Fifteen respondents representing 15.3% had been diagnosed with cancer of the head and neck region, breast cancer constituted 21.4%, cancers of the abdomen/pelvic organs (mainly cervix, rectum, stomach and prostate) comprised 52%, and others; 11.3%. Five respondents (5.1%), received only chemotherapy, 16(16.3%), received both chemotherapy and radiotherapy, whilst 77 (78.6%) had radiotherapy only. 0ver 95% of patients were diagnosed of cancer within the past 24 months of the study. Sixty eight percent of respondents were treated with curative intent, whilst 22% were treated with palliative intent; the intention to treat was not available in 10% of cases examined.
Among CAM users, 62.7% noted not abandoning conventional treatment for CAM. Majority (83.3%) of the CAM users did not inform their doctors about the CAM they were using or had used in the past.
Reported side effects include gastric upsets, nausea, itching, headaches, diarrhoea, and stomach aches. Others are dizziness, unpleasant smell, water retention, loss of appetite, and bleeding.
Tables and depict details of univariate and logistic regression analysis respectively performed on the data derived from the questionnaire.
Contingency table of Patient characteristics and CAM use
Results of logistic regression for the model
Elements of what is referred to as CAM in contemporary literature are part of the lifestyle of Ghanaians and West Africans, and have been practised since antiquity. This is very different from what is reported in the literature from Europe and North America. Whether there is concurrent use of CAM and modern medicine in cancer patients, and its consequences are not documented in our environment. In this study we sought to establish whether there is concurrent use of CAM and main stream medicine, prevalence of CAM use in cancer patients, the kinds of CAM used, the potential influence of CAM use on compliance to treatment, side effects of CAM, and predictors of CAM use in a setting where there is a changing paradigm to disease causation.
Participants were approached and invited to participate in the completion of the questionnaire instead of using mailed questionnaire, none of the patients invited to participate in the study declined (response rate of 100%) . In mailed questionnaire, non CAM users are likely not to respond, thus introducing bias, to that extent, our method is advantageous.
The study was carried out in Korle Bu Teaching Hospital which provides tertiary services and therefore has a good mix of rural and urban clientele, drawn from all over the country but with majority from the south.
While some studies included only a single disease site, quite a number also involved multiple disease sites like ours and were not restricted to a particular CAM [13
We found that 73.5% of cancer patients used CAM for various reasons. This figure is close to the reported prevalence of CAM use in the general Ghanaian population of 70%, most patients are therefore CAM users even before diagnosis and do not stop the practice because they are undergoing anti cancer treatment. CAM is used both for prevention, maintenance and curative purpose [3
]. For instance it is believed that most diseases are caused by accumulation of mucus in the body, any treatment or concoction that removes mucus like laxatives is considered to have medicinal potential according to CAM practitioners. It is not uncommon to hear advocates of CAM use advertising this feature even to healthy individuals and encouraging its use to promote and maintain health. A study reported no difference in CAM use between cancer patients and non cancer patients, this is however not consistent with other studies [14
In a review of 26 surveys from 13 countries carried out from 1977 to 1998, prevalence of CAM use in cancer patients was 31.4% with a range of 7% to 64% [17
], more recent studies have reported 70.2% and 83.3% [15
]. This may be a reflection of the instrument used, the definition of CAM and the sample size, nevertheless our reported figure falls within this range, the only difference is that in our setting, cancer patients have not resorted to its use only because of the diagnosis.
The most frequently used CAM types reported is a reflection of the perception of disease causation. A recent study on the causes of chronic disease including cancer in Ghana reported seven causes as follows; poor diets, poor lifestyle practices, heredity, physical factors, the environment, spiritual factors and psychological factors. In view of this, within an individual, there is often a conflict between the legitimized orthodox medicine and the often frowned upon local medicine since these ideas are well ingrained [4
]. It is therefore not surprising that patients continue to use CAM in addition to orthodox medicine.
Massage, herbalism, vitamins, chinese medicine and prayers are the most subscribed CAM. This is not too different from studies carried out elsewhere, except that Massage and Spiritual Practice(Prayers) ranked high, compared to other cultural settings, but this is similar to the picture from Nigeria probably because of similarities in culture [13
], the only deviation with respect to other reports in Africa is the high usage of Chinese Medicine in Ghana. Chinese medicine, Vitamins and Rituals witnessed the greatest increase in usage after the diagnosis of cancer. The least used CAM like osteopathy, reflexology and electromagnetic touch, may be a reflection of availability rather than preference for the others [16
In Ghana, most conventional therapies are out of pocket payments similar to CAM, insurance cover or affordability may therefore not necessarily be a predictive factor. There is however a wide range in the cost of most CAM, ranging from very expensive to free. Resort to CAM use may be the only choice available when the cost of conventional therapy is high relative to the choice of a particular CAM that is available to the patient.
Some patients used CAM because they wanted to just try anything (31.2%); this is a reflection of doubt in the efficacy of conventional treatment. Majority of patients in the developing world including Ghana are diagnosed at a stage when most conventional therapies fail; this is a result of the absence of screening and educational programmes, as well as paradigm to disease causation, others also recur after varying periods of remission and majority become incurable with conventional therapies. In a study among newly diagnosed breast cancer patients, the causes of delayed presentation were: previous medical consultations 26(29.4%), ignorance 19(28.8%), fear of mastectomy 16(24.2%), herbal treatment 13(19.7%), prayer/prayer camps 13(19.7%) and financial incapability 12(18.2%). Fear of mastectomy 20(57.1%), herbal treatment 13(37.1%), financial incapability 11(31.4%) and prayers/prayer camps 10(28.6%) which were prominent causes of late presentation, were the main reasons for absconding [9
]. A vicious cycle of late presentation emanating from paradigm to disease causation leading to diminished chances of cure and therefore reduced belief in the efficacy of conventional therapies ensues and increases subscription to CAM.
Whilst 40.6% of CAM users actually believed that CAM fights the cancer, majority used it to improve their quality of life by relieving symptoms caused by the cancer or conventional therapy(23.2%), relax or sleep(17.4%), for improvement in the emotional and physical well being (14.5%) and wound healing(4.3%). This finding is similar to that found in United States where patients resorted to CAM to improve their quality of life, boost the immune system and relieve symptoms [15
] but is at variance with what is reported by patients from Nigeria, United Kingdom and Turkey where users expected CAM to directly cure their disease [13
Positive results have been reported for some forms of CAM, for instance, acupuncture has been shown to relieve chemotherapy induced nausea and vomiting [21
], self-hypnosis, massage or acupuncture induce pain relief [22
], short term improvement in psychological well being with aromatherapy massage and relief of dyspnoea with acupuncture, acupressure or relaxation/breathing techniques [23
Non users cited lack of belief in the efficacy of CAM, others were discouraged by previous users reflecting a negative experience with the use of CAM.
The reported side effects may be a result of the biological activity of the active ingredients in ingested CAM [24
] or pesticide, fungal and bacterial contamination [25
]. There may be use of incorrect plant species [26
], absence of standardisation (leading to possible substitution, adulteration, incorrect dosing or preparation and inappropriate labelling or advertising) [27
]. Some herbal preparations have toxic effects (kava causes hepatotoxicity), interact with prescription drugs (St John Wort), or cause surgical complications (garlic, ginko and ginseng may enhance bleeding and ginseng causes hypoglycaemia) [27
Pelvic radiation causes inflammation of the bowel (enteritis and proctitis) in itself, additional gastrointestinal toxicity arising from any of the factors listed is likely to exacerbate diarrhoea and abdominal cramps.
In a study carried out in Ghana, 52.9% clients of traditional medicine and 75% orthodox medicine users claimed that the use of traditional medicine is not safe as compared to orthodox medicine, but only 17.1% and 5% of traditional medicines users and orthodox medicine users respectively described traditional medicine usage as remarkably safe and totally out of harm’s way [29
The observation that 83.3% of CAM users had not informed their doctors about CAM use is troubling because of the issues associated with concurrent use as described including the negative effect of supplemental anti oxidant and vitamin administration during radiotherapy and chemotherapy [12
] and the detrimental effect of vitamin E and Selinium as demonstrated in the SELECT study [30
]. In a systematic review comprising 21 studies, 11% to 95% admitted CAM use, however between 20% and 77% of users did not disclose their CAM use to their Oncologist. Reasons cited include; doctors lack of enquiry, patients anticipation of doctors disapproval, disinterest, or inability to help, and patients perception that disclosure of CAM use is irrelevant to their conventional care [31
Predictors of CAM use in our setting are gender and intention to treat on univariate analysis (table ). Women and patients treated with palliative intent are more likely to use CAM, with p values of 0.004 and 0.032 respectively. Age, marital status, level of education and tumour site were not statistically significant. Our finding in relation to intention to treat is in agreement with those of Molassiotis et al., who reported greater use in patients treated with palliative intent or patients treated for cancers with poorer prognosis [16
]. Kritoffersen et al. also reported higher prevalence of CAM use among cancer patients with poorer prognosis, other studies have reported otherwise [32
Even in an environment of high CAM usage by the general population, gender continued to be significant on multivariate analysis (p=0.01) (table ). Tumour site was also seen to be a significant factor affecting the use of CAM with a p-value of 0.028. It can be said that, those married are 29.5% more likely to use CAM than singles. Males are 86.8% less likely to use CAM than females. Similarly, a year increase in age reduces the use of CAM by 3.7%. In other words younger people have a higher tendency to use CAM. At the educational level, those with basic, secondary and tertiary education are 1.8%, 73.4% and 59.6% less likely to use CAM than the uneducated. As one moves from secondary to tertiary level of education, there is an increase in CAM usage but those with basic education have a higher usage of CAM. Tumours at the abdominal/pelvic, head and neck and thoracic areas are 84.9%, 95.4% and 75.8% respectively less likely than tumours at other parts of the body to use CAM, particularly head and neck patients are less likely to use CAM, this is probably due to the difficulty such patients have with swallowing. These findings are in agreement with most studies [13
Media and friends constitute the greatest source of information on CAM. In spite of the fact that radio coverage in Ghana is almost hundred percent, its content with respect to traditional medicine is hardly regulated, with vendors making unsubstantiated claims that potentially influences patient behaviour and preference. The preparations on the market usually lack labels, and do not report side effects, dosing is usually verbal. In a recent publication, buyers were admonished to beware of the potential for ingested CAM to cause side effects or hinder the efficacy of conventional therapies [33
]. Even though there is an attempt at regulation by the Traditional Medical Council, it does not go far enough. The Mampong Center for Research into Plant Medicine seeks to apply scientific protocols to the practice of traditional medicine.
Our study is limited by the rather low number of participants, non-probability sampling method used, and the fact that it was performed in a single institution. Additionally it is hospital based, there may be cancer patients who are CAM users but do not attend hospital at all, their responses especially in respect of reasons for subscription to CAM will be interesting. Nevertheless, it provides valuable insight into the behaviour of cancer patients with respect to CAM use in an environment where there is high patronage for CAM in the general population.