Baseline Demographic Information
A total of 510 questionnaires were sent to the cancer patients, and 448 questionnaires were valid for final analysis, others were excluded due to the incompleteness filling. The majority of cancer patients (373/448, 83.3%) had used CAM at least one time, and the others (75/448, 16.7%) were non-CAM users.
All of the demographic and diagnosis information is presented in Table 1. For the CAM users, the average age was 63.7 years (SD, 9.5), with more woman (59.8%) participated. Most of the patients (68.4%) completed high school, and 20.6% graduated from college or university. The mean disease duration time was 41.4 months (SD, 25.8). More than half of the CAM users were at clinical stage I (55.5%) and ECOG-PS score 1 (59.8%). Lung cancer (74.5%) was the most common cancer, followed by colorectal (10.5%) and stomach (5.6%).
Table 1 Characteristics of Cancer Patients (N = 448).
Variable
|
CAM Users
(n = 373)
|
Non-CAM Users
(n = 75)
|
P-value
|
Age, years, mean ± SD
|
63.7 ± 9.5
|
58.9 ± 11.4
|
0.006
|
Sex, n (%)
|
|
|
0.857
|
Male
|
150 (40.2)
|
31 (41.3)
|
|
Female
|
223 (59.8)
|
44 (58.7)
|
|
Education, n (%)
|
|
|
0.003
|
Primary school
|
41 (11.0)
|
13 (17.3)
|
|
High school
|
255 (68.4)
|
57 (76.0)
|
|
College or university
|
77 (20.6)
|
5 (6.7)
|
|
Annual household income, $, n (%)
|
|
|
0.109
|
< 12 000
|
60 (16.1)
|
17 (22.7)
|
|
12 000 - 18 000
|
202 (54.2)
|
40 (53.3)
|
|
18 000 - 30 000
|
81 (21.7)
|
16 (21.3)
|
|
30 000 - 45 000
|
21 (5.6)
|
2 (2.7)
|
|
45 000 - 15 000
|
6 (1.6)
|
0 (0.0)
|
|
>150 000
|
3 (0.8)
|
0 (0.0)
|
|
Health insurance, n (%)
|
|
|
< 0.001
|
National medical card
|
305 (81.8)
|
39 (52.0)
|
|
Non-national medical card
|
68 (18.2)
|
36 (48.0)
|
|
Disease duration, months, mean ± SD
|
41.4 ± 25.8
|
34.2 ± 15.6
|
0.015
|
Cancer stage, n (%)
|
|
|
0.455
|
Stage I
|
207 (55.5)
|
33 (44.0)
|
|
Stage II
|
56 (15.0)
|
22 (29.3)
|
|
Stage III
|
51 (13.7)
|
14 (18.7)
|
|
Stage IV
|
59 (15.8)
|
6 (8.0)
|
|
Table 1 (continued).
Variable
|
CAM Users
(n = 373)
|
Non-CAM Users
(n = 75)
|
P-value
|
ECOG - PS score
|
|
|
0.072
|
0
|
118 (31.6)
|
33 (44.0)
|
|
1
|
223 (59.8)
|
36 (48.0)
|
|
2
|
30 (8.0)
|
4 (5.3)
|
|
3
|
2 (0.5)
|
2 (2.7)
|
|
Cancer type, n (%)
|
|
|
0.469
|
Lung
|
278 (74.5)
|
60 (16.1)
|
|
Colorectal
|
39 (10.5)
|
5 (1.3)
|
|
Stomach
|
21 (5.6)
|
1 (0.3)
|
|
Liver
|
14 (3.8)
|
4 (1.1)
|
|
Breast
|
11 (2.9)
|
3 (0.8)
|
|
Ovary
|
9 (2.4)
|
1 (0.3)
|
|
Cervix
|
5 (1.3)
|
1 (0.3)
|
|
Kidney
|
5 (1.3)
|
0 (0)
|
|
Esophagus
|
3 (0.8)
|
1 (0.3)
|
|
Pancreas
|
3 (0.8)
|
0 (0.0)
|
|
Bladder
|
3 (0.8)
|
0 (0.0)
|
|
Prostate
|
2 (0.5)
|
0 (0.0)
|
|
Other
|
6 (1.6)
|
3 (0.8)
|
|
Abbreviations: CAM: complementary and alternative medicine; ECOG: Eastern Cooperative Oncology Group; PS: performance status; SD: Standard deviation.
Among the non-CAM users, four did not believe in CAM, 39 did not know enough about CAM, 14 had no interest, seven were concerned about the cost, seven reported CAM was declined by their oncologists and 16 felt very difficult to take CAM therapies. More than half of the non-CAM users (68.0%) reported would like to try CAM therapy in the future.
By multivariable logistic regression analyses, CAM users were predicted only by national health insurance (odds ratio [OR] = 3.47, 95% CI = 2.00 - 5.99), which is provided in Table 2.
Table 2 Multivariable Analysis of Factors Predictive of Patients’ CAM Use (N = 448).
Predictor
|
Received CAM Treatment
|
Odds Ratio
|
95% CI
|
P-value
|
Age (≥ 65 vs < 65 years)
|
1.61
|
0.94 - 2.76
|
0.082
|
Sex (female vs male)
|
1.22
|
0.71 - 2.10
|
0.469
|
Education (primary and high school vs college and university)
|
2.64
|
0.96 - 7.30
|
0.061
|
Annual household income (≥ 30000 vs < 30 000)
|
1.65
|
0.34 - 8.11
|
0.539
|
Health insurance (national medical card vs non-national medical card)
|
3.47
|
2.00 - 5.99
|
< 0.001
|
Disease duration (≥ 40 vs < 40 months)
|
1.38
|
0.79 - 2.43
|
0.264
|
ECOG - PS score (0 - 1 vs 2 - 3)
|
1.28
|
0.49 - 3.38
|
0.612
|
Abbreviations: CAM: complementary and alternative medicine; CI: confidence interval; ECOG: Eastern Cooperative Oncology Group; PS: performance status.
Perception
Cancer patients’ perception in CAM treatments and medical pattern is presented in Table 3. Half of the cancer patients (51.2%) presented that they had received adequate information in CAM cancer treatments. Sixty-eight patients (18.2%) thought CAM would cause negative effects and 33 patients (8.8%) had once experienced any side effects. Among those patients, the most frequent side effect events were stomachache (30.3%) and abnormal liver function (30.3%), followed by lack of appetite (12.1%) and diarrhea (12.1%). For medical pattern, most of patients believed medical appointment (40.2%) and online medical service (27.6%) might be widely implemented in the future. However, most of the patients could not predict when CAM oncology clinic recover.
Table 3 Perceptions of the cancer patients who used CAM (N = 373).
Questions
|
N (%)
|
- Have you received adequate information in CAM cancer treatment?
|
|
Yes
|
191 (51.2)
|
No
|
182 (48.8)
|
- Do you think CAM therapies would cause negative effects?
|
|
Yes
|
68 (18.2)
|
No
|
305 (81.8)
|
- Do you experience any negative effects from CAM?
|
|
Yes
|
33 (8.8)
|
No
|
340 (91.2)
|
- Which of the following negative effect/effects caused by CAM have you ever experienced?
|
|
Abnormal liver function
|
10 (30.3)
|
Stomachache
|
10 (30.3)
|
Lack of appetite
|
4 (12.1)
|
Diarrhea
|
4 (12.1)
|
Myelosuppression
|
3 (9.1)
|
Fatigue
|
3 (9.1)
|
Table 3 (continued).
Questions
|
N (%)
|
- Which of the following negative effect/effects caused by CAM have you ever experienced? (continued).
|
|
Nausea/vomiting
|
1 (3.0)
|
Constipation
|
1 (3.0)
|
Cardiac arrhythmias
|
1 (3.0)
|
Other
|
2 (6.1)
|
- After the epidemic of COVID-19, do you think there will be any changes in the pattern of CAM oncology clinic in future?
|
|
Medical appointment
|
150 (40.2)
|
Online medical service
|
103 (27.6)
|
Home visit
|
49 (13.1)
|
No change
|
82 (22.0)
|
I don't know
|
102 (27.3)
|
Other
|
1 (0.3)
|
- Once the COVID-19 is under control, how long do you predict the CAM oncology clinic will recover to normal?
|
|
Regard the current pattern as normal during the COVID-19 pandemic
|
109 (29.2)
|
1-3 months
|
23 (6.2)
|
4-6 months
|
8 (2.1)
|
7-8 months
|
1 (0.3)
|
9-12 months
|
14 (3.8)
|
More than 12 months
|
47 (12.6)
|
No longer back to normal
|
22 (5.9)
|
Not clear
|
149 (39.9)
|
Abbreviations: CAM: complementary and alternative medicine; COVID-19: coronavirus disease 2019.
Attitudes
A Likert scale is used to present the attitudes of cancer patients towards CAM and medical pattern after the epidemic of COVID-19 (Fig. 1). After witnessed the better efficacy of CAM in treating COVID-19 [13], 296 cancer patients (79.4%) had full of confidence in CAM which would be also effective in treating cancer and 262 cancer patients (70.2%) showed a strong desire to learn more about CAM in the future. For medical pattern, nearly half of the cancer patients (44.0%) thought their oncology clinics had been greatly affected due to the COVID-19. However, when they faced to the online medical service pattern, strongly promoted by the government and hospitals to provide convenient medical services, most of the cancer patients (82.8%) refused. Nevertheless, the same as online service, online appointment seemed to receive more favor (55.0%) and might have broad application prospect in the future.
Clinical practice
All the questions listed in Table 4 are about the clinical practice of the cancer patients in CAM. Chinese herbal medicine was widely used in cancer patients before (89.5%) / after (90.3%) the epidemic of COVID-19, followed by proprietary Chinese medicine before (20.4%) / after (21.2%) the epidemic of COVID-19. The utilization rate of acupuncture and moxibustion therapy was slightly declined from 3.2% to 2.4%. The main purpose of receiving CAM therapy was to improve immune system (71.8%) and prevent recurrence and metastasis after surgery (61.1%). Comparing to the time before the epidemic of COVID-19, the frequency of patients’ visiting the clinic decreased significantly. Despite the challenges of COVID-19, most patients didn’t change their CAM oncologists/therapists (74.0%) or follow-up pattern (90.0%).
Table 4 Clinical practice of the cancer patients who used CAM (N = 373).
Questions
|
Before COVID-19,N(%)
|
Since COVID-19, N(%)
|
P-value
|
- Which kinds of CAM cancer treatment did you use?
|
|
|
0.668
|
Chinese herbal medicine
|
334 (89.5)
|
337 (90.3)
|
|
Proprietary Chinese medicine
|
76 (20.4)
|
79 (21.2)
|
|
Acupuncture and moxibustion therapy
|
12 (3.2)
|
9 (2.4)
|
|
Diet-based therapy
|
8 (2.1)
|
8 (2.1)
|
|
Chi gong
|
6 (1.6)
|
9 (2.4)
|
|
Massage therapy
|
0 (0.0)
|
0 (0.0)
|
|
Tai chi
|
3 (0.8)
|
4 (1.1)
|
|
Other
|
1 (0.3)
|
1 (0.3)
|
|
- What was your purpose of using CAM?
|
|
|
0.732
|
Prevent recurrence and metastasis after surgery
|
231 (61.9)
|
228 (61.1)
|
|
Improve immune system
|
260 (69.7)
|
268 (71.8)
|
|
Manage symptoms
|
100 (26.8)
|
108 (29.0)
|
|
Increase the effect of conventional treatment
|
52 (13.9)
|
58 (15.5)
|
|
Improve quality of life
|
42 (11.3)
|
46 (12.3)
|
|
Not clear
|
6 (1.6)
|
2 (0.5)
|
|
- How often did you come to the CAM oncology clinic?
|
|
|
< 0.001
|
Once a week
|
2 (0.5)
|
2 (0.5)
|
|
Twice a week
|
250 (67.0)
|
192 (51.5)
|
|
Thrice a week
|
18 (4.8)
|
27 (7.2)
|
|
Table 4 (continued).
Questions
|
Before COVID-19,N(%)
|
Since COVID-19, N(%)
|
P-value
|
3. How often did you come to the CAM oncology clinic? (continued).
|
|
|
|
Once a month
|
85 (22.8)
|
123 (33.0)
|
|
Twice a month
|
7 (1.9)
|
17 (4.6)
|
|
Thrice a month
|
4 (1.1)
|
4 (1.1)
|
|
Once half a year
|
7 (1.9)
|
8 (2.1)
|
|
- Since the epidemic of COVID-19, have you ever changed your CAM oncologist/therapist?*
|
|
|
-
|
No, I have never changed
|
-
|
276 (74.0)
|
|
Basically, but I have once changed
|
-
|
37 (9.9)
|
|
Yes, I have changed
|
-
|
44 (11.8)
|
|
I haven't a specified oncologist/therapist
|
-
|
15 (4.0)
|
|
Other
|
-
|
1 (0.3)
|
|
- Since the epidemic of COVID-19, how about the cost of the CAM cancer treatment?*
|
|
52 (13.9)
|
|
Increased
|
-
|
15 (4.0)
|
|
Decreased
|
-
|
151 (40.5)
|
|
No change
|
-
|
155 (41.6)
|
|
I don't know
|
-
|
|
|
- Since the epidemic of COVID-19, have you changed the follow-up pattern?*
|
|
|
-
|
Yes
|
-
|
34 (9.1)
|
|
No
|
-
|
339 (90.9)
|
|
Table 4 (continued).
Questions
|
Before COVID-19,N(%)
|
Since COVID-19, N(%)
|
P-value
|
- How did you contact your physician?#
|
|
|
< 0.001
|
Hospital
|
34 (100.0)
|
32 (94.1)
|
|
Wechat
|
5 (14.7)
|
24 (70.6)
|
|
Telephone/message
|
0 (0.0)
|
12 (35.3)
|
|
Online medical service
|
2 (5.9)
|
9 (26.5)
|
|
E-mail
|
0 (0.0)
|
0 (0.0)
|
|
Other
|
0 (0.0)
|
0 (0.0)
|
|
Abbreviations: CAM: complementary and alternative medicine; COVID-19: coronavirus disease 2019.
* Only available for the time after the epidemic of COVID-19.
# Only available for those who chose YES in question 6.