Complementary and alternative medicine use among patients with cancer in Mongolia: a National hospital survey

Following the descriptive cross-sectional design, the study was conducted at oncology outpatient clinics (radiotherapy and/or chemotherapy) at National Cancer Center (NCC), the only specialized cancer center in Ulaanbaatar, Mongolia. The National Cancer Center in Ulaanbaatar has both inpatient and outpatient chemotherapy and radiotherapy units where approximately 1300 patients receive the treatment over a period of 6 months. However, for this study only patients attending the outpatient clinics of chemotherapy and radiotherapy were surveyed. Moreover, with the help of hospital staff it was ensured that no patient was surveyed for more than one time in case they visited the clinics again for follow-ups during the study period.

After a literature review, the survey instrument appropriate to local context was initially drafted in English and assessed by two experienced oncologists, a pharmacist and a researcher. The questionnaire was then modified according to the assessment, translated into the Mongolian language by a professional translator, and then it was pilot-tested. Translation accuracy of the survey questionnaire was validated by back-translation into English. After this, another pilot test was conducted with 20 cancer patients at different stages of treatment in order to refine the questionnaire and improve its clarity. The final questionnaire comprised four sections. The first section had five questions concerning the individual’s health status, diagnosis, and whether they were currently receiving conventional cancer treatment. The second section consisted of 11 questions related to use of CAM. Questions on patterns of CAM, reasons for use, satisfaction with using CAM and source of information on CAM were only asked from respondents who reported using at least one modality of CAM. The third section contained four questions asking respondent’s attitudes and beliefs toward CAM. The last section dealt with five questions showing the participant’s age, gender, level of income, level of education and area of residence. Conventional cancer treatment, particularly chemotherapy and radiation, are known to cause a number of side effects [18]. After some literature review, a list of five common symptoms, which are routinely experienced by patients with cancer, was included in the survey instrument. All the respondents (CAM users and non-users) were asked to report the symptoms for which they would like to use CAM without a doctor’s prescription.

The cancer patients attending the oncology outpatient clinic of the hospital from September 1, 2015 to February 28, 2016 were recruited into this study. The inclusion criteria were adult patients (over 20 years old) of either gender with a diagnosis of cancer, aware of their diagnosis of cancer, able to understand the questions, and willing to participate in the study. The ethical approval for this survey was obtained from the School of Medicine at Hanyang University, South Korea (HYI-15-111-2) and the Ministry of Health and Sports, Mongolia (No-05). Enrollment was voluntary and all patients gave written consent to participate in the study.

All patients who met the inclusion criteria during the study period were invited to participate. Information about the research was given verbally to each respondent and consent was sought before the participation. Participants were informed that they could quit the survey anytime they wanted to. For interviewing cancer patients, three experienced interviewers were trained, who explained the CAM to the study participants administered the questionnaire. The patients were given the option either to fill out the questionnaire themselves or to verbally respond to the questions asked by the interviewers. In total, 504 patients agreed to participate in the survey. Of these, 22 were excluded due to an incomplete questionnaire; so the data of 482 participants were entered into the database for further analysis. A high response rate of 95.6% shows the willingness of survey respondents to be helpful as they were ensured complete anonymity.

Sociodemographic and clinical characteristics of the survey participants are presented in Table 1. Out of 482 respondents, the majority were females (63.9%), below 55 years of age (59.5%), from a rural area (66.4%), had less than or equal to high school education (64.1%) and had relatively low monthly household income (≤ $300US/month) (57.1%). The most frequent types of cancer included gastrointestinal (36.1%), urogenital (29%) and breast cancers (15.6%). The majority of patients (n = 324; 67.2%) were receiving chemotherapy at the time of study.

Use of CAM to manage symptoms associated with cancer and its treatment was reported by 47.9% (n = 231) of respondents. Half of users used CAM while receiving conventional cancer treatment. Survey participants more likely to use CAM were female, younger, and had middle/high school education, were more recently diagnosed of cancer, had gastro-intestinal or urogenital cancer, were receiving active chemotherapy, and had used CAM before diagnosis of cancer (Table 1).

A logistic regression model was used to assess if any socio-demographic and clinical characteristics were independently associated with the decision to use CAM for cancer-related outcomes (Table 2). The multiple logistic regression model shows that CAM use was significantly associated with female gender (OR 1.749, 95% CI 1.15–2.658, p = 0.009), younger age (OR 1.662, 95% CI 1.109–2.493, p = 0.014), higher level of education (OR 1.798, CI 1.196–2.702, p = 0.005), shorter time since diagnosis (OR 2.963, 95% CI 1.364–6.436, p < 0.006), and prior use of CAM (OR 3.027, 95% CI 2.031–4.513, p < 0.001).

The frequency of leading CAM modalities along with perceived effectiveness reported by CAM users are listed in Table 3. Products of animal origin (150 of 231 users, 64.9%) were the most popular modalities of CAM used for cancer-related outcomes followed by herbal medicine (32.9%), mind-body therapies (29.4%), dietary supplements (10.8%), and Mongolian traditional medicine (2.2%). Users of products of animal origin reported taking 18 different products while herbal medicine users reported using five different herbs. Of these products, tripe (37.2%), wild animal products (18.2%), rhubarb (18.2%), milk bath (16.9%), and dried foam from a camel’s mouth (16.0%) were most commonly used. Proportion of users who perceived CAM as helpful for the purposes they used for are also presented in Table 3.

As illustrated in Table 4, most CAM users obtained information about CAM modalities from other cancer patients (24.7%), followed by family members (22.5%), friends (19.0%) and mass media and the internet (15.2%). Health professionals including general practitioners and oncologists were least likely to recommend use of CAM (6.4%).

Increasing chance of cure (41.6%) was the most frequently reported reason for using CAM. Patients also associated the consumption of CAM with boosting the immune system (35.5%). Other reasons for using CAM by patients with cancer referred to symptom relief (18.2%) and others (11.3%) (Table 4).

Overall, about 65.8% of the CAM users agreed that use of CAM is generally safe, whilst 23.4% were “neutral” and 10.8% disagreed. Moreover, only 38.1% agreed that concurrent use of CAM and conventional treatment of cancer is safe, whereas 37.2% disagreed. Of the 231 users, only 29.0% discussed the concurrent use of CAM with their doctors. Most common reasons for nondisclosure were doctors did not ask (75.6%) and it was not necessary for doctors to know (18.9%) (Table 4).

As shown in Table 5, the majority of patients indicated that they would consider CAM use for pain management (38.2%), fatigue (27.0%), constipation (26.3%) and nausea and vomiting (21.6%). Anxiety or depression (17.4%) was least likely to cause use of CAM by patients with cancer.

There are a few limitations of our study. First, as some of the questions investigated past events, so recall bias might have influenced the results. Second, this study might have overestimated the use of CAM among cancer patients as a result of the voluntary response bias. Patients who had an interest in CAM or were using CAM modalities may have been more likely to participate in this study. Moreover, there was a low response from men with cancer and thus the views expressed by the study participants may not fully reflect those of the whole cancer population. As these are the first findings to report use of CAM in Mongolia, a broad range of CAM modalities were included in the survey. The authors are working on another research where Traditional Mongolian Methods of CAM such as bone art and balneotherapy will be reported in near future. Despite these limitations, this study sheds light on different but important aspects of CAM use among Mongolian patients with cancer.