The use of complementary and alternative medicine (CAM) is becoming increasingly prevalent in both adults and children.1,2 Pediatric patients with chronic illnesses are very likely to use CAM.3–9 Recent studies have shown that the use of CAM is especially common in pediatric oncology patients, with up to 80% of the patients using CAM during the treatment of their cancer.10–20
CAM is defined as “a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.”21,22 Complementary medicine is therapy used to supplement conventional medicine, whereas alternative medicine is therapy used in place of conventional medicine.21,22 Examples of commonly used types of CAM include nutritional supplements, vitamins, herbal remedies, changes in diet, spiritual therapies, aromatherapy, acupuncture, massage therapy, and yoga.
CAM therapies have significant potential to improve the quality of life for pediatric oncology patients; however, they also have the potential to interact harmfully with current standard oncology treatments, such as chemotherapy and radiation therapy. There are very few studies documenting the effectiveness and safety of CAM in the pediatric oncology population.23 However, harmful side effects of different types of CAM have been documented in the general pediatric literature.24
Although as many as 80% of pediatric oncology patients use complementary and alternative therapies, approximately 50% of pediatric oncology patients using CAM do not discuss these therapies with their physicians.1,11,12,16 One study showed that only half of general pediatricians have discussed CAM with their patients and, when CAM was discussed, it was usually because the patient's family initiated the conversation.25 Currently, there is poor communication between pediatricians and pediatric oncologists and their patients regarding the use of CAM.25–27
There are no studies documenting pediatric oncologists' views on their patients' use of CAM. Research is needed to assess the factors that have led to the poor communication between pediatric oncology patients and their physicians regarding the use of CAM. Increased communication about CAM can potentially lead to increased trust between pediatric oncologists and their patients, increased patient adherence with therapy, fewer drug-herb interactions, and a better quality of life for patients.28
MATERIALS AND METHODS
We obtained the e-mail addresses of 358 pediatric oncologists currently practicing in the United States. E-mail addresses were found on the Internet by searching the directories of academic institutions. Subjects were e-mailed a link to an anonymous online survey. A second e-mail was sent 2 weeks later to subjects who had not responded to the initial e-mail. The study was approved by the Institutional Review Board at the Children's Hospital at Montefiore.
The questionnaire consisted of 33 questions pertaining to subjects' demographic information and their views on CAM use in their patient population. The demographic data included physician sex, years in practice, United States or foreign medical school graduate, ethnicity of physician, and practice setting. It also included patient factors such as patient ethnicity, income, and the type of insurance used. Respondents were asked about their own use of CAM, how often they estimate their patients are using specific CAM therapies, how frequently they refer patients for CAM, and the degree to which they have conversations about CAM with their patients. The survey also asked whether participants found specific CAM therapies potentially harmful or potentially beneficial, assessed the participant's comfort level discussing specific CAM therapies, and asked the participant his/her initial reaction when patients discuss CAM. In addition, the participant was asked whether it is important for the physician to know which CAM therapies his/her patients are using, why he/she believes it is important, which CAM therapies he/she would like to learn more about, and where the participant gets his/her information on CAM. Finally, 5 questions included a scenario in which a patient initiates a conversation about using CAM and the participant is asked how he/she would react in each scenario. The format of the questions included multiple choice, Likert scale, and yes-no responses.
Descriptive statistics were generated for all variables. Fisher exact tests were applied to test the relationships among physician and patient continuous variables. χ2 tests were used to test the relationship between physician and patient categorical variables with physician inquiry of CAM and referral to CAM providers.
Three hundred fifty-eight e-mails were sent to practicing pediatric oncologists. One hundred and one pediatric oncologists responded to the survey, for an overall response rate of 28%. Eleven of these pediatric oncologists completed only the demographic data and their responses were not included in the study. The demographic data for those respondents who completed only the demographic data were not significantly different from those respondents who completed the survey. Eighty-three pediatric oncologists completed the entire survey. The 7 respondents who did not complete the entire survey only answered questions regarding demographics, self-use of CAM, their patients' use of CAM, and the frequency they asked their patients about use of CAM. The data from these respondents were only included in the analysis for those questions that were answered. The data from these 7 respondents were not used when calculating associations with physician referral rates secondary to lack of data points. Demographic data collected in the survey showed that of the 90 pediatric oncologists included in the study, 59% of respondents were men, 82% described their ethnicity as white, 59% have been practicing pediatric oncology for over 10 years, and 88% of the pediatric oncologists graduated from a medical school in the United States. Ninety-two percent of respondents practice in an urban environment, 51% of respondents' patients are insured by Medicaid, and 49% have private insurance (Table 1).
Physician and Estimated Patient Use of CAM
Forty-one percent to 54% of physicians surveyed reported current or prior use of the following CAM therapies: dietary supplements, vitamins, prayer, massage therapy, and guided imagery. Fewer than 6% of physicians surveyed reported current or prior use of the following CAM therapies: enzymes, homeopathy, magnets, reiki, chiropractic, cranio-sacral therapy, and martial arts (Table 2). Greater than 40% of pediatric oncologists estimate that at least 10% to 25% of their patients are using dietary supplements, herbal medicine, special diets, vitamins, and/or prayer to supplement their cancer therapy. Fifteen percent of physicians surveyed estimate that at least half of their patients are using vitamins during their treatment. Twenty-nine percent of physicians estimate that more than a quarter of their patients are taking dietary supplements during their treatment. Greater than 25% of pediatric oncologists estimate that at least 10% to 25% of their patients are using massage therapy, guided imagery, and/or antioxidants in addition to their cancer therapy. Fifteen percent to 55% of physicians reported not knowing the percentage of their patients using the specific CAM therapies asked about in the survey. For example, 15% of physicians were unsure of what percentage of their patients were using vitamins, 20% of physicians were unsure of what percentage of their patients were using herbal medicine, and 55% of physicians were unsure of what percentage of their patients were using reiki.
Pediatric Oncologists' Communication With Their Patients Regarding CAM
Many pediatric oncologists do not routinely ask their patients a general open-ended question about their use of CAM. Forty-three percent pediatric oncologists occasionally ask their patients an open-ended question about use of CAM, and 7% of pediatric oncologists never ask their patients a general question about use of CAM (Table 3). The frequency at which pediatric oncologists asked patients about specific CAM therapies varied greatly depending on the therapy. For example, more than one third of pediatric oncologists reported specifically asking more than 50% of their patients about their use of dietary supplements, herbal medicine, special diets, and vitamins. However, more than half of pediatric oncologists reported never asking patients about their use of aromatherapy, enzymes, acupuncture, homeopathy, magnets, prayer, chiropractics, cranio-sacral therapy, massage therapy, guided imagery, martial arts, meditation, and yoga (Table 4). Oncology patients most often ask their physicians about the use of vitamins, special diet, dietary supplements, herbal medicine, and antioxidants. Forty-nine percent of pediatric oncologists state lack of time and 47% note lack of knowledge as the reasons why they do not ask their patients about CAM therapies. Eighty percent of pediatric oncologists are equally as likely to discuss CAM with patients with poor prognosis disease compared with patients who have good prognosis disease.
Pediatric Oncologists' Attitudes, Knowledge, and Comfort With CAM
Many pediatric oncologists reported that certain CAM therapies may be effective in improving quality of life for their patients. Seventy-four percent of physicians believe that massage therapy and prayer may improve the quality of life for their patients, whereas 67%, 65%, 57%, and 45% believe that meditation, guided imagery, yoga, and acupuncture, respectively, may improve the quality of life for their patients. Some pediatric oncologists also reported that certain CAM therapies may be harmful to patients. At least half of physicians surveyed responded that dietary supplements, herbal medicine, special diets, vitamins, and chiropractic may be harmful to their patients (Table 2).
Most respondents state that they are comfortable discussing many of the CAM therapies with their patients including vitamins, meditation, prayer, and yoga. Fewer pediatric oncologists are comfortable discussing therapies such as aromatherapy, enzymes, magnets, reiki, and cranio-sacral therapy (Table 2). The major reasons that pediatric oncologists are uncomfortable discussing CAM therapies included lack of knowledge on the subject (93%) and concern over potential harmful side effects of the therapy (56%). More than half of respondents obtain information on CAM from medical journals, colleagues, and/or the Internet. In addition, greater than 50% of respondents would like to learn more about dietary supplements, herbal medicine, special diets, vitamins, acupuncture, guided imagery, meditation, and yoga.
Ninety-nine percent of pediatric oncologists surveyed believe it is important for pediatric oncologists to know which CAM therapies their patients are using. Ninety-nine percent believe this knowledge is important to prevent potential harmful drug interactions, whereas 84% believe it is important to improve trust between the physician and the patient.
Referrals to CAM Providers
The majority of pediatric oncologists do not refer patients known to be interested in complementary and alternative therapies to CAM specialists. Forty-two percent of pediatric oncologists surveyed sometimes refer their patients interested in CAM to specialists, and 41% of physicians never refer their patients to CAM specialists. Although the majority of pediatric oncologists are rarely referring their patients for CAM, when they do refer, they are most often referring patients to massage therapists and acupuncturists.
Physician Characteristics and Associations With CAM-related Practices
There was a trend seen with female pediatric oncologists asking patients a general, open-ended question about use of CAM more often then male colleagues; however, this was not statistically significant (P=0.056). Physicians who have previously used acupuncture for themselves were more likely to refer their patients to CAM specialists (P=0.007). No significant associations were found between physician's years in practice, physician's ethnicity, physician's attendance of United States or foreign medical school, or patient's insurance with the frequency of referral rates or the frequency of asking patients open-ended questions about CAM. No significant associations were found between physician's use of vitamins, massage therapy, or antioxidants and the frequency of referral rates or the frequency of physicians asking patients open-ended questions about CAM.
Pediatric oncologists are aware that the use of CAM in their patient population is highly prevalent, and prior studies describe up to 80% of pediatric oncology patients use or have used some form of CAM during their cancer treatment.11–19,29 Although essentially all pediatric oncologists believe it is important to be knowledgeable about their patients' use of CAM, they often do not ask patients if they use any complementary or alternative therapies. This may, in part, explain why greater than half of all patients using CAM do not discuss this treatment with their physicians.1,11,12,16,25
Pediatric oncologists are often not aware of which complementary and alternative therapies their patients are using largely owing to a lack of time to ask about CAM usage and owing to a lack of knowledge about CAM therapies. Pediatric oncologists have an enormous responsibility to gather information from their patients and to deliver information to them in a limited amount of time during each clinic visit. There are numerous CAM therapies available and discussing each type of therapy with all patients is not feasible given these time constraints. Knowing which questions to ask about CAM, to whom to ask these questions, and how to answer patients' questions about CAM is crucial to effective communication between the patient and physician. A brief CAM screening tool may assist physicians with obtaining information in limited time. A short, self-administered CAM screening tool could efficiently improve communication by allowing the physician to know which CAM therapies patients are currently using, and which therapies patients are interested in using. Given the increased emphasis on family-centered care and shared decision making, discussion of CAM use is necessary to provide patients with the best possible medical care.30
Pediatric oncologists believe that some CAM therapies have the potential to be harmful to their patients. Pediatric oncologists are specifically concerned about antioxidants, special diets, vitamins, dietary supplements, herbal medicine, and chiropractics. Prior studies and case reports portray some of the potential harmful side effects of a few of these therapies, validating this concern.24,31 As such, pediatric oncologists are asking a significantly higher percentage of their patients about therapies they believe to be potentially harmful, compared with therapies that they believe could potentially improve patient quality of life. For example, 74% of pediatric oncologists believe that massage therapy may be effective in improving the quality of life for their patients; however, 85% of these physicians ask fewer than 10% of their patients any questions regarding interest in, or use of, massage therapy. This is in contrast to the 63% of pediatric oncologists who believe that herbal medicine may be harmful to their patients—one third of physicians surveyed ask over 75% of their patients about their use of herbal medicine. This trend was seen with other therapies believed to be potentially harmful, such as vitamins, dietary supplements, special diets, and antioxidants, compared with therapies believed to have significant potential to improve the quality of life for patients, such as prayer, guided imagery, meditation, yoga, and acupuncture. It seems that many pediatric oncologists view their role in their patients' use of CAM is to ensure that the therapies patients are using do no harm. This is confirmed by 99% of respondents stating that it is important for pediatric oncologists to be knowledgeable about their patients' use of CAM to prevent potential harmful drug interactions. Thus, perhaps an inventory of dietary supplements, vitamins, antioxidants, and herbs being used should become part of the routine history. Physicians should discuss the information available, and lack of information available, regarding potential drug-therapy interactions and document this in the medical record.31,32
Physicians who previously used acupuncture are more likely to refer their patients to a CAM specialist when compared with physicians who noted no prior use of acupuncture. Physicians with prior use of acupuncture may be more comfortable with CAM therapies than those physicians with no prior acupuncture experience. In addition, these physicians may have increased interest in treatment with CAM, increased knowledge on the use of CAM, and increased knowledge of CAM providers in the community.
There was a trend toward female pediatric oncologists being more likely than male pediatric oncologists to ask their patients open-ended questions about CAM (P=0.056). This is in agreement with prior studies' findings that female physicians are more likely to discuss CAM with their patients and have a greater interest in CAM.8,33 However, we did not find female pediatric oncologists to be more likely than male pediatric oncologists to refer patients for CAM, as seen in the literature.8,33
The pediatric oncologists surveyed stated they would like to learn more about many of the CAM therapies they believe to be potentially harmful, and the therapies they believe to be potentially beneficial to their patients. This confirms data from prior studies indicating that physicians are interested in increased education on CAM, and is consistent with previous findings that physicians are most interested in learning about the following CAM therapies: meditation, yoga, guided imagery, acupuncture, vitamins, dietary supplements, special diets, and herbal medications.25,34,35 Increasing pediatric oncologists' knowledge about CAM will improve patient-physician communication regarding CAM. Medical schools across the United States are starting to integrate CAM into their curriculum; however, education on complementary and alternative therapies is limited during fellowship training and postfellowship practice.36,37 Offering formal education on CAM and its use in pediatric oncology patients during fellowship and increasing Continuing Medical Education is vital to supplying pediatric oncologists with the tools and knowledge to effectively and safely use CAM for their patients.
Currently there is little evidence about many of the potential benefits and potential side effects of CAM in pediatric oncology patients.23,31,38–41 A limited number of studies note the positive effects of massage therapy and mind-body therapy in pediatric oncology patients.38–41 The general pediatric literature documents that pediatric patients with chronic pain treated with acupuncture have increased relief of symptoms.42 Further studies are necessary to elucidate the benefits and negative side effects of specific CAM therapies used in the pediatric oncology population to allow pediatric oncologists to feel more comfortable advising patients on CAM, and to integrate CAM into their current practice. In the meantime, physicians could, at a minimum, raise the question of CAM use with their patients and evaluate the associated risks and benefits. The physician could engage the patient in the development of a care plan and document these discussions in the medical record. In addition, both the benefits and harmful side effects of complementary therapies used by patients could be monitored throughout treatment.31,32
This study is limited by responder bias. Pediatric oncologists who have a stronger opinion on the use of CAM may have been more likely to have responded to the survey. It is unclear, however, whether physicians who look more favorably or less favorably on the use CAM were more inclined to complete the survey compared with nonresponders. The overall response rate of 28% is lower than we predicted, with 89% of respondents partially completing the survey and 82% of respondents completing the entire survey. Data from respondents partially completing the survey were only used for questions to which an answer was given, and the reasons why these respondents did not complete the entire survey are unclear. In addition, the survey was only sent to pediatric oncologists affiliated with academic institutions and, therefore, does not represent pediatric oncologists in private and community practice across the United States. Also, knowing the actual prevalence of CAM use in the respondents' patient populations might have strengthened the study. Another limitation of the study was the use of multiple comparisons, thereby increasing the likelihood of finding a significant association by chance.
Pediatric oncologists believe that CAM is an important topic to discuss with their patients, but are limited by a lack of time to discuss CAM and a lack of knowledge on CAM. CAM research in pediatric oncology should prioritize those modalities physicians believe to be potentially beneficial to patient's quality of life, such as prayer, massage therapy, meditation, guided imagery, yoga, and acupuncture, and those modalities physicians believe to have potentially harmful side effects such as antioxidants, special diets, vitamins, dietary supplements, and herbal medicines.
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