Hot flashes are a bothersome symptom affecting hundreds of thousands of breast cancer survivors. In this study, we identified attitudes/beliefs, aspects of perceived behavioral control, and social norms related to the intention of using acupuncture for hot flashes. As expected from the TPB, we found that patients constructed therapeutic benefit and practical concerns in the setting of limited knowledge about acupuncture. While they rely on family and physicians for treatment information and decision support; survivors often ‘own’ the final decision. Beyond constructs in the TPB, we found that a desire for natural alternatives to medication was the main driver for survivors’ intentions to use acupuncture. The primary reason survivors would not want acupuncture for hot flashes was an appraisal that their hot flashes were not bothersome or urgent enough to be treated when they were experiencing other co-morbid conditions.
Several previous qualitative studies of factors affecting general use of CAM (rather than acupuncture specifically) among BCS39–42
have reported similar themes, such as that survivors believe that CAM therapies have minimal side effects39, 41, 42
and can be safely used to complement conventional therapies.39–42
Our study specifically found that one of the major determinants of acupuncture use among BCS was its appeal as a natural alternative. Studies also suggest that CAM is often used for managing symptoms related to cancer and its treatments and for boosting the immune system.39, 41, 42
Our study focused on hot flashes, a prevalent and bothersome symptom experienced by BCS, and revealed symptom appraisal of the severity of hot flashes to be one of the primary reasons for acupuncture use among BCS. However, to our knowledge, no qualitative studies have focused specifically on understanding the use of a single CAM modality among BCS to alleviate hot flashes. Furthermore, our study included BCS from both Caucasian and African American groups, as well as different educational backgrounds and prior CAM experience. Our approach overcomes some of the sampling limitations of previous research, such as including only CAM users,39
mostly Caucasians with higher socio-economic levels,42
or only Chinese participants.40
Given the fairly modest understanding of acupuncture and a lack of specific knowledge of acupuncture for hot flashes, an individual often relies on her family and consults her physician about the use of acupuncture for hot flashes. Compared with Caucasian women, African Americans tend to turn to their PCPs for information and decision support for symptom management. This is consistent with a previous study that found African Americans were more likely to endorse the delivery of survivorship care by PCPs.8
Our study underlines the importance for PCPs to be knowledgeable about acupuncture as well as therapeutic options for managing hot flashes in the context of survivorship so they can be well-equipped to facilitate decision making by their patients.
Although the TPB has been used to explain intentions to use CAM,37, 38
we were interested to find that it did not account for all of the factors that women described as affecting their intentions to use acupuncture. The TPB, like much of traditional health behavior theory, is based on the underlying notion of rational thought in which patients are assumed to be highly motivated to maintain or return to a universally agreed upon definition of good health.43, 44
Rational health decisions are based on maximizing benefits and minimizing losses or costs.45
For example, the TPB posits that if a woman has a positive attitude about acupuncture (attitude), has no significant barriers to obtaining acupuncture (perceived behavioral control), and has important others in her social network who advocate for using modalities such as acupuncture (subjective norms), she will likely intend to use acupuncture for symptoms such as HFs. Despite this, we found that symptom appraisal and desire for a natural remedy were important determinants as well, even though they did not fit into the TPB model. Many interventions operate under a similar premise that women will use a utilitarian model for making decisions about treating breast cancer symptoms. It is tempting to use traditional help-seeking models in research and practice because they explain much middle-class health-seeking behavior. However, these approaches treat as external to the model personal, cultural, and social factors which contribute to the meaning and experience of cancer related symptoms. We have modified the original constructs in the TPB to include symptom appraisal and a subjective appreciation for treatment properties to capture the additional elements that women utilized when making decisions about using acupuncture for HFs (see ).
Factors Linking Acupuncture with Symptoms of Hot flashes (FLASH Model)
Our study is among the first to explore demographic differences in treatment decisions related to hot flashes by breast cancer survivors. African Americans appear to be much more willing to accept the empirical evidence from historical use as a rationale for their willingness to try acupuncture. While we observed that all African American and most Caucasian patients endorsed acupuncture as a natural alternative, they arrived at this idea from different paths. Compared with Caucasians, African American women were much more likely to voice concerns about existing polypharmacy as a reason why another pill is not an option for them. At the same time, medical co-morbidities such as ongoing pain may also serve as a barrier to using acupuncture for hot flashes for African Americans. Our findings may reflect the clinical reality that African American patients are likely to have greater medical co-morbidity and often their decision of using a therapy for a condition is driven by multiple competing medical needs.
Several limitations of our study need to be acknowledged. Our sample was of limited size and drawn from an urban tertiary medical center. While these factors affect the generalizability of the findings, we did reach saturation of topics (i.e. no new themes emerged) by the twenty-fifth interview and thus feel confident that a larger sample size would not have yielded additional information. We studied decision making around intended use of acupuncture rather than actual use so the factors may not fully capture the complexity of a true clinical decision. Additionally, we conducted research from the perspectives of a primary care physician who practices integrative medicine (JJM) and a medical anthropologist (FB), thus, some degree of bias may present in our interpretation of the data. However, we often negotiated our different world views during research meetings. Finally, qualitative research seeks to identify a range of issues that are important in a group of people. It should not be used to infer causation or to quantify the magnitude of difference between groups in terms of beliefs or behaviors.
Summary and implication
As early detection and better treatments for breast cancer have decreased mortality rates, the survivorship period has become a new area of research and importance. PCPs and oncologists need a range of options for women who are experiencing distressing HFs as a result of their breast cancer treatment. The evaluation of acupuncture for hot flashes is limited and ongoing; thus the evidence base for it is limited with conflicting results.32
This raises the dilemma for physicians to recommend or recommend against acupuncture. In a situation in which there is no clear winner, incorporating patients’ perspectives may lead to more satisfied decision making and outcomes. Our study found that acupuncture may be more congruent with some women’s preferences for natural approaches to symptom management, thereby minimizing the need for additional medication. Clinicians need to understand that perceptions about the attributes of acupuncture are likely to vary according to racial group and symptom burden. In establishing the effectiveness of acupuncture in the real world, researchers must account for this variation in the acupuncture interventions that they test. As PCPs play a critical role in decision support for cancer survivors, this understanding may help facilitate patient-centered communication in assisting patients to choose therapeutic options that are acceptable and lead to symptom reduction and better quality of life.