1Support Care Cancer (2012) 20:461–473 Support Care Cancer (2012) 20:461–473

DOI 10.1007/s00520-011-1094-z

ORIGINAL ARTICLE

Complementary and alternative medicine use and

assessment of quality of life in Korean breast cancer
patients:
a descriptive study
Eunyoung Kang & Eun Joo Yang & Sun-Mi Kim & Il
Yong Chung & Sang Ah Han & Do-Hoon Ku & Soek-
Jin Nam & Jung-Hyun Yang & Sung-Won Kim

Received: 17 June 2010 / Accepted: 10 January 2011 / Published online: 28 January 2011
# Springer-Verlag 2011

Abstract Methods A total of 661 patients were invited to participate

Purpose The worldwide use of complementary and alter-
native medicine (CAM) among cancer patients has in-
creased, with breast cancer patients being more likely to
use CAM compared with any other cancer patients.
However, few surveys have systematically described
CAM use among Korean breast cancer patients. This study
investi- gated the use of CAM among patients who were
diagnosed with breast cancer, along with the relevant
demographic and clinical factors related to CAM use. We
also compared the difference in quality of life between
CAM users and nonusers.
E. Kang : S.-M. Kim : I. Y. Chung : S.-W. Kim (*)
Department of Surgery, Seoul National University Bundang
Hospital, Seoul National University College of Medicine,
Seongnam, South Korea
e-mail: brcakorea@gmail.com
E. J. Yang
Department of Rehabilitation Medicine, Seoul National
University Bundang Hospital, Seoul National University College
of Medicine,
Seongnam, South Korea
S. A. Han
Department of Surgery, East–West Neo Medical Center, Kyung
Hee University College of Medicine,
Seoul, South Korea
D.-H. Ku
Department of Surgery, Myongji Hospital, Kwandong University
College of Medicine,
Goyang, South Korea
in this study during routine clinic visits, with 425 patients
ultimately participating. Three hundred ninety-nine ques-
tionnaires were completed and used in the final analysis.
Quality of life was evaluated based on the Korean versions
of the EORTC QLQ-C30 and EORTC QLQ-BR23.
Results Previous or current CAM usage was reported by
229 patients (57.4%). Independent factors related to CAM
use were marital status, cancer stage, and coexisting illness.
The common types of CAM use included exercise therapy
(43.2%) and ingestion of vitamins and minerals (41.9%).
The reasons for CAM use were to boost the immune system
(53.2%), promote health (46.8%) and prevent recurrence
(37.7%). Large proportions (70.4%) of CAM users did not
discuss their CAM use with their physicians. Only a small
number of CAM users (2.5%) answered that they were
unsatisfied with their CAM use, with most CAM users
reporting that they would continue their CAM use. Quality
of life was not significantly different between CAM users
and nonusers.
Conclusions A significant number of patients with breast
cancer have used CAM, and health care providers should
be aware of the variety of CAM methods and their patients’
CAM uses for the proper management of breast cancer.
Keywords Breast cancer . Complementary and alternative
medicine . Quality of life
Introduction

S.-J. Nam : J.-H. Yang Worldwide surveys suggest that complementary and alter-
Department of Surgery, Samsung Medical Center, Sungkyunkwan
University College of Medicine, native medicine (CAM) use has become increasingly
Seoul, South Korea popular among the general population and among cancer
patients [1, 2]. In Korea, the prevalence of CAM in the
general population has increased from 29% to 75%
between
1999 and 2006, and the use of CAM in cancer patients has
also increased [3–6]. Morris et al. [7] reported that breast
cancer patients are far more likely to be CAM users
compared with other cancer patients. The prevalence of
CAM use by breast cancer patients varies, with reported
prevalence rates ranging from 20% to 84% [7–12]. Possible
reasons for this wide range in the prevalence of CAM use
could be due to differences in the definition of a CAM
user, which makes it difficult to compare the results from
the different studies [13, 14].
Previous studies have examined the use of CAM in
breast cancer patients. These studies have indicated that
younger age, higher socio-economic status, and higher
education levels are associated with the rate of CAM use
[10, 15–18]. Other studies have demonstrated that breast
cancer patients who use CAM tend to have higher degrees
of psychological distress and lower qualities of life [19,
20]. Burstein et al. [21] suggested that the use of
CAM in patients with early breast cancer is independently
associated with depression, fear of cancer recurrence,
decreased mental health and sexual satisfaction, and an
increased number of physical symptoms. Other factors
commonly associated with CAM use include the socio-
demographic status such as an ethnic difference. Ethnicity
plays an independent role in the use of CAM
modalities, use of CAM practitioners, and health
problems [22]. In Korea, traditional Oriental medicine has
been an integral part of health care, but Western practices
rapidly supplanted traditional medicine in institutional
health care in the nineteenth century. After the Korean
War, there has been an increased interest in Oriental
medicine by health institutes and Oriental medical
practitioners are legally protected in Korea. These medical
traditions may lead to some mistrust of CAM, which is
common among practi- tioners of Western medicine [23],
or give more opportunity to undertake CAM as legal
practice [24]. Knowledge of cultural diversity is necessary
when evaluating CAM in breast cancer survivors.
Although the overall survival of patients with breast
cancer has improved based on the development of
conventional treatments and the efficacy of CAM for
breast cancer remains unproved, the prevalence of CAM
use in these patients appears to be high. However, a large
number of patients had not communicated CAM use to
their physicians [25, 26], which may result in unexpected
adverse effects due to conflicting treatments. Therefore, it
is important for medical doctors to be aware of their
patients’ CAM uses, as well as the factors associated with
CAM use, and to understand the reasons for CAM use in
their patients. However, few reports have systematically
described CAM use among Korean patients with breast
cancer, and the factors related to CAM use are unclear. In
addition, there has been no study to evaluate the
relationship between quality of life and CAM use in
Korea.
The objectives of this study are to examine the
prevalence, common types, effects, and other various
parameters of CAM use among Korean breast cancer
patients and to identify demographic and clinical variables
associated with CAM use. An additional objective is to
compare the perceived difference in quality of life between
CAM users and nonusers.
Materials and methods
A cross-sectional study was conducted to examine CAM
use among Korean breast cancer patients, and this study
was approved by the institutional review board in our
institution. Subjects were recruited from among breast
cancer patients at least 3 months after cancer surgery
during the follow-up clinic visits between August 2008
and March 2009 at Seoul National University Bundang
Hospital. Eligible patients were women with breast
cancer who were at least 18 years old, who underwent
surgical treatment with or without adjuvant therapy, and
who were physically and emotionally able to complete
the survey. The study participants consisted of a
convenience sample of all available patients in our
center. When patients visited our outpatient clinic for
routine follow-up, the physician provided them with a
brief description of the study. A total of 661 patients
were invited to participate in this study, and 425 patients
who were interested in this survey received more
information from the research assistant and provided
their written informed consent. This survey was con-
ducted using a self-administered questionnaire, 399 of
425 questionnaires (93.9%) were returned, and the final
analysis was conducted on these 399 contributions.
The items to assess demographics, clinical character-
istics, and CAM use were developed based on a compre-
hensive review of the literature, and most of the items were
derived from the study Chung et al. [27]. The demographic
and clinically related questionnaire included age, residency,
marital status, religion, educational level, monthly house-
hold income, coexisting illness, date of surgery, cancer
stage, chemotherapy, radiotherapy, hormonal therapy use,
satisfaction with conventional treatment, and interest in
health. The questionnaire related to CAM use included
history of CAM use, type of CAM used, sources of
information about CAM, reasons for CAM use, time of
initiation of CAM use, duration of CAM use, costs of CAM
use, consultations with doctors about CAM use, reason for
not communicating with doctors, CAM use with conven-
46
Support Care Cancer (2012) 20:461–473
3 3
tional treatment, satisfaction with CAM, experienced side
effects of CAM, and continuance of CAM use.
The quality of life was evaluated based on the Korean
version of EORTC QLQ-C30 and EORTC QLQ-BR23,
with approval of the European Organization for Research
and Treatment of Cancer (EORTC) Group for research
into quality of life. The EORTC QLQ-C30 questionnaire
consists of a global health status, five functional scales,
and nine symptom scales. The EORTC QLQ-BR23, a
breast cancer-specific questionnaire, is composed of 23
questions assessing disease symptoms, treatment side
effects, body image, sexual functioning, and perspective
about the future. High scores on the functional scale and
for the global health status represent a high level of
function, and a high score in the symptom scale indicates
that the patient is experiencing a high degree of
problems.
For the purposes of analysis, we defined a CAM user
as an individual who had used one or more of the
reported types of CAM. According to a six-level model
described by Kristoffersen et al., our definition of CAM
use was classified as level 6 CAM use, including a visit
to a CAM provider, dietary supplements, self-help CAM
techniques, dietary changes, exercise, prayer, or a
combination of the above [14]. Additionally, clinically
related information on treatments and cancer stage was
obtained from a review of medical records and was used
for analysis of clinical characteristics including mean
months since surgery, cancer stage, type of surgery,
chemotherapy, radiation therapy, and hormonal therapy.
Other clinically related information was described based
on the patient-administered questionnaire.
All data were analyzed using Statistical Package for the
Social Science (SPSS) version 15.0. For the univariate
analyses to compare demographic and clinical character-
istics between CAM users and nonusers, we used the Chi-
square test or Fisher’s exact test for categorical data and
the Mann–Whitney U test for continuous data. We also
used the logistic regression model to explore independent
factors of CAM use. The variables selected for this model
were those with a trend (P<0.25) or a statistically
significant association (P<0.05) with CAM use based on
univariate analyses. The Mann–Whitney U test was used to
compare the qualities of life between the two groups. A P
value <0.05 was considered to be statistically significant.
Results
The demographic and clinical characteristics of CAM users
and nonusers are summarized in Table 1. All participants
were female, with a mean age of 50.6 years old (range, 25–
84 years). The mean recruitment time since surgery was
46
Support Care Cancer (2012) 20:461–473
26.5 months (range, 3.0–290.1 months). Current CAM use
was reported by 57.4% (N=229) of study participants, and
79% (N=181) of CAM users used more than two types of
CAM (Fig. 1). The most commonly used CAM domain was
exercise therapy (43.2%), followed by ingestion of
vitamins and minerals (Table 2). The patterns of CAM use
are shown in Table 3. The main reasons for CAM use
were to boost the immune system (53.2%) and to promote
health (46.8%). Although reasons related to breast cancer
were the least common, CAM users answered that they
used CAM to prevent breast cancer recurrence (37.7%), to
assist in conventional cancer therapy (10.5%), and to
reduce the side effects of cancer treatment (3.6%). The
most common source of information about CAM was
the media such as internet, television, radio, newspapers,
and magazines (47.5%). Only 18.7% of CAM users
reported using CAM prior to the diagnosis of breast
cancer, and new use of CAM after surgery was
common (76.4%). Large proportions (70.4%) of CAM
users did not discuss their CAM use with their
physicians. The main reason for not communicating
with their doctors was that they thought that it was not
important for doctor to know about their CAM use
(41.9%). Only a small number of CAM users (2.5%)
answered that they were dissatisfied with their CAM use,
and a large majority of CAM users (84.0%) reported that
they planned to continue their CAM use.
The results of the univariate analyses are shown in
Table 1. Marital status, mean months since surgery, cancer
stage, and coexisting illness were significantly associated
with CAM use. CAM users tended to live with their
spouses more often than did nonusers (P=0.012), and the
mean follow-up period from surgery to survey was longer
(P=0.019) in CAM users (28.6 months) than in nonusers
(23.6 months). The proportions of stage III and IV cancers
in CAM users (72.9%) were larger (P=0.009) than that in
nonusers (27.1%), and CAM users tended to have more
coexisting illnesses (64.7%) than did nonusers (35.3%; P=
0.010). In multivariate analyses, marital status, cancer
stage, and co-morbidity were independent factors related
to CAM use (Table 4).
Table 5 shows the mean for each scale of the EORTC
QLQ-C30. Overall, the mean scores for global health
status, five functional scales, three symptom scales, and
six single-item scales between CAM users and nonusers
were not statistically different. There were also no
statistical differences for any other breast cancer-specific
items except for arm symptoms (Table 6), where CAM
users reported a higher arm symptom score than did
nonusers (27.1± 22.2 vs. 21.0± 20.2, respectively; P=
0.004). However, there was no statistically significant
difference for arm symptom score between the two groups
after correcting for cancer stage (data not shown).
Table 1 Demographic and clinical characteristics of CAM users and nonusers

CAM users CAM nonusers P valuea

Number Percent Number Percent

Total 229 57.4 170 42.6

Mean age (SD) 50.6 (9.4) 50.6 (11.1) 0.756b
Marital status
Married 195 60.4 128 39.6 0.012
Single 9 37.5 15 62.5
Divorced or separated 11 64.7 6 35.3
Widowed 9 34.6 17 65.4
No answer 5 55.6 4 44.4
Education level
Middle school 46 59.7 31 40.3 0.532
High school 82 53.9 70 46.1
College 85 57.4 63 42.6
Graduate school 14 70.0 6 30.0
No answer 2 100.0 0 0.0
Income (KRW/month)
<2 million 42 58.3 30 41.7 0.982
2–4.99 million 120 58.8 84 41.2
>5 million 52 59.8 35 40.2
No answer 15 41.7 21 58.3
Religion
c
Christian 80 57.1 60 42.9 0.349
Catholic 42 50.6 41 49.4
Buddhist 53 63.9 30 36.1
Islam 2 100.0 0 0.0
No religion 44 54.3 37 45.7
No answer 8 80.0 2 20.0
b
Mean months since surgery (SD) 28.6 (26.1) 23.6 (18.8) 0.019
Stage
Early (0, I, II) 186 54.7 154 45.3 0.009
Advanced (III, IV) 43 72.9 16 27.1
Type of surgery
Mastectomy 98 60.5 64 39.5 0.300
Lumpectomy 131 55.3 106 44.7
Chemotherapy
Yes 157 57.7 115 42.3 0.847
No 72 56.7 55 43.3
Radiation therapy
Yes 162 57.4 120 42.6 0.973
No 67 57.3 50 42.7
Hormonal therapy
Yes 146 58.2 105 41.8 0.684
No 83 56.1 65 43.9
Coexisting illness
No 120 51.5 113 48.5 0.010
Yes 101 64.7 55 35.3
No answer 8 80.0 2 20.0
Table 1 (continued)

CAM users CAM nonusers P valuea

Number Percent Number Percent

Satisfaction with conventional medicine

Satisfied 182 57.8 133 42.2 0.831c
Average 44 55.0 36 45.0
Dissatisfied 1 100.0 0 0.0
No answer 2 66.7 1 33.3
Interest in health
High 101 61.2 64 38.8 0.410
Average 113 54.3 95 45.7
Low 12 57.1 9 42.9
No answer 3 60.0 2 40.0
a
Unless otherwise specified, P values were calculated using the Chi-square test
b
P value from Mann–Whitney U test
c
P value from Fisher’s exact test

Discussion perceived that the effectiveness of CAM use was above

In the present study, we report on the status of CAM use
among breast cancer patients in Korea and investigate the
relevant factors related to the use of CAM. Our survey
showed that more than half of the women with breast
cancer had used CAM, and many patients began to use
CAM after the diagnosis of breast cancer. Exercise was the
most commonly used CAMs followed by dietary or vitamin
supplements, with energy medicine and mind–body meth-
ods being less used. We found that CAM use was strongly
associated with marital status, cancer stage and non-cancer-
related medical conditions. CAM users were more likely to
experience arm symptoms than nonusers. Most CAM users
Fig. 1 Number of CAM techniques used per patient. Forty-eight
patients (21.0%) used only one type of CAM, while six patients
(2.6%) used more than seven types of CAM
average and desired to continue their CAM use. However,
communication between physicians and patients about their
CAM use appeared to be low.
CAM use in our study (57.4%) was lower than that
among the general population in Korea (74.8%) but was
similar to that in other studies of CAM in patients with
breast cancer (59–67%) [4, 10, 11, 20]. The prevalence of
CAM use in our study population was much higher than
that in a previous Korean report (36%) [27]. However, a
comparison of the observed prevalences of CAM between
studies is difficult because study populations and the
definition of CAM may differ across studies. For example,
the previous Korean study did not include exercise and
prayer as CAM categories [27]. However, our study
population was composed of individuals who had used
one or more of the reported types of CAM, including
exercise and prayer. Only 12 of 229 CAM users solely used
prayer or exercise; even when these subjects were excluded
from the analysis, the current CAM use was higher than
that in the previous study.
The types and patterns of CAM usage appear to be
related to the socio-cultural background. Recent studies
suggest that use of different CAM modalities varies
according to the demographic, clinical, and behavioral
characteristics [11]. In this study, the most commonly used
types of CAM were exercise therapy (43.2%), vitamins
(41.9%), medical Ginseng (33.6%), and mushrooms
(32.6%). The prevalence of a mind–body approach is lower
than that in other Western countries [28–30]. A recently
published paper from the American Cancer Society’s Study
of Cancer Survivors-I showed that among breast cancer
survivors, 85.7% used mind–body methods [31]. In a
Table 2 Type of CAM used
options. Patients with higher education and higher
Type of CAM Number Percent income are more aware of the available types of treatment
options. In
Western countries, CAM, such as mind–body medicine or
Biologically based practices difficult to cope up with their cancer and may therefore be
Health food/medical plants more willing to seek all available treatment
Mixed cereals/uncooked food 35 15.3
Vitamin/mineral 96 41.9
Chitosan/squalene 15 6.6
Medical mushrooms 74 32.3
Ginseng or ginseng products 77 33.6
Herbal medicine 40 17.5
Others 7 3.1
Immune-reinforcement or anticancer products
Placenta 2 0.9
Mistletoe 8 3.5
Others 1 0.4
Energy medicine
Elvan/germanium/loess 6 2.6
Bath remedy 26 11.4
Mind–body medicine
Music 12 5.2
Meditation 10 4.4
Prayer 33 14.4
Spiritual healing 1 0.4
Manipulative and body-based practices
Moxibustion 16 7.0
Hypogastric breathing 3 1.3
Massage 18 7.9
Yoga/dance 31 13.5
Physical therapy 11 4.8
Exercise therapy 99 43.2
Acupuncture 6 2.6
Others 6 2.6

prospective cohort study in the USA [32], 64.2% used

mind– body healing, and the frequent use of mind–body
healing approaches after a breast cancer diagnosis was
associated with being Hispanic, higher education, lower
income, and the use of other forms of CAM. A possible
explanation could be that patients in Korea are less aware
of available types of mind–body approach and less
resourceful in terms of seeking out possible additional
support in this area.
Studies reporting on the correlates of CAM use have
shown some consistent results relative to gender [33, 34],
age [35], educational status [33, 36], income levels [36],
disease status [37], marital status[38], and coping-related
behaviors [37]. Contrary to the previous studies, there are
no difference in age, income, and educational level
between the CAM user and nonusers in this study. This
difference might be based on the Korean cultural
background. Generally, young patients may find it more
energy medicine, is one of the updated treatment options
available. However, in Korea, there is still mistrust of
CAM due to medical tradition. In addition, many Korean
cancer patients tend to depend on the medical decisions of
their physicians. One cross-sectional study in Korea [24]
revealed that few Korean cancer patients (6%) used CAM
to have more control over the medical decisions.
The present study findings showed that marital status,
cancer stage, and non-cancer-related medical conditions
were associated with the use of CAM. Patients living with
their spouse tended to use CAM much more than did single
patients or patients separated from their spouses, and this
finding was consistent with those of previous studies [21,
39]. Our results also supported the previous findings that
CAM users were at a more advanced stage of disease than
were nonusers [12, 15, 40], and CAM users in the present
study were more likely to suffer from co-morbidities.
Carpenter et al. reported that non-cancer-related medical
conditions were a strong factor associated with CAM
usage, especially among very long-term breast cancer
survivors [20]. In addition, CAM users reported a higher
arm symptom score than nonusers. Yap et al. [41] also
showed that women with breast cancer who used CAM
were more likely to experience symptoms (e.g., stiffness,
pain, numbness, and swelling) in the shoulder or arm than
nonusers as an outcome of use. Another cross-sectional
study [42] reported that extremity swelling was associated
with the use of more CAM treatments. However, only 3.6%
reported that a reduction of side effects of treatment was
the reason for use in this study. The association between
CAM use and swelling may reflect a coping mechanism
[37] of breast cancer patients, even though they are not
certain that CAM would have a positive effect upon the
side effects of the cancer treatment itself [43]. However,
these associations should not be interpreted as causal,
given the cross- sectional nature of the study. In our study,
although time since surgery was not an independent factor
related to CAM use, it was statistically significant in
univariate analysis and marginally significant in
multivariate analysis. Girgis et al. [44] found that patients
who were diagnosed 1–5 years previous were significantly
more likely to use CAM. This increasing use of CAM
over time may be due to patients who had completed their
conventional treatment and were seeking CAM for health
maintenance, preventing recur- rence, and boosting the
immune system. However, another study did not show an
association between time since diagnosis and CAM use
among cancer patients [45].
Previous studies have suggested that cancer patients
with psychosocial difficulties and worse qualities of
life are more likely to use CAM [19–21]. Carlsson et al.
[19] found
Table 3 The patterns of CAM use

Questionnaire about CAM use Response rate Distribution of answer

Number Percent Number Percent

Source of information about CAM 204 89.1

Family and relatives 57 27.9
Friends 28 13.7
Medical doctor 15 7.4
Oriental doctor 4 2.0
Media (internet, television, radio, book) 97 47.5
Patients used CAM 40 19.6
Others 13 6.4
Reasons for CAM use 220 96.1
Emotional support 34 15.5
Boost immune system 117 53.2
Health promotion 103 46.8
Dissatisfaction with conventional therapy 2 0.9
Prevention of recurrence 83 37.7
Synergic effect of conventional therapy 23 10.5
Decrease side effect of conventional therapy 8 3.6
Treatment of other medical problems 27 12.3
Others 6 2.7
Time of initiation of CAM use 203 88.6
Before diagnosis 38 18.7
Between diagnosis and surgery 10 4.9
After surgery 155 76.4
Duration of CAM use (months) 208 90.8
<3 47 22.6
3–6 20 9.6
6–12 49 23.6
12–36 56 26.9
>36 36 17.3
Consult with doctor about CAM use 206 90.0
Yes 61 29.6
No 145 70.4
Reason for not consulting with doctor 136 93.8
Negative response for CAM use 40 29.4
Insufficient information of CAM 8 5.9
No need to consult with doctor 57 41.9
Others 31 22.8
CAM use during chemotherapy or radiotherapy 202 88.2
Yes 61 30.2
No 141 69.8
a
Costs of CAM use (KRW /month) 205 89.5
<100 thousand 107 52.2
100–500 thousand 75 36.6
500 thousand to 1 million 7 3.4
>1 million 16 7.8
Satisfaction with CAM 199 86.9
Satisfied 69 34.7
Average 125 62.8
Dissatisfied 5 2.5
Table 3 (continued)

Questionnaire about CAM use Response rate Distribution of answer

Number Percent Number Percent

Experience side effect of CAM 200 87.3

Yes 12 6.5
No 187 93.5
Side effects related CAM 11 91.7
Digestive symptoms (nausea/vomit/diarrhea) 4 36.4
Skin lesions (rash/urticaria) 4 36.4
Physical injury (burn/sprain/fracture) 0 0.0
Others 3 27.3
Continuance of CAM use 200 87.3
Yes 168 84.0
No 32 16.0

a
One US dollar was about 1,200 Korean won (KRW) at the time of the survey

that patients who selected CAM for their cancer treatment
had a lower quality of life and experienced more anxiety
than did patients who chose conventional treatments;
however, there were significant improvements in overall
quality of life at the 1-year follow-up in patients who had
used CAM. A recent study also revealed significantly
lower mental health functioning among CAM users than
among nonusers [20]. In the present study, the global
qualities of life between CAM users and nonusers were not
different, and we also have found no evidence of poor
emotional or social status among CAM users. However,
due to the cross- sectional design of this study and the
prospective follow-up of study subjects, it is not feasible
to identify the relationship between quality of life and
CAM use.
The most common source of information about CAM
in previous surveys in Korea was reported to be family
members and relatives [27]; however, media such as
internet, television, radio, newspapers, and magazines
were the main source of information about CAM in our
present study. South Korea has transformed itself into one
of the world’s most wired nations, and people can easily
search for various types of information using internet
search engines. Along
non-medical persons is the most common form of
informa- tion on CAM found on the internet. To prevent
abuse of CAM, health care professionals should assign
importance to patient CAM use and make an effort to
provide evidence- based information about CAM.
However, due to grouping internet, television, radio,
newspapers, and magazines as one category in our survey,
we could not infer the importance of each individual
medium, all of which have different audiences and
degrees of reliability. Future surveys should distinguish
between different media as information sources.
In our study, the use of CAM was discussed with
physicians by only 29.6% of patients using CAM. This is
similar to the 32.7% cited in a previous study of Korean
breast cancer patients [27]; however, it is much lower than
the 71% reported by breast cancer patients in the United
States [9]. Tasaki et al. [46] identified three barriers of
communication about CAM as perceived by patients:
physician indifference or opposition toward CAM use,
physician emphasis on scientific evidence, and patient
anticipation of a negative response from the physician.
The study emphasized that increased awareness is
important to improve communication about CAM [46].
The lack of communication may have a

Table 4 Multivariate analysis for the associated factors of CAM use

B SE Wald DOF P value OR Confidence interval

Lower Upper

Mean months since surgery 0.398 0.221 3.246 1 0.072 1.489 0.966 2.295
Cancer stage 0.784 0.323 5.888 1 0.015 2.190 1.163 4.126
Marital status 0.741 0.284 6.795 1 0.009 2.097 1.202 3.660
Coexisting illness 0.645 0.222 8.428 1 0.004 1.907 1.233 2.948
Constant −0.949 0.322 8.709 1 0.003 0.387
OR odds ratio
Table 5 General qualities of
life of CAM users and nonusers: CAM users (n=229) CAM nonusers (n=170) P value
analysis using EORTC
QLQ-C30 Mean SD Mean SD

Global health status 66.0 21.9 67.6 20.4 0.583

Functional scales
Physical functioning 79.2 14.5 80.1 16.3 0.267
Role functioning 79.6 21.0 80.5 21.8 0.514
Emotional functioning 75.2 20.7 77.1 18.5 0.454
Cognitive functioning 77.6 18.1 79.1 20.3 0.197
Social functioning 80.0 22.4 82.8 22.8 0.104
Symptom scales
Fatigue 33.2 21.4 30.1 20.3 0.231
Nausea and vomiting 6.5 12.9 6.7 14.7 0.596
Pain 18.3 19.1 16.6 19.7 0.221
Dyspnea 11.7 18.8 13.6 20.8 0.414
Insomnia 26.4 29.3 22.7 27.7 0.215
Appetite loss 12.4 21.2 11.3 21.5 0.412
Constipation 19.2 25.8 20.9 24.9 0.305
Diarrhea 9.4 16.6 8.3 17.0 0.396
Financial difficulties 19.1 25.7 20.0 27.4 0.907

negative impact on patient health as a result of toxicity
due to the CAM itself or to interactions with conven-
tional therapies. Therefore, physicians should not retrain
judgment of CAM and acknowledge the CAM use of
their patients, encouraging active discussion and research
for the proper use of CAM. Recently, Schofield et al.
developed guidelines for a balanced and useful discus-
sion of CAM with patients by conducting a systematic
review of the literature [47].
Our study has several limitations. First, because this is a
single institution study, the behavior related to CAM use
may not be representative of all Korean patients with breast
cancer. Second, there is a possibility of self-selection error
where patients with a greater interest in CAM participated
in this study as volunteers were determined using non-
probability sampling. Third, the study was based on patient
self-reports, and collected data were therefore not unerr-
ingly accurate according to participant memories and
activities. Finally, as our survey was designed as a cross-
sectional study, the relationships with CAM may not be
causal. Therefore, care must be taken when applying these
results to other populations.
Our findings may have implications for conventional
doctors who treat breast cancer patients. Our results suggest
that a large portion of CAM users initiated their CAM use
after the diagnosis of breast cancer, and they usually use
CAM in addition to standard treatments for cancer. Despite
the high interest in and use of CAM, communication
between physicians and patients about CAM use is lacking.
Although most CAM users in the present study did not

Table 6 Breast cancer related

qualities of life of CAM users CAM users (n=229) CAM nonusers (n=170) P value
and nonusers: analysis using
EORTC QLQ-BR23 Mean SD Mean SD

Functional scales
Body image 65.2 28.8 65.2 29.2
Sexual functioning 20.1 23.1 20.1 21.5
Sexual enjoyment 32.5 28.4 30.7 28.4
Future perspective 50.7 30.2 50.2 29.0
Symptom scales
Systemic therapy side effect 25.3 16.8 24.1 17.3
Breast symptoms 17.1 18.0 15.9 15.2
Arm symptoms 27.1 22.2 21.0 20.2
Upset by hair loss 41.1 35.4 43.5 35.1
experience adverse effects related to CAM, some types of
CAM may have potential toxicities and may interact with
conventional treatments. These results emphasize the
importance of open discussion between physicians and
patients about CAM use. Therefore, physicians who care
for patients with breast cancer should be aware of the
prevalence of CAM use, the types of CAM used, the
factors
associated with CAM use, and the benefits or adverse
effects of CAM.
Acknowledgement This research was supported by grant no 02-
2008-006 from the SNUBH Research Fund.
Conflict of interest The authors declare that they have no
competing interests.

Appendix

*The original questionnaire was written in Korean.

The questions related to CAM use and communication

1. Do you use or have you ever used a CAM technique?

1) No Please go to question 2.
2) Yes Please go to question 3.

2. For what reasons have you not used any CAM techniques? (Check all that apply.)
1) I am very satisfied with conventional therapy
2) The effect of CAM is not proven
3) The doctor did not recommend the CAM
4) CAM cost is high
5) Other ( )

If you use or have ever used the CAM,

please turn page over and continue the survey.
3. Check the appropriate category that you have used.

Mixed cereals/Uncooked food

Vitamin/Mineral
Chitosan/Squalene
Health food/medical plants Medical mushrooms
Ginseng or ginseng products
Herbal medicine
Others
Placenta
Immune-reinforcement or Mistletoe
anticancer products
Others

Elvan/Germanium/Loess
Energy Medicine
Bath remedy
Music
Meditation
Mind-Body Medicine
Prayer
Spiritual healing

Moxibustion
Hypogastric breathing
Massage
Manipulative and Body-Based
Practices Yoga/dance
Physical therapy
Exercise therapy
Acupuncture
Other

4. Who recommend the CAM?

1) Family/relative 2) Friend 3) Medical doctor

4) Oriental doctor 5) Media (internet, TV, radio, book) 6) CAM user

7) Other ( )

1. Who purchased the CAM?

1) Myself 2) Family/relative 3) Friend
4) Other ( )

6. For what reasons did you use the CAM? (Please check all that apply)
1) Emotional support 2) Boost immune system
3) Health promotion 4) Dissatisfaction with conventional therapy
5) Prevention of recurrence 6) Synergic effect of conventional therapy
 7) Decrease side effect of conventional therapy
8) Treatment of other medical problems
9) Other ( )

7. Did you consult with your doctor about CAM use?

1) Yes
2) No Please go to question 8.

8. What is the reason for not consulting with your doctor? (Please check all that apply.)
1) Doctor’s response would be negative
2) Doctor would not know sufficient information of CAM
3) Not important for doctor to know
4) Other ( )

9. When did you start using the CAM?

1) Before diagnosis
2) Between diagnosis and surgery
3) After surgery

10. Duration of your CAM use?

1) <3 months 2) 3-6 months 3) 6-12 months
4) 12-36 months 5) >36 months

11. Did you use the CAM during chemotherapy or radiotherapy?

1) Yes 2) No

12. How much have you spent on your CAM use in a typical month? (KRW/month)
1) <100 thousand 2) 100-500 thousand
3) 500 thousand-1 million 4) > 1 million

13. Were there any side effects from the CAM?

1) Yes Please go to question 15. 2) No

14. Check the CAM-related side effects that you experienced. (Please check all that apply.)
1) Digestive symptoms (nausea/ vomit/ diarrhea)
2) Skin lesions (rash/ urticaria)
3) Physical injury (burn/ sprain/ fracture)
4) Other ( )

15. To what extent are you satisfied with your CAM use?
1) Satisfied 2) Average 3) Dissatisfied

16. Will you continue your CAM use?

1) Yes 2) No
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