Introduction
The term ‘complementary and alternative medicine’ encompasses a wide range of health-related therapies which are often considered to be outside mainstream biomedical practice.1 There is ample evidence to suggest that complementary and alternative medicine use in Westernised society has increased steadily, particularly over the last 15 years. Population-based surveys have provided estimates of increased use and demand for complementary and alternative medicine products in the United Kingdom and the United States.1–Reference Eisenberg, Davis, Ettner, Appel, Wilkey and Van Rompay3 This trend is particularly obvious in the field of cancer and palliation.Reference Chatwin and Tovey4
There is very little literature available on usage of complementary and alternative medicine in patients attending head and neck oncology clinics.Reference Talmi, Yakirevitch, Migirov, Horowitz, Bedrin and Simon5 This is despite complementary and alternative medicine being described as an integral part of palliative care of head and neck cancer.Reference Talmi, Yakirevitch, Migirov, Horowitz, Bedrin and Simon5
The aim of this study was to identify the prevalence and usage pattern of complementary and alternative medicine used by a consecutive sample of patients attending the head and neck clinic of a teaching hospital in north-east Scotland.
Patients and methods
A total of 200 consecutive patients attending the Aberdeen Royal Infirmary head and neck clinic between October and December 2005 were invited to participate in the study. Patients less than 16 years of age and non-English-speaking patients were excluded. The selected patients were provided with a questionnaire, along with an information sheet detailing the authors' study.
The questionnaire was similar to those used in previous surveys. It included a tick list of 48 common herbal preparations and alternative therapies. It also contained items on age, sex, marital status, level of education, reason for use, opinion on complementary and alternative medicine efficacy, and whether the patient's general practitioner knew of their complementary and alternative medicine use. The patient's reason for attendance at the clinic was recorded from their medical record.
Statistical analysis
Data were collected using Microsoft Excel software and analysed using the Statistical Package for the Social Sciences version 13.0 for Windows software. Descriptive statistics were used to explore ‘ever vs never’ use of complementary and alternative medicine by demographic parameters, including age, sex, marital status and education. Education level was classified as university or college, school qualification only, or less than completion of high school level. Chi-square tests were used, and a p value of <0.05 was considered statistically significant.
Results
Sample characteristics
The questionnaire was distributed to 200 patients over the eight-week study period. Of these patients, 138 completed the questionnaire fully and could be included in the study. Patients' reasons for attendance at the head and neck clinic are documented in Table I. Of the 138 respondents, 84 (61 per cent) were male and 54 (39 per cent) were female (Table II). Seventy-five per cent of patients (103/138) were older than 50 years, 62 per cent (86/138) were married and 42 per cent (58/138) had not completed high school education (Table II).
Table I Patients' reasons for head & neck clinic attendance
Ca = cancer; post-op = post-operative patient
Table II Patient demographics
Y = years
Use of complementary and alternative medicine
A total of 69 patients (50 per cent) had previously used complementary or alternative therapies. Thirty-five patients (26 per cent) had used them in the previous year.
Ten out of these 69 patients (14 per cent) had used complementary or alternative medicine for the same reason as that cited for attendance at the head and neck clinic.
Complementary and alternative therapies were conventionally split into herbal and non-herbal categories. Respondents' usage is shown in Tables III and IV. The most common reasons for individual complementary and alternative medicine usage are documented in the third column of these Tables.
Table III Use of herbal products by CAM users
*Most commonly cited reason for use. CAM = complementary and alternative medicine; PMT = pre-menstrual tension; UTI = urinary tract infection
Table IV Use of non-herbal therapies by CAM users
*Most commonly cited reason for use. CAM = complementary and alternative medicine
The most popular herbal therapies used were cod liver oil (30/69 patients), primrose oil (16/69), cranberry (12/69), garlic (14/69), echinacea (9/69), aloe vera (8/69) and St John's wort (6/69).
The most popular non-herbal complementary and alternative therapies used were massage (15/69 patients), acupuncture (12/69), chiropractic (10/69), homeopathy (10/69), reflexology (9/69), reiki (9/69) and aromatherapy (8/69).
Forty-one patients (59 per cent) out of the 69 users of complementary and alternative therapies stated that such therapies were effective and that they would recommend them to others.
Information about the complementary and alternative medicine used was obtained most commonly from friends (38 patients; 55 per cent). Twenty patients (29 per cent) had obtained information from the media, and 18 (26 per cent) had obtained information from a healthcare professional.
Forty-five patients (65 per cent) obtained their complementary and alternative therapies from a high street store. Only eight patients (11 per cent) received their complementary and alternative therapy from their general practitioner.
Thirty-four patients (50 per cent) stated that their family physician was unaware of their usage of complementary and alternative medicine.
Statistical analysis of the sample characteristics of the ‘ever users’ of complementary and alternative medicine was carried out. The results are shown in Table V. The statistically significant patient characteristics which indicated an increased chance of complementary and alternative medicine use were female gender, age greater than 60 years and a university education.
Table V Patients' characteristics by CAM use
*n = 67 (48.6%); †n = 71 (51.4%); ‡n = 138. CAM = complementary and alternative medicine; y = years; sep = separated
Discussion
Many people with cancer use complementary therapies in order to help support themselves through the illness and its treatment. A large number of these people find complementary and alternative medicines helpful in a number of ways, particularly with regards to feelings of positivity about their illness and themselves. This benefit can lead to better coping with the complex and distressing emotions that cancer can provoke.
The current report represents the first British study to assess use of complementary and alternative medicines amongst patients attending a head and neck oncology clinic. We found that 50 per cent of patients attending the head and neck clinic of a regional teaching hospital had used complementary and alternative medicine at some stage, and that 26 per cent had used it in the preceding 12 months. Complementary and alternative medicine users were statistically more likely to be female, younger and better educated. Women were also more likely to consume multiple products. Studies of the general population have found that older age groups and those with higher income are more likely to use complementary and alternative medicine therapies.1 However, a survey of 1523 patients attending a general practice in north-east Scotland found a decreasing trend of complementary and alternative medicine use with increasing age, although female sex, higher income and higher level of education were associated with current and lifetime (i.e. ‘ever’) complementary and alternative medicine use.Reference Featherstone, Godden, Gault, Emslie and Took-Zozaya6, Reference Ross, Simpson and McLay7
There are methodological factors to consider when interpreting our study results. Firstly, our sample comprised a series of consecutive patients attending a major teaching hospital out-patient clinic serving the Grampian region (population 500 000). Only one Scottish region was included; therefore, extending the survey to include other surgical centres would have improved the generalisability of findings. We broadly categorised therapies as herbal or non-herbal, although some herbal products can be considered homeopathic if used within diluted preparations. We asked about complementary and alternative medicine usage in the previous year, but did not assess usage in the weeks before head and neck clinic attendance. However, our category of ‘ever’ usage of complementary and alternative medicine was comparable with other studies' assessment of lifetime use.Reference Featherstone, Godden, Gault, Emslie and Took-Zozaya6, Reference Tessier and Bash8 The questionnaire was self-administered; therefore, only limited information on patients' reasons for using particularly therapies was obtained. While an interview technique would have allowed further exploration of beliefs regarding efficacy and of patient's reasons for consumption, such a methodology is impractical for large-scale epidemiological surveys.
Sampling differences and variation in measurement methods will account for some of the observed variation in rates of complementary and alternative medicine utility across different populations.
Comparing complementary and alternative medicine ever-use in our sample with that of the general population reveals that complementary and alternative therapy usage rates in our population appeared to be markedly lower (50 per cent) than estimates from patients attending general practice (71 per cent).Reference Featherstone, Godden, Gault, Emslie and Took-Zozaya6 This was surprising, but may be partly explained by the fact that many patients attending the oncology clinic were of lower socio-economic status and therefore statistically less likely to use complementary and alternative medicine.1
We found that herbal medicines were most commonly used for general health care and disease prevention. Other remedies included cranberry to treat and prevent urinary tract infections, primrose oil for post-menopausal symptoms, aloe vera for healthy skin, echinacea for upper respiratory tract infections, ginseng and herbal vitamin supplements to boost energy, and St John's wort for depression.
The increase in use of herbal complementary and alternative medicines has important implications for surgery. The risks of herbal medication use and their interaction with synthetic drugs have been well reported, as has been the importance of detailed history-taking and advice to discontinue certain products in order to prevent adverse reactions.Reference Tessier and Bash8–Reference Ang-Lee, Moss and Yuan10 Some herbal preparations, particularly garlic, ginseng, ginkgo and St John's wort (Hypericum perforatum), are known to interact with synthetic drugs, such as digoxin and warfarin.Reference Izzo and Ernst9 Systematic reviews of the published evidence on the safety of herbal products have reported the serious clinical consequences arising from direct, pharmacodynamic and pharmacokinetic effects.Reference Izzo and Ernst9, Reference Ang-Lee, Moss and Yuan10 Anti-coagulation effects are the most widely reported; excessive use of garlic, Gingko biloba and ginseng can alter bleeding time and increase the risk of intra-operative haemorrhage. Gingko biloba, kava and echinacea can interact with barbiturates, used freely in anaesthetics, and may cause increased sedation. Long-term use of ephedra and ginseng can cause hypertension.Reference Tessier and Bash8
Given that certain complementary and alternative therapies can interact with conventional medications, it is important that healthcare providers know of their patients' use of such therapies. Only 50 per cent of our sample had informed their general practitioner of their complementary and alternative medicine use. Patients often consider alternative and conventional medicines as separate and distinct remedies, and fail to recognise that non-conventional therapies may have adverse effects. Many products are believed to be ‘natural’ and therefore inherently safe and less toxic than conventional medication.Reference Chatwin and Tovey4 Doctors inevitably enquire about prescribed medicines taken by patients, but asking about complementary and alternative medicine usage is extremely uncommon. Patients very uncommonly state complementary and alternative medicine usage freely, and some may even be embarrassed to declare their use of non-mainstream therapies.
When testing the questionnaire for our pilot study, we initially asked ‘do you use complementary or alternative medicine?’, whereupon the majority of patients answered in the negative. When the same patients were then shown a list of such products which the authors had compiled, they answered ‘yes’, and were unaware that certain products were classified as complementary and alternative medicine.
Sixty per cent of respondents who used complementary and alternative medicines thought them effective, and a similar figure stated that they would recommend use of such therapies to others. Most respondents had learned about complementary and alternative medicine from family and friends, with only a small percentage seeking information from healthcare professionals (26 per cent). The key issue here is safety, efficacy and interaction with conventional medication. Although the Internet is an extremely popular means of obtaining health information, being low cost, convenient and continually accessible, the health information obtained is often of poor quality. We believe that patients should report complementary and alternative medicine use to general practitioners and hospital staff; however, there is evidence that healthcare providers lack knowledge of the effects and associated risks of herbal products. A Canadian study assessed knowledge of nine commonly used herbal remedies amongst 28 anaesthetists; they found that only one third of questions were correctly answered, and that most respondents admitted to guessing at the correct answer.Reference Ross, Simpson and McLay7
Recent analysis of Scottish prescribing data for 2003–2004, covering 1.9 million patients from 323 general practices, found that 60 per cent of Scottish surgeries prescribed homeopathic or herbal remedies. This analysis also revealed that 4 per cent of patients were being prescribed herbal remedies along with conventional medicines that were well known to interact with herbal treatment.Reference Ross, Simpson and McLay7
• In the UK, there are 50 000 practitioners of complementary and alternative medicine
• The aim of this study was to explore the use of this practice in patients attending a head and neck oncology clinic in Aberdeen, Scotland
• Questionnaires were provided to 200 patients over an eight-week period. The questionnaire addressed demographic parameters, a list of 48 herbal preparations and alternative therapies, and respondents' reasons for use and opinions on efficacy
• All medical practitioners should be aware of increasing complementary and alternative medicine usage by the population, and should be able to counsel patients appropriately
It is essential that both patients and healthcare professionals have access to accurate and reliable information. In the United States, this issue has been addressed by the establishment of the National Centre for Complementary and Alternative Medicine.1
There is very little legislation to restrict practice of complementary and alternative medicine in the United Kingdom, despite the longstanding climate of patient protection which currently pervades every aspect of the National Health Service. Studies have highlighted the need for regulation in order to ensure quality of care and mechanisms to protect against potentially dangerous interactions.Reference Walker and Budd11
This study highlights the need for an increased awareness by otolaryngologists, and indeed all healthcare practitioners, of the increasing role of complementary and alternative medicine. We all have a responsibility to learn more about complementary and alternative medicine and its potential interactions. There should be more thorough documentation of complementary and alternative medicine usage by health professionals at all levels, and patients should have the opportunity both to inform us of such usage and to seek information when required.
