|Year : 2014 | Volume
| Issue : 4 | Page : 962-966
Depression, anxiety and quality of life through the use of complementary and alternative medicine among breast cancer patients in Turkey
Mehmet Emin Kalender1, Hakan Buyukhatipoglu1, Ozan Balakan1, Ali Suner1, Ahmet Dirier2, Alper Sevinc1, Feridun Bulbul3, Ali Murat Tatli4, Turgay Ulas5, Celaletdin Camci1
1 Department of Medical Oncology, Medical Faculty, Gaziantep Oncology Hospital, Gaziantep, Turkey
2 Department of Radiation Oncology, Medical Faculty, Gaziantep Oncology Hospital, Gaziantep, Turkey
3 Department of Psychiatry, Medical Faculty, Gaziantep University, Gaziantep, Turkey
4 Department of Medical Oncology, School of Medicine, Akdeniz University, Antalya, Turkey
5 Department of Medical Oncology, School of Medicine, Harran University, Sanliurfa, Turkey
|Date of Web Publication||9-Jan-2015|
Department of Medical Oncology, School of Medicine, Gaziantep University, 27310 Gaziantep
Source of Support: None, Conflict of Interest: None
Background and Aim: Breast cancer is the most common type of cancer amongst women today. The aim of this study was to examine the association between complementary and alternative medicine (CAM) and the quality of life (QoL), anxiety and depression and demographic characteristics of women with breast cancer.
Materials and Methods: QoL was measured by the European Organization for Treatment and Research of Cancer quality of life core questionnaire (QLQ-C30, version 3.0) and anxiety and depression was measured by the hospital anxiety and depression scale.
Results: In total, 122 patients with breast cancer were enrolled in the study and 50% (n = 61) of them reported that they were using CAM. The most commonly used CAM methods were stinging nettle (57%) and prayer and spiritual healing (49%). No relationship was found between the use of CAM and the patient's age, time to diagnosis, cancer stage, chemotherapy use, smoking and residence. However, the analyses showed a positive association between CAM and role functioning (P = 0.014) and financial difficulties (P = 0.011); and a negative association between CAM and emotional functioning (P = 0.033).
Conclusions: Based on the previous studies, 20-83.3% of breast cancer patients among different countries and cultures used CAM. Our results suggested that the use of CAM among women is quite popular, but they showed no correlation between CAM usage and anxiety and depression. In addition, CAM usage was more common in breast cancer patients with a poor emotional and financial status.
结果：总共122例乳腺癌患者参与调研，50%（n = 61）的人使用补充和替代医药(CAM)。最常用的CAM方法包括刺荨麻（57%）、祈祷和精神治疗（49%）。发现CAM的使用和患者的年龄，诊断时间，肿瘤分期，化疗，吸烟和居住是没有关系的。然而，分析表明，CAM和肌体功能（P = 0.014）和经济困难（P = 0.011）之间呈正相关；CAM和情绪功能之间呈负相关（P = 0.033）。
Keywords: Anxiety, breast cancer, complementary and alternative medicine, depression, quality of life, Turkey
|How to cite this article:|
Kalender ME, Buyukhatipoglu H, Balakan O, Suner A, Dirier A, Sevinc A, Bulbul F, Tatli AM, Ulas T, Camci C. Depression, anxiety and quality of life through the use of complementary and alternative medicine among breast cancer patients in Turkey. J Can Res Ther 2014;10:962-6
|How to cite this URL:|
Kalender ME, Buyukhatipoglu H, Balakan O, Suner A, Dirier A, Sevinc A, Bulbul F, Tatli AM, Ulas T, Camci C. Depression, anxiety and quality of life through the use of complementary and alternative medicine among breast cancer patients in Turkey. J Can Res Ther [serial online] 2014 [cited 2019 Nov 12];10:962-6. Available from: http://www.cancerjournal.net/text.asp?2014/10/4/962/138010
| > Introduction|| |
Breast cancer is the most common type of cancer among women. Despite the improving survival rate with new treatment strategies, breast cancer is still not a curative disease. There is a tendency toward the use of complementary and alternative medicine (CAM) among cancer patients and the general population world-wide.  Breast cancer patients are more likely to be CAM users than patients with other types of cancer. According to several studies, the prevalence of CAM usage varied anywhere between 20% and 98% respectively. ,,,,,, According to the World Health Organization definition, the term CAM is used interchangeably with "traditional medicine" and refers to a broad set of health care practices, including traditional Chinese medicine, acupuncture, herbal preparations, vitamins, homeopathic remedies, music therapy and other psychological, physical and spiritual techniques. , The aim of the following study was to examine the association between the usage of CAM and the quality of life (QoL), anxiety and depression and demographic characteristics of women with breast cancer living in the southeast region of Turkey.
| > Materials and methods|| |
The use of CAM by breast cancer patients were measured with a standard form which they filled out. The form was used to discover the association between CAM usage and depression, anxiety and QoL. All patients were asked if they were using CAMs such as green tea, stinging nettle, prayer and spiritual healing, vitamins, exercise, honey, massage, music, art, dance, meditation, kefir, ginger, black cumin, cinnamon, daisy and carob.
QoL was measured with the European Organization for Treatment and Research of Cancer (EORTC) quality of life core questionnaire (QLQ-C30, version 3.0). Anxiety and depression was measured with the hospital anxiety and depression scale (HADS).
The QLQ-C30 scale includes five functional scales, three symptom scales, one global health status/QoL scale and six single items. Row scores for each item ranged from 0 to 100. A high score for a functional scale indicates a healthier level of functioning. A high score level for the global health status and QoL indicates a better QoL. However, a high score for a symptom scale indicates a higher level of symptomatology and problems. 
The HADS questionnaire includes seven items which reflect anxiety and seven items which reflect depression. Each item is scored on a scale of 0-3 points. The total score for the questionnaire ranges from 0 to 21. Scores of 0-7 are considered "normal," 8-10 "borderline" and above 10 represents a mood disorder. 
Statistical analyses were performed using SPSS 11.0 for Windows (SPSS, Chicago, IL, USA). (We provided the manufacturer details) We used the Student's t-test to compare clinical and demographic characteristics between CAM users and non-users. For the bivariate correlation analyses, we used the Pearson's correlation test. P < 0.05 was considered to be statistically significant.
| > Results|| |
In total, 122 patients with breast cancer were enrolled into the study and 50% (n = 61) of patients reported that they were using at least one type of CAM. Characteristics of patients are demonstrated in [Table 1]. CAMs that were used by the patients are shown in [Table 2]. The most commonly used CAM methods were stinging nettle (57%) and prayer and spiritual healing (49%). Eleven patients (18%) began to use CAM according to their doctors' advice, but the majority of patients (82%) began CAM use by their own volition, or through other people's advice such as their partners, neighbors, relatives or some other acquaintance.
The statistical analysis showed that CAM usage was more common when the education level was higher (P = 0.031). No relationship was noted between the use of CAM and age, time since diagnosis, cancer stage, chemotherapy use, smoking and residence. The mean results of EORTC QLQ-C30 and the relationship between CAM usages are shown in [Table 3].
|Table 3: The mean results of EORTC QLQ-C30 and the relationship between CAM usages|
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We found a significant difference between CAM user and non-users in terms of role functioning (P = 0.014) and financial difficulties (P = 0.011). However, emotional functioning score was higher in non-CAM users than in CAM users (P = 0.033). (We did not use the abbreviations for emotional functioning, financial difficulties, and role functioning, and performed to the whole manuscript). The relationship between CAM usage and HADS is shown in [Table 4]. No difference was noted in CAM users and non-users in terms of anxiety and depression.
The RF2 (P = 0.02), EF (P = 0.047), fatigue (P = 0.038), Pain (PA) (P = 0.043) and depression results (P = 0.008) were better in patients with a higher education level. The results of EF (P = 0.006), cognitive functioning (P = 0.027), PA (P = 0.025), dyspnea (P = 0.045) and diarrhea (P < 0.001) were better in patients living in urban areas when compared to those living in rural areas.
| > Discussion|| |
This study was not designed to uncover the effectiveness of CAM methods in breast cancer treatment. Although behavioral and supportive methods do not prolong the survival rate of breast cancer patients, the usage of CAM can increase the QoL in women with breast cancer. ,,, On the other hand, QoL also improves using CAM methods. Several studies have shown that CAM apart from boosting the immune system also reduces the risk of cytotoxicity to normal cells. ,, The National Center defined CAM as a group of different medical and health care systems, practices and products that are normally not considered conventional medicine.  According to the various studies in the literature, 20-98% of breast cancer patients were using CAM, ,,,,,, yet it should be noted that there are various CAM methods in different countries and cultures.
Our results suggest that the usage of CAM among Anatolian women with breast cancer is popular. In a different study of Turkey the usage of CAM analyzed in patients with different cancer types.  This study has shown that 55.4% of cancer patients used at least one type of CAM. According to this study, the most frequently used CAM method was herbal therapy and the most commonly used herb was stinging nettle. In our study, the most commonly used CAM methods were stinging nettle (57%) and prayer and spiritual healing (49%).
Alternative therapies used by women with breast cancer differ in various ethnic populations. For example in a study among Iranian women with breast cancer, the most commonly used CAM method was prayer and spiritual healing.  In another study among Korean patients with breast cancer the most common types of CAM were exercise therapy (43.2%) and ingestion of vitamins and minerals (41.9%).  In a study among breast cancer women with different ethnicity, it was shown that the black women most often used spiritual healing, Chinese women most often used herbal remedies, Latino women most often used dietary therapies and spiritual healing and white women most frequently used dietary and physical methods such as massage and acupuncture.  Other commonly used CAM methods by breast cancer patients are healing therapies, dietary,  psychological therapies,  vitamins , and nutrition.  Therefore, the most commonly used CAM methods are related to socio-cultural backgrounds and religion properties. Moreover, the cost of the CAM methods affects the choice.
A study from Korea showed that QoL was not significantly different between CAM users and non-users.  Differently, in our study financial diffuculties and role functioning scores was better but emotional functioning was worse in CAM user breast cancer patients, meaning that the usage of CAM is more common among breast patients with poor emotional status and low financial status. In other words, there is a tendency toward the use of CAM in patients with financial and emotional problems.
Although some studies showed that the use of CAM in breast cancer patients was associated with depression and anxiety, , in our study there was no correlation between CAM usage and anxiety and depression. For example a study from Spain among gynecologic and breast cancer patients demonstrated a statistically significant reduction in anxiety, depression (HADS) and body discomfort with use of relaxation and guided imagery techniques.  In a survey done among long-term breast cancer survivors, among 64% that CAM could aid in managing stress associated with the illness.  In certainty, the effect of alternative methods on anxiety and depression may differ in different cultures.
The relationship between CAM usage and psychosocial factors has been evaluated in several studies. A study by Burstein et al. found a relationship between CAM usage and age and education level.  (The previously reference "22" was changed to "24") Furthermore we found a correlation between CAM usage and education level.
The nettle has a special position as a medicinal treatment in Turkey. Especially in recent years, there is a belief among Turkish people that stinging nettle or nettle leaves cure cancer. The traditional attitudes and beliefs of the people, the easy access to this plant and the low cost can explain why stinging nettle is the most preferred herb among the Turkish population. Other popular CAM methods were religious rituals, multivitamin and antioxidant treatments and non-herbal agents. ,,,, (We have not 35 references so we excluded "35" from this citations, the last reference is "34") The most commonly used CAM modality in this study was herbal therapy, 57% of which was comprised by stinging nettle, similar to reports by previous Turkish studies.
Finally, the usage of CAM methods is common among women with breast cancer world-wide. The choices of CAM types are different according to expectation and choice of patient, patient's sociocultural background and religion properties. However based on previous studies and our experience, the most important factors that are related to CAM usage is socio-economical and emotional status. On the other hand, the effect of CAM on anxiety and depression is debated. Various results have been reported. In our study, we found no association.
| > References|| |
Cassileth BR, Schraub S, Robinson E, Vickers A. Alternative medicine use worldwide: The International Union Against Cancer survey. Cancer 2001;91:1390 3.
Buettner C, Kroenke CH, Phillips RS, Davis RB, Eisenberg DM, Holmes MD. Correlates of use of different types of complementary and alternative medicine by breast cancer survivors in the nurses′ health study. Breast Cancer Res Treat 2006;100:219 27.
Gray RE, Fitch M, Goel V, Franssen E, Labrecque M. Utilization of complementary/alternative services by women with breast cancer. J Health Soc Policy 2003;16:75 84.
Ashikaga T, Bosompra K, O′Brien P, Nelson L. Use of complimentary and alternative medicine by breast cancer patients: Prevalence, patterns and communication with physicians. Support Care Cancer 2002;10:542 8.
Cui Y, Shu XO, Gao Y, Wen W, Ruan ZX, Jin F, et al. Use of complementary and alternative medicine by chinese women with breast cancer. Breast Cancer Res Treat 2004;85:263 70.
Navo MA, Phan J, Vaughan C, Palmer JL, Michaud L, Jones KL, et al. An assessment of the utilization of complementary and alternative medication in women with gynecologic or breast malignancies. J Clin Oncol 2004;22:671 7.
Garg AK, Buchholz TA, Aggarwal BB. Chemosensitization and radiosensitization of tumors by plant polyphenols. Antioxid Redox Signal 2005;7:1630 47.
Konkimalla VB, Efferth T. Evidence based Chinese medicine for cancer therapy. J Ethnopharmacol 2008;116:207 10.
Liao GS, Apaya MK, Shyur LF. Herbal medicine and acupuncture for breast cancer palliative care and adjuvant therapy. Evid Based Complement Alternat Med 2013;2013:437948.
Duan DM, Tu Y, Chen LP, Wu ZJ. Efficacy evaluation for depression with somatic symptoms treated by electroacupuncture combined with fluoxetine. J Tradit Chin Med 2009;29:167 73.
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. The European Organization for Research and Treatment of Cancer QLQ C30: A quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365 76.
Snaith RP. The hospital anxiety and depression scale. Health Qual Life Outcomes 2003;1:29.
DiGianni LM, Garber JE, Winer EP. Complementary and alternative medicine use among women with breast cancer. J Clin Oncol 2002;20:34S 8.
Tagliaferri M, Cohen I, Tripathy D. Complementary and alternative medicine in early stage breast cancer. Semin Oncol 2001;28:121 34.
Yang C, Chien LY, Tai CJ. Use of complementary and alternative medicine among patients with cancer receiving outpatient chemotherapy in Taiwan. J Altern Complement Med 2008;14:413 6.
Patterson RE, Neuhouser ML, Hedderson MM, Schwartz SM, Standish LJ, Bowen DJ, et al. Types of alternative medicine used by patients with breast, colon, or prostate cancer: Predictors, motives, and costs. J Altern Complement Med 2002;8:477 85.
Helyer LK, Chin S, Chui BK, Fitzgerald B, Verma S, Rakovitch E, et al. The use of complementary and alternative medicines among patients with locally advanced breast cancer - A descriptive study. BMC Cancer 2006;6:39.
Shen J, Andersen R, Albert PS, Wenger N, Glaspy J, Cole M, et al. Use of complementary/alternative therapies by women with advanced stage breast cancer. BMC Complement Altern Med 2002;2:8.
Engel LW, Straus SE. Development of therapeutics: Opportunities within complementary and alternative medicine. Nat Rev Drug Discov 2002;1:229 37.
Ucan O, Pehlivan S, Ovayolu N, Sevinc A, Camci C. The use of complementary therapies in cancer patients: A questionnaire based descriptive survey from southeastern Turkey. Am J Clin Oncol 2008;31:589 94.
Montazeri A, Sajadian A, Ebrahimi M, Akbari ME. Depression and the use of complementary medicine among breast cancer patients. Support Care Cancer 2005;13:339 42.
Kang E, Yang EJ, Kim SM, Chung IY, Han SA, Ku DH, et al. Complementary and alternative medicine use and assessment of quality of life in Korean breast cancer patients: A descriptive study. Support Care Cancer 2012;20:461 73.
Lee MM, Lin SS, Wrensch MR, Adler SR, Eisenberg D. Alternative therapies used by women with breast cancer in four ethnic populations. J Natl Cancer Inst 2000;92:42 7.
Burstein HJ, Gelber S, Guadagnoli E, Weeks JC. Use of alternative medicine by women with early stage breast cancer. N Engl J Med 1999;340:1733 9.
Ganz PA, Desmond KA, Leedham B, Rowland JH, Meyerowitz BE, Belin TR. Quality of life in long term, disease free survivors of breast cancer: A follow up study. J Natl Cancer Inst 2002;94:39 49.
Boon H, Stewart M, Kennard MA, Gray R, Sawka C, Brown JB, et al. Use of complementary/alternative medicine by breast cancer survivors in Ontario: Prevalence and perceptions. J Clin Oncol 2000;18:2515 21.
Morris KT, Johnson N, Homer L, Walts D. A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites. Am J Surg 2000;179:407 11.
Risberg T, Jacobsen BK. The association between mental distress and the use of alternative medicine among cancer patients in North Norway. Qual Life Res 2003;12:539 44.
León Pizarro C, Gich I, Barthe E, Rovirosa A, Farrús B, Casas F, et al. A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality of life indices for gynecologic and breast brachytherapy patients. Psychooncology 2007;16:971 9.
Hann D, Baker F, Denniston M, Entrekin N. Long term breast cancer survivors′ use of complementary therapies: Perceived impact on recovery and prevention of recurrence. Integr Cancer Ther 2005;4:14 20.
Er O, Mistik S, Ozkan M, Ozturk A, Altinbas M. Factors related to complementary/alternative medicine use among cancer patients in central Anatolia. Tumori 2008;94:833 7.
Can G, Erol O, Aydiner A, Topuz E. Quality of life and complementary and alternative medicine use among cancer patients in Turkey. Eur J Oncol Nurs 2009;13:287 94.
Aydin Avci I, Koç Z, Sa?lam Z. Use of complementary and alternative medicine by patients with cancer in northern Turkey: Analysis of cost and satisfaction. J Clin Nurs 2012;21:677 88.
Yildiz I, Ozguroglu M, Toptas T, Turna H, Sen F, Yildiz M. Patterns of complementary and alternative medicine use among Turkish cancer patients. J Palliat Med 2013;16:383 90.
[Table 1], [Table 2], [Table 3], [Table 4]