The Use of Complementary and Alternative Medicine by Korean Breast Cancer Women: Is It Associated with Severity of Symptoms?

Background. Use of complementary and alternative medicine (CAM) among patients with breast cancer could be associated with severity of the cancer symptoms experienced, but there is little evidence to prove this. This study tried to investigate any difference in the severity of breast cancer symptoms between CAM users and nonusers. Methods. The study followed cross-sectional design using structured survey questionnaire. Survey participants were recruited from four different healthcare settings in Seoul, South Korea. The survey instrument comprised 39 items including questions on demographics, use of CAM, and six main symptoms associated with breast cancer and cancer treatment. Results. Out of 288 participants, 67% stated using one or more modalities of CAM. Age, education, and time duration since diagnosis of cancer were significantly associated with use of CAM. About 90% of the CAM users experienced side effects of cancer treatment. CAM users reported more severe anxiety and skin/hair changes than nonusers. Conclusions. CAM was used by those breast cancer patients who experience more severe symptoms to alleviate the conditions associated with breast cancer and cancer treatment. Our findings revealed motivation behind the CAM use, which has profound implications for clinicians to recognize patient-perceived needs.


Introduction
Breast cancer is a chronic disease associated with severe physical and emotional burden [1]. Results of a five-year observational cohort study in the UK showed presence of depression, anxiety, or both in nearly 50% of the women with breast cancer [2], and pain, fatigue, anorexia, and skin changes are common over the course of the disease and its treatment [3]. For managing these cancer-associated symptoms, there are few approved standard guidelines; therefore, as compared to patients with other cancers, use of complementary and alternative medicine (CAM) is most common among breast cancer women [4]. Such increase in popularity of CAM might be due to the breast cancer patients' dissatisfaction with conventional therapies so they could integrate it with use of CAM [5]. Furthermore, research suggests that symptom management is one of the most common reasons behind CAM use among women with breast cancer [6,7]. We hypothesize that use of CAM could be associated with severity of symptoms experienced by women with breast cancer. However, no conclusive research has been conducted to establish relationship between use of CAM and severity of symptoms associated with breast cancer and its treatment [8].
A number of studies have underscored high prevalence of CAM among women with breast cancer [9][10][11][12]. The variety 2 Evidence-Based Complementary and Alternative Medicine of CAM therapies used and the factors related to CAM use have also been recognized by several researchers. A study reported that dietary supplements are the most preferred type of CAM used by women with breast cancer, while another study reported that meditation, herbs, and spiritual healing are the most commonly used modalities of CAM among such patients [13,14]. Wanchai et al. demonstrated that women with breast cancer with higher level of education, higher income level, and younger age have increased tendency to be consumers of CAM [15].
In Korea, breast cancer is the most common type of cancer among female population and the prevalence has been increasing continuously [16]. Moreover, the most recent report reveals that more than 50% of the Korean women with breast cancer experience cancer-associated anxiety and depression [17]. Few studies have focused on the use of CAM among women with breast cancer in Korea; however, they did not investigate why these women use CAM. A survey on 160 Korean women with breast cancer highlighted the CAM usage by 36% of the participants [18]. The more recent survey conducted on the breast cancer patients in Korea reported the use of CAM by 57.4% of the patients [19]. The study discussed only quality of life indicators among CAM users and nonusers [19]. To the best of our knowledge, the surveys conducted in Asian populations so far have not studied differences in the severity of symptoms associated with breast cancer and its treatment between users of CAM and nonusers. The aim of this study is to evaluate the use of CAM in the Korean women with breast cancer by investigating differences in the severity of self-reported symptoms associated with breast cancer and its treatment between users of CAM and nonusers. Additionally, the study explored CAM users' attitudes towards CAM and conventional healthcare.

2.
1. Participants. The study followed cross-sectional design to investigate the CAM use among South Korean female breast cancer survivors. Structured questionnaire was used to conduct face-to-face survey for three weeks from May 31, 2012, to June 20, 2012. The subjects were Korean female breast cancer patients aged over 18 years and were invited to participate in the study when they visited outpatient department of four hospitals located in Seoul, namely, Hanyang University Seoul Hospital, Hanyang University Guri Hospital, Cheil General Hospital and Women's Healthcare Centre, and Jeongpajong Breast and Thyroid Clinic. A total of 300 subjects were invited and all of them agreed to participate in the survey. Given that 12 participants did not complete the questionnaire, data of only 288 participants were included in the final analysis.
Ethical approval for the study was obtained from the Institutional Review Board on Human Subjects Research and Ethics Committees, Hanyang University Guri Hospital. Prior to the survey, all participants provided IRB-approved written informed consent.

Data Collection.
In order to conduct the survey in each of the facilities, four surveyors were trained. The survey questionnaire, developed in the Korean language, is comprised of a total of 39 items. Questions were asked on use of CAM, demographic characteristics, CAM users' attitudes towards conventional health care, sources of information, and severity of six self-reported symptoms, namely, pain, fatigue, depression, anorexia, skin and hair changes, and anxiety. Severity of each symptom was rated on a 6-point Likert scale from 0 to 5 (no symptom to most severe). All of the participants were asked to respond to questions on demographic characteristics, CAM use, and severity of symptoms, whereas questions related to attitudes, types of CAM, source of information, and communication were asked from CAM users only.

Statistical Analysis.
Descriptive statistics (using number and percentage) were used to describe severity of symptoms, CAM users' attitudes, types of CAM, and sources of information. Linear logistic regression analysis was created (assuming confidence interval of 95%) to see any association between participants' characteristics and use of CAM. In the regression model, we considered use of CAM as dependent variable whereas independent variables comprising age, religion, education, marital status, employment, household income, family history of cancer, diagnostic institution, method of diagnosis, and time since breast cancer were diagnosed. We selected significance level of = 0.05 for all analyses. The data were analyzed using Statistical Package for Social Sciences (SPSS) v. 18.0. Table 1 displays characteristics of 288 study subjects. In terms of characteristics, 37.2% were aged >54 years, 58.7% followed Western religions (Roman Catholic, Christian), 62.5% had education up to high school, 82.6% were married, 55.2% were unemployed, 63.2% had household income <5 million KRW, 72.9% had no family history of cancer, and 54.2% were residents of Seoul.

Utilization of CAM and Predictors.
In total, 193 (67%) participants stated utilizing one or more modalities of CAM (Table 1). Participants who were more likely to use CAM were in the age between 46 and 54 years (39.4%) and were followers of Western religions (63.7%), of higher school or lower education level (58.5%), married (84.5%), unemployed (51.3%), with household income <5 million won/month (57.5%), without family history of cancer (72%), residents of Seoul (59.1%), and with cancer diagnosed at facilities other than tertiary care hospitals (61.1%), cancer detected by screening (56.5%), and cancer diagnosed since 12-36 months (33.7%). Logistic regression analysis revealed that age, level of education, and time since diagnosis were significantly associated with use of CAM. Table 2 presents Likert scale data with full frequency distributions of the scores on severity of self-reported symptoms among CAM users and nonusers. The proportion of high severity of symptoms is relatively   higher among CAM users than among the nonusers, especially in the case of anxiety and skin/hair changes. Similarly, proportion of participants without symptoms is relatively higher among nonusers than among CAM users for all symptoms.

Discussion
This study reports the recent trend of CAM use among breast cancer survivors in South Korea. Results of our study show high prevalence of CAM utilization by 67% of the participants, which is consistent with previous studies [15,20,21]. However, this rate is slightly lower when compared to use of CAM among general population in Korea [22]. Consistent with previous studies, likely predictors of CAM use included age, level of education, and time since diagnosis of breast cancer [10,15,23]. Patterns of CAM modalities used among the study participants reflect their sociocultural background as ginseng was the most popular among nutritional therapies (53.4%), whereas the previous Korean study reported its consumption as 33.6% [19]. Overall, dietary and nutritional therapies were the most commonly consumed category of CAM, consistent with the study conducted by Fasching et al. [24]. We also found that 38.3% of the CAM users, at some point, discussed CAM use with their healthcare provider. Previous Korean studies reported this number at 20% and 29.6%, respectively [18,19]. These numbers suggest increase in disclosure of CAM use to healthcare providers in the country.
Our results show that 90% of the CAM users experienced side effects of conventional therapy for cancer, which is supported by previous studies [25,26]. The breast cancer patients used CAM to complement conventional medical treatment, which is further confirmed by our results where majority of the CAM users believed that using CAM reduces neither overall costs of care nor healthcare utilization. Thus, as our results illustrate, participants used CAM mainly to prevent progress of disease and promote health, which is similar to findings from previous studies conducted in Korea and Malaysia [19,27]. Another major reason for using CAM was to alleviate symptoms and to enhance immune systems, which is similar to previous research [10,28]. In order to see any difference between CAM users and nonusers, we compared the two groups with relation to severity of selfreported symptoms.
Based on the literature review and our clinical experience [2,3,17], we selected six symptoms for investigation: pain, fatigue, depression, anorexia, anxiety, and skin and hair changes. These symptoms can seriously affect breast cancer patients' quality of life, which they experience over the course of disease and its treatment [29,30]. Our study found significant difference in the severity of fatigue, depression, anxiety, and skin and hair changes between CAM users and nonusers. Our results imply that CAM is used by those breast cancer patients who experience more severe symptoms. Moreover, these findings are in agreement with other results of this study where symptom management is one of the major reasons for CAM use. Previous studies also show that breast cancer patients use CAM to alleviate their symptoms [28,31]. A study conducted in the UK found that breast cancer patients undergoing radiotherapy believed that CAM would mitigate their fatigue and skin changes [32]. About 54% of CAM users in our study were using yoga as complementary therapy. There is strong evidence of yoga therapy improving fatigue in breast cancer survivors [33]. Moreover, yoga therapy can also mitigate anxiety and other symptoms among breast cancer outpatients undergoing conventional radiotherapy and chemotherapy [34] whereas a study conducted in the United States established relationship between restorative yoga and self-reported emotional symptoms and fatigue among breast cancer patients [35]. More than 53% of the CAM users in our sample used ginseng, which is commonly used for symptoms associated with breast cancer in Asian countries [36].
Our study has produced important findings regarding the motivation behind use of CAM among breast cancer patients. Patients, who experienced more severe symptoms, might have wanted to alleviate them via using CAM, whereas patients with milder symptoms did not use CAM. Results of the study have significant implications for clinical oncology as there is evidence of side effects from CAM use [37]. Furthermore, results of the study may enable oncologists to identify breast cancer patients' needs and expectations which are otherwise difficult in the absence of strong evidence supporting the effectiveness of CAM use in such patients [38]. We recommend that oncologists should be aware of the extent to which breast cancer patients use CAM and reasons for its usage. Moreover, oncologists should initiate the communication with their patients especially those who experience more severe symptoms as our results show that a large number of patients do not disclose their use of CAM. Findings of our study have given more insight into the trend of using CAM among breast cancer patients. Further studies are suggested using larger samples in different settings to more investigate the relationship between CAM use and symptoms associated with breast cancer and its treatment.

Conclusions
CAM is used by breast cancer patients who experience more severe symptoms associated with breast cancer and its treatment to alleviate the symptoms. Patients' perceptions and understanding of their illness, and health benefits from CAM use, are an evolving process that may have an influence on quality of life and health behavior choices. It remains to be discovered whether this motivation behind the use of CAM is in line with true medical benefit. As new information about CAM becomes available, it will be important to develop and provide education programs for health professionals and to increase awareness among patients.