experienced are not recorded by health care providers, as shown before [31].

The prevalence and type of T&CM used vary regionally for cultural [32] and economic reasons [33, 34]. For example, it is reported that it is used by up to 80% of the cancer survivors in some African countries where costs of conventional anti-cancer treatment are too high for many inhabitants [35], and over 90% in some Chinese regions where traditional Chinese medicine is prevalent [36].

Use of T&CM before a cancer diagnosis has been shown to remain mainly unchanged upon diagnosis [29]. It can then decrease during treatment and return to pretreatment levels after anti-cancer treatment [37]. On the contrary, a remarkable increase in use upon diagnosis has also been shown [38]. Use among long-term survivors is also reported [39]. Socio-demographic factors associated with T&CM use among European cancer survivors are female sex, higher education, and higher income [28, 30]. This is largely true for Norway too [40]. Breast cancer has been found to be a clinical predictor of T&CM use [41]. Longer time since diagnosis [42, 43], advanced stage of disease [44], and metastasis [45] have also been associated with T&CM use. It was also shown that cancer survivors using T&CM were more likely to have a history of surgery and chemotherapy [46]. However, some studies have shown no correlation between clinical factors and T&CM use [37, 47].

Clinical predictors of T&CM use among Norwegian cancer survivors have been studied across decades. A 1995 Norwegian multicenter study found no correlation between T&CM use and stage of disease and time since diagnosis [48]. A multicenter follow-up study from 2002 showed that palliative treatment, metastatic disease, and time since diagnosis predicted T&CM use [49]. In 2009, a study found that survivors with a poor prognosis were associated with more T&CM use than those with a better prognosis [50]. A 2012 study based on data from the sixth Tromsø Cohort Study found no significant associations between T&CM use and time since diagnosis; however, they found breast cancer to be a predictor of T&CM use [40]. As cancer screening programs get better, anti-cancer treatments improve, and the survivorship period lengthens [51], this study aims to revisit cancer- and treatment-related clinical predictors of T&CM use among Norwegian survivors who participated in the Tromsø 7 study.

Methods

The Tromsø Study

The data for this study were obtained from the Tromsø 7 study and the Cancer Registry of Norway (CRN). Tromsø, located in the Arctic, is the largest city in Northern Norway and is a center of education, research, and fishing [52]. The population is multicultural and is mainly made up of a Norwegian ethnic majority, Sami ethnic minority, and immigrants [53]. The Tromsø study is a prospective population-based study with repeated health surveys of the inhabitants in Tromsø, with seven surveys so far. Initially, the study was primarily about cardiovascular mortality, but emphasis has been put on various chronic diseases and health issues since its inception [54]. In Tromsø 7 (2015–2016), all residents of the Tromsø municipality aged ⩾40 years were invited to answer questions about their health, as well as a physical examination. A total of 21 083 participated (64.7% of all invited, Fig. 1)[55].

Study population

For the current study, 18 815 participants were excluded as they reported never having a cancer diagnosis (Fig. 1). A total of 219 participants reported a cancer diagnosis but this was not registered with the CRN, so this data was regarded as having no certain history of cancer and excluded from the study. A further 655 were excluded due to no information of self-reported history of cancer. The remaining 1394 participants all had a self-reported and a registered cancer diagnosis at the time of participation. Three participants without information on the use of T&CM were also excluded. A total of 84 participants who answered “no” to the use of one type of T&CM and had missing information on the remaining modalities of T&CM were also excluded as the use/non-use of T&CM could not be established. The final study sample was made up of 1307 participants who had a self-reported cancer diagnosis that was registered at the CRN and provided adequate information on the use of T&CM.

Figure 1: Flowchart of study participants

Basic characteristics

A four-page paper questionnaire (Q1) sent along with an invitation letter and an additional online survey (Q2) were used to collect the demographic (age, sex, living with a spouse/partner, education, and household income) and health information of the participants.

Traditional and Complementary Medicine use

Users of T&CM were defined as participants who reported visits to a T&CM provider and/or used non-provider interventions in the preceding 12 months. The use of a T&CM provider was based on a “yes” response to either of these three questions from Q1: “Have you during the past year visited a traditional healer (helper, “reader”, etc.?)”, “Have you during the past year visited an acupuncturist?” or “Have you during the past year visited a complementary medicine provider (homeopath, reflexologist, spiritual healer, etc.?)”. Non-provider T&CM use (natural remedies and self-help practices henceforth) was collected from Q2 through “Have you used herbal medicines, natural remedies, or herbal remedies during the last 12 months?”, and “Have you used meditation, yoga, Qigong, or tai chi as self-treatment during the last 12 months?” with the response options “yes” and “no”. Data on T&CM use was self-reported.

Health information

Data about self-reported cancer was obtained from Q1 through the question: “Have you ever had, or do you have cancer?” with the alternatives “no”, “yes, now” and “previously, not now”.

Self-reported health was collected through a categorical variable with five categories, sourced from Q1 that asked: “How do you in general consider your own health to be?” with the following answer alternatives; “very bad”, “bad”, “neither good nor bad”, “good”, and “excellent”. These were compressed to, “bad” (very bad and bad), “neither good nor bad”, and “good” (good and excellent).

Data linkage

The Tromsø study links to national disease registries, including the CRN, through a unique 11-digit personal identification number assigned to all people residing in Norway.

Cancer Registry of Norway

The CRN, established in 1951, registers cancer cases, research on cancer, and activities related to cancer. Reporting to the CRN is mandatory for all medical doctors. Thus, the registry reports on cancer type, stage, other pathological characteristics, and treatment [56]. The registry has been found to have a high degree of comparability, accuracy, and timeliness [57].

Data harvested from the CRN and used in this study comprised of cancer diagnosis (ICD-10 codes C00-D47), metastasis, date of diagnosis (multiple dates where relevant), and appurtenant treatments (several rounds of treatment where relevant).

Disease characteristics

Diagnosis per ICD-10 from the CRN was regrouped into cancer site of the body to create the variables, “Breast”, “Female genital organs”, “Prostate”, “Other male genital organs”, “Lung and other respiratory and intrathoracic organs”, “Melanoma and skin, Colon”, “Other digestive organs”, “Lymphoid”, “Hematopoietic and related tissue”, and “Other cancers”.

“Time since first diagnosis” was understood as the period since the first diagnosis date and the date of participation. It was used as a continuous variable to calculate the mean number of years since the first diagnosis and further merged into a categorical variable and grouped into 4 periods, “less than a year”, “1–5 years”, “6–10 years” and “more than 10 years”.

Type of treatment

Types of treatment were obtained from the CRN and re-grouped as follows:

Surgical treatment was understood as a surgical procedure made with the intent of treating the disease [58]. As such, registered diagnostic procedures (exploratory and biopsies) were not included. Surgical treatment for the first, second, third, and/or fourth diagnosis was combined to create the variable for “Surgery”.

Chemotherapy meant any kind of registered chemotherapeutical treatment [59]. Chemotherapy for the first, second, third and/or fourth diagnosis was combined to create the variable for “Chemotherapy”.

Radiation therapy was understood as all forms of radiation, including the gamma knife and radioactive iodine [60]. Radiation treatment for the first, second, third, and/or fourth diagnosis was combined to create the variable for “Radiation therapy”.

Hormonal therapy meant having received any kind of hormonal therapy, with or without the combination of other therapies/procedures [61]. Hormonal therapy for the first, second, third, and/or fourth diagnosis was combined to create the variable for “Hormonal therapy”.

Multimodal treatments were understood as receiving more than one form of the treatments above (regardless of times one has been diagnosed with cancer). This led to the following combinations, “Surgery and chemotherapy”, “Surgery and radiation”, “Surgery and hormonal therapy”, “Chemotherapy and radiation”, “Chemotherapy and hormonal therapy”, “Surgery, chemotherapy and hormonal therapy”, “Chemotherapy, hormonal therapy and radiation” “Surgery, chemotherapy and radiation”, “Surgery, chemotherapy, radiation and hormonal therapy”.

Metastasis was divided into 4 groups; no metastasis, localized/regional metastasis, distant metastasis, and primary tumor unknown.

Statistical analysis

Descriptive statistics were carried out using cross-tabulation and frequency analyses. Categorical variables were compared using Pearson’s Chi-square test or Fisher’s exact test while Independent sample t-test was used to compare continuous variables. Statistical significance was set at the p-value of < 0.05. All statistical analyses were done using Statistical Package for Social Sciences (SPSS) version 28.0 for Windows.

Results

Basic characteristics

The study population consisted of 1307 cancer survivors, 655 females (50.1%) and 652 males (49.9%). The average age of the participants was 65.6 years. A total of 74.4% of the participants reported living with a spouse. Most of the participants reported attaining tertiary education (46.8%) and reported medium and high income, (81.7%, Table 1).

Table 1

Prevalence and correlates of T&CM use

 

Total, n = 1307

%

T&CM, n = 408

%

No T&CM, n = 899

%

p-value

Sex

           

< .001

Females

655

50.1

242

36.9

413

63.1

 

Males

652

49.9

166

25.5

486

74.5

 

Age

           

.001

40–62

456

34.9

168

36.8

288

63.2

 

63 and above

851

65.1

240

28.2

611

71.8

 

Mean age (SD)

65.61 (10.742)

63.97 (11.325)

66.36 (10.388)

.011

Education

           

.406

Primary level

382

29.2

110

28.8

272

71.2

 

Secondary level

313

23.9

97

31.0

216

69.0

 

Tertiary

612

46.8

201

32.8

411

67.2

 

Income

           

.824

Low

228

18.3

72

31.6

156

68.4

 

Medium

567

45.5

170

30.0

397

70.0

 

High

452

36.2

143

31.6

309

68.4

 

Living with a spouse/partner

             

Yes

931

74.4

288

30.9

643

69.1

.860

No

321

25.6

101

31.5

220

68.5

 

Self-reported health

           

.077

Good

745

57.0

214

28.7

531

71.3

 

Neither

462

35.3

158

34.2

304

65.8

 

Poor

100

7.7

36

36.0

64

64.0

 

Cancer site first diagnosis

           

0.309

Breast

262

20.0

98

37.4

164

62.6

 

Female genital organs

105

8.0

32

30.5

73

69.5

 

Prostate

286

21.9

74

25.9

212

74.1

 

Other male genital organs

49

3.7

14

28.6

35

71.4

 

Respiratory organs

31

2.4

9

29.0

22

71.0

 

Melanoma and skin

127

9.7

42

33.1

85

66.9

 

Colon

99

7.6

29

29.3

70

70.7

 

Other digestive organs

72

5.5

23

31.9

49

68.1

 

Hematologic*

93

7.1

25

26.9

68

73.1

 

Other cancers

183

14.0

62

33.9

121

66.1

 

Metastasis at 1st diagnosis!

           

.179

No metastasis

754

57.7

236

31.3

518

68.7

 

Local/Regional

303

23.2

94

31.0

209

69.0

 

Distant

31

2.4

15

48.4

16

51.6

 

Primary tumor unknown

2

.2

1

50.0

1

50.0

 

Time since first cancer diagnosis

           

.072

less than a year

117

9.0

38

32.5

79

67.5

 

1–5 years

485

37.1

167

34.4

318

65.6

 

6–10 years

265

20.3

86

32.5

179

67.5

 

more than 10 years

440

33.7

117

26.6

323

73.4

 

Mean time since first cancer diagnosis

9.20 (9.299)

8.57 (9.489)

9.49 (9.202)

.098

Age at first cancer diagnosis

           

.132

0–20 years

31

2,7

7

22.6

24

77.4

 

21–49 years

344

30,0

122

35.5

222

64.5

 

50 years and above

770

67,2

234

30.4

536

69.6

 

Mean age

54.53 (14.467)

53.86 (13.813)

54.84 (14.759)

.143

Number of cancer diagnoses

           

.046

1 diagnosis

1067

81.6

346

32.4

721

67.6

 

2 and more diagnoses

240

18.4

62

25.8

178

74.2

 

Only one treatment!

           

.340

Surgery

184

14.1

54

29.3

130

70.7

 

CT

57

4.4

19

33.3

38

66.7

 

RT

186

14.2

71

38.2

115

61.8

 

HT

20

1.5

6

30.0

14

70.0

 

Multimodal treatment!

             

Surgery and CT

486

37.2

146

30.0

340

70.0

.480

Surgery and RT

647

49.5

205

31.7

442

68.3

.718

Surgery and HT

447

34.2

127

28.4

320

71.6

.115

CT and RT

521

39.9

171

32.8

350

67.2

.308

CT and HT

274

21.0

78

28.5

196

71.5

.269

Surgery, CT and HT

545

41.7

161

29.5

384

70.5

.269

CT, HT and RT

31

2.4

8

25.8

23

74.2

.511

Surgery, HT and RT

40

3.1

10

25.0

30

75.0

.389

Surgery, CT and RT

711

54.4

226

31.8

485

68.2

.627

Surgery, CT, RT and HT

731

55.9

232

31.7

499

68.3

.647

* Lymphoid, hematopoietic, and related tissue; !n is not equal to 1307 due to missing data; CT: Chemotherapy; RT: Radiotherapy; HT: Hormone therapy

Table 1: Prevalence and correlates of T&CM use

Disease characteristics

The most common cancers were prostate cancer (21.9%) and breast cancer (20.0%), followed by melanoma and other skin cancers (9.7%), cancers of the female genital organs (8.0%), colon cancer (7.6%), and other digestive organ cancers (5.5%), lymphoid, hematopoietic, and related tissue cancers (7.1%), other male genital organs (3.7%), and lung and intrathoracic organ cancers (2.4%, Table 1). Other cancers made up 14.0% of the diagnoses. Some non-reproductive cancers were more common in males than in females; other digestive organs than colon 62.2% vs 37.8% respectively, (p = .011).

Nearly two-thirds of the participant (57.7%) did not have metastatic cancer, 23.2% had local/regional spread, while 2.4% had distant metastatic cancer. Only 0.2% had an unknown primary tumor. The average age at first diagnosis was 54.5 years, and the mean time since the first cancer diagnosis was 9.2 years. Most participants had one cancer diagnosis only, n = 1067 (81.6%), and 240 people had 2 or more consecutive cancer diagnoses (18.4%, Table 1).

Use of T&CM

Overall use of T&CM was reported by 31.2% (Table 1). Natural remedies were the most reported modality of T&CM and were reported by 18.2% (n = 238) of the participants, followed by self-help practices which was reported by 8.7% (n = 114). Provider-based T&CM modalities were used by 10.0% (n = 131) and were each (acupuncturists; traditional healers; and other complementary medicine providers) reported by 4.0% of the participants (Table 2). Female cancer survivors reported significantly more use of T&CM than male cancer survivors, 36.9% vs 25.5% (p < .001), and they were more likely to visit a T&CM provider, but not at a significant level (p = .057). However, they reported more use of self-help practices than males (p < .001).

Table 2

Types of T&CM and gender specific prevalence of use

Type of T&CM

Number of users

%

Female, n = 655

%

Male, n = 652

%

p-value

Acupuncturist

54

4,2

36

2.8

18

1.4

.012

CM provider

52

4.0

27

2.1

25

1.9

.760

Traditional Healer

52

4.0

22

1.7

30

2.3

.282

Provider-based*

131

10

76

5.8

55

4.2

.057

Natural remedies

238

18.3

130

10.0

108

8.3

.118

Self-practices**

114

8.7

92

7.1

22

1.7

< .001

*Provider-based: Total users of Acupuncturist, other Complementary Medicine Provider, and or Traditional Healer;**Self-practices = Meditation, Yoga, Qi Jong or Tai Chi. T&CM: Traditional and Complementary Medicine

Table 2: Types of T&CM and gender-specific prevalence of use

Relationship between the use of T&CM and socio-demographic factors

Users of T&CM were significantly younger than non-users, 64.0 and 66.4 years respectively (p = .011, Table 1), but only among females at a significant level when sex-specific analyses were made (p = .040, Table 3). The use of T&CM increased with the level of education among females, (p = .005), but not among males (p = .370, Table 2). There were no statistical differences in annual income (p = .0824) and living with a spouse (p = .860).

Table 3

Gender specific correlates of T&CM use among cancer survivors

 

Women, n = 655

Men, n = 652

 

T&CM, n = 242

%

No T&CM, n = 413

%

p-value

T&CM, n = 166

%

No T&CM, n = 486

%

p-value

Age

       

.040

       

.145

40–62

116

41.4

164

58.6

 

52

29.5

124

70.5

 

63 and above

126

33.6

249

66.4

 

114

23.9

362

76.1

 

Mean age (Std. Deviation)

61.78 (11.239)

65.18 (10.877)

< .001

67.15 (10.709)

67.36 (9.855)

.073

Education

       

.005

       

.370

Primary level

59

28.9

145

71.1

 

51

28.7

127

71.3

 

Secondary level

54

35.8

97

64.2

 

43

26.5

119

73.5

 

Tertiary

129

43.0

171

57.0

 

72

23.1

240

76.9

 

Income

       

.092

       

.544

Low

49

34.8

92

65.2

 

23

26.4

64

73.6

 

Medium

91

33.2

183

66.8

 

79

27.0

214

73.0

 

High

85

42.7

114

57.3

 

58

22.9

195

77.1

 

Living with a spouse/partner

       

.060

         

Yes

160

39.6

244

60.4

 

128

24.3

399

75.7

.173

No

68

31.9

145

68.1

 

33

30.6

75

69.4

 

Self-reported health

       

.033

       

.213

Good

128

33.4

255

66.6

 

86

23.8

276

76.2

 

Neither

87

39.9

131

60.1

 

71

29.1

173

70.9

 

Poor

27

50.0

27

50.0

 

9

19.6

37

80.4

 

Cancer site first diagnosis

       

0.876

       

0.954

Breast

98

37.4

164

62.6

 

-

 

-

   

Female genital organs

32

30.5

73

69.5

 

-

 

-

   

Prostate

-

 

-

   

74

25.9

212

74.1

 

Other male genital organs

-

 

-

   

14

28.6

35

71.4

 

Respiratory organs

7

38.9

11

61.1

 

2

15.4

11

84.6

 

Melanoma and skin

24

40.0

36

60.0

 

18

26.9

49

73.1

 

Colon

16

34.0

31

66.0

 

13

25.0

39

75.0

 

Other digestive organs

12

38.7

19

61.3

 

11

26.8

30

73.2

 

Hematologic*

14

37.8

23

62.2

 

11

19.6

45

80.4

 

Other cancers

39

41.1

56

58.9

 

23

26.1

65

73.9

 

Metastasis at first diagnosis

       

.0281

       

.730

No metastasis

136

36.0

242

64.0

 

100

26.6

276

73.4

 

Local/Regional

57

37.3

96

62.7

 

37

24.7

113

75.3

 

Distant

14

63.6

8

36.4

 

1

11.1

8

88.9

 

Primary tumor unknown

1

100.0

0

0.0

 

0

0.0

1

100.0

 

Time since first cancer diagnosis

       

.002

       

.703

less than a year

21

42.0

29

58.0

 

17

25.4

50

74.6

 

1–5 years

100

45.9

118

54.1

 

67

25.1

200

74.9

 

6–10 years

48

35.6

87

64.4

 

38

29.2

92

70.8

 

more than 10 years

73

29.0

179

71.0

 

44

23.4

144

76.6

 

Age at first cancer diagnosis

       

.9161

       

.335

0–20 years

4

36.4

7

63.6

 

3

15.0

17

85.0

 

21–49 years

86

38.6

137

61.4

 

36

29.8

85

70.2

 

50 years and above

125

36.4

218

63.6

 

109

25.5

318

74.5

 

Number of cancer diagnoses

       

.132

       

.303

1 diagnosis

209

38.2

338

61.8

 

137

26.3

383

73.7

 

2 and more diagnoses

33

30.6

75

69.4

 

29

22.0

103

78.0

 

Only one treatment

       

.372

       

.5891

Surgery

28

38.4

45

61.6

 

26

23.4

85

76.6

 

CT

12

40.0

18

60.0

 

7

25.6

20

74.1

 

RT

60

45.8

71

54.2

 

11

20.0

44

80.0

 

HT

3

23.1

10

76.9

 

3

42.9

4

57.1

 

Multimodal treatment

                   

Surgery and CT

88

34.8

165

65.2

.363

58

24.9

175

75.1

.804

Surgery and RT

137

38.2

222

61.8

.478

68

23.6

220

76.4

.335

Surgery and HT

70

31.1

155

68.9

.025

57

25.7

165

74.3

.928

CT and RT

122

38.4

196

61.6

.465

49

24.1

154

75.9

.602

CT and HT

52

34.0

101

66.0

.386

26

21.5

95

78.5

.266

Surgery, CT and HT

94

33.8

184

66.2

.154

67

25.1

200

74.9

.858

CT, HT and RT

7

25.0

21

75.0

.181

1

33.3

2

66.7

.5861

Surgery, HT and RT

5

25.0

15

75.0

.261

5

25.0

15

75.0

.962

Surgery, CT and RT

151

38.1

245

61.9

.437

75

23.8

240

76.2

.350

Surgery, CT, RT and HT

154

37.7

255

62.3

.629

78

24.2

244

75.8

.474

T&CM: Traditional and Complementary Medicine. *Hematologic = Lymphoid, hematopoietic, and related tissue. 1Fisher-Freeman-Halton Exact Test. CT: Chemotherapy; RT: Radiotherapy; HT: Hormonal therapy

Relationship between the use of T&CM and cancer-specific factors

T&CM was used by 37.4% of participants with breast cancer, 33.1%, in participants with melanoma, 31.9% of participants with other digestive organs other than the colon, and 30.5% among those with cancer of the female genital organs. A quarter with prostate cancer (25.9%) reported use of T&CM. There were no significant differences in overall T&CM use related to cancer sites in the sample (p = .309), but participants with only one cancer diagnosis were more likely to use T&CM than those with multiple cancer diagnoses (p = .046). We found no associations between self-reported health (p = .077), metastatic disease at first diagnosis (p = .179), time since first diagnosis (p = .072), age at first diagnosis (p = .132), having received only one type of conventional cancer treatment (p = .340) or those who received a combination of conventional treatment (see Table 2 for the various combinations).

Table 3

Gender specific correlates of T&CM use

Natural remedies were the most used T&CM modality across all cancer sites as shown in Table 4. Traditional medicine was used more than the other provider-based modalities by colon cancer patients, hematologic cancer patients, and prostate cancer patients, while acupuncture was the most visited T&CM provider among participants with melanoma and skin cancer, digestive organs other than colon, female genital organs, and lung and other respiratory organs.

Table 4

Percentage of use of different T&CM modalities by cancer site

Diagnostic group (n)

Overall T&CM

Acupuncturist

Traditional Medicine

Other CM

Natural remedies

Self-practices*

Breast (n = 262)

37.4

4.1

3.2

5.4

21.1

14.1

Melanoma and skin (n = 127)

33.1

7.2

0.8

1.6

18.1

11.0

Other digestive organs (n = 72)

31.9

5.6

2.9

2.8

22.2

5.6

Female genital organs (n = 105)

30.5

4.9

4.0

1.0

15.4

10.5

Colon (n = 99)

29.3

5.1

7.1

3.0

18.2

5.1

Lung and other resp organs (n = 31)

29.0

3.4

0

0

25.8

0

Other male genital organs (n = 49)

28.6

2.1

4.2

10.4

18.4

2.0

Hematologic** (93)

26.9

1.1

7.5

4.3

11.0

8.8

Prostate (n = 286)

25.9

3.2

5.6

3.5

16.4

3.5

Other cancers (n = 183)

33.9

4.5

2.8

6.3

19.7

13.2

*Self-practices = Meditation, Yoga, Qi Jong, or Tai Chi; **Hematologic = Lymphoid, hematopoietic, and related tissue; T&CM: Traditional and Complementary Medicine

Table 4: Percentage of use of different T&CM modalities by cancer site

Poor health, distant metastasis, and time since the first diagnosis were significantly associated with T&CM use in females (Table 3). Females 1–5 years post the first diagnosis reported the most use and those more than 10 years post first diagnosis reported the least use of T&CM (p = .002). Female participants who received a combination of surgery and radiotherapy were associated with lower use of T&CM than participants receiving other treatment combinations (p = .025). Apart from self-reported health, we found similar trends in clinical predictors among males and T&CM use. However, there were no socio-demographic or cancer-related characteristics significantly associated with T&CM use among male participants (Table 3).

Discussion

This study revealed that 31.2% of the participants reported having used T&CM in the preceding year with higher use among female participants 1–5 years post-diagnosis, with distant metastasis, and with poor self-reported health.

Comparable studies

Incidence of cancer types differs globally, as does cancer mortality [62]. Additionally, availability and access to conventional cancer treatments also vary [63]. T&CM modalities are primarily used as a supplement to conventional treatment in the West, but are used as primary treatment in some areas around the globe [63]. Thus, meaningful international cross-study comparison of clinical correlates of T&CM is hard to achieve. For valid comparability, we compare our study to studies carried out in regions with a similar health service landscape, as well as similar access to it. Universal health care exists in all Europe, with the Nordic model (publicly financed comprehensive health care systems) being used in Norway [64].

The sex differences found in this study could be due to sex differences in the psychological and physical effects of the disease and differences in treatment strategies for various reasons like gender bias (where no apparent medical reason justifies why female patients are not offered the same treatment as males [65]). For example, a recent study showed that female rectal cancer survivors were less likely to receive preoperative radiotherapy than male survivors of the same age, level of comorbidity, and tumor depth [66]. Furthermore, female survivors have been associated with greater cancer-related distress [67]. These factors could lead female survivors to seek T&CM to a higher degree than males to compensate for the differences in the treatment offers not given.

Distant metastatic disease was a predictor of T&CM use among female survivors in our study, in accordance with a German study among cancer survivors with melanoma [71], and an earlier Norwegian study that found correlations between T&CM use and metastatic disease regardless of sex [68]. These findings could suggest that survivors at an advanced stage are more willing to supplement conventional treatment and are certainly in accordance with clinical experience where patients with more aggressive disease are more open to every treatment option available to them. Survivors have indeed reported that a diagnosis of distant cancer prompted them to seek out T&CM [69]. Kristoffersen et. al found that cancer survivors who use T&CM were more likely to have metastasis than non-users, and the use was linked to the little hope of cure given by physicians among this group, as well as greater fear of dying due to their diagnosis [50]. Although distant metastases sites can have different clinical outcomes [70], poor prognoses and severe symptoms seen in some survivors has been associated with the use of T&CM [71]. Metastatic cancer can also have led to more invasive cancer treatment and left the participants with a higher burden of late and long-term effects needing attention [25].

It comes as no surprise that poor self-reported health was associated with T&CM use as the perception of health and illness are major motivations for health care utilization [72]. Poor self-reported health has been associated with use of T&CM [73, 74] and with higher utilization of health services in general [75]. This finding can also be seen akin to metastasis, in that perceived poor health opens survivors up to supplementing conventional treatment for improvement of their health. Indeed, a recent Norwegian study found that most cancer survivors using T&CM used it to increase quality of life and well-being [76].

The use of T&CM was also associated with time since diagnosis among females in our study. Female participants 1–5 years post the first cancer diagnosis (short-term survivors) were more likely to use T&CM than those less than a year (acute survivors), and more than 5 years post-diagnosis (long-term survivors). This is in accordance with a study from the U.S. that found more use of T&CM self-help practices among short-term survivors compared to acute and long-term survivors [68]. Our findings of higher T&CM use among short-term survivors are, on the other hand, both similar and discordant to earlier Norwegian studies. Risberg et al. found no correlation between time since diagnosis and T&CM use in a 1995 study [48], but found a correlation between T&CM use and survivorship above 12 months in 2002 [68]. The reason for the higher use among short-term survivors in the current study might be multifaceted. One reason might be the fact that the majority of cancer survivors report unmet physical, emotional and practical concerns post anti-cancer treatment [77], opening them up to the use of non-conventional health services. Additionally, they report a sense of abandonment after discharge [78], a loss of a safety net, and decline in interpersonal support in this phase [79]. These factors might have driven the short-term cancer survivors to use T&CM to a larger degree than acute survivors who are followed by a multidisciplinary team at varying frequencies [80] and long-term survivors who could have adapted better to their diagnoses with time [81]. Although the Norwegian cancer patient pathway entails follow-up such as rehabilitation [82] that would help attend to survivors’ concerns in this phase, a study showed that the post-treatment/rehabilitation period is assigned low priority by professionals due to acute or urgent tasks like palliative care [83]. Additionally, cancer survivorship care is not yet formalized and part of conventional health professional schools’ curricula [84]. Breast cancer survivorship care in Norway, for example, is organized by the hospital that treated the survivor for the first two years with a recommended doctor’s consultation. The third and fourth year follow-up entails telephone consultations or nurse consultations at the hospital that treated the survivor, as well as a clinical examination with a primary or tertiary physician [85]. This can be perceived as inadequate healthcare by some, more so by survivors who use T&CM as they have been associated with high-use behavior of conventional health care services [86]. This mismatch of growing concerns and a less active role of conventional health care providers might make T&CM especially attractive during this transition to life after active anti-cancer treatment. Beyond unaddressed concerns from health care providers, the short-term survivorship period poses new challenges for the survivor. Although anti-cancer treatment might be completed and successful, survivors enter an unfamiliar phase with fear of recurrence, anxiety, and treatment-related or new symptoms [79]. T&CM has therefore been used in this phase to promote health and well-being, prolong life after active treatment, and for disease prevention [78, 87].

Our findings are otherwise discordant with several previous findings regarding the relationship between cancer site and T&CM use. Throughout recent decades breast cancer has been shown to predict T&CM use [28, 30, 40, 46, 88, 89]. The lack of positive correlation between breast cancer and T&CM use among women in the current study might be due to the rather long time since the cancer diagnosis (a mean of 9.2 years) combined with a 12-month prevalence of T&CM. We cannot rule out the possibility that long-term breast cancer survivors used more T&CM than participants with other cancer sites at the time of their acute or short-term survivorship.

In this study, we found negative as well as no associations between the use of T&CM and conventional anti-cancer treatment, contrary to previous studies [46, 88]. Vapiwala et al. found that T&CM use was more likely in survivors with a history of surgery and in those with current or prior chemotherapy in acute survivors during conventional anti-cancer treatment [46], while Berretta et al. found that survivors receiving chemotherapy were more likely to use T&CM in an Italian multicenter survey [88]. The reason for this difference in findings could be twofold. The informants of the Italian survey were undergoing conventional anti-cancer treatment at the time of the survey or had received it no more than three years prior to the survey. The participants in our study were mostly long-term survivors, and therefore, the majority were unlikely to be undergoing anti-cancer treatment at the time of participation in the Tromsø 7 study. Additionally, we investigated T&CM use in the preceding 12 months, mostly long after the anti-cancer treatment took place. Berretta et al. also reported a T&CM prevalence of 48.9%, much higher than that found in our study which might have led to different associations for use.

Strengths and limitations

One of the major strengths of this study is the large study population and rather high response rate and that self-reported cancer was confirmed by a diagnosis recorded at the CRN. This eliminated recall bias in terms of the time of diagnosis, type of cancer, and treatments used. The cohort was also well-balanced with 1:1 ratio of female and male participants. As the questionnaire was linked to a wider population-based health survey, there was minimal risk of self-selection bias to disproportionately attract T&CM users to participate. The sample in the present study also reflected cancer site incidence in Norway at the time of the study [51].

The CRN has an extensive overview of patients’ therapies, but due to low completeness of administered cancer therapies [90], data on several of the treatment modalities was lacking. Thus, interpretation of treatment-related correlates of T&CM use should be with caution.

Even though the questionnaire captures the different forms of T&CM modalities like provider-based, natural remedies, and self-help practices, the questions go ahead to specify the different types, but the lists were not exhaustive. This might have led to a confusion on how to understand T&CM and led to underreported use of T&CM modalities not listed.

It is unlikely that terminally ill cancer survivors participated in this study as the study took place outside a hospital/treatment center setting, and few patients reported very poor health. Additionally, some data on metastasis was missing. Thus, the association between disease severity and the use of T&CM, or lack thereof, could be non-representative in this study.

Although the cross-sectional design highlights correlates of T&CM use, it limits inferences of causality of T&CM use among the participants. Indeed, knowledge on reasons for T&CM use would improve the interpretation of the clinical correlates of T&CM use among cancer survivors. The reader should note that few of the participants of this study were acute cancer survivors, so generalizability of these findings is affected as they apply more to short and long-term cancer survivors. Finally, even though the self-reported use of T&CM regarded use in the preceding 12 months, recall bias could still influence the participants’ answers. We reckon there would be a realistic reporting of provider-based T&CM as these modalities entail meeting the provider and could be easier to recall, but a possible underreporting of non-provider based/self-management T&CM.

Implications of the study

Our findings add to the existing literature on the use of T&CM among Norwegian cancer survivors and have clinical and research implications. We show that clinical characteristics of a cancer diagnosis may help predict T&CM use in female cancer survivors. Conventional health care providers should be more sensitive to these indicators in interactions with survivors and initiate bias-free conversations about T&CM use. Moreso as cancer survivors appreciate open communication about T&CM with their conventional health care providers [91]. This can also help ward off the use of modalities without proven safety. Further research could examine why there is an increase in T&CM use 1–5 years post-diagnosis and solutions should be applied accordingly. This would help address unmet concerns among survivors and improve cancer survivorship care. The use of T&CM and its clinical correlates identified in this study could also help guide policymakers in the further development of survivorship care programs, as well as medical education programs for professionals.

Conclusion

Our study showed that slightly more than a third of the cancer survivors reported T&CM use and that distant metastasis, 1–5 years since first diagnosis, as well as poor self-reported health were correlates of T&CM use in the female participants. These results should be interpreted in the context of Norway which has a heavily subsidized healthcare system and T&CM is paid for out-of-pocket.

Abbreviations

T&CM

Traditional and Complementary Medicine

SD

Standard Deviation

CRN

Cancer Registry of Norway REK:Regional Committee of Medical and Health Research Ethics

UiT

University of Tromsø.

Declarations

Ethics approval and consent to participate

The study has been approved by the Regional Committee for Medical and Health Research Ethics (REK 2014/940) and was conducted in accordance with the Declaration of Helsinki Ethical Principles involving human subjects. Written informed consent was obtained from all participants. This sub project was approved by the Norwegian Centre for Research Data, NSD, under the reference number 750871.

Consent for publication

Not applicable.

Availability of data and materials

The raw dataset is not available due to Norwegian privacy regulations. Applicants for any data must be prepared to conform to Norwegian privacy regulations. Access to data files can be applied for upon reasonable request at [email protected] For more information visit 

https://uit.no/research/tromsostudy/project?pid=709148.

Competing interests

The last author Agnete Egilsdatter Kristoffersen is a member of the editorial board (Associate Editors) of BMC Complementary Medicine and Therapies. None of the other authors have competing interests.

Funding

The publication charges for this article have been funded by a grant from the publication fund of UiT The Arctic University of Norway. No further funding was received.

Authors’ contributions

KN and AEK conceived the study, conducted the initial and final analyses, and drafted the initial version of the paper. TS contributed with intellectual content, gave input in how to interpret and structure the findings, reviewed subsequent versions. All authors have read and approved the final manuscript.

Acknowledgements

We thank the people of Tromsø and the Tromsø Study for giving data to this study. We also thank Akilah Stewart for her recommendations of literature in press and contextualizing existing findings.

References

  1. Cancer in Norway 2019, Cancer incidence, mortality, survival and prevalence in Norway. In. Oslo: Cancer Registry of Norway; 2020.
  2. Marzorati C, Riva S, Pravettoni G: Who is a cancer survivor? A systematic review of published definitions. Journal of Cancer Education 2017, 32(2):228–237.
  3. Santucci C, Carioli G, Bertuccio P, Malvezzi M, Pastorino U, Boffetta P, Negri E, Bosetti C, La Vecchia C: Progress in cancer mortality, incidence, and survival: a global overview. Eur J Cancer Prev 2020, 29(5):367–381.
  4. Cancer survival in England: national estimates for patients followed up to 2017. Great Britain: Office for National Statistics; 2019.
  5. Suh E, Stratton KL, Leisenring WM, Nathan PC, Ford JS, Freyer DR, McNeer JL, Stock W, Stovall M, Krull KR et al: Late mortality and chronic health conditions in long-term survivors of early-adolescent and young adult cancers: a retrospective cohort analysis from the Childhood Cancer Survivor Study. Lancet Oncol 2020, 21(3):421–435.
  6. Wang H, Liu J, Xia G, Lei S, Huang X, Huang X: Survival of pancreatic cancer patients is negatively correlated with age at diagnosis: a population-based retrospective study. Scientific reports 2020, 10(1):1–9.
  7. Litvak A, Batukbhai B, Russell SD, Tsai HL, Rosner GL, Jeter SC, Armstrong D, Emens LA, Fetting J, Wolff AC et al: Racial disparities in the rate of cardiotoxicity of HER2-targeted therapies among women with early breast cancer. Cancer 2018, 124(9):1904–1911.
  8. Kwan ML, Yao S, Lee VS, Roh JM, Zhu Q, Ergas IJ, Liu Q, Zhang Y, Kutner SE, Quesenberry CP, Jr. et al: Race/ethnicity, genetic ancestry, and breast cancer-related lymphedema in the Pathways Study. Breast Cancer Res Treat 2016, 159(1):119–129.
  9. Ye J, Shim R, Garrett SL, Daniels E: Health-related quality of life in elderly black and white patients with cancer: results from Medicare managed care population. Ethn Dis 2012, 22(3):302–307.
  10. Rossi S, Schinzari G, Basso M, Strippoli A, Dadduzio V, D'Argento E, Cassano A, Barone C: Maintenance hormonal and chemotherapy treatment in metastatic breast cancer: a systematic review. Future Oncol 2016, 12(10):1299–1307.
  11. Hudson MM, Ness KK, Gurney JG, Mulrooney DA, Chemaitilly W, Krull KR, Green DM, Armstrong GT, Nottage KA, Jones KE et al: Clinical ascertainment of health outcomes among adults treated for childhood cancer. JAMA 2013, 309(22):2371–2381.
  12. McMurray RJ, Clarke OW, Barrasso JA, Clohan DB, Epps CH, Glasson J, McQuillan R, Plows CW, Puzak MA, Orentlicher D: Gender disparities in clinical decision making. JAMA 1991, 266(4):559–562.
  13. Costa AR, Lança de Oliveira M, Cruz I, Gonçalves I, Cascalheira JF, Santos CRA: The Sex Bias of Cancer. Trends in Endocrinology & Metabolism 2020, 31(10):785–799.
  14. Stark L, Tofthagen C, Visovsky C, McMillan SC: The Symptom Experience of Patients with Cancer. J Hosp Palliat Nurs 2012, 14(1):61–70.
  15. Boehmke MM, Dickerson SS: Symptom, symptom experiences, and symptom distress encountered by women with breast cancer undergoing current treatment modalities. Cancer nursing 2005, 28(5):382–389.
  16. Pedersen B, Koktved DP, Nielsen LL: Living with side effects from cancer treatment–a challenge to target information. Scandinavian journal of caring sciences 2013, 27(3):715–723.
  17. Majeed H, Gupta V: Adverse effects of radiation therapy. StatPearls [Internet] 2021.
  18. Peeters KCMJ, Velde CJHvd, Leer JWH, Martijn H, Junggeburt JMC, Kranenbarg EK, Steup WH, Wiggers T, Rutten HJ, Marijnen CAM: Late Side Effects of Short-Course Preoperative Radiotherapy Combined With Total Mesorectal Excision for Rectal Cancer: Increased Bowel Dysfunction in Irradiated Patients—A Dutch Colorectal Cancer Group Study. Journal of Clinical Oncology 2005, 23(25):6199–6206.
  19. Treanor CJ, Donnelly M: The late effects of cancer and cancer treatment: a rapid review. The Journal of community and supportive oncology 2014, 12(4):137–148.
  20. Gegechkori N, Haines L, Lin JJ: Long-term and latent side effects of specific cancer types. Medical Clinics 2017, 101(6):1053–1073.
  21. Alemany M, Velasco R, Simó M, Bruna J: Late effects of cancer treatment: Consequences for long-term brain cancer survivors. Neuro-Oncology Practice 2021, 8(1):18–30.
  22. Kiserud CE, Dahl AA, Fosså SD: Cancer survivorship in adults. In: Psycho-Oncology. edn.: Springer; 2018: 123–143.
  23. Smith PJ, Clavarino A, Long J, Steadman KJ: Why do some cancer patients receiving chemotherapy choose to take complementary and alternative medicines and what are the risks? Asia-Pacific Journal of Clinical Oncology 2014, 10(1):1–10.
  24. Yarney J, Donkor A, Opoku SY, Yarney L, Agyeman-Duah I, Abakah AC, Asampong E: Characteristics of users and implications for the use of complementary and alternative medicine in Ghanaian cancer patients undergoing radiotherapy and chemotherapy: a cross-sectional study. BMC complementary and alternative medicine 2013, 13(1):1–9.
  25. Kristoffersen AE, Mora D, Nilsen JV, Bjelland M, Weider B, Nordberg JH, Broderstad AR, Nakandi K, Stub T: Use of Complementary and alternative Medicine (CAM) for late and long-term effects of cancer diagnosis and treatment. In. In Press; 2022.
  26. Gureje O, Nortje G, Makanjuola V, Oladeji BD, Seedat S, Jenkins R: The role of global traditional and complementary systems of medicine in the treatment of mental health disorders. The Lancet Psychiatry 2015, 2(2):168–177.
  27. Wiesener S, Falkenberg T, Hegyi G, Hok J, Roberti di Sarsina P, Fonnebo V: Legal status and regulation of complementary and alternative medicine in Europe. Forsch Komplementmed 2012, 19 Suppl 2:29–36.
  28. Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S: Use of complementary and alternative medicine in cancer patients: a European survey. Annals of oncology 2005, 16(4):655–663.
  29. Wode K, Henriksson R, Sharp L, Stoltenberg A, Nordberg JH: Cancer patients’ use of complementary and alternative medicine in Sweden: a cross-sectional study. BMC complementary and alternative medicine 2019, 19(1):62.
  30. Puskulluoglu M, Uchańska B, Tomaszewski KA, Zygulska AL, Zielińska P, Grela-Wojewoda A: Use of complementary and alternative medicine among Polish cancer patients. Nowotwory Journal of Oncology 2021, 71(5):274–281.
  31. Strömgren AS, Groenvold M, Pedersen L, Olsen AK, Spile M, Sjøgren P: Does the medical record cover the symptoms experienced by cancer patients receiving palliative care? A comparison of the record and patient self-rating. Journal of pain and symptom management 2001, 21(3):189–196.
  32. Kakai H, Maskarinec G, Shumay DM, Tatsumura Y, Tasaki K: Ethnic differences in choices of health information by cancer patients using complementary and alternative medicine: an exploratory study with correspondence analysis. Social Science & Medicine 2003, 56(4):851–862.
  33. Erku DA: Complementary and Alternative Medicine Use and Its Association with Quality of Life among Cancer Patients Receiving Chemotherapy in Ethiopia: A Cross-Sectional Study. Evidence-Based Complementary and Alternative Medicine 2016, 2016:2809875.
  34. Farooqui M, Hassali M, Knight A, Shafie A, Farooqui M, Saleem F, Haq U: The use of Energy Medicines (EM), Manipulative Body Based Therapies (MBBT), therapies from Whole Medical Systems (WMS) and Health Related Quality of Life (HRQoL) of cancer patients. Altern Integr Med 2013, 2:121.
  35. Mwaka AD, Abbo C, Kinengyere AA: Traditional and Complementary Medicine Use Among Adult Cancer Patients Undergoing Conventional Treatment in Sub-Saharan Africa: A Scoping Review on the Use, Safety and Risks. Cancer management and research 2020, 12:3699.
  36. Teng L, Jin K, He K, Bian C, Chen W, Fu K, Zhu T, Jin Z: Use of complementary and alternative medicine by cancer patients at Zhejiang University Teaching Hospital, Zhuji Hospital, China. African Journal of Traditional, Complementary and Alternative Medicines 2010, 7(4).
  37. Luo Q, Asher GN: Complementary and alternative medicine use at a comprehensive cancer center. Integrative cancer therapies 2017, 16(1):104–109.
  38. Buckner C, Lafrenie R, Dénommée J, Caswell J, Want D: Complementary and alternative medicine use in patients before and after a cancer diagnosis. Current Oncology 2018, 25(4):e275.
  39. Sohl SJ, Weaver KE, Birdee G, Kent EE, Danhauer SC, Hamilton AS: Characteristics associated with the use of complementary health approaches among long-term cancer survivors. Supportive Care in Cancer 2014, 22(4):927–936.
  40. Kristoffersen AE, Norheim AJ, Fonnebo VM: Complementary and Alternative Medicine Use among Norwegian Cancer Survivors: Gender-Specific Prevalence and Associations for Use. Evid Based Complement Alternat Med 2013, 2013:318781.
  41. Keene MR, Heslop IM, Sabesan SS, Glass BD: Complementary and alternative medicine use in cancer: A systematic review. Complementary Therapies in Clinical Practice 2019, 35:33–47.
  42. Shin J-Y, Kim SY, Park B, Park J-H, Choi JY, Seo HG, Park J-H: Predictors of complementary and alternative medicine use in cancer care: results of a nationwide multicenter survey in Korea. Evidence-based complementary and alternative medicine: eCAM 2012, 2012:212386–212386.
  43. Kasprzycka K, Kurzawa M, Kucharz M, Godawska M, Oleksa M, Stawowy M, Slupinska-Borowka K, Sznek W, Gisterek I, Boratyn-Nowicka A: Complementary and Alternative Medicine Use in Hospitalized Cancer Patients—Study from Silesia, Poland. International Journal of Environmental Research and Public Health 2022, 19(3):1600.
  44. Jang A, Kang D-H, Kim DU: Complementary and alternative medicine use and its association with emotional status and quality of life in patients with a solid tumor: a cross-sectional study. The Journal of Alternative and Complementary Medicine 2017, 23(5):362–369.
  45. Klafke N, Eliott J, Wittert G, Olver I: Prevalence and predictors of complementary and alternative medicine (CAM) use by men in Australian cancer outpatient services. Annals of Oncology 2012, 23(6):1571–1578.
  46. Vapiwala N, Mick R, Hampshire MK, Metz JM, DeNittis AS: Patient initiation of complementary and alternative medical therapies (CAM) following cancer diagnosis. The Cancer Journal 2006, 12(6):467–474.
  47. Hammersen F, Pursche T, Fischer D, Katalinic A, Waldmann A: Use of complementary and alternative medicine among young patients with breast cancer. Breast Care 2020, 15(2):163–170.
  48. Risberg T, Wist E, Kaasa S, Lund E, Norum J: Spiritual healing among Norwegian hospitalised cancer patients and patients' religious needs and preferences of pastoral services. European Journal of Cancer 1996, 32(2):274–281.
  49. Risberg T, Kolstad A, Cassileth BR: Use of alternative medicine among Norwegian cancer patients is associated with mental distress-A follow-up study. Acta Oncologica 2002, 41(7–8):646–651.
  50. Kristoffersen AE, Fønnebø V, Norheim AJ: Do cancer patients with a poor prognosis use complementary and alternative medicine more often than others? The Journal of Alternative and Complementary Medicine 2009, 15(1):35–40.
  51. Cancer Registry of Norway. Cancer in Norway 2016 - Cancer incidence, mortality, survival and prevalence in Norway. In. Oslo; 2017.
  52. Hanssen B, Grimsgaard S, Launso L, Fonnebo V, Falkenberg T, Rasmussen NK: Use of complementary and alternative medicine in the Scandinavian countries. Scand J Prim Health Care 2005, 23(1):57–62.
  53. Hansen-Krone IJ, Braekkan SK, Enga KF, Wilsgaard T, Hansen JB: Alcohol consumption, types of alcoholic beverages and risk of venous thromboembolism - the Tromso Study. Thromb Haemost 2011, 106(2):272–278.
  54. Jacobsen BK, Eggen AE, Mathiesen EB, Wilsgaard T, Njølstad I: Cohort profile: the Tromso Study. Int J Epidemiol 2012, 41(4):961–967.
  55. Bakken K, Melhus M, Lund E: Use of hypnotics in Sami and non-Sami populations in northern Norway. Int J Circumpolar Health 2006, 65(3):261–270.
  56. About the Cancer Registry [https://. Accessed 15 January 2022.]
  57. Larsen IK, Småstuen M, Johannesen TB, Langmark F, Parkin DM, Bray F, Møller B: Data quality at the Cancer Registry of Norway: an overview of comparability, completeness, validity and timeliness. European journal of cancer 2009, 45(7):1218–1231.
  58. Electronic List of Variables In Systems - Surgery [https://metadata.kreftregisteret.no/variables/detail/5?tabIndex=4. Accessed 21 October 2021.]
  59. Electronic List of Variables In Systems - Chemotherapy [https://metadata.kreftregisteret.no/variables/detail/114?tabIndex=4. Accessed 21 October 2021.]
  60. Electoronic List of Variables In Systems - Radiotherapy [https://metadata.kreftregisteret.no/variables/detail/112?tabIndex=4. Accessed 21 October 2021.]
  61. Electronic List of Variables In Systems - Hormone Therapy [https://metadata.kreftregisteret.no/variables/detail/113?tabIndex=4. Accessed 21 October 2021.]
  62. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F: Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians 2021, 71(3):209–249.
  63. Hill J, Mills C, Li Q, Smith JS: Prevalence of traditional, complementary, and alternative medicine use by cancer patients in low income and lower-middle income countries. Global public health 2019, 14(3):418–430.
  64. Magnussen J, Vrangbaek K, Saltman R: EBOOK: Nordic Health Care Systems: Recent Reforms and Current Policy Challenges: McGraw-Hill Education (UK); 2009.
  65. Hamberg K: Gender bias in medicine. Women’s health 2008, 4(3):237–243.
  66. Sarasqueta C, Zunzunegui M, Enríquez Navascues JM, Querejeta A, Placer C, Perales A, Gonzalez N, Aguirre U, Baré M, Escobar A: Gender differences in stage at diagnosis and preoperative radiotherapy in patients with rectal cancer. Bmc Cancer 2020, 20(1):1–11.
  67. Giese-Davis J, Waller A, Carlson LE, Groff S, Zhong L, Neri E, Bachor SM, Adamyk-Simpson J, Rancourt KM, Dunlop B: Screening for distress, the 6th vital sign: common problems in cancer outpatients over one year in usual care: associations with marital status, sex, and age. BMC cancer 2012, 12(1):1–12.
  68. Risberg T, Vickers A, Bremnes R, Wist E, Kaasa S, Cassileth B: Does use of alternative medicine predict survival from cancer? European Journal of Cancer 2003, 39(3):372–377.
  69. van Dongen SI, De Nooijer K, Cramm JM, Francke AL, Oldenmenger WH, Korfage IJ, Witkamp FE, Stoevelaar R, van der Heide A, Rietjens JA: Self-management of patients with advanced cancer: A systematic review of experiences and attitudes. Palliative medicine 2020, 34(2):160–178.
  70. Wu SG, Li H, Tang LY, Sun JY, Zhang WW, Li FY, Chen YX, He ZY: The effect of distant metastases sites on survival in de novo stage-IV breast cancer: A SEER database analysis. Tumour Biol 2017, 39(6):1010428317705082.
  71. Lövgren M, Wilde-Larsson B, Hök J, Leveälahti H, Tishelman C: Push or pull? Relationships between lung cancer patients' perceptions of quality of care and use of complementary and alternative medicine. Eur J Oncol Nurs 2011, 15(4):311–317.
  72. Vedsted P, Fink P, Sørensen HT, Olesen F: Physical, mental and social factors associated with frequent attendance in Danish general practice. A population-based cross-sectional study. Soc Sci Med 2004, 59(4):813–823.
  73. Fjær EL, Landet ER, McNamara CL, Eikemo TA: The use of complementary and alternative medicine (CAM) in Europe. BMC Complementary Medicine and Therapies 2020, 20:1–9.
  74. Steinsbekk A, Adams J, Sibbritt D, Johnsen R: Complementary and alternative medicine practitioner consultations among those who have or have had cancer in a Norwegian total population (Nord-Trøndelag Health Study): prevalence, socio-demographics and health perceptions. In. [Oxford, England]: [Burlington, Mass.] :; 2010: 346–351.
  75. Blumenthal KJ, Chang Y, Ferris TG, Spirt JC, Vogeli C, Wagle N, Metlay JP: Using a self-reported global health measure to identify patients at high risk for future healthcare utilization. Journal of general internal medicine 2017, 32(8):877–882.
  76. Kristoffersen AE, Nilsen JV, Stub T, Nordberg JH, Wider B, Mora D, Nakandi K, Bjelland M: Use of Complementary and Alternative Medicine in the context of cancer. Prevalence, reasons for use, disclosure, information received, risks and benefits among people with cancer in Norway IN PRESS.
  77. Rechis R, Beckjord E, Nutt S, Hayes-Lattin B: Survivors' perspectives on cancer: Results from a LIVESTRONG survey. Journal of Clinical Oncology 2011, 29(15_suppl):9089–9089.
  78. Evans M, Shaw A, Sharp D, Thompson E, Falk S, Turton P, Thompson T: Men with cancer: is their use of complementary and alternative medicine a response to needs unmet by conventional care? Eur J Cancer Care (Engl) 2007, 16(6):517–525.
  79. Stanton AL: What happens now? Psychosocial care for cancer survivors after medical treatment completion. Journal of Clinical Oncology 2012, 30(11):1215–1220.
  80. Selby P, Popescu R, Lawler M, Butcher H, Costa A: The Value and Future Developments of Multidisciplinary Team Cancer Care. American Society of Clinical Oncology Educational Book 2019(39):332–340.
  81. Cubi-Molla P, Mott DJ, Shah K, Herdman M, Summers Y, Tsuchiya C, Devlin N: PCN382-quality of life in long-term cancer survivors: Implications for future health technology assessments in oncology. Value in Health 2018, 21:S79.
  82. Pakkeforløp for kreft [https://www.helsenorge.no/sykdom/kreft/pakkeforlop-for-kreft/]
  83. Lie NEK, Solvang PK, Hauken MA: “A limited focus on cancer rehabilitation”—A qualitative study of the experiences from Norwegian Cancer Coordinators in Primary Health Care. Eur J Cancer Care (Engl) 2019, 28(4):e13030.
  84. Council NR: From cancer patient to cancer survivor: lost in transition: National Academies Press; 2005.
  85. Nasjonalt handlingsprogram med retningslinjer for diagnostikk, behandling og oppfølging av pasienter med brystkreft. In., vol. IS-3034. http://www.helsedirektoratet.no/retningslinjer, Accessed 08 April 2022: Helsedirektoratet, Avdeling spesialisthelsetjenester (The Norwegian Directorate of Health, Department of specialist health services); 2022.
  86. Nakandi K, Mora DC, Stub T, Kristoffersen AE: Conventional health care service utilization among cancer survivors that visit traditional and complementary providers in the Tromsø study: a cross-sectional study. BMC Health Services Research 2022.
  87. Campo RA, Leniek KL, Gaylord-Scott N, Faurot KR, Smith S, Asher G, Porterfield D, Gaylord SA: Weathering the seasons of cancer survivorship: mind-body therapy use and reported reasons and outcomes by stages of cancer survivorship. Supportive care in cancer 2016, 24(9):3783–3791.
  88. Berretta M, Della Pepa C, Tralongo P, Fulvi A, Martellotta F, Lleshi A, Nasti G, Fisichella R, Romano C, De Divitiis C et al: Use of Complementary and Alternative Medicine (CAM) in cancer patients: An Italian multicenter survey. Oncotarget 2017, 8(15):24401–24414.
  89. Sewitch MJ, Yaffe M, Maisonneuve J, Prchal J, Ciampi A: Use of Complementary and Alternative Medicine by Cancer Patients at a Montreal Hospital. Integrative Cancer Therapies 2011, 10(4):305–311.
  90. Årsrapport 2019 med resultater og forbedringstiltak fra Nasjonalt kvalitetsregister for lungekreft. In. Oslo: Kreftregisteret; 2020.
  91. Salamonsen A: Doctor–patient communication and cancer patients’ choice of alternative therapies as supplement or alternative to conventional care. Scandinavian journal of caring sciences 2013, 27(1):70–76.

Tables

Table 1: Prevalence and correlates of T&CM use 

 
Total, n=1307
%
T&CM, n=408
%
No T&CM, n=899
%
p-value
Sex 
 
 
 
 
 
 
<.001
Females
655
50.1
242
36.9
413
63.1
 
Males
652
49.9
166
25.5
486
74.5
 
 
 
 
 
 
 
 
 
 Age
 
 




.001
40 - 62
456
 34.9
168
36.8
288
63.2

63 and above
851
65.1
240
28.2
611
71.8

Mean age (SD)
65.61 (10.742)
63.97 (11.325)
66.36 (10.388)
 .011
 
 
 
 
 
Education
 
 




.406
Primary level
382
29.2
110
28.8
272
71.2

Secondary level
313
23.9
97
31.0
216
69.0

Tertiary
612
46.8
201
32.8
411
67.2
 
 
 
 
 
 
 
 
 
Income
 
 




.824
Low
228
18.3
72
31.6
156
68.4

Medium
567
45.5
170
30.0
397
70.0

High
452
36.2
143
31.6
309
68.4
 
 
 
 
 
 
 
 
 
Living with a spouse/partner
 
 
 
 
 
 
 
Yes
931
74.4
288
30.9
643
69.1
.860
No
321
25.6 
101
31.5
220
68.5
 
 
 
 
 
 
 
 
 
Self-reported health
 
 




.077
Good
745
57.0
214
28.7
531
71.3

Neither
462
35.3
158
34.2
304
65.8

Poor
100
7.7
36
36.0
64
64.0
 
 
 
 
 
 
 
 
 
Cancer site first diagnosis
 
 




0.309
Breast
262
20.0
98
37.4
164
62.6

Female genital organs
105
8.0
32
30.5
73
69.5

Prostate
286
21.9
74
25.9
212
74.1

Other male genital organs
49
3.7
14
28.6
35
71.4

Respiratory organs
31
2.4
9
29.0
22
71.0

Melanoma and skin
127
9.7
42
33.1
85
66.9

Colon
99
7.6
29
29.3
70
70.7

Other digestive organs
72
5.5
23
31.9
49
68.1

Hematologic*
93
7.1
25
26.9
68
73.1

Other cancers
183
14.0
62
33.9
121
66.1
 
 
 
 
 
 
 
 
 
Metastasis at 1st diagnosis!
 
 

 

 
.179
No metastasis
754
57.7
236
31.3
518
68.7

Local/Regional
303
23.2
94
31.0
209
69.0

Distant
31
2.4
15
48.4
16
51.6

Primary tumor unknown
2
.2
1
50.0
1
50.0
 
 
 
 
 
 
 
 
 
 Time since first cancer diagnosis
 
 




.072
less than a year
117
9.0
38
32.5
79
67.5

1-5 years
485
37.1
167
34.4
318
65.6

6-10 years
265
20.3
86
32.5
179
67.5

more than 10 years
440
33.7
117
26.6
323
73.4
 
Mean time since first cancer diagnosis
9.20 (9.299)
8.57 (9.489)
9.49 (9.202)
.098
 
 
 
 
 
 
 
 
Age at first cancer diagnosis
 
 




.132
0-20 years
31
2,7
7
22.6
24
77.4

21-49 years
344
30,0
122
35.5
222
64.5

50 years and above
770
67,2
234
30.4
536
69.6
 
Mean age
54.53 (14.467)
53.86 (13.813)
54.84 (14.759)
.143
 
 
 
 
 
 
 
 
Number of cancer diagnoses
 
 
 
 
 
 
.046
1 diagnosis
1067
81.6
346
32.4
721
67.6
 
2 and more diagnoses
240
18.4
62
25.8
178
74.2

 
 
 
 
 
 
 
 
Only one treatment!
 
 




.340
Surgery
184
14.1
54
29.3
130
70.7

 CT
57
4.4
19
33.3
38
66.7

 RT
186
14.2
71
38.2
115
61.8

 HT
20
1.5
6
30.0
14
70.0

 
 
 
 
 
 
 
 
 Multimodal treatment!
 
 

 

 
 
Surgery and CT 
486
37.2
146
30.0
340
70.0
.480
Surgery and RT
647
49.5
205
31.7
442
68.3
.718
Surgery and HT
447
34.2
127
28.4
320
71.6
.115
CT and RT
521
39.9
171
32.8
350
67.2
.308
CT and HT
274
21.0
78
28.5
196
71.5
.269
Surgery, CT and HT
545
41.7
161
29.5
384
70.5
.269
CT, HT and RT
31
2.4
8
25.8
23
74.2
.511
Surgery, HT and RT
40
3.1
10
25.0
30
75.0
.389
Surgery, CT and RT
711
54.4
226
31.8
485
68.2
.627
Surgery, CT, RT and HT
731
55.9
232
31.7
499
68.3
.647

* Lymphoid, hematopoietic, and related tissue; !n is not equal to 1307 due to missing data; CT: Chemotherapy; RT: Radiotherapy; HT: Hormone therapy 

 

 

Table 2: Types of T&CM and gender specific prevalence of use 

Type of T&CM
Number of users
%
Female, n=655
%
Male, n=652
%
p-value
Acupuncturist 
54
4,2
36
2.8
18
1.4
.012
CM provider
52
4.0
27
2.1
25
1.9
.760
Traditional Healer
52
4.0
22
1.7
30
2.3
.282
Provider-based*
131
10
76
5.8
55
4.2
.057
Natural remedies
238
18.3
130
10.0
108
8.3
.118
Self-practices**
114
8.7
92
7.1
22
1.7
<.001

*Provider-based: Total users of Acupuncturist, other Complementary Medicine Provider, and or Traditional Healer;**Self-practices = Meditation, Yoga, Qi Jong or Tai Chi. T&CM: Traditional and Complementary Medicine

 

Table 3: Gender specific correlates of T&CM use among cancer survivors

 
Women, n=655
Men, n=652

T&CM, n= 242
%
No T&CM, n=413
%
p-value
T&CM, n=166
%
No T&CM, n=486
%
p-value
 Age




.040




.145
40 - 62
116
41.4
164
58.6

52
29.5
124
70.5

63 and above
126
33.6
249
66.4

114
23.9
362
76.1

Mean age (Std. Deviation)
61.78 (11.239)
65.18 (10.877)
<.001
67.15 (10.709)
67.36 (9.855)
.073
 
 
 
 
 
 
 
Education




.005




.370
Primary level
59
28.9
145
71.1

51
28.7
127
71.3

Secondary level
54
35.8
97
64.2

43
26.5
119
73.5

Tertiary
129
43.0
171
57.0

72
23.1
240
76.9

 
 
 
 
 
 
 
 
 
 
 
Income




.092




.544
Low
49
34.8
92
65.2

23
26.4
64
73.6

Medium
91
33.2
183
66.8

79
27.0
214
73.0

High
85
42.7
114
57.3

58
22.9
195
77.1

 
 
 
 
 
 
 
 
 
 
 
Living with a spouse/partner
 
 
 
 
.060
 
 
 
 
 
Yes
160
39.6
244
60.4

128
24.3
399
75.7
.173
No
68
31.9
145
68.1

33
30.6
75
69.4

 
 
 
 
 
 
 
 
 
 
 
Self-reported health




.033




.213
Good
128
33.4
255
66.6

86
23.8
276
76.2

Neither
87
39.9
131
60.1

71
29.1
173
70.9

Poor
27
50.0
27
50.0

9
19.6
37
80.4

 
 
 
 
 
 
 
 
 
 
 
Cancer site first diagnosis




0.876




0.954
Breast
98
37.4
164
62.6

-

-


Female genital organs
32
30.5
73
69.5

-

-


Prostate
-

-


74
25.9
212
74.1

Other male genital organs
-

-


14
28.6
35
71.4

Respiratory organs
7
38.9
11
61.1

2
15.4
11
84.6

Melanoma and skin
24
40.0
36
60.0

18
26.9
49
73.1

Colon
16
34.0
31
66.0

13
25.0
39
75.0

Other digestive organs
12
38.7
19
61.3

11
26.8
30
73.2

Hematologic*
14
37.8
23
62.2

11
19.6
45
80.4

Other cancers
39
41.1
56
58.9

23
26.1
65
73.9

 
 
 
 
 
 
 
 
 
 
 
Metastasis at first diagnosis




.0281




.730
No metastasis
136
36.0
242
64.0

100
26.6
276
73.4

Local/Regional
57
37.3
96
62.7

37
24.7
113
75.3

Distant
14
63.6
8
36.4

1
11.1
8
88.9

Primary tumor unknown
1
100.0
0
0.0

0
0.0
1
100.0

 
 
 
 
 
 
 
 
 
 
 
 Time since first cancer diagnosis




.002




.703
less than a year
21
42.0
29
58.0

17
25.4
50
74.6

1-5 years
100
45.9
118
54.1

67
25.1
200
74.9

6-10 years
48
35.6
87
64.4

38
29.2
92
70.8

more than 10 years
73
29.0
179
71.0

44
23.4
144
76.6

 
 
 
 
 
 
 
 
 
 
 
Age at first cancer diagnosis 




.9161




.335
0-20 years
4
36.4
7
63.6

3
15.0
17
85.0

21-49 years
86
38.6
137
61.4

36
29.8
85
70.2

50 years and above
125
36.4
218
63.6

109
25.5
318
74.5

 
 
 
 
 
 
 
 
 
 
 
Number of cancer diagnoses
 
 
 
 
.132
 
 
 
 
.303
1 diagnosis
209
38.2
338
61.8
 
137
26.3
383
73.7
 
2 and more diagnoses
33
30.6
75
69.4

29
22.0
103
78.0

 
 
 
 
 
 
 
 
 
 
 
Only one treatment




.372




.5891
Surgery
28
38.4
45
61.6

26
23.4
85
76.6

CT
12
40.0
18
60.0

7
25.6
20
74.1

 RT
60
45.8
71
54.2

11
20.0
44
80.0

 HT
3
23.1
10
76.9

3
42.9
4
57.1

 
 
 
 
 
 
 
 
 
 
 
 Multimodal treatment










Surgery and CT 
88
34.8
165
65.2
.363
58
24.9
175
75.1
.804
Surgery and RT
137
38.2
222
61.8
.478
68
23.6
220
76.4
.335
Surgery and HT
70
31.1
155
68.9
.025
57
25.7
165
74.3
.928
CT and RT
122
38.4
196
61.6
.465
49
24.1
154
75.9
.602
CT and HT
52
34.0
101
66.0
.386
26
21.5
95
78.5
.266
Surgery, CT and HT
94
33.8
184
66.2
.154
67
25.1
200
74.9
.858
CT, HT and RT
7
25.0
21
75.0
.181
1
33.3
2
66.7
.5861
Surgery, HT and RT
5
25.0
15
75.0
.261
5
25.0
15
75.0
.962
Surgery, CT and RT
151
38.1
245
61.9
.437
75
23.8
240
76.2
.350
Surgery, CT, RT and HT
154
37.7
255
62.3
.629
78
24.2
244
75.8
.474

T&CM: Traditional and Complementary Medicine. *Hematologic=Lymphoid, hematopoietic, and related tissue.  1Fisher-Freeman-Halton Exact Test. CT: Chemotherapy; RT: Radiotherapy; HT: Hormonal therapy

 

Table 4: Percentage of use of different T&CM modalities by cancer site

Diagnostic group (n)
Overall T&CM
Acupuncturist
Traditional Medicine
Other CM
Natural remedies
Self-practices*
Breast (n=262)
37.4
4.1
3.2
5.4
21.1
14.1
Melanoma and skin (n=127)
33.1
7.2
0.8
1.6
18.1
11.0
Other digestive organs (n=72)
31.9
5.6
2.9
2.8
22.2
5.6
Female genital organs (n=105)
30.5
4.9
4.0
1.0
15.4
10.5
Colon (n=99)
29.3
5.1
7.1
3.0
18.2
5.1
Lung and other resp organs (n=31)
29.0
3.4
0
0
25.8
0
Other male genital organs (n=49)
28.6
2.1
4.2
10.4
18.4
2.0
Hematologic** (93)
26.9
1.1
7.5
4.3
11.0
8.8
Prostate (n=286)
25.9
3.2
5.6
3.5
16.4
3.5
Other cancers (n=183)
33.9
4.5
2.8
6.3
19.7
13.2

*Self-practices = Meditation, Yoga, Qi Jong, or Tai Chi; **Hematologic=Lymphoid, hematopoietic, and related tissue; T&CM: Traditional and Complementary Medicine