Beliefs and Determinants of Use of Traditional Complementary/Alternative Medicine in Pediatric Patients Who Undergo Treatment for Cancer in South America

Integrative Medicine Across the Pediatric Cancer Care Trajectory: A Narrative Review

PURPOSE OF THE REVIEW

Children and adolescents with cancer, along with their parents and other informal caregivers, often report using complementary and alternative medicine (CAM) during active oncology and hemato-oncology treatment. Some adopt an "alternative" approach to conventional medical care, which often entails the use of these practices without the knowledge of the treating pediatrician. In contrast, many others search for consultation provided by a pediatric integrative oncology (IO) practitioner working with the conventional medical team. IO seeks to provide evidence-based complementary medicine therapies, many of which have been shown to augment conventional supportive and palliative care, while ensuring the patient's safety. The present narrative review examines the current state of and future direction for the IO setting of care.

RECENT FINDINGS

A large body of published clinical research supports the effectiveness of leading Pediatric IO modalities, while addressing potential safety-related concerns. Despite the growing amount of clinical research supporting the beneficial effects and implementation of Pediatric IO models of care, there is still a need for further studies in order to establish clinical guidelines in the treatment of children and adolescents with cancer. Such IO-directed guidelines will need to address both the effectiveness and the safety of the CAM modalities being used in pediatric oncology and hemato-oncology settings, promoting a better understanding among pediatric healthcare professionals and helping them understand the indications for referral to the IO treatment service.

Inter-Rater Reliability, Construct Validity, and Feasibility of the Modified "Which Health Approaches and Treatments Are You Using?" (WHAT) Questionnaires for Assessing the Use of Complementary Health Approaches in Pediatric Oncology

BACKGROUND

This study aimed to test the inter-rater reliability, construct validity, and feasibility of the modified "Which Health Approaches and Treatments Are You Using?" (WHAT) questionnaires in pediatric oncology; Methods: Parent-child dyads were invited to complete self- and proxy-report-modified WHAT, Pediatric Quality of Life Inventory, demographics, a diary of the child's recent use of CHA, and a questionnaire assessing the aspects of feasibility. Parents were asked to complete a satisfaction of their children's use of the CHA survey; Results: Twenty-four dyads completed the study. The mean weighted kappa showed strong inter-rater reliability (k = 0.77, SE = 0.056), and strong agreements between the modified WHAT and the diary (self-report [k = 0.806, SE = 0.046] and proxy-report [k = 0.894, SE = 0.057]). Significant relationships were found only between recent and non-recent CHA users in relation to the easy access to CHA (self-report [p = 0.02], proxy-report [p < 0.001]). The mean scores of the feasibility scale (out of 7.0) for the self- and proxy-report were 5.64 (SD = 0.23) and 5.81 (SD = 0.22), respectively, indicating the feasibility of the modified WHAT; Conclusions: The findings provide initial evidence of the reliability and validity of the modified WHAT and their feasibility. Further research is needed to test the theoretical relationships and further explore the validity and reliability of the modified WHAT.

Complementary Health Approaches for the Symptoms of Pediatric Oncology Patients

This study was conducted to determine the complementary health approaches (CHAs) used by pediatric oncology patients' parents for symptoms, their positive-negative effects, and the factors that influence their usage. The study was a descriptive design. The data were collected between March and November 2014 from the parents of 156 pediatric oncology patients in 2 different university hospitals in Turkey using the face-to-face interview method. In total, 99.4% of the parents who participated in the study used at least 1 CHA for their children. Complementary health approaches frequently adopted by the parents included praying (96.8%), oblation/sacrifice (50.6%), carob molasses (27.6%), grape molasses (22.4%), and massage (22.4%). Forty-three parents reported that they gave carob molasses to their children to reduce the symptoms of neutropenia, whereas 32 parents reported that they gave them grape molasses and 34 parents reported that they massaged their children to mitigate symptoms of pain. The parents reported that they used CHAs to enhance their child's immune system (61.3%), to do everything in their power to treat their child (42%), and to combat the side effects of medication/radiotherapy (25.8%). None of parents stated that they had observed any side effects from using CHAs. Almost all of the parents use one of the CHAs. The health personnel especially nurses should inform pediatric oncology patients and their parents about CHAs, which have no evidence and are potentially harmful and encourage them to approaches supportive to medical treatment.

Complementary Medicine Practice and Use of Dietary Supplements in Pediatric Cancer Patients in Croatia

Introduction: The use of complementary and alternative medicine (CAM) has become a customary practice among pediatric cancer patients worldwide. The frequency of its use by pediatric cancer patients in Croatia has not been previously determined. 

Methodology: In order to establish the frequency and detect factors affecting the use of CAM, a single-center, observational, cross-sectional study was conducted at the Children's Hospital Zagreb during a two-year period. The patients' parents and caregivers were offered an anonymous, multi-item questionnaire that collected socio-economic and clinical data, as well as details on CAM and dietary supplement practice. 

Results: Almost half of the participants reported CAM and more than two-thirds reported dietary supplement consumption, predominantly in the intensive phase of the treatment. Factors regarding children or parents had no effect on CAM and supplement utilization. Herbal medicine, vitamins, and minerals were among the most commonly used items. Every 10th child experienced at least one adverse event during CAM and supplement use.

Conclusion: Awareness of the CAM and dietary supplement application in pediatric oncology patients needs to be raised due to the potential interactions with conventional treatment modalities. For this reason, it is extremely important to inform parents and caregivers of pediatric oncology patients about the use of CAM and dietary supplements to predict and mitigate the occurrence and intensity of the side effects. In the majority of our cases, the patient's guardians informed the healthcare professionals about the CAM and supplement implementation in their children, therefore, they were offered additional information about the possible negative impact of CAM and supplement use on standard medical care in a timely manner.

Survey of the use of traditional and complementary medicine among children with cancer at three hospitals in Cameroon

INTRODUCTION

There is lack of diagnostic and treatment resources with variable access to childhood cancer treatment in low- and middle-income countries (LMIC), which may lead to subsequent poor survival. The primary aim of this study was to determine the prevalence and types of traditional and complementary medicine (T&CM) used in Cameroon. Secondarily, we explored determinants of T&CM use, associated costs, perceived benefits and harm, and disclosure of T&CM use to medical team.

METHODS

A prospective, cross-sectional survey among parents and carers of children younger than 15 years of age who had a cancer diagnosis and received cancer treatment at three Baptist Mission hospitals between November 2017 and February 2019.

RESULTS

Eighty participants completed the survey. Median patient age was 8.1 years (IQR4.1-11.1). There was significant availability (90%) and use (67.5%) of T&CM, whereas 24% thought T&CM would be good for cancer treatment. Common T&CM remedies included herbs and other plant remedies or teas taken by mouth, prayer for healing purposes and skin cutting. Living more than five hours away from the treatment center (P = 0.030), anticipated costs (0.028), and a habit of consulting a traditional healer when sick (P = 0.006) were associated with the use of T&CM. T&CM was mostly paid for in cash (53.7%) or provided free of charge (29.6%). Of importance was the fact that nearly half (44%) did not want to disclose the use of TM to their doctor.

CONCLUSION

Pediatric oncology patients used T&CM before and during treatment but were unlikely to disclose its use to the child's health care team.

Integrative oncology: Addressing the global challenges of cancer prevention and treatment

The increase in cancer incidence and mortality is challenging current cancer care delivery globally, disproportionally affecting low- and middle-income countries (LMICs) when it comes to receiving evidence-based cancer prevention, treatment, and palliative and survivorship care. Patients in LMICs often rely on traditional, complementary, and integrative medicine (TCIM) that is more familiar, less costly, and widely available. However, spheres of influence and tensions between conventional medicine and TCIM can further disrupt efforts in evidence-based cancer care. Integrative oncology provides a framework to research and integrate safe, effective TCIM alongside conventional cancer treatment and can help bridge health care gaps in delivering evidence-informed, patient-centered care. This growing field uses lifestyle modifications, mind and body therapies (eg, acupuncture, massage, meditation, and yoga), and natural products to improve symptom management and quality of life among patients with cancer. On the basis of this review of the global challenges of cancer control and the current status of integrative oncology, the authors recommend: 1) educating and integrating TCIM providers into the cancer control workforce to promote risk reduction and culturally salient healthy life styles; 2) developing and testing TCIM interventions to address cancer symptoms or treatment-related adverse effects (eg, pain, insomnia, fatigue); and 3) disseminating and implementing evidence-based TCIM interventions as part of comprehensive palliative and survivorship care so patients from all cultures can live with or beyond cancer with respect, dignity, and vitality. With conventional medicine and TCIM united under a cohesive framework, integrative oncology may provide citizens of the world with access to safe, effective, evidence-informed, and culturally sensitive cancer care.

Cannabis-Related Perceptions as Mediators of the Association Between Trait Impulsivity and Cannabis Outcomes

OBJECTIVE

Normative perceptions have been shown to mediate the effect of personality traits on cannabis outcomes. We examined descriptive norms, injunctive norms, and the role of cannabis in college life as possible mediators of the association between impulsivity-related traits (i.e., negative urgency, positive urgency, sensation seeking, perseverance, and premeditation) and cannabis outcomes (i.e., frequency of cannabis use and negative consequences) among college students from five countries.

METHOD

A total of 1,175 college students (United States, n = 698; Argentina, n = 153; Spain, n = 178; Uruguay, n = 79; and Netherlands, n = 67) who were also cannabis users (i.e., reported cannabis use at least once within the previous month) completed an online survey. We used path analysis to test whether the proposed double-mediated paths (impulsivity-like traits→perceived cannabis norms→cannabis use frequency→negative cannabis-related consequences) were invariant across countries/cultures.

RESULTS

Cannabis-related perceptions, particularly college cannabis beliefs and injunctive norms, significantly mediated the association between impulsivity and cannabis outcomes. Two significant double-mediated paths, which were invariant across sex and countries, were found: (a) higher positive urgency→higher endorsement of internalized norms→higher cannabis use frequency→more negative cannabis-related consequences and (b) higher sensation seeking→higher endorsement of injunctive norms→higher cannabis use frequency→more negative cannabis-related consequences.

CONCLUSIONS

The study corroborates previous findings on normative perceptions mediating the effects of impulsivity-like traits on cannabis outcomes and suggests that these processes may operate similarly among college student cannabis users in different legal and cultural contexts. The findings highlight the need to address internalized norms and suggest these normative perceptions may be a good intervention candidate to reduce cannabis use/consequences.

Prevalence of the Use of Herbal Medicines among Patients with Cancer: A Systematic Review and Meta-Analysis

Background

Although herbal medicines are used by patients with cancer in multiple oncology care settings, the magnitude of herbal medicine use in this context remains unclear. The purpose of this review was to establish the prevalence of herbal medicine use among patients with cancer, across various geographical settings and patient characteristics (age and gender categories).

Methods

Electronic databases that were searched for data published, from January 2000 to January 2020, were Medline (PubMed), Google Scholar, Embase, and African Index Medicus. Eligible studies reporting prevalence estimates of herbal medicine use amongst cancer patients were pooled using random-effects meta-analyses. Studies were grouped by World Bank region and income groups. Subgroup and meta-regression analyses were performed to explore source of heterogeneity.

Results

In total, 155 studies with data for 809,065 participants (53.95% female) met the inclusion criteria. Overall, the pooled prevalence of the use of herbal medicine among patients with cancer was 22% (95% confidence interval (CI): 18%–25%), with the highest prevalence estimates for Africa (40%, 95% CI: 23%–58%) and Asia (28%, 95% CI: 21%–35%). The pooled prevalence estimate was higher across low- and middle-income countries (32%, 95% CI: 23%–42%) and lower across high-income countries (17%, 95% CI: 14%–21%). Higher pooled prevalence estimates were found for adult patients with cancer (22%, 95% CI: 19%–26%) compared with children with cancer (18%, 95% CI: 11%–27%) and for female patients (27%, 95% CI: 19%–35%) compared with males (17%, 95% CI: 1%–47%).

Conclusion

Herbal medicine is used by a large percentage of patients with cancer use. The findings of this review highlight the need for herbal medicine to be integrated in cancer care.

Complementary and alternative medicine use by pediatric oncology patients before, during, and after treatment

Background

The prevalence of complementary and alternative medicine (CAM) use and the modalities used by pediatric oncology patients vary widely across studies. In addition, the changes in the use of CAM over the course of treatment are understudied. Thus, this study aimed to explore (1) CAM use by pediatric oncology patients in relation to specific time intervals and (2) communication about CAM use between parents and oncologists.

Methods

This retrospective cross-sectional study was conducted among parents of children diagnosed with cancer at a Swiss pediatric hematology-oncology center by means of an online questionnaire. Questions were related to their child’s CAM use over different time intervals, sources of information about CAM use, and communication with the oncologists.

Results

Among 140 respondents, CAM was used by 54.3% of patients before diagnosis and 69.3% of patients after diagnosis. During each defined time interval, between 50 and 58.8% of the patients used at least one CAM. Homeopathy was the most popular CAM modality used during oncology treatment, during the first year after treatment, and between 1 and 5 years after the end of treatment. Osteopathy was the most popular CAM ≥5 years after the end of oncology treatment. Forty percent of respondents did not discuss CAM with their oncologist.

Conclusions

The high prevalence of CAM use and the different trends of use during the oncology care pathway and afterward underline the need to increase communication about CAM in the pediatric oncology setting, notably regarding benefits and risks of interaction with oncology treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03271-9.

Questionnaires assessing the use of complementary health approaches in pediatrics and their measurement properties: A systematic review

OBJECTIVES

To identify questionnaires assessing the use of complementary health approaches (CHA) in pediatrics, describe their content, and appraise the methodological quality of the studies and the measurement properties of the questionnaires.

METHOD

Major electronic databases were searched from 2011 to 2020. Studies which aimed to assess the use of CHA and studies which reported developing and validating CHA questionnaires in pediatrics were included. Two reviewers independently screened the studies, extracted the data, and rated the methodological quality of the studies and measurement properties of the questionnaires using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. When consensus was not reached, a third reviewer was consulted.

RESULTS

Thirty-eight studies were included. From these studies, 35 CHA questionnaires with a variety of different items were identified. Only two studies aimed to evaluate the measurement properties of two questionnaires. One questionnaire, available as a self- and proxy-report, was initially validated in children with juvenile idiopathic arthritis, and the other, available as an interviewer-administered questionnaire, was validated in children with cancer. According to the COSMIN, the methodological quality of both studies was inadequate or doubtful, and both questionnaires was not thoroughly validated.

CONCLUSION

This systematic review showed a lack of a thoroughly validated CHA questionnaire in pediatrics. However, two questionnaires were found to hold promise. To address this gap, one of the existing questionnaires should be adapted and further validated.

Review of nutritional status, body composition, and effects of antineoplastic drug disposition

The overall survival for children with cancer in high income countries is excellent. However, there are many disparities that may negatively affect survival, which are particularly problematic in low income countries, such as nutritional status at diagnosis and throughout therapy. Nutritional status as well as concomitant foods, supplements, and medications may play a role in overall exposure and response to chemotherapy. Emerging science around the microbiome may also play a role and should be further explored as a contributor to disease progression and therapeutic response. This article highlights some of these issues and proposes additional areas of research relevant to nutritional status and pharmacology that are needed in pediatric oncology.

Complementary and Alternative Medicine Methods Used Among Turkish Pediatric Oncology Patients

PURPOSE

Complementary and alternative medicine (CAM) methods are gradually becoming common in pediatric oncology. The aim of this study was to determine the current use of CAM methods by Turkish mothers for their children with cancer.

DESIGN AND METHODS

The sample for this descriptive and cross-sectional study consisted of the mothers (n = 110) of children with cancer undergoing treatment in a hematology-oncology clinic and outpatient clinic. The data were collected using a questionnaire that included the CAM methods used by mothers for their children with cancer.

RESULTS

Of 110 children, 65 (59.1%) were diagnosed with leukemia and 107 (97.3%) underwent chemotherapy. More than half of the mothers (53.6%) were using CAM methods. The most common CAM method was the use of natural products (93.2%), of which the most frequently used were carob, mulberry, and grape molasses. Mothers used CAM to support the treatment of their children with cancer and alleviate the side effects of chemotherapy and, in most cases, without previously consulting healthcare professionals about their use.

CONCLUSIONS

This study revealed that most mothers used CAM methods for their children.

PRACTICE IMPLICATIONS

It is important that healthcare professionals are aware about the use of CAM methods in children with cancer to prevent any possible negative interaction between conventional (i.e., chemotherapy) and alternative treatments.