Australian oncologists’ knowledge and attitudes regarding non-traditional therapies used by cancer patients par 0

Sallie Newell PhD, 1 Research Academic; Rob W Sanson-Fisher PhD, 2,3 Director		par 1

NSW Cancer Council Cancer Education Research Program (CERP), Locked Bag 10, WALLSEND, NSW, 2287.

This is the original submitted versions.
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par 2
1. Dr Newell was also a conjoint lecturer with the Discipline of Behavioural Science in Medicine, Faculty of Medicine and Health Sciences, University of Newcastle, NSW at the time this study was conducted. She is also currently in this position. par 3
2. 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
3. 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’ 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 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. The therapies 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 room for improvement in oncologists’ education about the non-traditional therapies which may be used by their patients. par 12

Introduction		par 13
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. This terminology was chosen as it is more all-encompassing than others used in the literature. For example, non-traditional therapies can be used along with traditional therapies, making the term “alternative” sometimes inappropriate. However, they can be used instead of traditional therapies, making the term “complementary” sometimes inappropriate. As there are now some meta-analyses concluding that psychosocial therapies can improve patients’ emotional well-being and physical symptoms (1,2), the term “unproven” can also be inappropriate. par 14
A number of recent studies have confirmed the popularity of non-traditional therapies among Australian cancer patients: 22 - 52% of medical oncology patients (3,4), 40% of palliative patients (5) and 46% of paediatric patients (6) 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 (3-6). However, dietary therapies, antioxidants, high dose vitamins and herbal therapies are also among the most popular (3-6). Many of these are poorly evaluated and could pose physical threats to patients, either directly, or by interfering with the effectiveness of traditional therapies. Despite the lack of scientific evidence, 25 – 73% of patients using non-traditional therapies expected them to cure their cancer or to prolong their lives (3,6) and 74 – 86% expected the non-traditional therapies to assist their traditional therapies (4).par 15
Despite fairly high reported satisfaction and perceived benefit levels with non-traditional therapies (3,4), 17% of patients in one study reported negative side effects (6), 10 – 36% of patients reported no perceived benefit or feeling worse (3,4) and around 20% reported they would not take the therapy again or recommend it to other cancer patients (4). 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 (3); Miller et al (1998) found patients had spent between $74 and $27,000 on non-traditional therapies (4). Again, despite fairly high satisfaction levels, only 64% of patients felt the non-traditional therapies had provided value for money (3). These data suggest that cancer patients need to be better informed about non-traditional therapies. par 16
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 (7). This suggests that oncologists need at least a basic understanding of non-traditional therapies. However, only two relevant studies could be identified: a quantitative survey of 106 Italian oncologists (8) and a qualitative study of 18 Canadian oncologists (9). They found limited knowledge about non-traditional therapies (8,9), relatively positive attitudes towards the psychological therapies (8,9), more negative attitudes towards the more invasive therapies (9), negative attitudes towards non-traditional therapy practitioners (8) and more positive attitudes towards the use of non-traditional therapies by palliative patients (9). par 17
The surveys of Australian cancer patients have indicated that 40 – 57% of those using non-traditional therapies had not discussed their use with their oncologist (3,6). 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 (4).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 listed as members of their Medical and Radiation Oncology Groups at the end of April 1997: these included 155 Australia-based medical and 62 radiation oncologists. As the Medical Oncology Group of Australia advised they were aware of only 165 practising medical oncologists residing in Australia, the COSA list was considered comprehensive for medical oncologists. However, the Royal Australasian College of Radiologists’ (RACR) Faculty of Radiation Oncology advised that 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 included in the COSA list: a further 56 radiation oncologists received surveys using this method, giving a total sample of 118 radiation oncologists. par 22

The survey instrument 		par 23
Each of the results tables alphabetically lists the 19 therapies explored in this survey. They covered the wide range of psychosocial and physical therapies commonly discussed in the literature and the media. A brief survey was designed (see Appendix A) , where oncologists rated their levels of knowledge about each therapy on a 4 point scale, ranging from “none/never heard of it” to “lots”. 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. par 24

Procedure		par 25
The surveys were mailed to the 273 identified oncologists in May and June 1997 with one written reminder where no response was received within 4 weeks. An additional telephone reminder was made to those oncologists, with contact details, still not having responded after an additional two weeks. par 26

Analyses		par 27
Descriptive statistics are reported regarding oncologists’ knowledge and attitudes. In addition, 95% confidence intervals were calculated around the proportion of oncologists knowing some or 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 (10). 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 removed or obliterated the identifying number which allowed this differentiation to be made. par 35

Oncologists’ knowledge about non-traditional therapies 		par 36
Table 1 summarises the oncologists’ reported knowledge levels about each non-traditional therapy. Acupuncture and antioxidants were the two most familiar therapies, closely followed by meditation, relaxation and visual imagery. 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 be helpful to palliative patients and, conversely, to be more likely to be harmful to 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. Table 3 also summarises the reported levels of usage by Australian cancer patients in the previous studies (3-6). 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

Discussion		par 42
In keeping with overseas data, self-identified gaps were found in oncologists’ knowledge about many non-traditional therapies (8,9), suggesting the need for improved education to allow oncologists to adequately discuss these issues with their patients. 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 (8,9). The more positive attitudes towards psychosocial therapies is encouraging as, at least some, proven benefits exist for these therapies (1,2). par 43
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. 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 (4,11-13). par 44
A potential weakness of the current study was the decision not to collect oncologists’ demographic information. This decision was made as all Australian oncologists were targeted and in order to keep the survey instrument brief, in an attempt to maximise the response rate. This strategy appears justified given that responses were received from over 60% of all Australian oncologists and covered the full range of responses. Therefore, 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
Another problem in the current study was that 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

Conclusion and Future Directions 		par 47
Given the high levels of usage of non-traditional therapies reported by Australian cancer patients, the data indicate a need to improve oncologists’ knowledge about these therapies and about their patients’ usage of them. Consequently, the Cancer Education Research Program group is preparing to collect data about NSW oncologists’ knowledge of their individual patient’s usage of each non-traditional therapy, in order to identify areas most in need of information. The group is also completing a large-scale, systematic, critical review of the effectiveness of the psychosocial non-traditional therapies, one of the most commonly-used and positively-viewed group of such therapies (14-17), to allow the production of evidence-based information for oncologists in this area. 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
1. Meyer TJ, Mark MM. Effects of psychosoical interventions with adult cancer patients: A meta-analysis of randomized experiments. Health Psychol 1995;14(2):101-8. par 52
2. Devine EC, Westlake SK. The effects of psychoeducational care provided to adults with cancer: meta-analysis of 116 studies. Oncol Nurs Forum 1995;22(9):1369-81. par 53
3. Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. Med J Aust 1996;165(18 Nov):545-8. par 54
4. Miller M, Boyer MJ, Butow PN et al. The use of unproven methods of treatment by cancer patients: Frequency, expectations and cost. Supportive Care Cancer 1998;6(4):337-47. par 55
5. Yates PM, Beadle G, Clavarino A et al. Patients with terminal cancer who use alternative therapies: their beliefs and practices. Sociology Health Illness 1993;15(2):199-216. par 56
6. Sawyer MG, Gannoni AF, Toogood IR et. The use of alternative therapies by children with cancer. Med J Aust 1994;160:320-2. par 57
7. National Health & Medical Research Council. Clinical Practice Guidelines: The Management of Early Breast Cancer. Sydney: The Stone Press; 1995. par 58
8. Crocetti E, Crotti N, Montella M, Musso M. Complementary medicine and oncologists' attitudes: A survey in Italy. Tumori 1996;82:539-42. par 59
9. Bourgeault IL. Physicians attitudes toward patients’ use of alternative cancer therapies. Can Med Assoc J 1996;155(2):1679-85. par 60
10. Dobson AJ. Calculating sample size. Trans Menzies Found 1984;7:75-9. par 61
11. Risberg T, Lund E, Wist E. Use of non-proven therapies. Differences in attitudes between Norwegian patients with non-malignant disease and patients suffering from cancer. Acta Oncologica 1995;34(7):893-8. par 62
12. Sollner W, Zingg-Schir M, Rumpold G, Fritsch P. Attitude toward alternative therapy, compliance with standard treatment, and need for emotional support in patients with melanoma. Arch Dermatol 1997;133:316-21. par 63
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
14. Newell S, Sanson-Fisher RW, Savolainen N. Systematic review of psychological therapies for cancer patients: effectiveness for side effect outcomes. J Natl Cancer Inst (under editorial review) 1999. par 65
15. Newell S, Sanson-Fisher RW, Savolainen N. Systematic review of psychological therapies for cancer patients: effectiveness for psychosocial outcomes. J Natl Cancer Inst (under editorial review) 1999. par 66
16. Newell S, Sanson-Fisher RW, Savolainen N. Systematic review of psychological therapies for cancer patients: effectiveness for longevity outcomes. J Natl Cancer Inst (under editorial review) 1999. par 67
17. Newell S, Sanson-Fisher RW, Savolainen N. Systematic review of psychological therapies for cancer patients: literature overview. J Natl Cancer Inst (under editorial review) 1999. par 68

Table 1: Oncologists’ perceived levels of knowledge regarding non-traditional therapies. 		par 69

% oncologists reporting knowing ... (N=161)*

Therapy

Some / Lots (95% CI) Nothing / Never heard of it
Acupuncture 84 (77-89) 1
Anti-oxidants/ high dose vitamin C 82 (75-88) 1
Aromatherapy 46 (41-51) 3
Cellular therapy 10 (6-16) 65
Coffee enemas 57 (52-62) 6
Diet therapy (Gerson/ macrobiotic) 54 (49-59) 11
Faith healing/ spiritualism 57 (52-62) 5
Herbal therapies/ naturopathy 67 (62-72) 1
Homeopathy 56 (51-61) 6
Hypnotherapy 58 (53-63) 3
Immune-enhancing therapy 41 (36-46) 19
Iridology 31 (26-36) 11
Iscador/ mistletoe therapy 34 (29-39) 36
Magnetotherapy 15 (10-21) 57
Meditation/ relaxation/ visual imagery 81 (74-87) 1
Microwave/ Tronado therapy 48 (43-53) 26
Ozone therapy 26 (22-31) 40
Psychic surgery 20 (14-27) 46
Shark cartilage therapy 60 (55-65) 7

* 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.



Helpful Harmful
Therapy N* Curative patients Palliative patients Curative patients Palliative patients
Acupuncture 160 25 58 1 1
Anti-oxidants/ high dose vitamin C 160 5 5 30 23
Aromatherapy 156 9 21 2 1
Cellular therapy 57 0 0 29 26
Coffee enemas 151 1 1 71 70
Diet therapy (Gerson/ macrobiotic) 142 2 4 49 48
Faith healing/ spiritualism 152 12 23 24 15
Herbal therapies/ naturopathy 159 8 13 22 15
Homeopathy 150 4 8 12 6
Hypnotherapy 156 31 46 4 3
Immune-enhancing therapy 131 3 5 27 22
Iridology 144 1 1 15 8
Iscador/ mistletoe therapy 103 2 2 55 45
Magnetotherapy 69 5 8 8 6
Meditation/ relaxation/ visual imagery 159 69 82 3 2
Microwave/ Tronado therapy 120 7 7 45 37
Ozone therapy 96 1 2 46 37
Psychic surgery 87 2 2 57 56
Shark cartilage therapy 150 1 1 23 17

* 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. 		par 71

Table 3: Comparing oncologists’ perceptions of usage with Australian cancer patients’ reported usage of non-traditional therapies.


Oncologists’ perceptions Australian cancer patients’ reported usage
Therapy N* Median % curative patients Median % palliative patients % pediatric patients (n=48) (6) % palliative patients (n=151) (5) % medical oncology patients (n=319) (3) % medical oncology patients (n=156) (4)
Acupuncture 160 6 10 - 7 3 5
Anti-oxidants/ high dose vitamin C 160 15 20 8 24 12 12 – 16
Aromatherapy 156 5 10 - - - ½
Cellular therapy 57 3 3 - - - -
Coffee enemas 151 3 5 - - - 1
Diet therapy (Gerson/ macrobiotic)# 142 10 10 8 (diet therapy) 18 (special foods) 13 (diet therapy) 30 (changed diet) ½ (Gerson)
Faith healing/ spiritualism 152 5 10 6 9 7 3
Herbal therapies/ naturopathy 159 20 25 8 3 - 8 6 5 – 10
Homeopathy 150 10 15 2 5 3 2
Hypnotherapy 156 5 5 15 - - 3
Immune-enhancing therapy 131 5 8 - 3 4 -
Iridology 144 3 5 - - - 3
Iscador/ mistletoe therapy 103 2 3 - - - -
Magnetotherapy 69 2 3 - - - ½
Meditation/ relaxation/ visual imagery 159 20 20 4 – 17 19 10 – 13 12 – 28
Microwave/ Tronado therapy 120 1 1 - - - -
Ozone therapy 96 3 5 - - - -
Psychic surgery 87 1 1 - - - -
Shark cartilage therapy 150 5 10 - - - 4

* 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

Appendix A: Cancer Specialists’ Survey: Knowledge and Attitudes About Alternative Therapies


How To Complete the Survey
par 73
The first question column asks you to rate your level of knowledge about each of the listed therapies. Please circle ONE number for each therapy. par 74
You need only complete the remaining two columns for the therapies that you have heard of. In other words, if you circled the number 1 in the first column, you do not need to answer further questions about that therapy. par 75
For each therapy that you have heard of, the second question column asks you to rate how helpful or harmful you think the therapy is. Please circle TWO numbers for each therapy: ONE for patients being treated palliatively (in the line indicated by a “P” over the page) and ONE for patients being treated curatively (in the line indicated by a “C” over the page). par 76
For each therapy that you have heard of, the last column asks you to estimate the proportion of YOUR cancer patients who you think would be using, or have used, the therapy. Please indicate TWO proportions for each therapy: ONE for patients being treated palliatively (in the line indicated by a “P” over the page) and ONE for patients being treated curatively (in the line indicated by a “C” over the page).
How To Return the Survey
par 77
Please place the completed survey in the reply-paid envelope provided and post it back to us. par 78
We would appreciate receiving your reply at your earliest convenience. par 79

 ANSWER FOR ALL THERAPIES ANSWER ONLY FOR THERAPIES YOU’VE HEARD OF
Perceived Knowledge Level Perception of Benefit or Harm % patients
Therapy Type None/ Never heard of it Very little Some Lots
Very helpful Fairly helpful Neither helpful/ harmful Fairly harmful Very harmful Don’t know think use/ have used
Acupuncture 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Anti-oxidants/ high dose vitamin C 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Aroma- therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Cellular therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Coffee enemas 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Diet therapy (Gerson/ Macrobiotic) 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Faith healing/ Spiritualism 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Herbal therapies/ Naturopathy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Homeopathy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Hypno- therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Immune-enhancing Therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Iridology 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Iscador/ mistletoe Therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Magneto- therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Meditation/ relaxation/ visual imagery 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Microwave/ Tronado therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Ozone therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Psychic surgery 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
Shark cartilage Therapy 1 2 3 4 P 1 2 3 4 5 9




C 1 2 3 4 5 9
This is the original submitted version.