INTRODUCTION
During the course of the illness, patients quite frequently use complementary therapy. A metaanalysis on complementary and alternative medicine (CAM) found frequent use of such therapies around the world, especially among cancer patients (Ernst & Cassileth, Reference Ernst and Cassileth1998). In France, more than 30% of cancer patients have resorted to such methods (Simon et al., Reference Simon, Prebay and Beretz2007). Recourse to popular or traditional treatment is deeply rooted in French culture, and cancer is a factor that may increase recourse to such methods (Novak & Chapman, Reference Novak and Chapman2001). A combination of treatment models and skills is prevalent today. It is nonetheless necessary to dissociate the traditional healers—whose gift is passed on from popular learning or by another healer—from the modern practitioners, who receive a particular training (Laplantine, Reference Laplantine1978).
Distinction is now clearly well established between medical practices referred to as “alternative” and those referred to as “complementary.” In the first instance, patients choose only unconventional therapies; in the second, which is more frequent, patients are simply seeking support to be combined with conventional treatments (Eisenberg et al., Reference Eisenberg, Kessler and van Rompay2001; Dilhuydy, Reference Dilhuydy2003; Leis & Millard, Reference Leis and Millard2007). Naturopathy (including phytotherapy) and homeopathy are the most frequently used complementary therapies (Dilhuydy, Reference Dilhuydy2003; Girgis et al., Reference Girgis, Adams and Sibbritt2005), apart from acupuncture and massage. Naturopathy is defined as a combination of methods that seeks the root causes of the illness and treats the whole person, taking into account all aspects of the person's being (Eisenberg, Reference Eisenberg2002; Dilhuydy, Reference Dilhuydy2003). It aims to reestablish or maintain an individual's health through natural means and lifestyle changes. The practitioner takes preventive action by trying to redress the biological elements and their detrimental effects by setting up a program of natural hygiene and natural remedies (health and personalized diet, natural remedies and nutritional supplements, etc.) (Beuth, Reference Beuth2010).
Women with gynecological cancer have been reported as very high users of CAM (Träger-Maury et al., Reference Träger-Maury, Tournigand and Maindrault-Goebel2007). The literature, moreover, shows the benefits of complementary medicine, especially for women affected by breast cancer (Buettner et al., Reference Buettner, Kroenke and Phillips2006; Boon et al., Reference Boon, Olatunde and Zick2007; Fasching et al., Reference Fasching, Thiel and Nicolaisen-Murmann2007; Träger-Maury et al., Reference Träger-Maury, Tournigand and Maindrault-Goebel2007; Nazik et al., Reference Nazik, Nazik and Api2012).
Thus, the main objective of our study was to explore the expectancies of female patients affected by advanced gynecological cancer in regard to naturopathy and their cancer treatment.
METHOD
The local ethics committee and institutional review board of the Hospices Civils de Lyon approved our study.
Participants
The main criterion for inclusion in the study was the use of naturopathy as a complementary adjunct to cancer treatment. The other criteria for inclusion were as follows: being female patients, being able to speak and understand French, and currently being treated for an advanced gynecological cancer.
Procedure
A research nurse met all the female patients from the oncology day care unit, giving them an information leaflet on the present study. They either gave their consent at the end of that meeting, or later via a phone call. They had to sign the consent form, including the authorization to record the interviews.
A qualitative method was chosen, exploring meaning behind the words and understanding patient experience (O'Connor & Payne, Reference O'Connor and Payne2006). The semistructured interviews were led with the help of guidelines that had been tested (see Appendix 1) to get patients' opinions on naturopathy as well as the benefits that they believe they gained from it, especially as related to their quality of life. These interviews were recorded, transcribed, and anonymized.
Data Analysis
Two of the authors (ML and MF) conducted a semantic analysis of each interview before proceeding to a transversal thematic analysis by comparing the interviews. This work enabled us to highlight the most frequent thematic groups.
Sample Size Determination
In qualitative research, sample size is determined when the researchers reach data saturation, which means that no new information or theme will emerge from new interviews. In our case, data saturation was reached after six interviews, which put an end to the selection of new patients.
Presenting Results
Quotes from the interviews are presented in italics to support our conclusions. We used ellipses (…) to indicate that irrelevant information was deleted from a quote. We added information in square brackets ([…]) when it was necessary to clarify the quote.
RESULTS
Participants
Between October of 2011 and May of 2012, the research nurse met with 104 consecutive female patients in the oncology day care unit: 3 refused to meet the nurse, and 70 did not use complementary medicine. From the 31 people screened using naturopathy, the first 6 were included until data saturation. The average length of interviews was 39 minutes. The longest interview lasted 45 minutes and the shortest 25. The mean age of participants was 56 years (standard deviation, 12).
Themes
The Physical and Psychological Impact of Disease and Treatments
The patients mention the difficulty of breaking the news of the cancer. It always starts with an anomaly: a painful symptom, a lump. After that comes a large number of tests, a sequence of appointments:
“It was fairly significant, my breast was dripping.”
“During the night, I had to get up six or seven times to urinate, and while pressing on my bladder, it hurt.”
“Everything happened very quickly … there were the scans, the biopsies.”
Some patients mention how their bodies have been mutilated by the illness or by the treatment. These physical marks contribute to the impression left upon patients, a scar almost invisible to the doctor, but which remains a reminder to the patients, and with which they have to deal:
“The mutilation is already not something funny.”
“I had lost my hair, and that, for a woman, it's a drama of its own.”
The patients use the terms “stress,” “breakdown,” and “anger.” They look for ways to cope with the illness. They need to cope with the difficulties of daily life and changes to their body:
“When you come back here, you must already be a bit in bereavement … we are more and more fragile with the illness.”
“I was crying a lot because I had some difficulty accepting this cancer.”
The illness and the specific treatments mean that patients have to reorganize their everyday life: dealing with fatigue, getting out and about with reduced mobility or coming up with creative strategies to manage to eat:
“It is necessary to take pleasure in these moments, in the food. It has to be varied, with many colors.”
The regular checkups can also be a threat to patients, sometimes highlighting the progression of the illness and the path toward death:
“All the checks are really exhausting for the people affected by cancer, because in less than a minute, your whole life is turned inside out.”
The patients highlight the need for psychological assistance, being fully aware of changes that take place within them with which they do not always know how to deal:
“It was a chance to put words on things, to express oneself.”
“One really needs some psychological help to accept it.”
Perceptions of Chemotherapy
The need for chemotherapy is not questioned by any of the patients: the obviousness is there for the patients; the hope of a cure comes from conventional treatments, even if they are heavy:
“I think we shouldn't stop the treatment.”
“We have to go through that.”
“[Chemotherapy] makes you calmer, and during that time, we can think that the illness is not there.”
“When I went in chemotherapy … I saw this product going in my veins almost as a positive product.”
Moreover, these treatments are perceived as drugs and sometimes patients do not always take some of them:
“We are already drugged by the chemo, so if you are taking as much medication as you are prescribed, you get really stoned.”
The most important expectation is that conventional treatment will lead to the best possible quality of life and the hope of remission. Nevertheless, the patients talk about the recurrence of their disease with lucidity and are fully aware that the conventional treatments are not curing the disease:
“Traditional medicine, well, you needed it to try … not to cure, because we don't cure, but to mainly to be in remission in regards to the breast cancer.”
“There is a tumor mass that remains, but they're leaving me in peace about it.”
The Perception of the Use of Naturopathy
The length of time that patients had used complementary medicine varied: some had been practicing it for years while others began only quite recently. The conventional treatment affects their quality of life. That's why patients use naturopathy alongside to give them physical and psychological relief:
“[The naturopath] didn't tell me he would cure me, but he just said he was going to help my body to cope with the chemo. … He was mainly treating my liver … the liver, because that is where it … well, chemo goes through the liver.”
“Naturopathy is complementary. I think that adding something on the side, it helps a lot.”
Unlike conventional treatments, naturopathy is not perceived as drugs.
“All the things they prescribe …, I wouldn't take it; I would take my plants and that'd work very well.”
The patients press for a holistic approach to their care and wish to remain active decision makers in their care journey:
“I believe in the two, hey, and I'm the one managing it. I'm still the master of my own person and I can feel what helps and what doesn't.”
“It's my little thingy of mine, my own little business, it's my little medicine to try to … for my comfort, for my well-being.”
“It's still our own health!”
“The medication that she gave me to drain, I didn't take it at all during the chemo, because during the chemo, there are already so many things, and I'm not really the medication type.”
They look for ways of achieving better quality of life in order to deal with the cancer and with the cancer treatment. Then they associate naturopathy with symptom improvement:
“It helped me a lot.”
“I didn't get any ulcers, you see, those things, those inconveniences.”
“Nausea, things like that, I didn't have any, compared to others.”
To the patients, a sense of well-being far outweighs the cost of naturopathic treatment and any difficulties of the treatment taking effect:
“The cost, we don't really look at it when it comes to improving our well-being.”
“You must be crazy to take some of those. [laughs] One really needs to believe that one needs it. Now, I've changed to a powder solution …, but when one needed to do liquid preparations, then, it was really disgusting.”
The Need for Information
The patients would have appreciated the availability of some information on complementary medicine in the hospital. There is concern about “scams,” and so detailed information about the different types of treatment and whether it is safe would be reassuring to patients. On the other hand, some patients are afraid to tell the oncologist that they approve of complementary medicine, for fear that he might disregard them:
“We take care of our doctors … make them feel comfortable with us. You see, we wouldn't want to displease them.”
DISCUSSION
The goal of this pilot study was to explore patients' opinions on naturopathy as well as the benefits that they believed they gained from it, especially with respect to their quality of life. Our results highlight the significant impact of cancer and cancer treatment, both physically and psychologically. Patients reported trusting conventional medicine, but they used naturopathy as a holistic approach to increase their own quality of life and reduce the side effects of cancer treatments.
The news of a cancer diagnosis, in spite of systematic support provided by the hospital, is a traumatic event for patients (Mills & Sullivan, Reference Mills and Sullivan1999; Shockney & Back, Reference Shockney and Back2013). Adaptation mechanisms are used in order to not give up, but psychological resources might weaken and be shaken, little by little, with the progress of the illness (de Ridder et al., Reference de Ridder, Geenen, Kuijer and van Middendorp2008). The anthropologist François Laplantine has posited two explanatory models to define representations of the illness, and sheds light on how to apprehend it as well as possible recourse to diverse types of care (Laplantine, Reference Laplantine1997). The conventional medical method represents the most common model. An external therapeutic model corresponds to that, excluding all active participation from the patient apart from his full participation in the treatment. The latter is targeted at fighting the invasive illness of the patient in order to obtain a full recovery, or a remission. The reversed etiological combination makes the illness an alarm signal that is linked to the spirit, with the experience, the history, and the environment of the person. In this manner, the objective is not to silence this reaction but to generate a reflection, personal or guided, in order to create a balance that will improve the person's way of life and thus obtain a more sustainable well-being. As the illness and its consequences evolve, the two models are interlaced and patients develop a new way of thinking and a new way of life.
The use of naturopathy is heterogeneous, but some studies have tried to define a profile of complementary medicine users. Anxiety and depression are not predictive factors (Rakovitch et al., Reference Rakovitch, Pignol and Chartier2005; Cassileth, Reference Cassileth2009). However, an awareness of the risks of recurrence and death is a favorable factor (Girgis et al., Reference Girgis, Adams and Sibbritt2005; Cassileth, Reference Cassileth2009). It reveals the desire of the patient to be a decision maker in the management of the cancer, and for a holistic approach to be used (Rakovitch et al., Reference Rakovitch, Pignol and Chartier2005). What the patients express on how their psyche is affected seems to be a plea for them to be treated holistically and not just as a body.
Patients we met reported trusting conventional medicine. Nevertheless, it appeared that they tend to consider treatments as mutilating and aggressive, which can interfere with medication compliance. This could explain why they choose specifically whom they turn to for a specific need and why they look for holistic care (Eisenberg, Reference Eisenberg2002; Dilhuydy, Reference Dilhuydy2003). Furthermore, the use of CAM in occidental populations is on the increase, especially among cancer patients (Novak & Chapman, Reference Novak and Chapman2001; Fouladbakhsh & Stommel, Reference Fouladbakhsh and Stommel2010; Anderson & Taylor, Reference Anderson and Taylor2012; Lafferty et al., Reference Lafferty, Bellas and Corage Baden2004). Indeed, they wish a new balanced life and to deepen their personal quest. Combining conventional medicine and naturopathy responds to such a quest, both by the reassurance of conventional medicine and by the nonscientific nature of complementary medicine (Olivier de Sardan, Reference Olivier de Sardan1995; le Breton, Reference le Breton2005). In varied studies on patients' expectancies of naturopathy, patients perceived naturopathy as a way of diminishing the side effects of the anticancer treatments, rapidly reducing the toxicity of the chemotherapy, alleviating the symptoms and strengthening the immunity (Träger-Maury et al., Reference Träger-Maury, Tournigand and Maindrault-Goebel2007; Marcelin-Benazech, Reference Marcelin-Benazech2010). The attention given by the naturopathic practitioners to the body, to the psyche, the time he takes, the combination of taste, smell, and sight of the treatments prescribed—as well as the diet—are all messages to the patient that life is still there. We are not just in the presence of a diseased organ; we are in the presence of a living human being. Furthermore, our results emphasize the dichotomy between the negative perception of conventional treatment and naturopathy, regarded as harmless, which is consistent with the literature (Ernst, Reference Ernst2000; Dilhuydy, Reference Dilhuydy2003).
Promoting a healthy and balanced diet and fighting against excessive drinking and smoking is highlighted as a preferred strategy to reduce the development of some cancers. Lifestyle evolves from eating enough to eating healthily (Poulain, Reference Poulain2001).
Our results also suggest the need for patients to get more information about CAM. Just after the consultant has broken the news to the patient, information about the diagnosis and validated and recommended treatments is given. We can nonetheless advocate for having a deeper human approach to how the news about the cancer is given, especially if it is metastatic (Dolbeault & Brédart, Reference Dolbeault and Brédart2010).
Our findings concerning the patient's perception of naturopathy in this pilot study should be explored more deeply in further studies looking at the relationship between the use of CAM and patient psychological distress. The frequency with which patients use complementary medicines should encourage oncologists to have an open dialogue with patients on the use of unconventional treatments.
Naturopathy, like other complementary medicines, has its constraints, but these appear to be less than the perceived benefits: the cost and the type of concoction (e.g., decoction, capsules, smells) are frequently mentioned, but they are bearable. The important thing is that the patient is able to make the choice of their own free will, based on their acceptance of the constraints. This is also necessary to evaluate the risk of interaction with oncological treatments (Dilhuydy, Reference Dilhuydy2003).
Finally, our study challenges the role that palliative care plays in a context of multiple types of care. The place of the patient as an active player in the cancer journey is one that should be of increasing importance. The use of naturopathy is an indication of the gaps that exist, and is even perhaps a sign of the failure of medical care to consider the patient holistically (Ernst, Reference Ernst2000; Eisenberg, Reference Eisenberg2002).
LIMITATIONS OF THE STUDY
Our study contains several limitations. First, the monocentric and qualitative nature of this study, including the small sample size, does not allow for generalization of our results. However, qualitative research has been recognized as an appropriate way to explore the opinions, feelings, and experiences of a specific population (Chesebro & Borisoff, Reference Chesebro and Borisoff2007; O'Connor & Payne, Reference O'Connor and Payne2006). These findings should be confirmed by a multicenter study with a larger sample. Furthermore, because the patients used other types of complementary medicine, in addition to naturopathy, we cannot link our findings to the use of one specific treatment.
CONCLUSION
Our findings suggest that female patients with metastatic gynecological cancer use naturopathy and, more widely, complementary medicines, to improve their quality of life. The use of different therapeutic options gives a meaning to the care journey through personal reflection and enables patients to take a more active role in their care.
ACKNOWLEDGMENTS
We thank Avril Jackson for her careful manuscript review.
APPENDIX 1. GUIDANCE FOR INTERVIEWS
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■ Can you please tell me about how and when you received the diagnosis of your disease?
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■ What has your care journey been like following the diagnosis?
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■ Can you tell me what led you to consult other health professionals (such as the naturopath) as well as the cancer specialist?
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■ Can you tell me what you expect from conventional cancer treatments versus naturopathy?
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■ Can you tell me which benefits and constraints result from naturopathy (symptoms relief, discomfort, nutritional restrictions)? And from conventional cancer treatment?
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■ Fear is sometimes associated with the use of complementary medicine. Do you feel it is “necessary,” “important,” or “out of the question” to say that other therapies are helping you? What reactions do you get from other people in regard to the methods you are using?
