To our knowledge, this is the first study to explore the prevalence and patterns of T&CM use among the cancer patients in Nepal. The overall prevalence of T&CM use among Nepali cancer patients was 31.6%, and among the cancer groups, the prevalence of T&CM ranged from 13.3% (hematologic cancer) to 62.3% (lung cancer). The finding was in agreement with a previous study [4], a systematic review of T&CM use in cancer patients in low-income and lower-middle-income countries.
Of all variables tested, T&CM usage was associated with various factors such as education, residence, cancer stage, and perceived disease severity, which are in line with the previous studies such as a higher level of education [29, 31–33], residing outside the urban [6], the early stage of cancer [18], and the higher perceived disease severity [18]. Interestingly, the prevalence rates of T&CM use were different based on cancer types and stages. Despite suggestions from the literature that T&CM use was significantly higher in the group with advanced diseases and recurrent diseases [34], some studies showed that tumor stage is not associated with the use of alternative therapies [28, 35]. Moreover, the present study showed that patients with advanced cancer stage used less T&CM. These results suggest that cancer stages affecting the use of T&CM are varied. These variations between studies may be explained by various causes such as the attitude of oncologists, cultural and religious beliefs, the cost of conventional treatment, and the questionnaire used to collect the data [36].
It was also interesting to see the prevalence of T&CM use in Nepal, where a wide range of modalities such as Ayurveda, Spiritual healers (Dhami-Jhankri), and self-treatment with medicinal plants, have been officially established as a part of traditional medical systems [6]. The results of this study showed that the prevalence of T&CM use (31.6%) is similar to a previous study in Germany (29.0%) [37], Turkey (33.8%) [28], and India (38.7%) [22]. However, it was lower than the prevalence reported in Italy [29], Mongolia [27], and South Korea [38]. The potential reasons for variations between the results are the heterogeneity of study designs, such as differences in definitions of T&CM [11, 13, 29], or in sampling strategies that cause selection bias [11, 39]. Another possible explanation may be that cancer patients from resource-limited countries, such as Nepal [40], may not attend cancer treatment facilities [4].
Ayurveda, as a part of T&CM, is commonly used in South Asian countries, such as Nepal and India. This is not unexpected, as many patients seek traditional medicine in Nepal and India [7]. Congruent with the results reported in India [25], nearly half of cancer patients using T&CM have taken Ayurveda. In addition, our results show that the patients with a higher perceived level of disease severity are more likely to practice Yoga/meditation and consume Honey, Ginger, and Tulsi than the group with lower perceived severity. An interesting key finding was that patients who perceived cancer as serious are more likely to use T&CM. So we further analyzed how respondents used different T&CM modalities based on their perceived level of disease severity. Unlike general preference, cancer patients with higher self-rated severity more likely to use Yoga, Meditation, Honey, Ginger, and Tulsi than the lower group. The high popularity of natural products is because many patients may believe that these modalities were safe [22, 41, 42]. However, natural products are not completely natural and safe in all cases [43]. For example, ginger, one of the widely be cultivated herbs in Nepal, may cause an increase of nausea when co-dosed with aprepitant [44, 45], therefore, caution should be taken when it is taken concurrently with conventional medicine. Furthermore, the popularity of natural honey consumption among cancer patients suggests that although the health benefits of honey on cancer are well documented [46], further research is required to examine the potential role in alleviating the causes of cancer.
Our findings are consistent with previous studies conducted in developing countries [9, 47], which showed that the most commonly reported reasons for cancer patients’ use of T&CM are due to its curative and holistic effects, beliefs in T&CM, and dissatisfaction with conventional medicine [27, 42]. Thus, patients' perception on T&CM as a cure for cancer [24, 44] is associated with a delay in seeking appropriate cancer treatment, especially in the LDCs where health resources are limited [24, 48]. Moreover, a previous study reported the risk of interactions between T&CM and conventional medicine, which may have serious clinical consequences [37]. Therefore, creating a drug interaction database could be useful for oncology clinicians for providing better patient care in developing countries [49, 50].
Considering the prevalence of T&CM use among cancer patients [13, 27] and T&CM’s potential interactions with conventional medicines [51], physician-patient communication on T&CM use is important. However, T&CM use is rarely discussed with conventional health care providers, and the conversation on its use is most likely to be initiated by the patient [52]. Moreover, including this study, their disclosure rates to their physicians were still not high, mainly grouped around the 40 ~ 50% range [13]. The reason for not disclosing their use to physicians primarily depends on how the patient perceives their physician's attitude such as oncologists’ indifference (lack of inquiry) and opposition (fear of physician’s disapproval) towards T&CM [13, 53, 54]. Additionally, the physicians may feel inadequate skills and knowledge to counsel patients on T&CM use [55]. Thus the doctor should consider patients’ cluster differences in disclosure, their attitude towards T&CM use, and gained cancer patient's confidence in the delivery of healthcare services [56].
Similar results have been reported in India [25], where the common source of T&CM information was family/friends. On the other hand, the western study showed that the media is the primary source of information followed by family and friends [29], whereas a low proportion of cancer patients obtain information on T&CM use from healthcare professionals [27, 57]. Moreover, oncology patients are more likely to continue using T&CM in the hospital setting even though they are uncertain about the efficacy and effectiveness of the non-conventional medicine use [58]. This can be a significant concern for the patients as their use is neither supported by the scientific evidence nor gained the approval from the healthcare professionals [9]. Furthermore, healthcare professionals’ lack of knowledge on T&CM may result in them responding negatively to patients’ use and queries regarding T&CM [59, 60]. Thus, it is important for oncologists to be informed about T&CM use among patients and provide appropriate care.
This study shows value in light of the following limitations and strengths. First, as we only evaluated patients who attended hospital settings, which would exclude patients who make do without conventional cancer treatment are not well represented in this study, it might reduce generalizability. Second, in terms of methodology, it is also possible that the use of the face-to-face interview could have influenced the participant's response, or there may be a recall bias for experience (e.g., discrepancies between what the patient used and remembered as T&CM). Despite these limitations, our findings call for further studies in other Hindu Kush Himalayan countries.