Cancer patients' attitudes towards Chinese medicine: a Hong Kong survey

Background This article reports a survey conducted in Hong Kong on the cancer patients' attitudes towards Chinese medicine treatment. Methods Cancer patients from three Chinese medicine clinics and one oncology clinic were interviewed with a structured questionnaire. Results Of a total of 786 participants included in the study, 42.9% used Western medicine only; 57.1% used at least one form of Chinese medicine; 5 participants used Chinese medicine only; and 56.5% used Chinese medicine before/during/after Western medicine treatment. Commonly used Western medicine and Chinese medicine treatments included chemotherapy (63.7%), radiotherapy (62.0%), surgery (57.6%), Chinese herbal medicine (53.9%) and Chinese dietary therapy (9.5%). Participants receiving chemotherapy used Chinese medicine (63.3%) more than those receiving any other Western medicine treatments. Spearman correlation coefficients showed that the selection of Chinese medicine was associated with the cancer type (rs = -1.36; P < 0.001), stage (rs = 0.178; P < 0.001), duration (rs = -0.074; P = 0.037), whether receiving chemotherapy (rs = 0.165; P < 0.001) and palliative therapy (rs = 0.087; P = 0.015). Nearly two-thirds of the participants (N = 274) did not tell their physicians about using Chinese medicine. Over two-thirds of all participants (68.2%) believed that integrated Chinese and Western medicine was effective. Conclusion Chinese medicine is commonly used among Hong Kong cancer patients. The interviewed cancer patients in Hong Kong considered integrative Chinese and Western medicine is an effective cancer treatment.

Chinese medicine and Western medicine differ fundamentally in their etiological concepts and therapeutic approaches. In Western medicine, cancer is perceived as uncontrolled growth of malignant cells which may be treated by surgery, chemotherapy, and radiotherapy [11]. According to Chinese medicine theory, cancer is the manifestation of a qi disturbance which may be treated by mobilizing qi. Study results support the use of Chinese medicine to treat liver cancer and leukaemia [12,13], and recent meta-analyses demonstrated that Chinese medicine improved tumor response to chemotherapy as well as patient's survival rates [14,15]. Five common Chinese medicine modalities, namely Chinese herbal medicine, acupuncture and moxibustion, therapeutic massage, qigong and Chinese dietary therapy have been used to treat cancer [16]. Moreover, acupuncture relieves pain and acute vomiting during conventional cancer treatment [15,17] While some researchers suggest that Chinese medicine should be integrated into a comprehensive cancer treatment scheme [18], cancer patients' attitude towards Chinese medicine is largely unknown. The present study aimed to reveal the prevalence and pattern of the use of Chinese medicine among cancer patients in Hong Kong and to assess their attitudes and intentions about such use.

Participants
This study was approved by the Committee on the Use of Human and Animal Subjects in Teaching and Research of the Hong Kong Baptist University (HKBU) and the Research Ethics Committee of the Hospital Authority (HA) Hong Kong. Between April 2008 and August 2008, all cancer patients attending any of the three HKBU Chinese medicine clinics and the outpatient clinics of the Department of Clinical Oncology in Queen Elizabeth Hospital (QEH) were invited to participate in this crosssectional survey.
Oral informed consent was obtained from cancer patients before participation. Each participant completed a questionnaire, which was then checked by one of the authors (YCL). Completed and checked questionnaires were coded to mask patients' identities. Another author (CWC) double-checked the collected questionnaire to ensure good quality.
In this paper, Chinese medicine user is defined as the person who receives treatments of Chinese herbal medicine, acupuncture and moxibustion, therapeutic massage, qigong, Chinese dietary therapy and/or other therapies that are based on the theory of Chinese medicine. Data are presented as the actual number of patients (percentage in that group). Chi-square tests were conducted between Western medicine and Chinese medicine users. Data are presented as the actual number of patients (percentage in that group). Chi-square tests were conducted between Western medicine and Chinese medicine users. Data are presented as the actual number of patients (percentage in that group) who received Western medicine and Chinese medicine treatments.

Questionnaire
The development of the questionnaire (in Chinese language) included four stages as follows (1) a draft questionnaire was prepared; (2) the questionnaire was reviewed by Chinese medicine experts (N = 6) and Western medicine practitioners (N = 2) were collected; (3) the draft questionnaire was revised by the authors and tested on a small group (N = 10) of cancer patients;.(4) the questionnaire was finalized. The final questionnaire consisted of three parts. The first part was about background information of the participants (e.g. age, gender, marital status, educational level), type of cancer, date of diagnosis, use of Western medicine cancer treatment and/or Chinese medicine treatment. The second part focused on participants' perception of Western medicine treatment and/or Chinese medicine treatment, such as times to initiate Chinese medicine treatment, motivations for using Chinese medicine, whether or not their physicians were told about the use of Chinese medicine and why, responses from physicians, reasons for choosing Western medicine treatment and/or Chinese medicine treatment, satisfaction with the treatment. Finally, participants were asked whether they intended to continue or stop their use of Western medicine treatment and/or Chinese medicine treatment, or other CAM therapies in the future, and their opinion on the effectiveness of the integration of Chinese and Western medicine in their cancer treatment. In the third part, participants were asked to express their views on the integration of Chinese medicine and Western medicine in cancer treatment.

Data management and statistical analyses
YCL, one of the authors, entered the data into an Access (Microsoft, USA) database, and CWC, another author, checked the data independently. All data disagreements were resolved through further checks against raw data. Data were analyzed with the Statistical Package for Social Sciences program (SPSS 13.0, SPSS, USA). Demographic and clinical characteristic differences between Western medicine and Chinese medicine users were assessed with chi-square test. Spearman correlation between the use of Chinese medicine and other variables of interest was determined. All statistical tests were two-tailed with a confidence level of alpha of 0.05.

Demographic and clinical characteristics of study participants
Seven hundred and ninety-one (791) questionnaires were distributed, of which 786 (99.4%) received responses. Common cancers among the participants were lung cancer, breast cancer, colorectal cancer and nasopharyngeal cancer (Table 1).
Compared with Western medicine users, Chinese medicine users were better educated among whom Stage III or IV lung cancer, breast cancer and nasopharyngeal cancer and cancers which had been diagnosed within the last 36 months (P < 0.05).    (Table 5).

Factors contributing to treatment modality preference
With the hopes to reduce side-effects from Western medicine (65.5%), suppress tumor progression (60.8%), relieve symptoms (57.5%) and improve quality of life (48.4%), 54.2% of the participants (N = 426) preferred combined Chinese medicine and Western medicine treatments. Out of 347 (44.1%) participants who used Western medicine only, 67.7% did so because they believed that Western medicine alone could suppress tumor progression (Table 6).
Over two-thirds of all participants (68.2%) believed that integrated Chinese and Western medicine was effective.
Participants who were ambivalent about integrated Chinese and Western medicine effectiveness accounted for 31.4% (N = 245), while only 0.4% (N = 3) thought integrated medicine would not be effective ( Figure 2). Patients' intention in the use of Chinese medicine, Western medicine or integrative Chinese and Western treatment in the future (N = 786) Figure 2 Patients' intention in the use of Chinese medicine, Western medicine or integrative Chinese and Western treatment in the future (N = 786).
Patients' satisfaction with their current treatment and the factors affecting their satisfaction levels A total of 469 participants (59.7%) claimed that they would continue or try Chinese medicine as an alternative therapy in the future, while 63 participants (8.0%) would not consider using Chinese medicine only (Figure 3).

Demand for integrative Chinese-Western medicine treatment
Regarding whether or not the Hong-Kong government should further promote the integration of Chinese medicine and Western medicine in cancer treatment, 690 participants (87.8%) agreed, 92 (11.7%) had no opinion, while only 4 (0.5%) thought it was unnecessary.

Discussion
Among many studies reporting the use of CAM to treat cancer patients [2][3][4][5][6][7]9,[19][20][21], few reports were based on large-scale survey. This survey interviewed a large number of patients (N = 786) with various types of cancers to evaluate the characteristics of their treatment as well as their attitudes towards Chinese medicine treatment. The present study indicates that the use of Chinese medicine in cancer treatment in Hong Kong (57.1%) is much more than that in Japan (7.1%) [7], but lower than that in the mainland China (100%) [6]. As overseas Chinese often think of Chinese medicine as their first choice of CAM [22,23], this difference in the use of Chinese medicine may be due to socio-cultural difference among ethnics groups [22] rather than regional differences in medical systems.
Findings that cancer patients in Hong Kong favored Chinese herbal medication are consistent with previous studies [9,22]. The present study discovered that nearly half (49.93%) of the participants recruited from Western medicine clinics used Chinese medicine. Several factors were found to encourage the use of Chinese medicine among cancer patients [7,20,24,25], such as recommendations from the relatives and ward-mates, patients' own willingness, and advice from physicians. Biases may exist in this study as a result of the non-randomized recruitment method. A total of 117 (14.9%) par-ticipants were recruited from three HKBU Chinese medicine clinics. The use of Chinese medicine among these participants may be higher than the participants from ordinary clinics. The recruitment from the Oncology Outpatient Department excluded those patients from the palliative day-care clinics. Nevertheless, among the participants (N = 669) recruited from Western medicine clinics, nearly half (49.93%) did use Chinese medicine. Even though the sample may not be representative of all cancer patients in Hong Kong, the large scale and interesting findings of this study does warrant a more structured and population-based sample in the future.

Conclusion
Our findings indicate that most cancer patients in Hong Kong considered integrative Chinese and Western medicine as an effective cancer treatment. Randomized controlled trials to evaluate Chinese medicine treatments, establishment of integrative Chinese and Western medical facilities, and public education about Chinese medicine are greatly demanded.