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Year : 2019  |  Volume : 15  |  Issue : 5  |  Page : 1155-1161

The relationship between hopelessness level and complementary and alternative medicine use in patients with breast cancer

Department of Midwifery, Faculty of Health Sciences, Ege University, Bornova, Izmir, Turkey

Date of Web Publication4-Oct-2019

Correspondence Address:
Mahide Demireloz Akyuz
Department of Midwifery, Faculty of Health Sciences, Ege University, Bornova, Izmir-35100
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_815_17

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 > Abstract 

Introduction: Following the diagnosis and treatment of breast cancer, women may experience some emotions such as anxiety, uncertainty, andhopelessness, and these experiences may vary from person to person. Many patients, along with conventional treatments, can resort to traditional methods to support the treatment, prevent recurrence of cancer, cope with the side effects of the treatment, and strengthen physically and mentally.
Aims: The study was aimed at determining the relationship between hopelessness level and use of complementary and alternative medicine (CAM) methods in women with breast cancer.
Materials and Methods: In this descriptive and cross-sectional study, 336 women with breast cancer who presented to the mammography unit were contacted. Among the CAM methods used, herbal treatment methods rank first. Of the reasons, women prefer these methods; “CAM provides psychological comfort” takes the first place.
Results: The mean scores obtained from the Beck Hopelessness Scale by the women who used and who did not use CAM were 5.45 ± 5.18 and 4.44 ± 4.10, respectively. The difference between the two groups was statistically significant (P < 0.05).
Conclusion: In conclusion, women with breast cancer may attempt to use CAM due to hopelessness. Therefore, in the course of medical treatment of patients, CAM practices should be questioned, they should be provided counseling and if necessary, referred for psychological support.

Keywords: Breast cancer, complementary and alternative medicine methods, hopelessness

How to cite this article:
Akyuz MD, Oran NT, Yucel U, Eksioglu A, Kocak YC. The relationship between hopelessness level and complementary and alternative medicine use in patients with breast cancer. J Can Res Ther 2019;15:1155-61

How to cite this URL:
Akyuz MD, Oran NT, Yucel U, Eksioglu A, Kocak YC. The relationship between hopelessness level and complementary and alternative medicine use in patients with breast cancer. J Can Res Ther [serial online] 2019 [cited 2022 Jan 18];15:1155-61. Available from: https://www.cancerjournal.net/text.asp?2019/15/5/1155/244236

 > Introduction Top

The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM therapies as the health-care systems, products, and practices not yet considered as a part of conventional medicine.[1] The NCCAM classifies CAM therapies into five categories: [2] alternative medical systems (homeopathy, naturopathy, Ayurveda, etc.), body–mind interventions (music therapy, spiritual healing, prayers, etc.), biologically based therapies (herbs, dietary supplements, medicinal herbal teas, or body parts of animals such as shark cartilage, etc.), manipulative and body-based treatments (massage, chiropractic manipulation, osteopathy, etc.), and energy treatments (reiki, qigong, electromagnetic therapies, etc.).

CAM has been used for centuries in the world and its use is affected by such factors such as education, ethnic group, age, gender, socioeconomic status, religious beliefs, culture, and health status. In recent years, in many developing and industrialized countries, the use of CAM has increased steadily. According to the National Health Interview Survey report, in the United States, between 2002 and 2007, 4 out of every 10 adults used CAM.[3] In developing countries, the prevalence of CAM use has been described by very few studies. Available literature indicates that few studies have evaluated the prevalence of CAM use in the general population. A study on the self-reported use of CAM in Jeddah Western Saudi observed that over 80% of the populations in developing countries depend on CAM products and/or traditional healing modalities, including herbal remedies, for health maintenance and therapeutic management of disease.[4] However, other studies on CAM use in developing countries were among women with breast cancer in Singapore where out of 146 patients analyzed, 58.6% consumed CAM along with chemotherapy with 72.1% consuming CAM even before diagnosis was made.[5]

All over the world, CAM use in the treatment of chronic diseases, particularly of cancer is on the increase due to the following reasons: willing to lead a longer and healthy life, to strengthen the immunity system, and to relieve the side effects of drugs, lack of definite treatment of some chronic diseases which is also long, uncomfortable and costly for patients, unaffordable health-care costs of innovative health technology, difficulty in accessing these technologies, giving up hope of conventional treatment, and health workers' lack of opportunity to spare enough time to patients.[6]

CAM use is also widespread in patients with breast cancer. In a study involving European countries, the rate of CAM use in patients with breast cancer was reported to be 25.9% of the general population had used CAM during the past 12 months. Typically, only one CAM treatment had been used, and it was used more often as complementary rather than alternative treatment. The use of CAM varied greatly by country, from 10% in Hungary to almost 40% in Germany.[7]

In studies conducted on the frequency of CAM use in patients with breast cancer in Turkey, the rate is reported to range between 30% and 87%.[8],[9],[10],[11]

With the diagnosis of cancer and onset of its treatment, patients experience problems such as physical discomfort, economic and social losses, loss of personal control, and the inability to perform self-care activities. Physical and psychosocial disorders directly affect a patient's perceptions of the disease, emotional and behavioral responses, coping style, quality of life, compliance to the treatment, and future expectations.[12] Nevertheless, the impact of all unfavorable physical, psychological, and social changes related to cancer can vary among individuals.

In clinical practices, primarily, physical assessments of patients are performed and their treatment is planned. Keeping social, emotional, spiritual, economic, and cultural needs in the background or ignoring them makes it even more difficult to solve the problems that patients experience. Unlike in the past, breast cancer is not necessarily a death sentence. With such advances, the focus today should perhaps be on healing the patient holistically, taking into consideration their psychological, social, and spiritual well-being, and sometimes even treating the family too. Many hospitals are striving toward this goal by instituting a better holistic needs' assessment and holistic care programs.[13] In its guidelines prepared to improve the outcomes of cancer treatment, the National Cancer Survivorship Initiative emphasized the necessity and importance of the holistic needs assessment.[14]

Recently, the concepts of hope and hopelessness are frequently discussed. These two concepts play an important role in patients' compliance with the disease and treatment who have been diagnosed with cancer. Hope is regarded as a dynamic power that strengthens one's adaptation to the future, encourages him/her to be interested in the future and his life, and a positive outlook on life experienced by us all at times, though it is not a permanent state of mind-like optimism or its opposite, pessimism.[15],[16] Hopelessness is defined as an emotional state in which individuals have no options to solve problems or to achieve their wishes, or they cannot activate the energy they have to fulfill their goals.[17] Upon the diagnosis of cancer, future appears uncertain to patients. This ambiguity may be cause patients to experience intense feelings of despair and hopelessness. Nevertheless, patients may also experience despair because of other reasons independent of breast cancer. Therefore, other causalities must be taken into consideration while managing the patient.[18],[19],[20] While there are a limited number of studies in the literature investigating the relationship between CAM use and hopelessness, there are no studies investigating this relationship in patients with breast cancer.

 > Materials and Methods Top

In the present study, it was aimed to determine the relationship between hopelessness levels of breast cancer patients and CAM methods they use.

Sampling methodology

The population of this cross-sectional and descriptive study consisted of all women diagnosed with breast cancer who presented to the Mammography Unit of the Medical Faculty Radiology Department of Ege University (n = 1.025). The smallest sample size to be included in the study was calculated as 279 people using the StatCalc (Epi Info - Free Tool For Public Health Practices) at a confidence interval of 95%, with 50% unknown prevalence and 5% error rate. No sampling method was implemented in this present study, all the patients in the population were intended to be included in the sample, and thus all the women who volunteered to participate in the study between September 2013 and December 2015 (n = 336) were included in the study using the improbable sampling method. Some of the women did not agree to participate in the study due to the biological and psychological burden of cancer on them and some other women did not complete the questionnaires during the implementation; therefore, data loss occurred. Of the women, those who were not diagnosed with breast cancer and/or did not agree to participate in the study were excluded from the study.

Data collection tools

The data were collected using two different forms; “The sociodemographic information form” and “The Beck Hopelessness Scale” (BHS). The forms were administered using the face-to-face interview method.

The sociodemographic information form

In the study, the “sociodemographic information form” which contained 36 items was developed in line with the literature. In the questionnaire, 15 items questioned the participants' sociodemographic characteristics, whereas 21 items questioned risk factors for breast cancer, the participants' knowledge levels regarding the prevention, and treatment methods and their CAM use during the treatment process. Before applying research form, the validity and pilot application of the sociodemographic information form was performed on 12 women.

The Beck Hopelessness Scale

BHS is a 20-item true/false survey based on the definition of hopelessness as “a system of negative expectancies concerning a patient and his/her future life.” It yields a score ranging from 0 to 20, scored as 0–3, normal; 4–8, mild hopelessness; 9-14, moderate hopelessness; and 15 or greater, severe hopelessness.[21] The first Turkish validity and reliability study of the scale was conducted by Dilbaz and Seber and the scale's internal consistency coefficient was calculated as 0.86, item-total correlations ranged between 0.07 and 0.72, and test-retest reliability coefficient was 0.74.[22] The same scale was later worked on by Durak and Palabıyıkoğlu, and they calculated the scale's internal consistency coefficient as 0.85, item-total correlations as between 0.31 and 0.67, and split-half reliability as 0.85.[23] In the present study, the BHS was used to determine factors affecting the participants' CAM use and their negative expectations concerning their future.

Statistical analysis

The study data were analyzed using the SPSS software package program (Version 16.0, SPSS Inc., Chicago, IL) and the significance level was accepted as P < 0.05. During the analysis process of the data, number-percentage distribution, mean values, the Chi-square test, dependent Samples t-test, Independent Samples t-test, and one way ANOVA were used.[24]

Ethical consideration

Ethical approval to conduct the study was obtained from the Local Ethics Committee of Tepecik Training and Research Hospital affiliated to the General Secretariat of İzmir Public Hospitals Union. The principles set out by the Declaration of Helsinki and national and local ethical guidelines for research were also followed. All the patients were informed of the purpose the study with written documents and were told that the information would not be disclosed and their oral consents were obtained.


Women with biological and psychological problems did not agree to participate in the research. For this reason, research data collection process has been extended to reach more women. Due to the single face-to-face interview technique, the data presented here indicate only instantaneous hopelessness status; however, it may vary across the treatment course of participants.

 > Results Top

The mean age of the women participating in the study was 55.84 ± 0.58 (min = 21, max = 88) and most of them were between 51 and 60 years of age. Of them, 84.5% were married and 75.9% had a nuclear family (father, mother, and child) Data on the participants' health and illness history were given in [Table 1], on their CAM use in [Table 2] and [Table 3], and the comparison of the participants using CAM with those not using CAM in terms of their BHS scores in [Table 4].
Table 1: Participants' cancer history

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Table 2: Data on the participant's complementary and alternative medicine use

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Table 3: Comparison of the participants using complementary and alternative medicine with those not using complementary and alternative medicine

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Table 4: Comparison of the participants using complementary and alternative medicine with those not using complementary and alternative medicine in terms of the mean scores they obtained from the Beck Hopelessness Scale

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Of the participants, 34.8% had a family history of breast cancer. Most of the relatives were aunts, mothers, and sisters. Of the participants, 42.3% length of cancer history ranged between 1 and 5 years and most of them had stage first cancer [Table 2].

The frequency of using CAM for women was found to be 42.6%. Of the CAM methods the participants used, herbal medicine took the first place (87.4%), followed by religious practices (78.3%). However, 25.9% women stated that they used the guided imagery technique. Most of the women started CAM use after they were diagnosed with cancer. Of the participants, 74.1% reported that they used the CAM method more than 24 months and of the participants, 21.0% said that the CAM method they used met their expectations [Table 2]. The vast majority of the participants using CAM reported that they were encouraged to use CAM by the media (41.4%), friends or people around them (24.7%), people with similar illnesses (19.5%), health workers (9.3%), and other people (5.1%). When the effective causes are examined, several reasons were cited for the participants' CAM use. Of those reasons, psychological comfort ranked first (27.8%), followed by the strengthening of the immunity system (21.8%), coping with helplessness (19.8%), strengthening of the body (16.6%), and increasing the effectiveness of the treatment (14.0%) (women gave more than one response).

In [Table 3], the group using CAM is compared with the group not using CAM in terms of some variables reflecting their sociodemographic and health characteristics. There was no significant statistical difference between the groups in terms of age (P = 0.298), educational level (P = 0.441), marital status (P = 0.250), employment status (P = 0.368), family type (P = 0.983), monthly income (P = 0.708), social security (P = 0.498), family history of cancer (P = 0.298), and presence of a chronic illness. However, there was a significant difference between the participants who received chemotherapy (P = 0.045), radiotherapy (P = 0.044), hormone therapy (P = 0.042), and surgery (P = 0.004) in terms of CAM use.

The mean score the women participating in the study obtained from the BHS used to assess the causes of their CAM use, and negative expectations concerning their future were 4.87 ± 0.26. While the mean score was 4.44 ± 4.10 for those who did not use CAM, it was 5.45 ± 5.18 for those who used CAM. The difference between the two groups was statistically significant (P = 0.030) [Table 4].

 > Discussion Top

Due to the increasing use of CAM methods, it has become necessary to investigate the frequency of CAM use and causes of CAM use in different diseases. In this study, the frequency of CAM use of women diagnosed with breast cancer and some characteristics regarding CAM use were investigated. In addition, the relationship between the patients' hopelessness level concerning their future and CAM use was investigated using the BHS.

Of the participants, 42.6% used CAM. This rate is similar to the rates reported in some studies conducted in Turkey. While the rate of the women with breast cancer who used CAM was 48.8% in Kurt et al.'s study, it was 54.8% in Taş et al.'s study.[25],[26] In a study conducted by Uğurluer et al., 44.8% of the patients undergoing chemotherapy used CAM; the rate was higher (60.9%) in patients with breast cancer.[27]

Studies conducted in various countries demonstrated that CAM use was widespread in patients with breast cancer. The rate was 40% in Lebanon, 56% in Thailand, between 48% and 70% in the USA, and 81.9% in Canada.[28],[29],[30],[31] In their literature review study (2000), Bebiş et al. reviewed 16 studies conducted with 75,510 women with breast cancer in European countries, the United States, Asian countries, Australia, New Zealand, Far East countries, and the United Kingdom, and they found that CAM use varied between 24% and 98%.[32] Although the rate of CAM use in patients with breast cancer varies from one country to another and from one study to another within the same country, CAM use is quite widespread in all studies. Whether patients use CAM and what type of CAM the users prefer are influenced by various factors such as the geographical region they live in, lifestyles, socioeconomic and cultural conditions, religious beliefs, ethnicity, and health/illness beliefs; therefore, the wide range in the CAM use rate is an expected reality. On the other hand, the fact that the CAM methods used are many may also have affected this rate.

The National Center for CAM has identified more than 200 CAM methods and classified them into five categories.[2] The most common method used by the participants in the present study was herbal medicine, which falls into the category of biologically based therapies. The second most frequently used CAM method by the participants was religious practices that fall into the body–mind interventions. Many similar studies show that herbal medicine and saying prayers are the most commonly used methods.[25],[27],[29],[33],[34],[35],[36],[37] Since nutritional drug interactions might pose a risk of affecting the treatment adversely, health-care workers should question whether the patient has used herbal products or plant derivatives, even if he/she quit it recently, while taking his/her medical history.[27],[38],[39] In a review study of the 33 studies mostly conducted in the United States, Canada, China, and Australia, the most frequently used methods were biologically based therapies in 21 studies, and body–mind interventions in 9 studies (saying prayers, meditation, etc.).[35] Biologically based therapies vary from country to country or according to some characteristics of patients. Among the widely used herbal medicinal products in Turkey are annual nettle, black cumin, and herbal teas.[9],[18],[25],[26],[40] In their literature review study (2000), Bebiş et al. reviewed studies conducted in various countries and found that vitamins and minerals were used as supplements.[32] Studies show that, while in Western countries, expensive methods such as multivitamins, meditation, homeopathy, and hypnotherapy are common, in the eastern countries, cheaper, and easier to apply methods such as herbal blends and religious practices are common.[25],[30]

As for Turkey, similar to other studies, the present study demonstrates that, in Turkey, cheap and easy-to-apply methods are preferred to expensive methods. There was no significant relationship between the study group's CAM use and variables such as age, education, employment status, the presence of a chronic disease, health status, and marital status. Some studies conducted in Turkey have reported that the geographical region they live in and sociodemographic characteristics affect CAM use. In some of these studies, women with lower educational levels living in rural areas are reported to use CAM more.[26],[27],[40],[41] On the other hand, in some studies in Turkey, CAM use is more common in women with higher education.[27],[38] Similarly, the results of several studies conducted in various countries on the relationship between CAM use and sociodemographic characteristics such as economic and marital status vary. Wanchai et al. who reviewed 33 studies found that CAM use was more common in younger and higher-educated women with breast cancer in 22 studies and in older patients only in one study. In some of these studies reviewed, no relationship was determined between CAM use and variables such as education, age, and marital status.[35]

CAM use is more common in patients receiving chemotherapy, radiotherapy, hormone therapy, and surgical treatment than those who do not receive these treatments. Similarly, in a study conducted by Bebiş et al., the majority of the patients were reported to use CAM, while they underwent chemotherapy or after they had surgery.[32]

Many women stated that they started to use CAM methods, after getting recommendations from other patients who had used these methods or after watching or listening to a program on the radio, TV, or Internet. Usually, in such sources of information, the adverse effects of the CAM methods used, their disadvantages, and interactions with the current medical treatment, and how reliable they are usually not mentioned.[11],[34] According to the Institute of Medicine Report on CAM in the United States, people obtain information about traditional and complementary medicine from friends, written media, and the Internet.[42] For the participants in the present study, media took the first place as the information source about CAM use, followed by friends and relatives. Similarly, in their study, Kav et al. reviewed 21 studies conducted in Turkey and found that the information source of cancer patients was mostly friends and relatives and other patients and these patients' relatives.[38] In another study, the source of information was also family members and friends.[35] The fact that the media were the primary source of information in the present study may be due to the fact that the issue and the legislative work of the Ministry of Health related to the issue were on the agenda of the media in the past few years.[43]

The majority of women who use CAM do not tell health-care providers that they have used CAM either because they do not think it is necessary or because they are afraid of the doctor's negative reaction. Similarly, many studies have reported that a significant proportion of cancer patients using CAM do not tell health workers that they have used CAM because they are afraid of getting a negative reaction from health workers.[27],[38],[39],[42],[44],[45] This is why health professionals are required to take thorough and accurate medical history of patients with breast cancer, to steadily evaluate the outcomes of the treatment, and to inform patients about the pros and cons of CAM methods they use.[27],[38] During medical treatment, health-care professionals should encourage women with breast cancer to share their CAM use experiences comfortably and should question their CAM use nonjudgmentally.

In a literature review study, the reasons stated by women with breast cancer to use CAM were that CAM was useful for their health, improved their general health, had a curative effect, reduced some side effects of medical treatment, and strengthened the immunity system.[32] Among the reasons determined in the present study, the one ranked first was that “CAM provides psychological comfort.” Beck's hopelessness scale scores were somewhat higher in the participants using CAM than in the participants not using CAM. The comparison of those who used CAM and those who did not use CAM revealed that, despite the fact that all women need psychological support in the process of accepting and coping with breast cancer, CAM users needed psychological support more. In another study conducted in Turkey, Beck's hopelessness scale scores of patients using CAM were close to those of patients not using CAM.[39] This result is not consistent with the result obtained from the present study. It can be thought that the feeling of hopelessness may urge patients to resort to different methods in addition to their medical treatments; however, hopelessness may not be the sole determinant of resorting to different methods.

 > Conclusion Top

That the hopelessness scores of the women with breast cancer were not high can be considered as a positive outcome in terms of compliance with the course and treatment of the disease. However, it should be kept in mind that factors such as disease perception, treatment methods, life expectancy, and recurrence risk can cause anxiety and hopelessness in an individual. Health personnel should take into account breast cancer patients' feelings and needs for a psychological support while they provide medical treatment and services for those patients. In addition, women with breast cancer should be encouraged to share their CAM use experiences with the health staff. During the medical treatment process, they should question patients' CAM use and provide effective counseling services.


We would like to extend our sincere thanks to the staff of the Ege University Medical Faculty Radiology Department's Mammography Unit where the research was held and to the women who participated in the research for their great support. This work was supported by the Ege University Scientific Research Project Fund. We would also like to thank the Rectorship of Ege University which supported the research with Scientific Research Fund.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]

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