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Jeanne Dalen
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and form for publication on microfilm:
Approved by the Dissertation Committee:
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Accepted: r^
Dean, Graduate School
JUL 1 5 2008
Date
COMPLEMENTARY MEDICINE UTILIZATION AMONG
WOMEN WITH CERVICAL CANCER:
PREVALENCE AND CHARACTERISTICS
ASSOCIATED WITH USE
BY
LISA JEANETTE DALEN
B.A., International Development, New Mexico State University, 1995

B.A., Psychology, University of New Mexico, 1998
M.S., Psychology, University of New Mexico, 2005
DISSERTATION
Submitted in Partial Fulfillment of the

Requirements for the Degree of
Doctor of Philosophy
Psychology
The University of New Mexico

Albuquerque, New Mexico
July, 2008
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COMPLEMENTARY MEDICINE UTILIZATION AMONG
WOMEN WITH CERVICAL CANCER:
PREVALENCE AND CHARACTERISTICS
ASSOCIATED WITH USE
BY
LISA JEANETTE DALEN
ABSTRACT OF DISSERTATION
Submitted in Partial Fulfillment of the

Requirements for the Degree of
Doctor of Philosophy
Psychology
The University of New Mexico

Albuquerque, New Mexico
July, 2008
COMPLEMENTARY MEDICINE UTILIZATION AMONG WOMEN
WITH CERVICAL CANCER: PREVALENCE AND CHARACTERISTICS
ASSOCIATED WITH USE
by
Lisa Jeanette Dalen
B.A., International Development, New Mexico State University, 1995
B.A., Psychology, University of New Mexico, 1998
M.S., Psychology, University of New Mexico, 2005
Ph.D., Psychology, University of New Mexico, 2008
ABSTRACT
In order to expand treatment options, educate physicians and patients, and
improve patient-provider communication about complementary medicine (CM), it is
important to determine CM utilization patterns, especially within gynecologic cancer, a
population which has received much less attention within the literature. Additional
assessment is also required to empirically validate the characteristics associated with
patients who are likely to be utilizing CM. The development of a user profile could assist
in identifying patients who could potentially benefit both physically and psychologically
from CM and assist in monitoring those patients who are already using these therapies.
This dissertation study explored the prevalence of CM utilization in women with
cervical cancer and attempted to develop a user profile based on characteristics associated
with use. This study had three research aims: 1) To determine prevalence of CM
utilization since diagnosis and to examine how utilization changes over time, 2) To
evaluate characteristics associated with CM utilization and to develop a user profile based
iv
on the relative importance of each characteristic, and 3) To examine differences in the
user profile in patients who utilize multiple CM therapies.
The sample consisted of 197 women diagnosed with cervical cancer. The data
presented are part of a larger study examining quality of life in both long-term and short-
term cervical cancer survivors. The measures used included questions designed
specifically to assess complementary medicine use. Additionally, data were collected on
demographics, cervical disease severity, other medical conditions, and cervical disease
knowledge. Also included were multi-item scales assessing lifestyle behavioral factors,
optimism, religiousness, social support, coping, depression, and quality of life.
More than half of the sample (56%) had used CM since their diagnosis with an
average of 2.83 therapies utilized. Women with higher education were 1.5 times more
likely than less educated women, women with diagnosis related adverse conditions were
3.2 times more likely than women without adverse conditions, and women with co-
morbid medical conditions were 3.1 times more likely than women without co-morbid
medical conditions to use complementary therapies. Implications of this study along with
limitation and future directions for research are discussed.
V
TABLE OF CONTENTS
LIST OF TABLES vii
INTRODUCTION 1
Overall Introduction 1
Purpose of Present Study 5
CHAPTER ONE: LITERATURE REVIEW 6
Overview of Cervical Cancer 6
State of the Illness 6
Risk Factors for Cervical Cancer 7
Mortality Rates and Disparity Issues for Cervical Cancer 8
Defining Complementary Medicine 9
Complementary Medicine Modalities and Efficacy 10
Prevalence of Complementary Medicine
Utilization in Cancer Populations 11
Patterns of Complementary Medicine Utilization 12
Socio-Demographic Factors 14
Lifestyle and Health Practice Factors 15
Psychosocial Characteristics 16
Quality of Life and Health Status Factors 17
Research Aims and Hypotheses to Be Tested 19
CHAPTER 2: RESEARCH DESIGN AND METHODOLOGY 22
Participants 22
Procedures 22
Vi
Measures 23
Description of Data Analysis 28
Research Aim One: Prevalence of CM Utilization: 28
Research Aim Two: Development of a User Profile 29
Research Aim Three: Comparison of

High Level CM Use and Low Level CM Use: 30
CHAPTER 3: RESULTS 32
Whole Sample Demographics 32
Classification of CM Users and Non-users . 33
Prevalence of Complementary Therapies 33
Utilization over Time 35
Logistic Regression Predicting

Complementary Medicine Use 37
Logistic Regression Predicting High

Level Use of Complementary Therapies 41
CHAPTER 4: DISCUSSION 44
Prevalence of Complementary Medicine Utilization 44
Most Common CM Therapies Used 45
Utilization of CM Therapies over Time 49
Overall Predictors of CM Utilization 50
Predictors of Multiple CM Therapies 53
Limitations 55
Conclusion 56
REFERENCES 58
VI i
LIST OF TABLES
Table 1. Prevalence of complementary therapy use among cervical cancer patients

reporting use since diagnosis (N = 111).
Table 2. Correlations examining CM therapy use across 3 time points since

diagnosis: 1) During Diagnosis, 2) After Diagnosis, and 3) Currently.
Table 3. Patterns of use among the four most commonly used complementary therapies
assessing the relationship between use of the therapy since diagnosis and use of the
therapy before diagnosis (N = 111).
Table 4. Mean values or frequencies for predictor variables as a function of

complementary medicine use since diagnosis.
Table 5. Logistic regression predicting complementary medicine use.
Table 6. Mean values or frequencies for predictor variables as a function of using

multiple complementary therapies since diagnosis (N = 111).
Table 7. Logistic regression predicting high level use of complementary medicine

therapies (3 or more therapies since diagnosis).
viy^
INTRODUCTION
The evolving role of medicine and health in our society along with higher patient
expectations has started to bring about changes in the way health care is being
conceptualized (1). Presently, rigid conventional disease management programs are
giving way to more flexible and integrated programs tailored to the needs of the patient.
One area of medicine and health care where this is more apparent is in the use of
complementary medicine (CM) with cancer patients. CM is the current term that is
applied to a vast array of therapies not commonly included in mainstream medicine. Yet,
these therapies demonstrate potential for being non-invasive adjunctive treatments for
many of the physical and psychological conditions associated with chronic illness. Health
care professionals as well as patients and their families have become increasingly
knowledgeable about CM and how these therapies can be helpful to patients with cancer
(2).
The popularity of CM has grown exponentially in past years and this popularity
has impacted every element of health care in the US and all medical specialties, including
pain and palliative care. For example, research has show that visits to CM providers
increased 47.3% from 1990-1997, exceeding total visits to all primary care physicians in
that time period (3). Within the government system, the National Institute of Health
(NIH) created an office of complementary and alternative medicine, which in 1998, was
given the name The National Center for Complementary and Alternative Medicine
(NCCAM) (4). In the academic arena, many medical and nursing schools in North
America now offer elective courses in CM, and the number of research articles about CM
in major medical journals has consistently increased (4).
1
The use of CM to treat chronic illness and disability has been steadily increasing
in many conditions such as osteoarthritis, coronary artery disease, and particularly cancer.
In fact, research has found CM use to be typically higher among cancer patients than in
the general population and much of the literature on CM utilization is conducted within
this illness population (5). While the experience of cancer is different for each
individual, research suggests that certain psychosocial factors play a role in disease onset,
progression, and psychological adjustment (6). In addition, despite improved
pharmacological management, patients receiving chemotherapy continue to experience a
variety of treatment-related side effects, including nausea, fatigue, anxiety, and pain.
Effective non-pharmacological treatments for these negative symptoms are particularly
important with this population for many reasons. For example, cancer patients are often
on complex and time-intensive medication regimens. Furthermore, they may take other
medications to manage the side effects of diagnosis or chemotherapy. As more
medications are added (e.g. for pain or depression), the risk of drug interactions, adverse
side effects, and non-adherence to the medication regimen increases. Thus, any
intervention that assists in treating side effects and increasing well being could be
advantageous.
The goal of complementary therapies is to increase well-being, both physical and
psychological and although many questions about these therapies remain unanswered, the
current literature suggests that many of these therapies may help to alleviate a variety of
problematic conditions associated with cancer, not only by providing symptom relief but
increasing quality of life and adding a dimension of self-care and control over one's
health (7). Although results are far from conclusive, many controlled studies have started
2
to yield promising results with cancer patients and the use of complementary therapies in
the areas of chronic pain, insomnia, nausea, anxiety, and depression (8). There is
emerging evidence, for example, to support the use of 1) acupuncture for nausea and
pain, 2) massage therapy for anxiety, and the use of 3) mind-body techniques such as
meditation and relaxation for pain, insomnia, and anxiety. Additionally, there are
therapies starting to show potential for benefit, including Reiki and Healing Touch, and
NIH has recently funded several clinical trials to gather empirical evidence on their
usefulness. However, other therapies that fall under the rubric of complementary
therapies, such as large doses of vitamins and herbal supplements, have been more
controversial, and although there is potential danger of interactions with conventional
medications, this has not deterred patients from using them (8).
Despite the increased prevalence in CM utilization by cancer patients, the
motivation for its use is not yet clearly understood. Although CM use is widespread
within cancer disease management, not everyone with a diagnosis of cancer uses these
therapies as part of their treatment. Although several hospitals and clinic settings have
begun to incorporate complementary therapies into their oncology programs, thus
providing education and access, most patients opt to use these treatments on their own
and communication about utilization with physicians is typically low (9).
Thus, the patterns of CM use in cancer populations is still virtually unknown and
it is unclear if prior use of CM is a predictor of ongoing or current use, if CM use is
related to general health, or if CM use is reserved only for specific disease management
and treatment. In addition, nearly all of the research conducted on CM utilization in
3
cancer populations has focused on patients with breast cancer (10-12). The rate of CM
utilization specifically among women with gynecologic cancers is unknown (13).
To date, most studies conducted of cancer patients and of the general public show
that those who seek CM therapies tend to be better educated, of higher socioeconomic
status, female, and younger than those who do not (14,15). Typically, they are also more
health conscious and use more conventional medical services than do people who choose
to not use complementary therapies (16, 17). Aside from these demographics however, a
clear picture of the typical CM user has been difficult to ascertain. Studies have
suggested that possible variables associated with CM utilization include lifestyle and
health behaviors, psychosocial factors including attitude and personality characteristics,
and the influence of quality of life and health status factors. Limited research attempting
to associate these additional characteristics with CM use however has found mixed
results (18,19). One reason for the discrepancy in findings may be due to the substantial
variation in CM research questionnaires which range anywhere from surveying four to
five complementary therapies to upwards of two dozen different therapies (20-22). The
ability to detect differences between groups could be problematic due to the present
problem concerning standardization of instruments and clarity regarding which therapies
and treatments actually constitute a complementary medicine classification.
A wide variety of motivations for using CM have been reported in the literature
dismissing any simple characterization of why cancer patients use these therapies (23-
25). One problem with general characterizations of why people use CM is that they tend
to overlook different motivations for initiating CM and sustaining CM use over time.
Additional research is needed to determine if a typical profile of the CM user in cancer
4
populations exists or if instead CM use is contextual-factor dependent. In addition,
distinctions between newer CM users and those who have more experience with CM are
important for clarifying the role of these factors in the choice to use CM.
For these reasons, this dissertation makes a significant contribution to the
empirical literature on complementary medicine utilization in cancer populations while
adding to our understanding of the use of complementary therapies in women with
gynecological malignancies.
Purpose of Present Study
This dissertation study explored the prevalence of complementary medicine
utilization in a group of women diagnosed with cervical cancer and attempted to develop
a user profile based on characteristics theorized in the literature as being associated with
utilization of complementary medicine therapies.
This study had three research aims:
1) To determine prevalence of CM utilization since diagnosis and to
examine how utilization changes over time.
2) To evaluate the association of socio-demographic, health behavior,
psychosocial, quality of life, and health status characteristics with CM
utilization and to develop a user profile based on the relative importance
Of each characteristic.
3) To examine differences in the user profile in patients who utilize
multiple CM therapies.
5
The literature review begins with an overview of cervical cancer including state of
the illness, risk factors, mortality rates, and disparity issues. Next, a review of how CM
is organized and defined within NIH along with a summary of the current evidence
regarding the efficacy and safety of CM therapies in cancer treatment. Next,
characteristics of CM users will be reviewed including what is currently known in
regards to prevalence and patterns of CM utilization, sociodemographic factors, health
behaviors, personality characteristics, and quality of life and health status factors.
Finally, several hypotheses are posited and an in-depth methodological procedures
section is offered.
Overview of Cervical Cancer
State of the Illness
Cancer is the second leading cause of death in the United States with nearly half
of all men and a little over one third of all women developing cancer during their
lifetimes (26). According to the Center for Disease Control, in 2002, 1.2 million people
were diagnosed with cancer in the United States and an estimated 10.1 million Americans
were living with a previous diagnosis of cancer (26).
Gynecologic cancers are diagnosed in female reproductive organs that include the
uterus, ovaries, cervix, fallopian tubes, vulva, and vagina. Throughout the world, the
incidence of cervical cancer is second only to breast cancer as the leading, invasive
cancer among women, although in some developing nations, cervical cancer is more
prevalent (27). Half of women diagnosed with this cancer are between the ages of 35 and
55 with slightly over 20% of women with cervical cancer being diagnosed over the age of
6
65. The American Cancer Society estimated that in 2006, about 9,710 new cases of
invasive cervical cancer were diagnosed in the United States with approximately $1.7
billion spent on treatment. (28). Researchers estimate that noninvasive cervical cancer
(carcinoma in situ) is about four times more common than invasive cervical cancer. The
treatment options for cervical cancer depend mostly on the stage of the cancer. The three
main types of treatments for cervical cancer are surgery, radiation, and chemotherapy
(27).
Risk Factors for Cervical Cancer
Distinct from age, family history, and possible genetic determinants are
modifiable risk factors that have been associated with cervical cancer, including sexual
history, multiple pregnancies, use of birth control pills for more than five years, smoking,
diet, and not receiving regular cervix screenings,. Human papillomavirus (HPV)
infection is the main risk factor for cervical cancer and women who have had many
sexual partners or who have had sexual intercourse with a man who has had many sexual
partners may be at higher-than-average risk of HPV infection. In addition, women who
have had many full-term pregnancies or have used birth control pills for five or more
years show an increased risk. Women who smoke are about twice as likely as those who
don't to get cervical cancer and diets low in fruits and vegetables have been linked to an
increased risk of cervical and other cancers (28, 29). Cervical cancer is also more
common among women who do not have regular Papanicolaou (Pap) tests (28, 29).
The risk of developing cervical cancer increases with age through a woman's 20s
and 30s; the risk remains about the same for women over the age of 40. Minority women
and women of low socioeconomic status have higher rates of cervical cancer and an
7
increased mortality rate. According to the Centers for Disease Control and Prevention
(CDC), African-American, Asian-American, and Hispanic women have a higher-than-
average incidence of the disease, while African-American and Hispanic women have a
higher rate of cervical cancer-related death (29).
Mortality Rates and Disparity Issues for Cervical Cancer
When found and treated early, cervical cancer often can be cured. Indeed, the
incidence of invasive cervical cancer has decreased significantly over the last 40 years, in
large part because of screening for, and treatment of, precancerous cervical lesions
through the use of the Pap test. This screening procedure can find changes in the cervix
before cancer develops and can also find early cancer in its most curable stage.
Therefore, the death rate from cervical cancer continues to decline by nearly 4% a year
with a reported five-year relative survival rate for the earliest stage of invasive cervical
cancer around 92%, and the overall (all stages combined) five-year survival rate for
cervical cancer around 73% (28).
However, women in America have not benefited equally from the decrease in
overall cervical cancer mortality. Hispanic, Native Americans, Native Alaskans,
Vietnamese, and Korean women have higher than average cervical cancer mortality rates
and African American women continue to have more than twice the mortality rate
compared with white women (28). This is in conjunction with other countries which
report that of the 471,000 new cases of cervical cancer diagnosed annually worldwide,
most are predominantly among the economically disadvantaged in both developing and
industrialized nations (27). Many factors have been cited as possible determinates for
this disparity including biology, socio-cultural factors, economics, and provider issues.
8
For example, deaths from cervical cancer occur disproportionately among women who
are uninsured or underinsured and Pap tests are underused by women who have no
source, or no regular source of healthcare; women without health insurance; and women
who immigrated to the United States within the last 10 years (27).
Defining Complementary Medicine
Complementary medicine (CM) refers to a large number of therapies, systems,
and techniques that exist largely outside the institutions where conventional medicine is
taught and delivered (1). Typically, both the terms "complementary" and "alternative"
medicine are usually grouped together, however, it is important to note that there are
distinct and vital differences between the two terms. Most notably, complementary
therapies are used in conjunction with conventional medicine, while alternative therapies
are used in place ©/"conventional medicine (30). In regards to complementary therapies,
typically they are thought of as adjuncts to traditional cancer care and are supportive
measures to control symptoms, enhance well being, and contribute to overall patient care
(3). Complementary therapies address the body, mind, and spirit, aiming to enhance
quality of life for patients and families. Over time, some complementary therapies have
been proven safe and effective. These therapies have then become integrated into
mainstream care, producing what Cassileth & Deng (2004), calls integrative oncology,
which is "a synthesis of the best of mainstream cancer treatment and rational, data-based,
adjunctive complementary therapies", p. 81 (30).
On the other hand, alternative therapies are products and therapeutic regimens ^
promoted for use instead of conventional cancer care. Alternative therapies typically are
invasive, costly, and potentially toxic (1,31). Although debated by practitioners and
9
patients, most alternative cancer therapies are currently unproven by modern scientific
data. Many physicians advocate that alternative cancer therapies can be dangerous
clinically because they delay some patients' receiving of conventional medicine (30, 32).
This can be especially problematic in oncology, when delayed treatment can reduce the
possibility of remission and cure. Research has found that although a minority of cancer
patients seek unproved therapies promoted as independent treatments for use instead of
using conventional procedures such as surgery, chemotherapy, and radiation, the majority
of cancer patients choose to use therapies in conjunction with traditional medicine (8).
Due to this, this study is assessing the use of therapies in conjunction with conventional
medicine and thus uses the term complementary medicine.
Complementary Medicine Modalities and Efficacy
Although CM approaches are diverse and abundant, NCCAM has made an
attempt at organization by grouping CM therapies and systems under five major domains;
1) Alternative Medical Systems, 2) Mind-Body Therapies, 3) Biologically-Based
Therapies, 4) Manipulative and Body-Based Therapies, and 5) Energy Therapies.
Although much research is still needed, many of these complementary therapies have
shown to be effective in dealing with symptoms associated with palliative care and could
be helpful in the treatment of pain, anxiety, fatigue, and depression (1). Other therapies,
although promising, are yet unproven and can be potentially dangerous. Preliminary
evidence gathered from pilot studies, case reports, and limited randomized trials suggest
that CM therapies may offer non-invasive adjunctive treatments for many of the physical
and psychological conditions associated with cancer including nausea, pain, fatigue,
insomnia, mood disturbances, anxiety, and stress (3, 8). Studies of good methodological
10
quality are relatively few, however, and consistent difficulties exist with many of the
studies published in this area including small sample size, and inconsistent standards on
intervention and outcome variables (33). At this stage of investigation, the therapeutic
applications of CM relating to cancer treatment remain largely unexplored.
Although using the word CM implies a homogenous group of therapies, research
in each modality is at a different stage of development and sophistication. For example,
research in acupuncture is now well established and studies are now moving towards
more sophisticated controlled designs. Research in mind-body therapies, while not in its
early stages, has not yet fully developed into large controlled trials; although randomized
trials are now beginning to surface. Research in other modalities including energy
therapies and biologically-based treatments however, are in their infancy and will require
an expanded research initiative to confirm their effects.
Prevalence of Complementary Medicine Utilization in Cancer Populations
Many studies have been conducted over the past decade designed to determine the
prevalence of CM utilization among cancer patients. Research has found CM use to be
typically higher among cancer patients than in the general population (5). Early reports
of use ranged from 7% to 64% of patients sampled with an average prevalence of 31%
(34), however in recent years, there has been some indication that CM use among cancer
patients is actually growing (8). For example, according to Zappa & Cassileth (2003), it
is recently estimated that 37% to 83% of cancer patients use CM therapies as an adjunct
to their mainstream treatment (3). The higher prevalence rates reported are usually
credited to breast cancer patients with estimates in this group ranging from 40% to 83%
11
(15, 35-38). However, this finding has been inconsistent with other studies reporting no
relationship between the prevalence of CM use and type of cancer (39-41). Indeed,
recent studies conducted with gynecologic oncology patients have reported high rates of
use in this population. Estimates range from 50% to 76%, although reported rates of use
for cervical cancer patients have been considerably lower than other gynecologic
malignancies such as ovarian cancer and uterine cancer (42-44).
Researchers attribute small study samples and the use of different survey
instruments to the substantial variation in prevalence estimates across studies (45). As of
yet, a consistent survey tool for all studies that measures specific CM therapies has not
been developed, and so this methodological limitation is not likely to be resolved soon.
Patterns of Complementary Medicine Utilization in Cancer Populations
As stated above, some patients with cancer abandon conventional treatment in
favor of CM possibly because of beliefs in the ability of these therapies to cure cancer
(46, 47). However, most patients do not reject conventional therapy altogether, and in
most cases, CM is used to complement, not replace, conventional therapy (48, 49).
Research has also found evidence that those who choose to utilize CM, use
multiple therapies (50) and report high satisfaction rates (51, 52). Several studies, using
different categorization criteria, have reported the number of types or modalities of CM
used by patients. The mean number of CM therapies used by patients with cancer ranged
from 1.6 to 6.6 (36, 41, 53). The frequency and duration of use of CM products and
therapies have been found to vary, ranging from regular daily consumption to more
sporadic use (54).
12
A recent systematic review was conducted examining the most common CM
therapies used by cancer patients, hi data gathered from 26 surveys of cancer patients
from 13 countries, including five from the US, it was found that the most commonly used
therapies included dietary treatments, herbs, homeopathy, hypnotherapy,
imagery/visualization, meditation, megavitamins, relaxation, and spiritual healing (55).
Other surveys substantiate these findings (45, 56, 57). For example, in a survey
conducted by members of the European Oncology Nursing Society, it was found that the
five most frequently used therapies were similar across most countries. Herbs were the
most common treatment - used in 13 of the 14 countries and the number one CM
treatment in nine. Most of the herbs were specific to each country. Homeopathy was
among the top five in seven countries as were medicinal teas, with vitamins or minerals
featured in the top five in nine countries (58). In one of the few published studies
examining gynecologic oncology outpatients, prayer was found to be the most widely
used (40%) as were green tea (17%), nutritional supplements (17%), garlic (16%), and
exercise (16%) (59). In another study conducted by Swisher et al. (2002) involving 113
patients diagnosed with gynecologic cancer, 66% of CM users had used faith healing or
therapeutic touch, 39% had used mental imagery/visualization, and 32% had used
meditation, yoga, or other relaxation techniques (60).
Research conducted on the primary information source for CM therapies has
generally found that referrals are generally by family or friends, consistent with the
observation that word of mouth is a usual method of finding CM therapies and
practitioners (61). However, recent research by Shen et al. (2002) suggests that
information sources may vary according to CM modality. For example, among patients
13
who took herbal medicine and/or practiced relaxation and meditation techniques, the two
most common primary information sources were mass media and friends or family
members. Information on other CM therapies such as acupuncture, vitamins and special
diets were more likely to come from health professionals in conventional settings and
CM practitioners (62).
Sociodemographic Factors
To date, virtually all studies conducted of cancer patients and of the general
public show that those who seek CM therapies tend to be better educated, of higher
socioeconomic status, female, and younger than those who do not (15, 36, 38, 41, 46, 47,
63-68) with a few exceptions regarding age (69-71) and socioeconomic status (72, 73).
Logically, women who are more educated may be more informed, on average, of CM
therapies, as well as having greater financial resources to seek out CM therapies that are
not covered under insurance programs (74). Reasons why females tend to use more CM
therapies then men are not currently known, although researchers have suggested that
there may be psychological differences in the way in which men and women cope with a
cancer diagnosis (75).
Culture can also strongly influence an individual's health-seeking behavior
including both the decision to use CM and the type of therapies used (76). Studies
examining ethnic differences in regards to CM use have been sparse providing limited
information. For example, some studies have suggested that Caucasian ethnicity predicts
CM use along with the amount of therapies used (15, 46, 77). However, in a study of a
multi-ethnic cancer population from Hawaii, Gotay (1999) found no differences in CM
14
use by ethnicity (78) reflecting other studies, both breast cancer and gynecologic cancer,
finding no relationship between ethnicity and CM utilization (47, 79-81).
In addition, studies suggest that Latinos and Mexican-Americans show lower
rates of usage then their non-Hispanic white counterparts. Two surveys conducted in the
1990's showed that only 6% -10% of Hispanic respondents reported using any form of
CM (82). However, when specific cultural practices have been examined, such as the use
of traditional folk remedies and prayer, considerably higher usage rates have been found
with estimations from 55% - 75% (83-88).
Lifestyle and Health Practice Factors
Although a number of sociodemographics have been identified as perhaps
predisposing patients with cancer to use complementary therapies, motivational processes
to use CM are not well understood. One theory that has garnered attention in the past
decade is that CM use may be related to an individual's worldview. For example, in a
survey conducted by Astin (1998), it was concluded that CM users find complementary
therapies to be more compatible with their own values, beliefs, and philosophical
orientations toward health (25). Moreover, CM users have been found to be more health
conscious and believe more strongly that people can influence their health through the
choices they make regarding lifestyle (89). Research suggests that individuals who use
complementary therapies typically have a greater awareness of preventive health
practices such as reducing stress, getting proper sleep (90), and also report making more
healthy food choices (91). Research conducted in Germany found that 68% of patients
with a variety of illnesses who opted to use complementary therapies indicated good
15
health behaviors such as low use of smoking (89%), alcohol (81%), and sweets (62%).
Many also claimed healthy eating habits (87%), regular health checkups (66%), and
participation in sport activities (55%) (92). However, none of these health practices
distinguished CM users on the basis of length or frequency of CM use and the extent to
which CM use promotes behavioral changes contributing to positive health outcomes
remains unknown.
Psychosocial Characteristics
Because most patients make choices about CM utilization independent from their
physician's guidance, their own psychosocial characteristics may play a considerable role
in their decision to use complementary therapies. For example, Honda and Jacobson
(2005) found that psychological characteristics such as personality, coping, and social
support was associated with CM use in a sample of US adults (93). In a study conducted
by Sollner (1997) active coping style was associated with CM utilization although social
support was not (94). Findings from the Sollner study also suggested that religiousness
was associated with increased use of CM. This is in conjunction with other studies that
have found a correlation between religiousness and CM utilization (95). Within
gynecologic oncology studies, McKay, Bentley, and Grimshaw (2005) found women
who considered themselves religious to be more likely to use CM and Swisher et al.
(2002) found a trend towards greater CM usage and religiousness (96, 97). Other studies
however, have failed to find a relationship between CM utilization and religiousness (38,
72, 98). It is unclear whether including prayer/spiritual healing as a CM therapy helps to
explain the significant relationship found between religiousness and CM use. For
16
instance, prayer/spiritual healing was also included as a CM therapy in the three studies
that did not find a significant relationship between the two variables.
Research has also investigated the role of optimism as a potential personality
characteristic associated with CM utilization. It has been suggested that positive
expectancies assists in coping with chronic illness by allowing the individual to perceive
illness as modifiable and thus, promotes adaptive behaviors such as choosing to use
complementary therapies (99). Indeed, CM users frequently report optimistic attitudes
towards treatment in general and a positive appraisal of complementary therapies (92). In
the Swisher et al. (2002) study, gynecologic oncology patients reported an improvement
in optimism and hope as the most common actual benefit of using complementary
therapies. Additional research conducted by Wyatt (1999) found CM users to be
significantly more optimistic than non-users and among breast cancer survivors, Buettner
and colleagues found higher optimism scores for those who opted to use relaxation and
imagery (38, 100). Nevertheless, the role optimism plays in CM utilization is still unclear
as other studies have failed to find a relationship (101).
Quality of Life and Health Status Factors
Another large inquiry of investigation which has produced mixed results has been
examining emotional and social distress as possible motivators for CM use. Based on a
preliminary study by Burstein, Gelber, Guadagnoli, and Weeks (1999) which found that
women who initiated the use of CM after surgery for cancer reported a worse quality of
life than women who never used CM (102), other researchers have also found that CM
users experience more somatic symptoms, and score higher on depression, and anxiety
17
scales than non-users (46, 47, 103). Kao and Devine (2000) reported lower satisfaction
regarding role functioning, cognitive functioning, social functioning, physical symptoms
and global quality of life in a group of patients diagnosed with prostate cancer who opted
to use CM (104). Nonetheless, although some studies suggest that the use of CM is a
marker of greater psychosocial distress and poorer quality of life, other studies have
failed to replicate these findings (105-107), or on the contrary have found CM use to be
related to active coping behavior (108) greater positive affect (109), and higher personal
control (110).
Other factors found to be associated with increased CM use include being in more
advanced stages of cancer (111) and poorer health status has been found to predict CM
use (25, 112). Specifically, the use of CM has been associated with a greater number of
physical symptoms such as nausea and vomiting (15, 36, 113). For example, in a
population-based telephone survey of CM use among cancer patients, both men and
women with high levels of physical symptom distress were more likely to use alternative
providers. Among men, those with higher physical symptoms, including nausea,
vomiting, abdominal pain, and decreased sexual function were almost three times more
likely to use CM (110). In another study involving 1,027 Israeli oncology patients,
functional quality of life and physical symptom scores were significantly worse for recent
CM users compared with nonusers, controlling for age, sex, and disease status (103).
However, many studies have not been able to replicate the finding that disease severity is
related to CM use (36, 73, 98, 114-116) and researchers have posited that the findings of
greater reported physical pathology in users of CM could be explained by the fact that
those studies contained a higher proportion of seriously ill patients (117).
18
Research Aims and Hypotheses to Be Tested
In order to expand treatment options, educate physicians and patients, and
improve patient-provider communication about CM, it is important to determine CM
utilization patterns, especially within gynecologic cancer, a population which has
received much less attention. Examining utilization during treatment and long term use
over time will assist in shedding light on whether CM therapies and products are used on
a more contextual treatment basis or whether it is consistent over time. Additional
assessment is also required to empirically validate the characteristics associated with
patients who are likely to be utilizing CM. The development of a user profile could assist
in identifying patients who could potentially benefit both physically and psychologically
from complementary therapies and assist in monitoring those patients who are already
using these therapies. Finally, distinctions between newer CM users and those who have
more experience and use more CM therapies are important for clarifying the role of these
factors in the choice to use CM. Examining differences between those who use few
therapies and those who use multiple therapies could help to shed light on the
discrepancy in findings that characterize much of the research literature on CM utilization
in cancer patients. The following hypotheses are specifically designed to address these
issues.
This study articulates three research aims. Within each research question are
specific hypotheses that were examined.
19
Research Aim One was to determine the prevalence of CM utilization and to examine
how utilization changes over time. Examination of prevalence rates, satisfaction with
therapy use, and reasons for therapy use were exploratory in nature and thus, no specific
hypotheses were posited. Examination of utilization over time however, was
hypothesized as follows:
HI: Use of complementary therapies before treatment would be correlated with
use since diagnosis and use of complementary therapies during or after treatment
would be correlated with current use of therapies.
Research Aim Two was to evaluate the association of sociodemographic, health behavior,
psychosocial, quality of life, and health status characteristics with CM utilization and to
develop a user profile based on the relative importance of each characteristic. Research
aim two was hypothesized as follows:
H2: CM utilization would be associated with younger age, higher education,
income, and having health insurance coverage.
H3: CM utilization would be associated with more preventive health behaviors
such as receiving checkups, lower smoking and alcohol intake, and higher
physical activity, fruit and vegetable intake.
H4: CM utilization would be associated with higher scores on optimism,
religiousness, social support, quality of life, and coping, and lower scores on
depression.
H5: CM utilization would be associated with severity of diagnosis, including a
diagnosis of carcinoma in situ, more adverse physical conditions associated with
20
diagnosis, lower physical quality of life and presence of additional medical
conditions.
Research Aim Three was to examine differences in the user profile in patients who utilize
multiple CM modalities ( > 3) (N = 50) since diagnosis versus those patients who utilized
only one or two therapies (n = 37) since diagnosis. From a theoretical standpoint, it is not
clear at this time what constitutes "multiple therapy use" and so for the purposes of this
study, the two groups were chosen based on a natural split in the data. Examination of
multiple therapy users was exploratory in nature and thus, no specific hypotheses were
posited.
21
RESEARCH DESIGN AND METHODOLOGY
Participants
The total sample consisted of 197 women who had been diagnosed with cervical
cancer between 1980 and 1999. Eligibility criteria included a diagnosis of invasive
cervical cancer or carcinoma in situ between 1980 and 1999; Hispanic or non-Hispanic
white ethnicity; age 25 through 79; and New Mexico residency at diagnosis. The data
presented in this study are part of a larger study examining quality of life in both long-
term and short-term cervical cancer survivors. This larger study titled, 'Adaptation and
Quality of Life among Long-term Survivors of Cervical Cancer' was part of a
collaborative effort among several sites in conjunction with associated tumor registries:
Yale University (Connecticut Tumor Registry), Wayne State University (Metropolitan
Detroit Cancer Surveillance System), Cancer Research Center of Hawaii (Hawaii Tumor
Registry, and University of New Mexico (New Mexico Tumor Registry). The aim of the
larger study was to provide information on the long-term effects of cervical cancer and
treatment on quality of life among survivors.
Procedures
All participants in this study were recruited through the University of New
Mexico and consent procedures for this study were reviewed and approved by the Human
Research and Review Committee. Women were ascertained through the New Mexico
Tumor Registry (NMTR). Eligibility criteria included: a diagnosis of invasive cervical
cancer or carcinoma in situ between 1980 and 1999; Hispanic or non-Hispanic white
ethnicity; age 25 through 79; and New Mexico residency at diagnosis. A total of 2,016
22
women were eligible: 596 invasive cases; 1,420 in situ cases. This included 933 Hispanic
cases and 1,083 non-Hispanic white cases. Diagnostic and demographic information as
well as the name and address of the diagnosing physician were collected from the
NMTR. An introductory letter describing the study along with a brochure that further
explained the study purpose and goals, detailed the forthcoming questionnaire and
explained the role of NMTR was sent to both physicians and women. Physicians
indicated if a woman should not be contacted and non-response was considered passive
approval. Only two physicians refused contact for subjects. Of the total 1,264
participants presumed to have received the questionnaire, 197 returned the questionnaire
(16%) and 1067 did not return the questionnaire (84%). All 197 women who completed
and returned the questionnaire were included in this study.
Measures
The measures used in testing the hypotheses included questions designed
specifically to assess complementary medicine use. Additionally, data were collected on
demographics, cervical disease severity, other medical conditions, and cervical disease
knowledge. Also included were multi-item scales assessing lifestyle behavioral factors,
optimism, religiousness, social support, coping, depression, and quality of life.
1.) Complementary Medicine Utilization. Designed specifically for the quality of life
study, participants were asked about their use of complementary therapies and were
allowed to choose from a list of nine identified therapies as well as to specify any CM
therapy usage not mentioned. These choices included: acupuncture, massage or another
form of body work, herbs/tea, individual prayer, spiritual/faith healer,
23
vitamins/supplements, visualization/meditation, yoga/Tai Chi Chi'h, and healing touch,
reiki, or another form of off-the-body touch. Participants were asked to mark each time
they had used each therapy at four different time points in their lifetime: 1) before
diagnosis, 2) during treatment, 3) after treatment, and 4) currently. Definitions of each
CM therapy were not included in this questionnaire. Participants were also asked if they
had specifically used the therapy to treat cervical disease or to treat the side effects of
cervical treatment, and how helpful or satisfied they were with each remedy.
2.) Participant Sociodemographics. In order to gain descriptive information regarding the
sample, a general demographic questionnaire designed specifically for the quality of life
study was given and included questions regarding age, education, income, ethnicity, and
health insurance coverage.
Measures Assessing Health Behaviors
3.) The New Mexico Behavioral Risk Factor Surveillance Survey fBRFSS) 1998-1999.
The BRFSS was used to assess lifestyle behavioral factors. The BRFSS is the primary
source of scientific, state-based data on adult health risk behaviors that lead to chronic
diseases such as cancer, diabetes and heart disease. Assessed dimensions included daily
consumption of fruit and vegetables, physical activity in the past month, number of days
of alcohol consumption in the past month, current smoking status, years since last
smoking behaviors, and being advised to lose weight in the past 12 months. In addition,
screening behaviors regarding mammogram, clinical breast exam, and pap smears were
assessed for two timeframes: 1) ever in lifetime and 2) years since last screening.
4.) Knowledge Regarding Cervical Cancer. Developed specifically for this study, this
question directly asked the participant's level of cervical cancer knowledge at two
24
timepoints: 1) at diagnosis, and 2) two years after diagnosis. Participants responded on a
5 point Likert scale with 1 = ("very knowledgeable") to 5 = ("not at all knowledgeable").
Measures Assessing Psychosocial Characteristics and Quality of Life
5.) The Life Orientation Test (LOT) (118). The LOT was used to assess optimism and
includes eight statements about general expectations regarding the future. Participants
responded by indicating how much they agreed or disagreed with each statement on a 1
("strongly disagree") to 5 ("strongly agree") scale. Four items assess positive
expectations (e.g., "in terms of uncertainty, I usually expect the best") and four items
assess negative expectations about the future (e.g., "I hardly ever expect things to go my
way"). The negative expectation items were reverse coded so that the scale as a whole
assesses positive expectations regarding the future. Although combining items tapping
positive and negative expectancies could be considered as both optimism and pessimism,
we will refer to the measure as "optimism" in this article to match the original usage of
the authors of this scale. Cronbach's alpha for the scale was .87.
6.) The Duke Relifiion Index (DRI) (119). The DRI is a 5-item scale that captures
organizational, non-organizational, and intrinsic religiosity dimensions. The items are
responded to on five or six point Likert scales. The five point scale was converted to a
six point scale to give equal value to each item. The items of the scale were modified to
include aspects of both religion and spirituality because of the overlap in meaning of the
terms religion and spirituality. For example, the item "How often do you attend church,
synagogue, or other religious meetings?" was changed to "How often do you attend faith
community or other religious/spiritual meetings?" Cronbach's alpha for this measure
was .86.
25
7.) Medical Outcomes CMOS) Social Support Survey (120), The MOS, developed for
patients in the Medical Outcomes Study in 1985, was used to evaluate social support
systems. This survey contains 19 functional support items designed to measure five
dimensions of social support: 1) emotional support (expression of positive affect,
empathetic understanding, encouragement of expressions of feelings; 2) informational
support (offering of advice, information, guidance or feedback); 3) tangible support
(provision of material aid or behavioral assistance); 4) positive social interaction
(availability of other persons to do fun things with); and 5) affectionate support
(expressions of love and affection). The overall score ranges from 0 - 1 0 0 with higher
scores indicating more support available. The authors recommend that each subscale is
scored and analyzed separately. One additional question was added asking about
utilization of cancer support services and how helpful they were.
8.) Coping Measure. Seven items were asked regarding specific coping skills based on
the "I Can Cope" Support Group Program offered by the American Cancer Society.
9.) Center for Epidemiologic Studies Depression Scale (CES-D) (121). The CES-D, a
short 20-item self-report scale, was used to measure current symptoms of depression.
Responses are scored from 0 - 3 , representing the amount of time each symptom was
experienced. Scores range from 0 to 60 with higher scored indicating more symptoms of
depression. Independent of the CED-D scale, which is based on symptoms reported for
the past week, women were also asked to respond to whether they had ever been
diagnosed as having depression.
Measures Assessing Quality of Life
26
10.) The SF-36 Health Survey (122). The SF-36 was used to assess functional health
status. The multi-item scales measure eight health dimensions: 1) physical functioning;
2) role limitations because of physical functioning; 3) bodily pain; 4) social functioning;
5) general mental health (psychological distress and psychological well-being; 6) role
limitations because of emotional problems; 7) vitality (energy/fatigue); and 8) general
health perceptions. Scores on each dimension range from 0 (indicating low functioning
and well-being) to 100 (indicating high functioning and well-being). The scale
distinguishes between performance and capacity to perform activities and minimizes the
potential for value judgments regarding the impact of independent variables on
functioning.
11.) Self-Report Rating of Current Quality of Life. In addition to the SF-36, a one item
measure of current quality of life was used that asked "Overall, how would you rate your
quality of life currently?" and participants responded by selecting one of give responses
ranging from 1 ("Excellent") to 5 ("Poor").
Measures Assessing Health Status Factors
12.) Diagnostic and Treatment Information. Designed specifically for the quality of life
study, questions were asked related to type of cancer diagnosis including invasive
cervical cancer, carcinoma in situ, or cervical disease and types of treatment received
including surgery, radiation, and chemotherapy. In addition, participants were asked
about five adverse conditions associated with cervical disease including 1) diarrhea or
inability to control bowels, 2) inability to control bladder, 3) painful intercourse, 4)
vaginal discharge, and 5) difficulty or pain in walking.
27
13.) Charlson Weighted Index of Comorbidity (CWIC) (123). Conditions listed on the
CWIC were used to assess information about co-morbid illnesses. Participants were
asked whether they had been diagnosed with the following co-morbid conditions: heart
problems, asthma, several lung diseases, ulcers, diabetes, kidney disease, rheumatoid
arthritis, lupus, polymyalia, cirrhosis, leukemia, lymphoma, or AIDS. In addition, eight
additional questions were added assessing co-morbid sexual conditions including genital
warts, genital herpes, trichomonas infection, Chlamydia, gonorrhea, syphilis, pelvic
inflammatory disease (PID), and human papillomavirus infection (HPV).
Description of Data Analysis
Data analysis occurred in six steps.
Research Aim One: Prevalence of CM Utilization:
In the first step, classification of CM users and nonusers was conducted and
descriptive analyses were used to assess the prevalence of each CM therapy. Those
women who had used at least one complementary therapy since diagnosis were classified
as "CM users" whereas those women who had not used any complementary therapies
since diagnosis were classified as "CM nonusers". Prevalence statistics reported for each
CM therapy included 1) the percentage of people who reported using the therapy since
diagnosis; the whole sample and the ethnic breakdown between Hispanic and Caucasian
ethnicity, 2) the percentage of users who reported using the therapy specifically to treat
cervical disease or to treat the side effects of cervical disease, and 3) the mean
satisfaction rating for each therapy.
28
HI: For the second step, in order to test hypothesis 1, Pearson correlation
analyses were conducted to examine use of CM therapies over three time points: 1)
during treatment, 2) after treatment, and 3) current use. As a third step, further evaluation
of the four most commonly used therapies in this sample was conducted examining the
relationship between patterns of use before diagnosis and patterns of use after diagnosis
and treatment. Specifically, for each of the four most commonly used therapies, a two-
way contingency table analysis using crosstabs was conducted evaluating the relationship
between the number of patients using the therapy before treatment and the number of
patients reporting use of the therapy 1) during treatment, 2) after treatment, and 3)
currently. The decision to evaluate the top four therapies was chosen based on sample
size considerations and having sufficient power to run the analysis.
Research Aim Two: Development of a User Profile
H2 - H5: The primary analysis focused on assessing the association between
patient characteristics and CM utilization. In order to test hypotheses 2-5, binary logistic
regression was used to assess which patient characteristics were predictive of CM use.
First, means and standard deviations were calculated for continuous variables, and
frequencies and percentages were calculated for categorical variables. Differences
between CM users and nonusers with respect to demographic, health behaviors,
psychosocial, quality of life, and health status characteristics were assessed by chi-square
tests or student t-tests, depending on the measurement of the variable (i.e. dichotomous or
continuous). Continuous variables were evaluated for normal distribution. Typically,
variables with significance levels of p < .25 in univariate models are considered candidate
variables for further assessment in multivariate models (124). However, due to the
29
number of variables being assessed, a more conservative approach was taken in this study
and a significance level of p < .15 was used.
Candidate variables were then entered into a multivariate logistic regression
model to assess their relationship with CM use. The model provides an odds ratio (OR)
and 95% confidence interval (CI) for each variable while simultaneously controlling for
the effect of other variables. The OR is a statistical estimate of the probability of
observing an association between the variable of interest, and the 95% CI provides a
measure of precision for the estimate. A forward-stepping algorithm was used to add
significant variables to the model based on the Wald statistic of less than or equal to 0.05.
The Hosmer-Lemeshow chi-square test was used to assess the goodness of fit between
the observed and predicted number of outcomes for the final model, and p > .05 indicates
a good fit (125). SPSS 15.0 was used to perform all analyses and all p value tests were
two-tailed.
No adjustments were made for multiple testing in the univariate models because
these exploratory tests were performed only to identify variables to include in the
multivariate model, not for definitive conclusions about CM use. The P values as stated
were used to identify the relative significance levels between the variables tested, but all
conclusions on the predictors of use were based on the multivariate analyses.
Research Aim Three: Comparison of High Level CM Use and Low Level CM Use:
As a fifth step, classification of CM users using multiple therapies was conducted.
What was the highest number of therapies reported by any one woman. Perhaps include
a sentence on the number of therapies used by any single woman among those who used
CM ranged from one to xxx. Those women who reported use of three or more
30
complementary therapies since diagnosis were classified as "CM high level users"
whereas those women who reported use of only one to two complementary therapies
since diagnosis were classified as "CM low level users". As a sixth and final step, the
logistic regression procedure stated above was re-run with the two new groups: 1) CM
high level users, and 2) CM low level users.
Report the number of women who had at least one imputed data value. Also, how
many variables were affected and which variables were most frequently missing data?
What was the highest number of imputed values for any one person? All missing data
was addressed by generating a value using the structural mean function in SPSS. No
participants were excluded from the analyses due to missing data.
31
RESULTS
Whole Sample Demographics
The 197 participants ranged in age from 26 to 72 with a mean age of 51 years
(s.d. = 9.13). Mean years since diagnosis was 10.30 (s.d. = 5.01; range = 1 - 2 2 years).
Sixty-seven percent of the respondents were married, 24% were divorced or separated,
3% were widowed, and the remaining 6% were single/never married. Ethnicity of the
patient sample was representative of the southwestern United States, where data were
collected: 70% Caucasian, 26% Hispanic, 3% Native American or Alaska Native, and 1%
non-Hispanic African American. Income and education were treated as continuous
variables with 1 as the lowest and 5 as the highest level. The median annual family
income for the whole sample was between $30,000- $49,999 (range = under $10,000 to
over $50,000 per year) and the mean highest level of education for the whole sample was
"Some College or Technical School". Finally, just over half of the women in the sample
were employed and most worked full-time.
With regard to disease-related characteristics for the whole sample, 48% were
diagnosed with invasive cervical cancer and 52% were diagnosed with carcinoma in situ
where cancer cells had not yet spread into the surrounding tissues. Nine percent reported
a family history of cancer. The majority of women were treated with surgery (87%);
18% also reported treatment with radiation or chemotherapy. Eighty-five percent of the
whole sample reported having health care coverage with 30% reporting having private
insurance.
32
Classification of CM Users and Non-users
Those women who reported use of at least one complementary therapy since
diagnosis were classified as a "CM user" (n = 111) (56%) and those women who reported
no use of any complementary therapy since diagnosis were classified as a "CM nonuser"
(n = 86) (44%). Those participants who reported only using a therapy at some point prior
to their diagnosis with cancer but had never used that therapy since diagnosis were
classified as a "nonuser" for that particular therapy. However, since most participants
used each therapy during multiple time points and/or used multiple therapies, only six
participants reported only using therapies before they were diagnosed with cancer and
thus, were classified in the "nonuser" group.
Prevalence of Complementary Therapies
The mean number of reported therapies used was 2.83 (s.d. = 1.89) and the
breakdown of number of therapies used was as follows: one therapy (32%), two therapies
(23%), three therapies (15%), four therapies (10%), five therapies (11%), six therapies
(5%), seven therapies (1%), eight therapies (1%), and nine therapies (2%). Table 1
presents the prevalence statistics reported for each CM therapy assessed and includes: 1)
the percentage of people reporting using the therapy since diagnosis, 2) utilization
breakdown between Hispanic and Caucasian ethnicity, 3) the percentage of people
reporting using the therapy at three different time points assessed including 'during
treatment', 'after treatment', or 'current use', 4) the percentage of users who reported
using the therapy specifically to treat cervical disease or to treat the side effects of
33
cervical disease, and 5) the mean satisfaction rating for each therapy. The most
commonly used CM therapy was individual prayer (77%), followed by
vitamins/supplements (66%), herbs (34%), and massage/body work (31%). Of these four
most commonly used therapies, more women reported use after treatment or currently
rather than during their cervical treatment. In addition, when asked whether or not the
therapy was used specifically in the treatment of cervical cancer or in treating the side
effects of the cancer, only 28% of vitamin/supplements users, and 19% of the individual
prayer, herbs, and massage/body work users reported that the therapies were used
specifically for cervical disease. This same pattern was also found in the other
complementary therapies assessed. Other than use of a spiritual/faith healer, more
women reported using the therapy after treatment or currently rather then during their
treatment and the percentages of women who reported using the therapy for treatment of
cervical disease was low with numbers ranging from 5 - 13%. Utilization differences
were observed between women of Caucasian and Hispanic ethnicity. Specifically, the
percentage of utilization for Caucasian women was significantly higher for every CM
therapy with the exception of prayer. The mean satisfaction ratings were highest for
healing touch/reiki, followed by massage, individual prayer, visualization, and yoga.
Participants reported being only somewhat satisfied with a spiritual/faith healer,
acupuncture, vitamins, and herbs.
34
Table 1. Prevalence of complementary therapy use among cervical cancer patients reporting use
since diagnosis (N = 111).
Used Used to Mean
Therapy Used Used treat Satisfaction
Since During After Current cervical Rating*
Diagnosis Caucasian Hispanic Treatment Treatment Use Disease (sd) **
% % % % % % %
Acupuncture 16 22 3 2 14 4 13 1.93 (.79)
Massage / Body Work 31 40 9 6 19 22 19 1.50 (.96)
Herbs 34 42 16 11 22 27 19 2.35(1.5)
Individual Prayer 77 73 84 58 58 68 19 1.51 (1.0)
Spiritual / Faith Healer 13 14 9 9 8 8 7 1.88(1.3)
Vitamins / Supplements 66 71 53 31 44 56 28 2.18(1.1)
Visualization / Meditation 23 28 9 12 18 11 7 1.59 (.79)
Yoga / Tai Chi Chi'd 15 22 0 1 12 8 13 1.75(1.1)
Healing touch / Reiki / 9 10 6 3 9 4 5 1.13 (.35)
*Mean satisfaction score based on the Likert Scale 1 = Very Satisfied - 3 + Not Satisfied; Lower scores = higher satisfaction
** sd = standard deviation
Utilization over Time
Pearson correlation coefficients were computed examining the use of each CM
therapy across time. Results are displayed in Table 2 and show significant correlations
across the three time points since diagnosis including 1) 'during treatment' and 'after
treatment', 2) 'during treatment' and 'current use', and 3) 'after treatment' and 'current
use' for the majority of all CM therapies except acupuncture, and yoga/tai chi. Use of
acupuncture during treatment was not significantly correlated with use after treatment or
with current use and use of yoga/tai chi during treatment was not correlated with current
use.
35
Table 2. Correlations examining CM therapy use across 3 time points since
diagnosis: 1) During Diagnosis, 2) After Diagnosis, and 3) Currently.
During During After
Treatment Treatment Treatment
and After and Current and Current
Treatment Use Use
Acupuncture .15 -.03 .21*

Massage / Other form of body work .35** .22* .47**
Herbs .52** .44* .52**
Individual Prayer .82** .50** .61**
Spiritual / Faith Healer 7j** .60** .76**
Vitamins / Supplements .63** .40** .50**
Visualization / Meditation .56** .51** .60**
Yoga/Tai Chi Chi'd .26** -.03 .41**
He aling touch / Reiki / .53** .27** .61**
*Correlation is significant at the 0.05 level (2-tailed).

** Correlation is significant at the 0.01 level (2-tailed).
Further evaluation of the four most commonly used therapies in this sample were
conducted with a two-way contingency table analysis using crosstabs to evaluate whether
there was a relationship between use of the therapy since diagnosis and use of the therapy
before diagnosis. Specifically, we evaluated the number of women using the therapy
before diagnosis with two levels (yes and no) and the number of women who used the
therapy 1) during treatment, 2) after treatment, and 3) currently, each with the same two
levels (yes and no). Results are shown in Table 3 and indicate that for each of the four
most common therapies used, there was a significant relationship between use of the
therapy before diagnosis and use of the therapy after diagnosis. Effect size statistics were
computed with the Phi statistic, which measures the correlation between two categorical
variables, and ranged from .32 - .64. Specifically, the majority of women who reported
using individual prayer, vitamins/supplements, herbs, and massage/body work during
36
treatment reported first using that therapy before being diagnosed. A small percentage of
women reported using a therapy during their treatment when they had not used it
previously before their diagnosis (30% individual prayer, 12% vitamins/supplements, 5%
herbs, and 3% massage/body work). The same pattern was shown for use after treatment
and current use with the majority of women reporting use of that therapy before diagnosis
and only a small percentage of women reporting using a therapy that they had not used
previously before being diagnosed.
Table 3. Patterns of use among the four most commonly used complementary therapies assessing the relationship
between use of the therapy since diagnosis and use of the therapy before diagnosis (N = 111).
Did not use treatment Used treatment
before diagnosis before diagnosis
% % D2(df=l) p-value Phi
Individual Prayer
Used During Treatment 30 92 43.95 .000 .63
Used After Treatment 30 92 43.95 .000 .63
Used Currently 44 96 33.56 .000 .55
Vltamins/SuDDlements
Used Currently 39 97 32.19 .000 .54
Herbs
Used Currently 18 77 24.88 .000 .47
Massage/Bodv Work
Used Currently 14 100 39.84 .000 .60
Logistic Regression Predicting Complementary Medicine Use
Table 4 details characteristics of CM users and nonusers regarding
sociodemographic, physical health status, psychosocial, and health behavior variables.
The univariate analysis indicated that women with higher education (g. = .02), and less
knowledge since diagnosis (p_ = .01) were more likely to use CM. In addition, women
37
with lower mental health status (p = .02), higher depression (p_ = .01), lower social
support (p = .15), higher coping (p = .15), and higher quality of life (p = .07) were more
likely to use CM. Finally, women who had invasive surgery (p = . 13), more adverse
conditions associated with diagnosis (p = .00), and more co-morbid medical conditions (p
= .00) were more likely to use CM.
38
Table 4. Mean values or frequencies for predictor variables as a function of complementary medicine use
since diagnosis.
Non-Users of CM Users of CM
N == 86 N == 111
Continuous Variables Mean Std. Dev. Mean Std. Dev. t-test p value cohen's d
Sociodemographics
Age 40.10 8.85 42.00 9.49 -1.13 ns 0.21
Education 3.94 1.11 4.36 , 1.26 -2.45 0.02 0.35
Income 4.38 1.76 4.32 1.68 .20 ns -0.03
Health Behaviors
Days of alcohol intake/ last month 1.83 2.27 2.28 2.60 -1.27 ns 0.18
Fruit and vegetable intake/weekly 3.77 2.15 4.21. 2.36 -1.31 ns -0.2
Knowledge since diagnosis 2.46 1.1 2.07 0.94 2.60 0.01 -0.38
Psychosocial and Oualitv of Life
SF36 Mental health 72.88 18.99 65.70 23.38 2.35 0.02 -0.34
Depression - CES-D 14.84 9.90 18.9 12.26 -2.50 0.01 0.36
Social Support MOS 74.46 19.49 70.18 20.52 1.45 0.15 -0.21
Post Traumatic Growth 64.51 33.76 70.09 26.36 -1.22 ns 0.18
Coping 13.93 12.45 16.36 10.13 -1.46 0.15 0.21
Optimism 29.94 5.46 29.30 5.95 0.76 ns -0.11
Religiousness 18.47 5.88 19.10 5.80 -0.73 ns 0.11
QOL Current 2.05 1.04 2.34 1.19' -1.80 0.07 0.26
QOL 2 yrs after diagnosis 2.05 1.04 2.35 1.21 -1.84 0.07 0.27
Health Status
SF36 Physical health 78.7 20.91 71.65 23.11 2.18 0.03 -0.32
Dichotomous Variables % % D2 (df=l) p-value Phi

Sociodemo graphics
Ethnicity - Caucasion 65.1 71.2
Ethnicity - Hispanic 29.1 24.3 0.84 ns 0.07
Insurance coverage 84.5 88.2 0.55 ns 0.05
Private insurance 32.1 29.1 . 0.21 ns 0.03
Family history of cancer 11.6 7.2 1.14 ns -0.08
Health Behaviors
Mammograms 89.4 89.0 0.01 ns 0.01
Breast exams 100 98.2 1.56 ns 0.09
Current Smokers 29.1 24.8 0.86 ns 0.07
Physical activity/last month 75.3 78.0 0.19 ns -0.03
Health Status
Diagnosis of invasive cervical cancer 44.2 52.3 1.26 ns 0.08
Invasive surgery 52.3 63.1 2.30 0.13 0.12
Type of treatment
Adverse conditions with diagnosis 31.8 58.6 13.88 0.00 0.27
Comorbid medical conditions 53.5 79.3 14.82 0.00 0.27
Note: T-test used for all continuous variables and Chi-square test used for all dichotomous variables.
CM users and nonusers did not differ with respect to demographic variables such
as age, income, ethnicity, insurance coverage, or family history of cancer. No differences
were seen with respect to health behaviors such as days of alcohol and fruit and vegetable
39
intake in the past month, receiving mammograms and breast exams, being a current
smoker, or participating in physical activity during the last month, hi addition, no
differences were seen with respect to the psychosocial variables examining posttraumatic
growth, optimism, and religiousness. Finally, no differences were seen with respect to
type of diagnosis received. However, CM users differed from CM nonusers with respect
to education, knowledge gained since diagnosis, mental health status, depression, social
support, coping, quality of life, physical health status, having invasive surgery, adverse
conditions associated with diagnosis, and co-morbid medical conditions.
When the twelve potential predictors were examined in a multivariate logistic
regression model, use of CM was predicted (X2 = 34.8, p_ = .001) by higher education,
more adverse conditions associated with diagnosis, and more co-morbid medical
conditions. Please see Table 5. Women with higher education were 1.5 times (95% CI,
1.17 to 2.02) more likely than less educated women, women with adverse conditions
associated with their diagnosis were 3.2 times (95% CI, 1.66 to 6.05) more likely than
women without adverse conditions, and women with co-morbid medical conditions were
3.1 times (95% CI, 1.59 to 6.06) more likely than women without co-morbid medical
conditions to use complementary therapies. Therefore, the final logistic model with three
variables exhibited a satisfactory fit ((X2 = 5.2, p_ = .74) between obtained and expected
outcomes.
Table 5. Logistic regression predicting complementary medicine use.
Variable Odds Ratio Beta S.E.(beta) Wald Exp(B) 95% CI p

Education 1.5 0.43 0.14 9.48 1.54 1.17-2.02 0.002
Adverse conditions associated with diagnosis* 3.2 1.15 0.33 12.19 3.21 1.66-6.05 .000
Co-morbid medical conditions* 3.1 1.13 0.34 11.05 3.11 1.59-6.06 0.001
* Reference groups were adverse conditions vs. no adverse conditions, and co-morbid conditions vs.
no co-morbid conditions.
40
Logistic Regression Predicting High Level Use of Complementary Therapies
Of the 111 women who reported CM use since diagnosis, approximately half
(46%) (n = 51) reported use of three or more therapies and were classified as "high level
users", while 54% (n = 60) reported using only one to two therapies and were classified
as "low level users". Within the high level user group, the mean number of reported
therapies used was 4.5 (s.d. - 1.52) and the breakdown of number of therapies used was
as follows: three therapies (33%) (n = 17), four therapies (22% (n = 11), five therapies
(25%) (n = 13), six therapies (12%) (n = 6), seven therapies (2%) (n = 1), eight therapies
(2%) (n = 1), and nine therapies (4%) (n = 2). Within the low level user group, the mean
number of reported therapies used was 1.42 (s.d. = .50) and the breakdown of number of
therapies used was as follows: one therapy (58%) (n = 35), and two therapies (42%) (n =
25).
Table 6 details characteristics of CM "high level users" and "low level users"
regarding the same demographic, physical health status, psychosocial, and health
behavior variables that were examined in the first logistic regression. The univariate
analysis indicated that compared with low level users, high level users reported higher
levels of education (p_ = .08), higher percentage of women with Caucasian ethnicity (p =
.005), higher quality of life two years after diagnosis (p_ = .04), higher percentage of
women diagnosed with invasive cervical cancer (p_ = .01), and higher percentage of
women who had received invasive surgery (p_ = .02).
41
Table 6. Mean values or frequencies for predictor variables as a function of using multiple complementary therapies
since diagnosis (N = 111).
Low Level Users of CM High Level Users of CM
l t o 2 Therapies 3 or More Therapies
N = 60 N == 51
Continuous Variables Mean Std. Dev. Mean Std. Dev. t-test p value Cohen's d
Sociodemo graphics
Age 41.62 9.09 41.57 10.02 0.03 ns -0.01
Education 3.92 1.31 4.33 1.19 -1.74 0.08 0.33
Income 3.82 1.71 3.91 1.84 -0.21 ns 0.05
Health Behaviors
Days of alcohol intake/ last month 2.07 2.61 2.52 2.52 -0.92 ns 0.18
Fruit and vegetable intake/weekly 4.07 2.31 4.41 2.34 -0.65 ns 0.15
Knowledge since diagnosis 2.1 0.85 2.0 1.01 0.97 ns -0.11
Psychosocial and Quality of Life
SF36 Mental health 66.22 23.39 65.08 23.09 0.25 ns -0.05
Depression - CES-D 18.38 11.39 19.51 12.47 -0.49 ns 0.09
Social Support MOS 71.82 20.99 68.26 19.11 0.93 ns -0.18
Post Traumatic Growth 68.71 27.72 71.73 22.48 -0.62 ns 0.12
Coping 15.95 10.69 16.84 9.29 -0.46 ns 0.09
Optimism 29.89 5.73 28.61 6.17 1.11 ns -0.21
Religiousness 18.95 6.31 19.26 5.19 -0.28 ns 0.05
QOL Current 2.20 1.11 2.49 1.25 -1.28 ns 0.25
QOL 2 yrs after diagnosis 2.13 1.13 2.60 1.27 -2.00 0.04 0.4
Physical Health Status
SF36 Physical health 72.41 22.24 70.75 23.84 0.38 ns -0.07
Dichotomous Variables % % D2 (df=l) p-value Phi

Sociodemo graphics
Ethnicity - Caucasion 60.0 84.3 7.94 0.005 0.27
Ethnicity - Hispanic 40.0 15.7 7.94 0.005 0.27
Insurance coverage 90.0 86.0 0.42 ns -0.06
Private insurance 31.7 26.0 0.43 ns -0.06
Family history of cancer 10.0 3.9 1.52 ns -0.12
Health Behaviors
Mammograms 90.0 87.8 0.14 ns 0.04
Breast exams 100 100 ns
Current Smokers 25.0 24.5 0.01 ns -0.06
Physical activity/last month 76.3 80.0 0.22 ns 0.05
Health Status
Diagnosis of invasive cervical cancer 41.7 64.7 5.87 0.01 0.23
Invasive surgery 53.3 74.5 5.31 0.02 0.23
Adverse conditions with diagnosis 56.7 60.8 0.19 ns 0.04
Comorbid medical conditions 80.0 78.4 0.04 ns -0.02
Note: T-test used for all continuous variables and Chi-square test used for all dichotomous variables.
When these five potential predictors were examined in a multivariate logistic
regression model, use of CM was predicted (X2 (2) = 14.8, r> = .001) by Caucasian
ethnicity, and diagnosis of invasive cervical cancer. Please see Table 7. Women who
42
reported Caucasian ethnicity were 3.9 times (95% CI, 1.52 to 10.13) more likely than
Hispanic women, and women who had received a diagnosis of invasive cervical cancer
were 2.8 times (95% CI, 1.26 to 6.34) more likely than women who had received a
diagnosis of carcinoma in situ to have reported high level use of CM therapies.
Therefore, the final logistic model with two variables exhibited a satisfactory fit (X2 =
.08, p_ = .96) between obtained and expected outcomes.
Table 7. Logistic regression predicting high level use of complementary medicine therapies
(3 or more therapies since diagnosis).
Variable Odds Ratio Beta S.E. (beta) Wald Exp(B) 95% CI P

Caucasion ethnicity* 3.9 1.37 0.48 8.01 3.93 1.52-10.13 0.005
Diagnosis of invasive cervical cancer* 2.8 1.04 0.41 6.31 2.82 1.26-6.34 0.01
* Reference groups were Caucasian ethnicity vs. Hispanic ethnicity, and diagnosis of invasive <
cervical cancer
vs. carcinoma in situ.
43
DISCUSSION
This study was designed to explore the prevalence of complementary medicine
utilization in a group of women diagnosed with cervical cancer. Using binary logistic
regression, a user profile was developed based on sociodemographic, health behavior,
psychosocial, quality of life, and health status characteristics theorized in the literature as
being associated with utilization of complementary medicine therapies in cancer
populations.
Prevalence of Complementary Medicine Utilization
More than half of the sample (n = 111) (56%) had used at least one form of
complementary medicine since their diagnosis with an average of 2.83 therapies utilized.
Most women reported relatively high satisfaction rates with use. Although this is
consistent with findings from other studies who report prevalence rates between 50 -
76% within gynecologic oncology, typically the reported rates of use for cervical cancer
patients have been considerably lower than other types of cancer (126). For example,
Munstedt, Kirsch, Milch, Sachsse, and Vahron (1996) found that only 26% of women
with cervical cancer reported CM use compared to 58% for ovarian cancer and 47% for
breast cancer (98). However, in a study by Mckay, Bentley, and Grimshaw (2005),
though cervical cancer patients were less likely to use CM than other gynecologic
oncology patients, nonetheless a relatively high percentage (59.1%) of women with
cancer of the cervix did report use of CM (127).
In addition, significant utilization differences were found between Caucasian and
Hispanic women with Caucasian women reporting a higher utilization of every CM
therapy with the exception of prayer. This finding is consistent with other studies
44
examining the impact of ethnic identity on CM use. For example, Goldstein, et. al (2005)
found that Latinos consistently reported a lower level of use then Caucasians on every
measure of CM utilization except self-directed prayer, where they report more use (86).
However, other research suggests that the specific methods used to ask about CM
use in ethnic populations could alter the report of usage rates. For example, Herman,
Dente, Allen, and Hunt (2006), found similar rates of overall current CM use between
New Mexican Hispanics (65.5%) and non-Hispanic whites (67.8%) diagnosed with a
Rheumatoid condition (128). One reason suggested for the possible high rates of usage
reported in this Hispanic population is the way the data was collected. In addition to the
data being collected by interview, the explanation did not use CM terminology. Instead
participants were asked "about ways they managed their condition on their own, beyond
what their primary care provider prescribed and recommended"(128). This discrepancy
in findings points to the need for more studies examining ethnic specific CM use and.
recognition that relying on broad, ambiguous measures may not be sensitive enough to
specify the relationships in question.
Most Common CM Therapies Used
The most commonly used CM therapies reported in this study were individual
prayer, followed by vitamins/supplements, herbs, and massage/body work. This finding
is consistent with studies involving gynecologic oncology and other cancer populations
indicating that the most frequently used CM therapies include spirituality/prayer,
nutritional supplements/ vitamins, herbs, and relaxation strategies (58, 129-133).
45
Within the CM literature, the consideration as to whether prayer, spirituality, faith
healers, shamanism, and other therapies that are not considered health care practices
should be included have been questioned (134). In this study, individual prayer produced
the highest percentage usage rate. If prayer had been excluded from the study, the
percentage of CM users would have dropped from 56% to 44%. Since prayer was
included on the original questionnaire, we chose to include prayer for the purposes of this
study. However, further discussion on how to treat this issue in the future is needed.
Currently, there exists no clear understanding as to what therapies should belong under
CM and thus, controversy exists whether to include therapies such as vitamin use,
nutrition and diets, behavioral medicine, exercise and any and all treatments that have not
been integrated into conventional medical systems. Further complicating matters is the
fact that studies use different terminology and most do not clarify what is actually meant
by utilizing a therapy. For example, in regards to prayer, terms used in the literature
include prayer, faith healing, spiritual healing, and spiritual healing by others; but most
do not give precise definitions so the reader typically has to rely on their own subjective
interpretations. In regards to assessing vitamin use, it is rarely clear what type of vitamin
use is being assessed, whether it is the ingestion of an everyday multi-vitamin or the use
of more potent mega-vitamins promoted for their curative properties in cancer disease
management. As mentioned earlier, NCCAM has made an attempt at organization by
grouping CM therapies and systems under five major domains. As researchers, it is now
important to discuss and develop a standardized index of CM therapies to include under
the five domains that uses its own precise operational definitions. At this stage of dialog,
it is also important to continue to gather information from those who actually use these
46
therapies, giving them opportunity to educate us on how they define and interpret their
use in addition to how frequently, how much, and for what intent. Employing this type of
two-way discussion to inform the process of standardization could provide a much more
accurate picture of and a richer perspective of the use of CM in people's lives.
Clarifying these matters is an important issue as the reported rise in the use of
dietary supplements and herbal medications by cancer patients makes it necessary to
evaluate the efficacy of these treatments with quality clinical studies. Among
complementary approaches, high-dose vitamin C is one of the most widely used and
studied. However, other popular treatments such as mistletoe, shark cartilage and
countless others have very limited research behind them and recent inquiries have offered
little evidence of the effectiveness of these treatments, both short and long term (135,
136). Currently, a major concern regarding the use of herbal and vitamin supplements is
that the supplements are not required to undergo any federally regulated safety testing
(135). Formulations for herbal supplements may contain 4-12 different ingredients and
are available in many different formats, including teas, powders, pills, tinctures, and
syrups (135). Supplements are typically not tested for purity or consistency, so each
sample may contain a different formulation or dosage. In addition, the U.S. Food and
Drug Administration passed legislation in 1994 allowing herbal supplements to be sold
over the counter (137), as well as absolving doctors and pharmacists from having to
report any potential side effects the supplements may cause (135).
Another area of concern is a lack of physician notification regarding supplement
use on the part of the patient. Although we did not specifically ask about physician
communication regarding complementary therapy use in this study, findings from other
47
studies indicate that many patients do not disclose to their oncologists or nurses if they
are using supplements. For example, in a recent survey, as many as 72% of patients had
not informed their physicians of their use of herbal supplements (138, 139). In addition,
more than 70% of patients who used CM therapies in a national survey (140) and 54% is
a breast cancer study (9) reported that they had not disclosed CM use to their physicians.
Lack of reporting about supplement use can potentially be dangerous as herbs and/or
vitamins may interfere biologically with conventional cancer medications and treatments
(141, 142). In addition, many patients take combinations of different herbs and vitamins
at the same time and usually take these products in higher doses than recommended
(143). Unmonitored combinations and dosages of herbs and/or vitamins have
considerable potential for detrimental chemotherapy-herb/vitamin interactions. For
example, in a study involving 76 adult cancer patients receiving chemotherapy, it was
found that herb and vitamin use was common (78%) and one-third of the study
participants were at risk for a detrimental chemotherapy - herb/vitamin interaction (142).
In addition, the American Cancer Society in 2003 reported that herbal medicine has
become the leading cause of hepatotoxicity (144). Researchers have speculated that liver
damage and other negative interactions related to herbal medicine may be from the lack
of quality control of herbal supplements involving impurities or from the use of
supplements with prescribed medications, resulting in adverse drug interactions (135,
141).
48
Utilization of CM Therapies over Time
Support was found for the first hypothesis that use of complementary therapies
before treatment would be associated with use since diagnosis and use of therapies during
or after treatment would be associated with current use of therapies. Specifically,
significant correlations across the three time points since diagnosis were found for the
majority of all CM therapies except acupuncture, and yoga/Tai Chi. In addition, patterns
of use among the four most common therapies used showed that the majority of women
who used a therapy since their diagnosis actually began use of the therapy before they
received the diagnosis of cervical cancer. These findings are congruent with what
researchers have tentatively started too hypothesized in that CM usage before diagnosis
may be an important predictor of CM usage during and after cancer diagnosis (145).
This suggests that familiarity with and exposure to CM therapies before diagnosis
may play a role in the decision to use CM both during and after cancer treatment. This
also suggests that use of CM therapies remains consistent over time and is not just
treatment dependent. Many investigators have reported the need for routine assessment
of cancer patients to include documentation of CM use (Richardson 2002). One key
implication of our finding is if past use is a reliable predictor of future use, then obtaining
accurate histories of CM usage before treatment could assist patient-physician
communication and disclosure during treatment. Thus, developing a standardized
instrument which allows physicians to gage a woman's familiarity and comfort level with
various CM therapies could provide a useful tool in monitoring CM use during cancer
treatment and over time.
49
This is an important topic of discussion since as previously mentioned, one large
concerning finding presenting itself in the literature is the lack of disclosure by CM users
to their physicians (9,146-148). Although disclosure to physicians regarding CM use has
been found to be relatively low, research also suggests that the majority of CM users
report that they would welcome the opportunity to talk to their physicians about their use
of these therapies. In a study by Sparber et al. (2000), 57% of patients' physicians did
not ask them about CM therapies. However, 62% stated that talking to their physicians
was important, 82% believed that they would be supported in their use of CM and 90%
believe that CM therapy use would not jeopardize their participation in a research
protocol (41).
Given this difference between willingness to disclose use and actual disclosure of
use, it is necessary to both understand the reasons for and to help develop tools to assist
both patients and physicians in bridging this gap and find a common ground for
discussion and dialogue concerning CM utilization.
Overall Predictors of CM Utilization
Univariate analyses indicated that women with higher education and less
knowledge since diagnosis were more likely to use CM. However, apart from these
findings, differences between CM users and nonusers focused more on physical health
status and quality of life factors than on demographic or health behavior factors.
Specifically, women who utilized CM therapies since diagnosis had considerably more
health status problems then women who did not use CM including lower functional
physical health status, having invasive surgery, more adverse conditions associated with
50
diagnosis, and more co-morbid medical conditions. In addition, they had lower
psychosocial functioning including lower general mental health status, higher depression,
and lower social support. However, despite these findings, CM users still reported higher
coping ability, and significantly higher quality of life both currently and two years after
diagnosis, the implications of which will be discussed in the next section.
The strongest predictors of CM utilization showed that women with higher
education were 1.5 times more likely than less educated women, women with adverse
conditions associated with their diagnosis were 3.2 times more likely than women
without adverse conditions, and women with co-morbid medical conditions were 3.1
times more likely than women without co-morbid medical conditions to use
complementary therapies.
Thus, partial support was found for the second hypothesis that CM utilization
would be associated with higher education. However, no differences were found with
respect to the other sociodemographic variables hypothesized to be of significance such
as age, income, ethnicity, insurance coverage, or family history of cancer. This is
consistent with other studies that have indicated that variables such as age (149-151), and
socioeconomic status (72, 73) may not be consistent indicators of CM utilization.
No support was found for the third hypothesis that CM utilization would be
associated with more preventive health behaviors. Thus, we were not able to duplicate
previous research suggesting that CM users have a greater awareness of preventive health
practices and engage in more healthy behaviors such as low use of smoking and alcohol,
healthy eating habits, regular health checkups, and participation in sport activities (92).
In our study, CM users did report higher monthly fruit and vegetable intake, higher
51
monthly physical activity, and a lower percentage of current smokers; though it was not
enough to reach significance. In fact, the only significant difference between users and
nonusers indicated that women who had gained less knowledge since diagnosis (p = .01)
were more likely to use CM. In addition, CM users reported slightly higher use of
alcohol, and a slightly lower percentage of women receiving mammograms and breast
exams; though again, these differences did not reach significance. One reason for these
findings may be due to the sensitivity of the measurements used in this study in that most
behaviors assessed a relatively small time frame; typically in the past month or year.
More research in this area is needed to examine the relationship between CM use and
health behaviors over time.
Significant differences were found between CM users and nonusers with respect
to psychosocial and quality of life variables although some findings were in the opposite
direction then hypothesized. Partial support was found for the fourth hypothesis,
consistent with other studies (108, 152), that CM utilization would be associated with
higher scores on quality of life and coping. The significant findings for global mental
health status, depression, and social support, however, were in the opposite direction
hypothesized. This association between poorer social distress and CM use has been
implicated as possible motivators for CM use by other investigators (46, 47,103, 104,
153). Consistent with some of the literature, we found no differences with regards to
posttraumatic growth, optimism (154), and religiousness (38, 72, 98).
Support was found for our fifth hypothesis that CM utilization would be
associated with health status. This is consistent with much of the complementary
medicine literature indicating that poorer health status (25, 112), a greater number of
52
physical symptoms such as nausea and vomiting (15, 36, 155), abdominal pain, and
decreased sexual function (110) (103) may drive the decision to use CM. Some
researchers have posited that these findings could be explained by the fact that those
studies contained a higher proportion of seriously ill patients (156). In our study,
however, the diagnoses of invasive cervical cancer (48%) and carcinoma in situ (52%)
were almost evenly split between the full sample with little more than half (53%)
reporting no adverse conditions associated with their diagnosis. In addition, 51% of the
full sample reported one or less co-morbid medical condition.
The fact that our study mimics the varied results found in the literature examining
the relationships between quality of life, health status and CM use indicates that much
more nuanced research needs to be conducted in this area. Based on the preliminary
findings of this study and others, one potential hypothesis is that perhaps health status,
quality of life, and emotional distress provide differential contributions and are not
necessarily orthogonal constructs. Specifically, the initial decision to use CM could be
motivated by poorer health status and emotional distress, but that over time, CM
utilization begins to enhance active coping skills and quality of life overall by providing a
sense of control over one' s health outcomes.
Predictors of Multiple CM Therapies
The findings also indicate that complementary medicine users may not be a
homogenous group; those women who chose to utilize multiple therapies may be
distinctly different than those who utilize a minimal number of therapies. Specifically,
this study found that compared with low level users, high level users reported even higher
levels of education, a higher percentage of women with Caucasian ethnicity, a higher
53
quality of life two years after diagnosis, a higher percentage of women diagnosed with
invasive cervical cancer, and a higher percentage of women who had received invasive
surgery.
The strongest predictors of multiple CM therapy use were those women who
reported Caucasian ethnicity were 3.9 times more likely than Hispanic women, and
women who had received a diagnosis of invasive cervical cancer were 2.8 times more
likely than women who had received a diagnosis of carcinoma in situ to have reported
high level use of CM therapies.
These findings have several implications. First, these findings suggest that
women who are in more advanced stages of cancer, educated, and of Caucasian ethnicity
may potentially utilize many more types of CM therapies to assist with conventional
treatment. Women diagnosed with invasive cervical cancer typically undergo more
rigorous conventional treatment regimens, thus, it is important for physicians to closely
monitor CM utilization in these patients, including frequency and duration.
Second, these findings may help to begin shedding light on why much of the
research within complementary medicine has found mixed results. For example, a few
studies have found that Caucasian ethnicity predicts CM use along with the amount of
therapies used (15, 46), while other research have not been able to duplicate this
relationship (157) (47, 81,158,159). This study's findings suggest that ethnicity is a
significant predictor in the chose to use multiple CM therapies, but not in the choice to
use CM in general. Though much more research needs to be conducted to specify the
relationship between ethnicity and CM use, ethnic populations might only rely on those
specific therapies that are accessible, familiar, and in line with their cultural beliefs; thus
54
resulting in using fewer therapies. Along the same line, many studies have not been able
to replicate the finding that disease severity is related to CM use (36, 73, 98, 160-162);
however, in this study, adverse conditions with diagnosis were related to CM use overall,
and severity of diagnosis was related to the chose to use multiple CM therapies. Thus,
different factors may indeed drive the decision making process to use CM but it may be
dependent on the context and the level of utilization the researcher is examining.
Lastly, more women reported use of CM therapies after treatment or currently
rather than during their cervical treatment. In addition, when asked whether or not
therapies were used specifically in the treatment of cervical cancer or in treating the side
effects of the cancer, it was found that only a small percentage of respondents reported
using therapies specifically for cervical disease. This implies that perhaps other
contextual factors are involved, other then a diagnosis of cancer that both motivates and
sustains use of complementary medicine in cancer populations. For example, the
strongest predictors of CM use overall were those women who had physical health
problems related to their diagnosis of cancer, but they also were more likely to have
additional medical conditions that they were contending with. In addition, perhaps
having dealt with a chronic illness with considerable health consequences could make
people become more health conscious in general and more willing to explore and use
therapies on their own in conjunction with conventional medicine.
Limitations
This study had several limitations. First, the questionnaire measuring CM use
was limited; this study was not able to determine the frequency of use of specific
55
products and services, and did not ask as to whether a practitioner of CM was seen or if
they made use of CM on their own. This study was also did not gather information
regarding physician communication and disclosure. In addition, definitions of specific
CM therapies were not included and so it is not possible to know how participants were
thinking about therapy use and how they defined particular therapies. One potential issue
of this is that some women who reported no use may have in fact been using CM
therapies without realizing it. For example, Navo (2004) found that when medication
histories were reviewed, many women were using agents that by definition were types of
CM, even though they self-reported no CM use. Second, the response rate was modest
making it difficult to know how well these findings generalize. These findings could be
an artifact of the current sample and potentially not generalizable to other cervical cancer
populations. Finally, the results from this study were from cross-sectional data and were
based on findings that represent one plausible theoretical representation of the constructs.
It is important to note that there could be equally plausible models that represent different
relationships between the variables.
Conclusion
Despite these limitations, this study adds to the growing literature examining
complementary medicine utilization in cervical cancer populations and the characteristics
associated with women who are likely to be utilizing CM. Both supporters and skeptics
agree about the value of further research to better define the appropriate place for CM.
Moreover, cancer patients are increasingly seeking out complementary therapies as
adjuncts to conventional treatment in their efforts to relieve symptoms and increase
56
overall quality of life. Because of the increasing use of CM by cancer patients, the
medical community has a responsibility to assure that CM use is consistent with the
practice of responsible and safe medicine. Healthcare professionals must become
informed practitioners so that they can provide appropriate and meaningful advice to
patients concerning benefits and limitations of CM while increasing communication with
patients and families regarding CM use (1). According to Speca (2000) growing interest
in the use of these therapies reflects a desire for a more holistic approach to cancer
treatment and acknowledges our growing understanding of the links between social,
psychological, and physiological determinants of health (163). Ultimately, integration of
CM therapies represents the meaning of health in a broader context which includes the
role individuals can have in their own health and quality of life.
57
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Vu Dalen Cam Use Psychology

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Jeanne Dalen

This dissertation is approved, and it is acceptable in quality

Approved by the Dissertation Committee:

LISA JEANETTE DALEN

B.A., International Development, New Mexico State University, 1995

Submitted in Partial Fulfillment of the

The University of New Mexico

LISA JEANETTE DALEN

Submitted in Partial Fulfillment of the

The University of New Mexico

WITH CERVICAL CANCER: PREVALENCE AND CHARACTERISTICS

ASSOCIATED WITH USE

Lisa Jeanette Dalen

B.A., International Development, New Mexico State University, 1995

B.A., Psychology, University of New Mexico, 1998

M.S., Psychology, University of New Mexico, 2005

Ph.D., Psychology, University of New Mexico, 2008

In order to expand treatment options, educate physicians and patients, and

improve patient-provider communication about complementary medicine (CM), it is

important to determine CM utilization patterns, especially within gynecologic cancer, a

assessment is also required to empirically validate the characteristics associated with

This dissertation study explored the prevalence of CM utilization in women with

user profile in patients who utilize multiple CM therapies.

specifically to assess complementary medicine use. Additionally, data were collected on

optimism, religiousness, social support, coping, depression, and quality of life.

limitation and future directions for research are discussed.

LIST OF TABLES vii

Purpose of Present Study 5

CHAPTER ONE: LITERATURE REVIEW 6

Overview of Cervical Cancer 6

State of the Illness 6

Risk Factors for Cervical Cancer 7

Mortality Rates and Disparity Issues for Cervical Cancer 8

Defining Complementary Medicine 9

Complementary Medicine Modalities and Efficacy 10

Prevalence of Complementary Medicine

Utilization in Cancer Populations 11

Patterns of Complementary Medicine Utilization 12

Lifestyle and Health Practice Factors 15

Quality of Life and Health Status Factors 17

Research Aims and Hypotheses to Be Tested 19

CHAPTER 2: RESEARCH DESIGN AND METHODOLOGY 22

Description of Data Analysis 28

Research Aim One: Prevalence of CM Utilization: 28

Research Aim Two: Development of a User Profile 29

Research Aim Three: Comparison of

Whole Sample Demographics 32

Classification of CM Users and Non-users . 33

Prevalence of Complementary Therapies 33

Utilization over Time 35

Logistic Regression Predicting

Logistic Regression Predicting High

Prevalence of Complementary Medicine Utilization 44

Most Common CM Therapies Used 45

Utilization of CM Therapies over Time 49

Overall Predictors of CM Utilization 50

Predictors of Multiple CM Therapies 53

Table 1. Prevalence of complementary therapy use among cervical cancer patients

Table 2. Correlations examining CM therapy use across 3 time points since

Table 4. Mean values or frequencies for predictor variables as a function of

Table 5. Logistic regression predicting complementary medicine use.

Table 6. Mean values or frequencies for predictor variables as a function of using

Table 7. Logistic regression predicting high level use of complementary medicine

conceptualized (1). Presently, rigid conventional disease management programs are