| Australian oncologists’ self-reported knowledge and attitudes regarding non-traditional therapies used by cancer patients | par 0 |
Sallie Newell PhD, 1,2 Research Academic; Rob W Sanson-Fisher PhD, 3,4 Director | par 1 |
NSW Cancer Council Cancer Education Research Program (CERP), Locked Bag 10, WALLSEND, NSW, 2287.
This is the first revised version of this article, electonically published 9 November 1999. | par 2 |
| 1. Dr Newell is also, and was at the time of this study, a conjoint lecturer with the Discipline of Behavioural Science in Medicine, Faculty of Medicine and Health Sciences, University of Newcastle, NSW. | par 3 |
| 2. Dr Newell is currently an epidemiologist/research officer with the Northern Rivers Institute for Health and Research, Lismore, NSW, Australia. | par 3a |
| 3. Professor Sanson-Fisher was also the Professor of the Discipline of Behavioural Science in Medicine, Faculty of Medicine and Health Sciences, University of Newcastle, NSW at the time this study was conducted. | par 4 |
| 4. Professor Sanson-Fisher is currently the Dean of the Faculty of Medicine and Health Sciences, University of Newcastle, NSW. | par 5 |
Abstract | par 6 |
| Objective: To assess Australian radiation and medical oncologists’ self-reported knowledge about and attitudes towards a range of non-traditional therapies used by people with cancer. | par 7 |
| Design: A paper survey was mailed to all radiation and medical oncologists within Australia. | par 8 |
| Participants: 161 completed surveys were returned, representing a 61% response rate. | par 9 |
| Outcome Measures: The therapies included in the survey were acupuncture, antioxidant therapy, aromatherapy, cellular therapy, coffee enemas, diet therapy, faith healing, herbal therapies, homeopathy, hypnotherapy, immune-enhancing therapy, iridology, iscador, magnetotherapy, meditation (including relaxation and visual imagery), microwave therapy, ozone therapy, psychic surgery and shark cartilage therapy. For each therapy, oncologists rated their own level of knowledge and, for each known therapy, indicated their perceptions of its likely harm or benefit and of the prevalence of use among their patients. These perceptions were rated separately for patients being treated curatively and palliatively. | par 10 |
| Results: Oncologists reported the highest knowledge levels about acupuncture, antioxidant therapy and meditation and the lowest knowledge levels about cellular therapy, magnetotherapy and psychic surgery. The therapies most likely to be considered helpful were meditation, acupuncture and hypnotherapy. Those most likely to be considered harmful were coffee enemas, psychic surgery, iscador therapy and diet therapies. Perceptions of patients’ use of most therapies varied widely with herbal therapies, antioxidant therapy and meditation considered the most commonly-used. | par 11 |
| Conclusions: These results provide the first quantitative information in this area, indicating self-identified gaps in oncologists' knowledge about non-traditional therapies their patients may use and suggesting a need to consider including education about these therapies in oncologists' training. | par 12 Comment Comment Comment |
Introduction | par 13 |
| [] See Figure 1. | par 14 Comment |
| Recent studies have confirmed the popularity of non-traditional therapies among Australian cancer patients: 22 - 52% of medical oncology patients (1,2), 40% of palliative patients (3) and 46% of paediatric patients (4) report using at least one non-traditional therapy. Many of the most popular non-traditional therapies are psychosocial, such as relaxation practice, meditation and visual imagery, and are unlikely to pose threats to patients’ health (1-4). However, dietary therapies, antioxidants, high dose vitamins and herbal therapies are also among the most popular (1-4). Many of these are poorly evaluated and could pose physical threats to patients, either directly, or by interfering with [] traditional therapies. | par 15 |
| Despite the lack of scientific evidence, 25 – 73% of patients using non-traditional therapies expect them to cure their cancer or to prolong their lives (1,4) and 74 – 86% expect them to assist their traditional therapies (2). Despite fairly high reported satisfaction and perceived benefit levels with non-traditional therapies (1,2), 17% of patients in one study reported negative side effects (4), 10 – 36% of patients report no perceived benefit or feeling worse (1,2) and around 20% report they would not take the therapy again or recommend it to other cancer patients (2). Even if not harmful, many non-traditional therapies are expensive: Begbie et al (1996) found the median annual cost of such therapies to patients was $530, with a maximum of $20,000 (1); Miller et al (1998) found patients spent between $74 and $27,000 on non-traditional therapies (2). Again, despite fairly high satisfaction levels, only 64% of patients felt the non-traditional therapies provided value for money (1). These data suggest that cancer patients need to be better informed about non-traditional therapies. | par 16 Comment |
| Recent guidelines highlight the need for oncologists to be aware of non-traditional therapies being used or considered by their patients and to encourage their patients to discuss them (5), suggesting that oncologists need at least a basic understanding of non-traditional therapies. Only two relevant studies could be identified: a quantitative survey of 106 Italian oncologists (6) and a qualitative study of 18 Canadian oncologists (7). They found limited knowledge about non-traditional therapies (6,7), relatively positive attitudes towards psychological therapies (6,7), more negative attitudes towards more invasive therapies (7), negative attitudes towards non-traditional therapy practitioners (6) and more positive attitudes towards the use of non-traditional therapies by palliative patients (7). | par 17 Comment Comment |
| The surveys of Australian cancer patients indicated that 40 – 57% of those using non-traditional therapies had not discussed their use with their oncologist (1,4). However, patients having discussed their use with their doctors, although not necessarily oncologists, perceived them to be generally supportive of acupuncture, antioxidants, exercise therapy and meditation and relaxation programs but unsupportive of high dose vitamin C and herbal therapies (2). | par 18 |
| Given the lack of data, this study explored Australian medical and radiation oncologists’ knowledge and attitudes about non-traditional therapies and their perceptions of their frequency of use among their patients. Given the increased tolerance of palliative patients using non-traditional therapies in the overseas literature, separate assessments were sought for palliative and curative patients. | par 19 |
Method | par 20 |
Sample identification | par 21 |
| The Clinical Oncological Society of Australasia (COSA) provided a list of all the individuals registered with their Medical and Radiation Oncology Groups in late April 1997: 155 Australia-based medical and 62 radiation oncologists. As the Medical Oncology Group of Australia advised they were aware of only 165 practising Australian-based medical oncologists, the COSA list was considered comprehensive for medical oncologists. However, the Royal Australasian College of Radiologists’ (RACR) Faculty of Radiation Oncology advised they had 123 members currently practising in Australia. As the RACR had a policy of not releasing members’ contact details, they agreed to mail surveys to their members not on the COSA list: 56 additional radiation oncologists received surveys using this method, giving a total sample of 118. | par 22 Comment Comment Comment Comment |
The survey instrument | par 23 |
| []A brief survey was designed where oncologists rated their own levels of knowledge about each of the 19 therapies listed in each results table on a 4 point scale (“none/never heard of it” “very little”, “some” or “lots”. The oncologists received no additional information about these therapies, which covered the wide range of psychosocial and physical therapies commonly discussed in the literature and media. For each known therapy, the oncologists rated how harmful or helpful (very, fairly, neither or don’t know) they considered it, giving separate ratings for patients being treated palliatively and curatively. The oncologists also estimated the proportion of their patients they believed were using, or had used, each known therapy - again separately for palliative and curative patients. The authors are happy to provide copies of the survey instrument to interested readers. | par 24 Comment Comment Comment |
Procedure | par 25 |
| The surveys were mailed to the 273 identified oncologists in May and June 1997 with a written reminder to non-responders after four weeks and a telephone reminder after six weeks. | par 26 Comment Comment |
Analyses | par 27 |
| Descriptive statistics are reported regarding oncologists’ knowledge and attitudes and 95% confidence intervals were calculated around the proportion of oncologists knowing [] lots about each therapy. All analyses were conducted using the SAS statistical package; 95% confidence intervals were calculated using an excel spreadsheet based on the standard binomial approximation formula (8). | par 28 |
Funding Source | par 29 |
| This study was supported by the NSW Cancer Council’s funding of the Cancer Education Research Program (CERP). The Cancer Council had no direct role in the design and/or analyses for this study or over the decision about publication of the results. | par 30 |
Ethics | par 31 |
| This study was approved by the University of Newcastle’s Human Research Ethics Committee. | par 32 |
Results | par 33 |
Sample characteristics | par 34 |
| Of the 273 oncologists identified, four medical and two radiation oncologists were no longer practising and two radiation oncologists received surveys via both lists, leaving 265 eligible oncologists. Of these, 161 (61%) returned completed surveys: 60 were radiation oncologists, 64 were medical oncologists and 37 could not be classified as they had destroyed the identifying number indicating this differentiation. | par 35 |
Oncologists’ knowledge about non-traditional therapies | par 36 |
| Table 1 summarises the oncologists’ reported knowledge levels about each non-traditional therapy. [] Meditation, relaxation and visual imagery were the therapies that most oncologists, around a quarter, reported knowing lots about. Around a fifth of the oncologists surveyed also reported knowing lots about antioxidants and microwave, or Tronado, therapy. The least known therapies were cellular therapy, magnetotherapy and psychic surgery. | par 37 |
Oncologists’ perceptions of each therapy’s potential harmfulness / helpfulness | par 38 |
| Table 2 summarises the oncologists’ attitudes regarding the potential harmfulness or helpfulness of each non-traditional therapy. The psychosocial therapies tended to be considered helpful for both palliative and curative patients, as was acupuncture, especially for palliative patients. Many therapies were considered more likely to help palliative patients and, conversely, to be more likely to harm curative patients. Not surprisingly, the less familiar, more physical or invasive therapies dominated those considered likely to be harmful. | par 39 |
Oncologists’ perceptions of their patients’ usage of each therapy | par 40 |
| Table 3 summarises the median proportion of curative and palliative patients oncologists perceived to be using, or to have used, each non-traditional therapy, with a consistent trend to estimate higher usage among palliative patients. It also summarises the reported levels of usage by Australian cancer patients (1-4). Oncologists’ estimates of usage were within the ranges reported by Australian cancer patients for acupuncture, antioxidants, faith healing, hypnotherapy, iridology and meditation, relaxation and visual imagery. However, the oncologists overestimated patients’ usage of aromatherapy, coffee enemas, herbal therapies, naturopathy, homeopathy, immune-enhancing therapy, magnetotherapy and shark cartilage. No patient data were available for comparison for cellular, mistletoe, microwave and ozone therapies or psychic surgery. The estimates for diet therapy were difficult to compare due to the varied definitions used. | par 41 Comment Comment |
Discussion | par 42 |
| In keeping with overseas data, self-identified gaps were found in oncologists’ knowledge about many non-traditional therapies (6,7). [] It is interesting to note, however, that the therapies most patients reported using, meditation, relaxation and visual imagery and antioxidants, were also the therapies that most oncologists, although still only up to a quarter, reported lots of knowledge about. | par 43 |
| Also consistent with overseas data, psychosocial therapies were viewed positively and non-traditional therapies were considered more likely to be potentially helpful to palliative patients and potentially harmful to curative patients (6,7). The more positive attitudes towards psychosocial therapies could be a reflection of the oncologists' awareness of the existence of some evidence of proven benefits for these therapies (9,10). | par 43a |
| Although the oncologists surveyed tended to accurately perceive their patients’ usage of the more commonly-used non-traditional therapies, they tended to overestimate patients’ usage of the less commonly-used, more radical therapies, especially those with higher media profiles, such as coffee enemas and shark cartilage. Although these comparisons should be viewed with some caution as the oncologists' and patients' estimates come from different surveys of different populations collected at different points in time, making some degree of variation inevitable, such variation is unlikely to explain the reasonably large differences found for many of the lesser-used therapies. The trend for oncologists to estimate higher usage of non-traditional therapies among palliative than curative patients is in keeping with Australian and international data suggesting that patients with more advanced cancers are more likely to use non-traditional therapies (2,11-13). | par 44 |
| [] In discussing these findings, it is important to consider some other limitations of this study. First, as all Australian oncologists were targeted and in order to keep the survey instrument brief, to maximise the response rate, no demographic information was asked of the oncologists surveyed, prohibiting any assessment of their representativeness of the population of Australian oncologists. However, as responses were received from over 60% of the population and covered the full range of responses, the authors are confident that the data provide the first quantitative, reasonably representative overview of Australian oncologists’ knowledge and attitudes regarding non-traditional therapies. | par 45 Comment Comment |
| Second, the survey instrument assessed oncologists' self-reported levels of knowledge about these therapies and did not provide an objective assessment of their actual knowledge. As the oncologists are considered unlikely to have considerably underestimated their knowledge levels, these estimates should probably be interpreted as best case scenarios. The survey instrument also provided no definitions of "helpful" or "harmful" for oncologists' to use in rating their attitudes towards the therapies. While this left it to individual oncologists to decide what constituted a harm or a help, this was done intentionally as patients report using non-traditional therapies in search of a range of benefits, including physical, psychosocial and spiritual. | par 45a |
| Third, while the results of this survey represent the first quantitative data regarding oncologists' knowledge and attitudes in this area, they can, of course, not be generalised to other clinicians treating people with cancer, such as surgeons, haematologists and general practitioners. Future surveys of these and other groups may be useful in building a more comprehensive picture of clinicians' opinions in general. | par 45b |
| Finally, almost one quarter of respondents removed the coded identification number from their surveys, making comparisons between medical and radiation oncologists difficult. However, no consistent differences emerged between the identified medical and radiation oncologists in relation to knowledge, attitudes or perceptions of patients’ use of these non-traditional therapies. | par 46 |
| Sceptics may question the need for oncologists to increase their knowledge about non-traditional therapies when most remain of unproven benefit. However, without some knowledge of, at least, each therapy's existence, the basics of what is involved and any demonstrated adverse reactions, oncologists run the risk of being unable to adequately advise patients who may be using or considering potentially-harmful non-traditional therapies. As outlined in NHMRC guidelines, overly heavy-handed and dismissive doctors are unlikely to succeed in discouraging their patients from using such therapies whereas more rational and considered discussions with patients may succeed(5). Alternatively, without knowledge of any proven benefits associated with non-traditional therapies, such as the psychosocial therapies, oncologists run the risk of being unable to adequately advise their patients about potentially-beneficial therapies. | par 46a |
Conclusion and Future Directions | par 47 |
| Given the high levels of usage of non-traditional therapies reported by Australian cancer patients, the data, although showing higher levels of knowledge regarding more commonly-used therapies, indicate a need to improve the extent of oncologists' basic knowledge about non-traditional therapies to enable them to adequately discuss their potential harms and benefits with patients who may be considering or using them. Therefore, future research is needed to facilitate the production of evidence-based information summaries for oncologists in this area, to compare oncologists' perceptions of usage with their own patients' reported use of non-traditional therapies and to establish the knowledge and attitudes of other clinicians treating cancer patients. | par 48 |
Acknowledgments | par 49 |
| This research was funded by the NSW Cancer Council’s Cancer Education Research Program. The views expressed are not necessarily those of the Cancer Council. The authors gratefully acknowledge the assistance of the Clinical Oncological Society of Australasia and the Royal Australasian College of Radiologists’ (RACR) Faculty of Radiation Oncology for their assistance with identifying eligible oncologists and, of course, the oncologists who completed the surveys. | par 50 |
References | par 51 |
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| 13. Risberg T, Lund E, Wist E, Dahl O, Sundstrom S, Anderson OK, Kaasa S. The use of non-proven therapy among patients treated in Norwegian oncological departments. A cross-sectional national multicentre study. Eur J Cancer 1995;31A(11):1785-9. | par 64 |
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Table 1: Oncologists’ perceived levels of knowledge regarding non-traditional therapies. | par 69 |
* The remaining response option was “a little” knowledge – the balance of the 100% of oncologists for each therapy selected this response option. | par 70 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Table 2: Oncologists’ perceptions of the potential helpfulness or harmfulness of non-traditional therapies.
* The attitudinal items were asked only of those oncologists reporting at least “very little” knowledge of each therapy – this column indicates the denominator for each therapy. The remaining response options were "neither helpful or harmful" and "don't know" -- the balance of the 100% of oncologists for each therapy selected one of these response options. | par 71 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Table 3: Comparing oncologists’ perceptions of usage with Australian cancer patients’ reported usage of non-traditional therapies.
* The attitudinal items were asked only of those oncologists reporting at least “a little” knowledge of each therapy – this column indicates the denominator for each therapy. # As diet therapies included those ranging from basic dietary changes through to very restricted diets (eg: Gerson diet), the actual wording used in each of the Australian studies is included in this table. | par 72 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Why "Non-Traditional Therapies? In this manuscript, the term "non-traditional therapies" has been used to describe all therapies other than surgery, radiotherapy, chemotherapy and hormone therapy, which have been labelled "traditional therapies". The following terms, also used in the literature, were avoided for the following reasons
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