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University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 1 Use of Complementary and Alternative Therapies to Manage Cancer Related Symptoms in Hospitalized Patients Jennifer Jonas, Dr. Ann Horgas, and Dr. Saun Joo Yoon College of Nursing, University of Florida Patients with cancer frequently experience pain, fatigue, and sleep disturbances. This study investigates (a) the presence and severity of symptoms, (b) the various types of complementary and alternative therapies (CAM) patients currently use to manage cancer related symptoms, n = 13) completed an anonymous survey to assess self reported pain, fatigue, sleep disruptions, and CAM based symptom management therapies. Self reported sleep disruptions was the most common symptom (79.6%). Prayer (53.8%) was the most frequently used CAM therapy. Patients reported the most interest in learning about massage (66.7%), biofeedback (41.7%), and meditation (41.7%). These fin dings highlight the preva lence of pain, fatigue, and sleep disruptions in this population and the fact that many patients currently use CAM therapies to manage their symptoms and are interested in learning about other strategies. Nurses have an important role in he lping patients t o manage their symptoms and in educating patients about safe use of CAM. INTRODUCTION Common Symptoms in Patients with Cancer Cancer is one of the most common medical diagnoses in the United States and is associated w ith many disease and treatment side effects (Hayat, Howlader, Reichman, & Edwards, 2007). Fatigue, nausea, and pain are among the most common cancer related symptoms (Cella et al., 2007). Pain is one of the most familiar and problematic symptoms among cancer patients and is a major source of concern for patients (Miaskowski, Kragness, Dibble, & Wallhagen, 1997). Studies have found that women with cancer (Cleeland et al., 1994) and elderly adults with cancer (Green et al., 2003) are at risk for under tre atment of pain. Studies also suggest that persistent unrelieved pain leads patients to seek alternative therapies (Vallerand, Fouladbakhsh, & Templin, 2005). Fatigue is highly prevalent among cancer patients. It is a major symptom of cancer treatment and functional level and well being (Wu & McSweeney, 2007). Cancer related fatigue fluctuates over time, is severe, causes debilitating tiredness, and is more extreme than typical fatigue (Gibson et al., 2005). Fatigue interferes with patient suggests that patients suffering from fatigue are more likely to experience depression and anxiety (Hotopf, 2004). Insomnia, similar to fatigue, is associated with reduced functioning. One quarter of all c ancer survivors suffer from chronic insomnia that negatively aff ects daytime functioning and quality of life (Fleming, Gillespie, & Espie, 2009). In a study of 982 respondents, 75% of cancer survivors had chronic insomnia that lasted six months or more (Da vidson, MacLean, Brundage, & Schulze, 2002). Recent studies have found that sleep disturbances result in other significant consequences including reductions in treatment compliance, survival, pain control, immune and metabolic functions (Sateia & Lang, 200 8). Most patients with cancer related pain, fatigue, and sleep disruptions use medications to treat their symptoms. Pharmacologic treatments, however, are not effective for everyone, and often cause adverse side effects such as constipation, sedation, or r espiratory suppression (Evans & Rosner, 2005). As such, many cancer patients seek complementary and alternative therapies to manage their cancer related symptoms (Richardson, Sanders, Palmer, Greisinger, & Singletary, 2000). Complementary and Alternative M edicine Complementary and alternative medicines (CAM) are (Eisenberg et al., 1993). More specifically, complementary medicine is used in conjunction with conventional treatments ( Fouladbakhsh, Stommel, Given & Given 2005; Sollner et al., 2000), whereas alternative medicine is used in place of conventional medicine (Field et al., 2008). The National Center for Complementary and Alternative Medicines (NCCAM) categorizes the different types of CAM practices into four domains: mind body practices, biologically based practices, manipulative and body based practices, and energy medicine (Fouladbakhsh et al., 2005). Prevalence of CAM Use in Can cer Patients Complementary and alternative medicine is popular among cancer patients as they often seek remedies to supplement conventional medical treatment. It has been

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JENNIFER J ONAS DR ANN HORGAS & DR SAUN JOO Y OON University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 2 estimated that between 44 83% of cancer patients used at least one CAM therapy to control their symptoms ( Richardson, et al., 2000; Wells et al., 2007). The most commonly used therapies were spiritual practices, vitamins and herbs, and physical therapies, used in combination with con ventional treatment (Richardson et al., 2000). Reasons for CAM Use a mong Cancer Patient s According to a study of 453 outpatient cancer patients, the most common reason for using CAM was a desire to feel hopeful (73.0%) (Richardson et al., 2000). Patients in this study represented a variety of cancers, incl uding breast, prostate, gastrointestinal, head/neck, sarcoma/melanoma, and lymphoma. Patients reported using CAM because they felt these methods were nontoxic (48.9%) and wanted to maintain control in the decisions about their medical care (43.8%). The sur vey concluded that their expectations of CAM were to improve their quality of life, boost their immune system, prolong life, or relieve symptoms (Richardson et al., 2000). In sum, there is ample evidence to support the fact that persons with cancer experience pain, fatigue, and sleep disruptions associated with their disease and/or their treatment. Several recent studies have examined the use of complementary and alternative medicine among cancer patients, but only a few have investigated what patien ts currently know versus what patients have interest in learning. Thus, the purpose of this study was to investigate the various types of complementary and alternative therapies that patients with cancer currently use to manage their cancer related symptoms and which types of CAM they are most interested in learning about. In addition, we sought to confirm the presence of pain, fatigue, and sleep disruptions in this population as a basis for using CAM therapies. Specifically, we asked the following r esearch questions: What percentage of hospitalized patients with cancer report experiencing pain, fatigue, and sleep disruptions? What are the most commonly used types of CAM reported by hospitalized patients with cancer? What types of CAM are patients most interested in learning about? METHOD Participants A convenience sample of hospitalized patients with cancer on the Shands @ UF (SUF) oncology unit was recruited to complete this anonymous survey. Inclusion criteria for enrollment were a diagnosis of cancer (any type) and at least 18 years old. The study sample consisted of 13 participants, 7 (53.8%) male and 6 (46.2%) female All of the participants were non Hispanic Caucasians with an average age of 60 years (Range = 49 82 years). Education was distributed as follows: 5 (38.5%) were high school graduates or GED recipients, 4 (30.8%) had some college or vocational experienc e, and 4 (30.8%) were college graduates. The most frequent types of cancer represented in the sample were lymphoma (30.8%), sarcoma (23.1%), and breast (7.7%) (see Table 1 for sample description) T able 1 : Sample Characteristics ( n = 13) Procedure Approval to conduct this study was obtained from the University of Florida Health Science Center IRB 01. Staff nurses on the oncology unit at SUF distributed the anonymous questionnaire to all cancer patients admitted to the hospital in the patient admissi on packets. Respondents returned the completed survey in an envelope provided to placed in an opaque and marked box for pick up. Data were entered into SPSS for analysis. Characteristic To tal Sample n (%) Sex Male 7 (53.8) Female 6 (43.2) Race White 13 (100) Hispanic 0 (0) Marital Status Married 5 (29.4) Unmarried* 8 (70.6) Education level H.S. grad or GED 5 (38.5) Some college/vocational 4 (30.8) College graduate 4 (30.8) Household Income** < 20,000 6 (50) 20,000 49,000 2 (16.7) 50,000 74,000 2 (16.7) >75,000 2 (16.7) Never married, widowed, separated, and divorced participants ** One participant did not answer

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COMPLEMENTARY AND AL TERNATIVE THERAPIES TO MANAGE CANCER RELATED S YMPTOMS University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 3 Measures The questionnaire in cluded six tools assessing demographics, health conditions, self reported pain, fatigue, sleep disruptions, and CAM use and/or interest. Measures are described in the following sections Demographic Characteristics Respondents were asked to provide demogr aphic characteristics, such as their age, sex, race, marital status, education, insurance status, household income (categorized), and with whom they live. Health, Hea lth Conditions, and Medications Respondents were asked to rate their overall subjective (poor). Participants were presented with a list of 13 medical conditions, including ca ncer, and asked to indicate which medical diagnoses they have been told by a health care professional that they have and which medications they take for any of the medical conditions that they endorsed. Pain Pain was measured using the Brief Pain Inventor y (Short F orm ) (Cleeland & Ryan, 1994). This survey contains 15 items about the presence and locations of pain, pain intensity, and the impact of pain on sleep, functioning, mood, and general well being. Pain intensity was rated on a 0 10 scale (0 = no pai n, 10 = pain as bad as can be imagined). Participants were asked to indicate how much relief they received from pain medications or treatments in the last 24 hours (0% = no relief 100% = complete relief). In addition, participants were asked the extent to which pain interfered with their general activity, mood, walking ability, work, social relationships, sleep, and enjoyment of life. Fatigue Fatigue was measured using the Brief Fatigue Inventory ( Mendoza et al., 1999). This survey consists of 10 question s about the presence and severity of fatigue and the impact of fatigue on daily functioning and quality of life. Participants were asked to rate their current level of fatigue and in the last 24 hours. Responses were on a 0 10 scale (0 = no fatigue, 10 = a s bad as can be imagined). Participants were also asked to indicate how fatigue interfered with general activity, mood, walking ability, work, social relationships, sleep, and enjoyment of life in the last 24 hours. Sleep Disruptions The Insomnia Severity Index ( Morin, Belleville, & Blanger 2006) was used to assess perceptions of insomnia and sleep disruption. This instrument consists of seven items that assess the severity of self reported sleep disruptions. Participants were asked to rate difficulty st aying asleep, falling asleep, or problems with waking up too early on a 0 4 scale (0 = none, 4 = very severe). Participants also indicated the degree to which sleep interfered with daily functioning, was noticeable to others, and caused worry or distress. Total Insomnia Severity Index scores were categorized as follows: 0 7 = no clinically significant insomnia, 8 14 = subthreshold insomnia, 15 21 = clinical insomnia (moderate severity), and 22 28 = clinical insomnia (severe). Complem entary and Alternative Medicine A Complementary and Alternative Medicine (CAM) Questionnaire (Yoon, 2008) was used to assess therapies respondents have used to manage their pain, fatigue, or sleep disruptions. The survey consists of 17 commonly used CAM therapies, ranging from m assage therapy and chiropractic to biofeedback and hypnosis. See Table 2 for a complete list of CAM therapies measured. Patients were asked to identify which CAM therapy they currently use, which symptom(s) they are using it for, and which CAM therapies th ey are interested in learning to use.

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JENNIFER J ONAS DR ANN HORGAS & DR SAUN JOO Y OON University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 4 Table 2 : Patient Use and Interest in CAM Type of CAM Used CAM n (% ) Reasons for CAM use n (% ) Interest in CAM n (%*) Pain Fatigue Sleep disruptions Multiple symptoms Massage 3 (23.1) 3 (100) 8 (66.7) Chiropractic 1 (7.7) 1 (100) 3 (25) Acupuncture 0 2 (16.7) Acupressure 1 (7.7) 1 (100) 2 (16.7) Energy healing 0 3 (27.3) Guided imagery 1 (7.7) 1 (100) 1 (8.3) Meditation 4 (30.8) 1 (25) 1 (25) 1 (25) 1 (25) 5 (41.7) Reflexology 1 (7.7) 1 (100) 2 (16.7) Hypnosis 0 2 (16.7) Biofeedback 0 5 (41.7) Prayer 7 (53.8) 1 (14.3) 6 (85.8) 4 (33.3) Spiritual healing 3 (23.1) 3 (100) 2 (16.7) Music therapy 3 (23.1) 1 (33.3) 2 (66.6) 2 (16.7) Herbal/folk remedies 1 (7.7) 1 (100) 3 (25) Megavitamins 2 (15.4) 1 (50) 1 (50) 3 (25) Yoga/tai chi 0 4 (33.3) TENS 0 3 (25) Valid percent reported RESULTS Prevalence of Sleep Disruptions The most commonly reported symptom was sleep disruptions, with 76.9% (n = 10) experiencing sleep disruptions over the last week (Figure 1). Thirty eight percent reported difficulty falling asleep at night, while 84.6% reported having moderate to very severe difficulty staying asleep. The majority of participants (53.8%) stated that they are dissatisfied with their sleeping patterns, and 76.9% reported that they worry and/or are distressed about t heir sleep. According to the Insomnia Severity Index, 75% (n = 9) of the participants had some degree of clinically significant insomnia.

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COMPLEMENTARY AND AL TERNATIVE THERAPIES TO MANAGE CANCER RELATED S YMPTOMS University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 5 Figure 1 : Percent of p atients r eporting pain, fatigue, and sleep di sruptions Prevalence of Pain More than half of the participants (53.8%) reported experiencing pain in the last 24 hours. The majority of pain experienced (76.9%) was reported in the upper body, including head, neck, shoulders, back, and abdomen. On average, participants reported their worst pain intensity as a 5 (mean = 4.9), and 46.2% reported pain scores of 6 or higher. With regard to pain relief from current medical treatments, 3 (23.1%) reported complete relief, 3 (23.1%) reported no relief, and the remainder reported little relief (15.4%) or some relief (26.1%). Pain interfered primarily (69.2%). Most participants reported no interference with social relationshi ps (61.5%) or walking (69.2%). Prevalence of Fatigue The majority of study participants (69.2%) reported experiencing fatigue. On average, participants reported that their worst fatigue intensity was a 5 (mean = 4.9), and the usual level of fatigue was a 4 (mean = 3.9). Respondents reported that fatigue interfered primarily with their ability to work (mean intensity = 4.5), but there was also moderate interference with general activity (mean = 3.6), mood (mean = 3.31) and enjoyment with life (mean = 3.5). Most Comm only Used CAM Of the 17 types of CAM assessed, prayer was the most commonly reported CAM therapy used (53.8%) (see Table 2). Of those using prayer (n = 7), most respondents (85.8%) reported using prayer for multiple symptoms. Use of spiritua l healing was also reported by 23.1% to heal multiple symptoms. Participants reported using meditation (30.8%) for pain, fatigue, and sleep disturbances. Massage was reported for pain by 23.1% reported. Participants in this study did not report the use of the following therapies: acupuncture, energy healing, hypn osis, biofeedback, yoga, or t ranscutaneous electrical nerve stimulation ( TENS ) Interest in Types of CAM Patients expressed interest in learning about massage (66.7%), biofeedback (41.7%), and meditation (41.7%) (see Table 3). Mind body practices generated the most interest, with study participants reporting biofeedback, meditation, prayer, and yoga/tai chi among the top ten CAM therapies that they are interested in learning about. Study partici pants reported that they were least interested in imagery (8.3%). 69.2 53.8 76.9 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Pain Fatigue Sleep Disruptions

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JENNIFER J ONAS DR ANN HORGAS & DR SAUN JOO Y OON University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 6 Table 3 : Top Ten Interesting CAM Therapies to Patients CAM Therapies Patient Interest in CAM n (% a ) Massage 8 (66.6) Biofeedback 5 (41.7) Meditation 5 (41.6) Prayer 4 (33.4) Yoga/tai chi 4 (33.3) Energy healing 3 (27.3) Chiropractic 3 (25) Herbal/folk remedies 3 (25.0) Megavitamins 3 (25.0) TENS 3 (25.0) a Valid percent reported DISCUSSION The results of this study confirm that pain, fatigue, and sleep disruptions are common symptoms among cancer patients undergoing treatment. The majority of hospitalized patients in this sample reported experiencing at least one of these symptoms. Not surprisingly, pain, fatigue, an d sleep Notably, very few patients reported complete pain relief from conventional therapies. Thus, it is not surprising that many turn to complementary and alternative therapies to help manage their s ymptoms. Prayer was the most commonly used CAM therapy. Prayer is often used to relieve stress and to cope with the issues of daily life (Dunn & Horgas, 2000). Pain, fatigue, and sleep disruptions can cause a considerable amount of and the high prevalence of prayer is not surprising in this context. This finding is consistent with prior studies that have documented the high use of prayer to cope with pain among older adults (Dunn & Horgas, 2000). These findings illustrate the fact t hat many cancer patients suffer from multiple symptoms during their treatment, most notably pain, fatigue, and sleep disruptions. These symptoms negatively influence their quality of life. Not surprisingly, patients report using CAM to help manage their pa in, and expressed interest in learning about other therapies. These findings have important implications for nurses, since they are in a key position to assess and manage symptoms among hospitalized patients. Nurses should recognize that symptoms are not a lways relieved by conventional medical therapy and should help patients consider CAM therapies. Nurses play an important role in educating patients and their families about symptom management and should be knowledgeable about the various forms of CAM thera pies that are available. Nurses can use this knowledge to help patients use CAM safely. It is also important that nurses and other health care professionals be aware of what patients are currently using, so that they can assess for potential interactions o r contraindications. Finally, with regard to prayer, nurses should be aware of its importance to many patients and be prepared to acknowledge it with their patients and/or make referrals as necessary. While this study yields some interesting preliminary r esults, several limitations should be noted. First, the sample size was small. Only 13 patients from Shands @ UF completed and returned the questionnaire to date. Thus, the sample may be biased towards patients who are well enough to complete the survey or those who use CAM. Other potential participants may have declined participation based on the purpose of the study. The study interested, they may not have responded. Unfortunately, because the stu dy was an anonymous survey, it is impossible for us to know how many patients were eligible to participate or why some did not respond. Second, the sample consisted of only Caucasians. Thus, the extent to which the results would vary in different racial gr oups is not known. Further study is necessary to obtain a larger and more diverse sample size. Third, the study used an anonymous survey methodology. This approach, however, relied heavily on the nurses and unit clerks to distribute surveys to newly admitt ed patients. The hectic and busy environment of the hospital may have caused these surveys to be overlooked. In further studies, it may be beneficial to conduct interviews with patients instead of distributing surveys. This might yield a more representativ e sample that would enable more in depth analyses of the symptom experience and CAM use in cancer patients. Despite these limitations, this study highlights the continuing problem of pain, fatigue, and sleep disruptions ptoms are not relieved during their hospitalization, and this is an important issue for nurses and other health care professionals to address. Further, patients use and seek information about CAM therapies to help them manage their symptoms and disease. Nu knowledgeable about CAM so that they can be in the best position to appropriately assist and educate patients.

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COMPLEMENTARY AND AL TERNATIVE THERAPIES TO MANAGE CANCER RELATED S YMPTOMS University of Florida | Journal of Undergraduate Research | Volume 12 Issue 3 | Summer 2011 7 REFERENCES Cella D., Wagner, L., Cashy, J., Hensing, T. A., Yount, S., & Lilenbaum, R. C. (2007). Should health related quality of life be measured in cancer symptom management clinical trials? Lessons learned using the functional assessment of cancer therapy. Journal of the National Cancer Institute. Monographs, 37 53 60. Cleeland, C. S., Gonin, R., Hatfield, A. K., Edmonson, J. H., Blum, R. H., Stewart, J. A., & Pandya K. J (1994). Pain and its treatment in outpatients with metastatic cancer. The New England Jour nal of Medicine, 330 (9), 592 596. Cleeland, C. S., & Ryan, K. M. (1994). Pain assessment: Global use of the brief pain inventory. Annals of the Academy of Medicine, Singapore, 23 (2), 129 138. Davidson, J. R., MacLean, A. W., Brundage, M. D., & Schulze, K. (2002). Sleep disturbance in cancer patients. Social Science & Medicine 54 (9), 1309 1321. Dunn, K. S., & Horgas, A. L. (2000). The prevalence of prayer as a spiritual self care modality in elders. Journal of Holistic Nursing: Official Journal of the American Holistic Nurses' Association, 18 (4), 337 351 Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins, D. R., & Delbanco, T. L. (1993). Unconventional medicine in the United States. Prevalence, costs, and patterns of use. The New Engl and Journal of Medicine, 328 (4), 246 252. Evans, R. C., & Rosner, A. L. (2005). Alternatives in cancer pain treatment: The application of chiropractic care. Seminars in Oncology Nursing, 21 (3), 184 189. Field, K. M., Jenkins, M. A., Friedlander, M. L., McK inley, J. M., Price, M. A., Weideman, P., Lindeman, G. J. (2009). Predictors of the use of complementary and alternative medicine (CAM) by women at high risk for breast cancer. European Journal o f Cancer 45 (4), 551 560. Fleming, L., Gillespie, S., & Espie, C. A. (2009). The development and impact of insomnia on cancer survivors: A qualitative analysis. Psycho Oncology, 19(9), 991 996. Fouladbakhsh, J. M., Stommel, M., Given, B. A., & Given, C. W. (2005). Predictors of use of complementary and alternative therapies among patients with cancer. Oncology Nursing Forum, 32 (6), 1115 1122. Green, C. R., Anderson, K. O., Baker, T. A., Campbell, L. C., Decker, S., Fillingim, R. B., (2003). The unequal burde n of pain: Confronting racial and ethnic disparities in pain. Pain Medicine 4 (3), 277 294. Gibson, F., Mulhall, A., Richardson, A., Edwards, J., Ream, E., Sepion, B., 2005. A phenomenologic study of fatigue in adolescents receiving treatment for cancer. O ncology Nursing Forum 32 (3), 651 660. Hayat, M. J., Howlader, N., Reichman, M. E., & Edwards, B. K. (2007). Cancer statistics, trends, and multiple primary cancer analyses from the surveillance, epidemiology, and end results (SEER) program. The Oncologist 12 (1), 20 37. Hotopf, M. (2004). Definitions, epidemiology, and models of fatigue in the general population and in cancer. In J. Armes, M. Krishnasamy, & I. Higginson (Eds.), Fatigue in Cancer (pp. 3 27). Oxford, NY: Oxford University Press. Mendoza, T. R., Wang, X. S., Cleeland, C. S., Morrissey, M., Johnson, B. A., Wendt, J. K., & Huber, S. L. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer 85 1186 1196. Miaskowski, C., Kragness L., Dibble, S., & Wallhagen, M. (1997). Differences in mood states, health status, and caregiver strain between family caregivers of oncology outpatients with and without cancer related pain. Journal of Pain and Symptom Management, 13 (3), 138 147. Morin, C.M., Belleville, G., Blanger, L. (2006). Validation of the Insomnia Severity Index [Abstract Supplement] Sleep ; 29 A 258 Richardson, M. A., Sanders, T., Palmer, J. L., Greisinger, A., & Singletary, S. E. (2000). Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology, 18 (13), 2505 2514. Sateia, M. J., & Lang, B. J. (2008). Sleep and cancer: Recent developments. Current Oncology Reports, 10 (4), 309 318. Sollner, W., Maislinger, S., DeVries, A., Steixner, E., Rumpold, G., & Lukas, P. (2000). Use of complementary and alternative medicine by cancer patients is not associated with perceived distress or poor compliance with standard treatment but with active coping behavior: A survey. Cancer, 89 (4), 873 880. Vallerand, A. H., Fouladbakhsh, J., & Templin, T. (2005). Patients' choices for the self treatment of pain. Applied Nursing Research 18 (2), 90 96. Wells, M., Sarna, L., Cooley, M. E., Brown, J. K., Chernecky, C., Williams, R. D., (2007). Use of complementary and alternative medicine therapies to control symptoms in women living with lung cancer. Cancer Nursing, 30 (1), 45 55; quiz 56 7. Wu, H. S., & McSweeney, M. (2007). C ancer it's so m uch more European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society, 11 (2), 117 125.


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Title: Summer Focus on Medical Research : Use of Complementary and Alternative Therapies to Manage Cancer-Related Symptoms in Hospitalized Patients
Series Title: Journal of Undergraduate Research
Physical Description: Serial
Language: English
Creator: Jonas, Jennifer
Horgas, Ann
Yoon, Saun-Joo
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2011
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Abstract: Patients with cancer frequently experience pain, fatigue, and sleep disturbances. This study investigates (a) the presence and severity of symptoms, (b) the various types of complementary and alternative therapies (CAM) patients currently use to manage cancer-related symptoms, and (c) participants’ level of interest in CAM use. A sample of hospitalized cancer patients (n = 13) completed an anonymous survey to assess self-reported pain, fatigue, sleep disruptions, and CAM-based symptom management therapies. Self-reported sleep disruptions was the most common symptom (79.6%). Prayer (53.8%) was the most frequently used CAM therapy. Patients reported the most interest in learning about massage (66.7%), biofeedback (41.7%), and meditation (41.7%). These findings highlight the prevalence of pain, fatigue, and sleep disruptions in this population and the fact that many patients currently use CAM therapies to manage their symptoms and are interested in learning about other strategies. Nurses have an important role in helping patients to manage their symptoms and in educating patients about safe use of CAM.
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Use of Complementary and Alternative Therapies to Manage

Cancer-Related Symptoms in Hospitalized Patients

Jennifer Jonas, Dr. Ann Horgas, and Dr. Saun-Joo Yoon

College of Nursing, University of Florida

Patients with cancer frequently experience pain, fatigue, and sleep disturbances. This study investigates (a) the presence and severity
of symptoms, (b) the various types of complementary and alternative therapies (CAM) patients currently use to manage cancer-related
symptoms, and (c) participants' level of interest in CAM use. A sample of hospitalized cancer patients (n = 13) completed an
anonymous survey to assess self-reported pain, fatigue, sleep disruptions, and CAM-based symptom management therapies. Self-
reported sleep disruptions was the most common symptom (79.6%). Prayer (53.8%) was the most frequently used CAM therapy.
Patients reported the most interest in learning about massage (66.7%), biofeedback (41.7%), and meditation (41.7%). These findings
highlight the prevalence of pain, fatigue, and sleep disruptions in this population and the fact that many patients currently use CAM
therapies to manage their symptoms and are interested in learning about other strategies. Nurses have an important role in helping
patients to manage their symptoms and in educating patients about safe use of CAM.


INTRODUCTION

Common Symptoms in Patients with Cancer

Cancer is one of the most common medical diagnoses in
the United States and is associated with many disease and
treatment side effects (Hayat, Howlader, Reichman, &
Edwards, 2007). Fatigue, nausea, and pain are among the
most common cancer-related symptoms (Cella et al.,
2007).
Pain is one of the most familiar and problematic
symptoms among cancer patients and is a major source of
concern for patients (Miaskowski, Kragness, Dibble, &
Wallhagen, 1997). Studies have found that women with
cancer (Cleeland et al., 1994) and elderly adults with
cancer (Green et al., 2003) are at risk for under-treatment
of pain. Studies also suggest that persistent unrelieved pain
leads patients to seek alternative therapies (Vallerand,
Fouladbakhsh, & Templin, 2005).
Fatigue is highly prevalent among cancer patients. It is a
major symptom of cancer treatment and impacts patients'
functional level and well-being (Wu & McSweeney, 2007).
Cancer-related fatigue fluctuates over time, is severe,
causes debilitating tiredness, and is more extreme than
typical fatigue (Gibson et al., 2005). Fatigue interferes with
patients' ability to function at work and home. Evidence
suggests that patients suffering from fatigue are more likely
to experience depression and anxiety (Hotopf, 2004).
Insomnia, similar to fatigue, is associated with reduced
functioning. One quarter of all cancer survivors suffer from
chronic insomnia that negatively affects daytime
functioning and quality of life (Fleming, Gillespie, &
Espie, 2009). In a study of 982 respondents, 75% of cancer
survivors had chronic insomnia that lasted six months or
more (Davidson, MacLean, Brundage, & Schulze, 2002).


Recent studies have found that sleep disturbances result in
other significant consequences including reductions in
treatment compliance, survival, pain control, immune and
metabolic functions (Sateia & Lang, 2008).
Most patients with cancer-related pain, fatigue, and sleep
disruptions use medications to treat their symptoms.
Pharmacologic treatments, however, are not effective for
everyone, and often cause adverse side effects such as
constipation, sedation, or respiratory suppression (Evans &
Rosner, 2005). As such, many cancer patients seek
complementary and alternative therapies to manage their
cancer-related symptoms (Richardson, Sanders, Palmer,
Greisinger, & Singletary, 2000).

Complementary and Alternative Medicine

Complementary and alternative medicines (CAM) are
defined as "medical interventions not taught widely at U.S.
medical schools or generally available at U.S. hospitals"
(Eisenberg et al., 1993). More specifically, complementary
medicine is used in conjunction with conventional
treatments (Fouladbakhsh, Stommel, Given & Given,
2005; Sollner et al., 2000), whereas alternative medicine is
used in place of conventional medicine (Field et al., 2008).
The National Center for Complementary and Alternative
Medicines (NCCAM) categorizes the different types of
CAM practices into four domains: mind-body practices,
biologically-based practices, manipulative- and body-based
practices, and energy medicine (Fouladbakhsh et al., 2005).

Prevalence of CAM Use in Cancer Patients

Complementary and alternative medicine is popular
among cancer patients as they often seek remedies to
supplement conventional medical treatment. It has been


University of Florida I Journal of Undergraduate Research I Volume 12, Issue 3 I Summer 2011
1





JENNIFER JONAS, DR. ANN HORGAS, & DR. SAUN-JOO YOON


estimated that between 44-83% of cancer patients used at
least one CAM therapy to control their symptoms
(Richardson, et al., 2000; Wells et al., 2007). The most
commonly used therapies were spiritual practices, vitamins
and herbs, and physical therapies, used in combination with
conventional treatment (Richardson et al., 2000).

Reasons for CAM Use among Cancer Patients

According to a study of 453 outpatient cancer patients,
the most common reason for using CAM was a desire to
feel hopeful (73.0%) (Richardson et al., 2000). Patients in
this study represented a variety of cancers, including
breast, prostate, gastrointestinal, head/neck,
sarcoma/melanoma, and lymphoma. Patients reported
using CAM because they felt these methods were nontoxic
(48.9%) and wanted to maintain control in the decisions
about their medical care (43.8%). The survey concluded
that their expectations of CAM were to improve their
quality of life, boost their immune system, prolong life, or
relieve symptoms (Richardson et al., 2000).
In sum, there is ample evidence to support the fact that
persons with cancer experience pain, fatigue, and sleep
disruptions associated with their disease and/or their
treatment. Several recent studies have examined the use of
complementary and alternative medicine among cancer
patients, but only a few have investigated what patients
currently know versus what patients have interest in
learning. Thus, the purpose of this study was to investigate
the various types of complementary and alternative
therapies that patients with cancer currently use to manage
their cancer related symptoms and which types of CAM
they are most interested in learning about. In addition, we
sought to confirm the presence of pain, fatigue, and sleep
disruptions in this population as a basis for using CAM
therapies. Specifically, we asked the following research
questions:

* What percentage of hospitalized patients with cancer
report experiencing pain, fatigue, and sleep
disruptions?
What are the most commonly used types of CAM
reported by hospitalized patients with cancer?
What types of CAM are patients most interested in
learning about?

METHOD

Participants

A convenience sample of hospitalized patients with
cancer on the Shands @ UF (SUF) oncology unit was
recruited to complete this anonymous survey. Inclusion
criteria for enrollment were a diagnosis of cancer (any


type) and at least 18 years old. The study sample consisted
of 13 participants, 7 (53.8%) male and 6 (46.2%) female.
All of the participants were non-Hispanic Caucasians with
an average age of 60 years (Range = 49-82 years).
Education was distributed as follows: 5 (38.5%) were high
school graduates or GED recipients, 4 (30.8%) had some
college or vocational experience, and 4 (30.8%) were
college graduates. The most frequent types of cancer
represented in the sample were lymphoma (30.8%),
sarcoma (23.1%), and breast (7.7%) (see Table 1 for
sample description).


Table 1: Sample Characteristics (n = 13)

Characteristic Total Sample n (%)
Sex
Male 7 (53.8)
Female 6 (43.2)
Race
White 13 (100)
Hispanic 0 (0)
Marital Status
Married 5 (29.4)
Unmarried* 8 (70.6)
Education level
H.S. grad or GED 5 (38.5)
Some college/vocational 4 (30.8)
College graduate 4 (30.8)
Household Income**
< 20,000 6 (50)
20,000-49,000 2 (16.7)
50,000-74,000 2 (16.7)
>75,000 2 (16.7)
Never married, widowed, separated, and divorced participants
** One participant did not answer


Procedure

Approval to conduct this study was obtained from the
University of Florida Health Science Center IRB 01. Staff
nurses on the oncology unit at SUF distributed the
anonymous questionnaire to all cancer patients admitted to
the hospital in the patient admission packets. Respondents
returned the completed survey in an envelope provided to
the nurses' station for collection. Sealed surveys were
placed in an opaque and marked box for pick up. Data were
entered into SPSS for analysis.


University of Florida I Journal of Undergraduate Research I Volume 12, Issue 3 1 Summer 2011
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COMPLEMENTARY AND ALTERNATIVE THERAPIES TO MANAGE CANCER-RELATED SYMPTOMS


Measures

The questionnaire included six tools assessing
demographics, health conditions, self-reported pain,
fatigue, sleep disruptions, and CAM use and/or interest.
Measures are described in the following sections.

Demographic Characteristics. Respondents were asked
to provide demographic characteristics, such as their age,
sex, race, marital status, education, insurance status,
household income (categorized), and with whom they live.

Health, Health Conditions, and Medications.
Respondents were asked to rate their overall subjective
health based on the question, "Overall, how would you rate
your health?" Responses ranged from 1 (excellent) to 5
(poor). Participants were presented with a list of 13
medical conditions, including cancer, and asked to indicate
which medical diagnoses they have been told by a health
care professional that they have and which medications
they take for any of the medical conditions that they
endorsed.

Pain. Pain was measured using the Brief Pain Inventory
(Short Form) (Cleeland & Ryan, 1994). This survey
contains 15 items about the presence and locations of pain,
pain intensity, and the impact of pain on sleep, functioning,
mood, and general well-being. Pain intensity was rated on
a 0-10 scale (0 = no pain, 10 = pain as bad as can be
imagined). Participants were asked to indicate how much
relief they received from pain medications or treatments in
the last 24 hours (0% = no relief, 100% = complete relief).
In addition, participants were asked the extent to which
pain interfered with their general activity, mood, walking
ability, work, social relationships, sleep, and enjoyment of
life.


10 questions about the presence and severity of fatigue and
the impact of fatigue on daily functioning and quality of
life. Participants were asked to rate their current level of
fatigue and in the last 24 hours. Responses were on a 0-10
scale (0 = no fatigue, 10 = as bad as can be imagined).
Participants were also asked to indicate how fatigue
interfered with general activity, mood, walking ability,
work, social relationships, sleep, and enjoyment of life in
the last 24 hours.

Sleep Disruptions. The Insomnia Severity Index (Morin,
Belleville, & Belanger, 2006) was used to assess
perceptions of insomnia and sleep disruption. This
instrument consists of seven items that assess the severity
of self-reported sleep disruptions. Participants were asked
to rate difficulty staying asleep, falling asleep, or problems
with waking up too early on a 0-4 scale (0 = none, 4 = very
severe). Participants also indicated the degree to which
sleep interfered with daily functioning, was noticeable to
others, and caused worry or distress. Total Insomnia
Severity Index scores were categorized as follows: 0-7 =
no clinically significant insomnia, 8-14 = subthreshold
insomnia, 15-21 = clinical insomnia (moderate severity),
and 22-28 = clinical insomnia (severe).

Complementary and Alternative Medicine. A
Complementary and Alternative Medicine (CAM)
Questionnaire (Yoon, 2008) was used to assess therapies
respondents have used to manage their pain, fatigue, or
sleep disruptions. The survey consists of 17 commonly
used CAM therapies, ranging from massage therapy and
chiropractic to biofeedback and hypnosis. See Table 2 for a
complete list of CAM therapies measured. Patients were
asked to identify which CAM therapy they currently use,
which symptoms) they are using it for, and which CAM
therapies they are interested in learning to use.


Fatigue. Fatigue was measured using the Brief Fatigue
Inventory (Mendoza et al., 1999). This survey consists of




















University of Florida I Journal of Undergraduate Research I Volume 12, Issue 3 I Summer 2011
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JENNIFER JONAS, DR. ANN HORGAS, & DR. SAUN-JOO YOON


Table 2: Patient Use and Interest in CAM


e of C Used CAM Reasons for CAM use Interest in CAM
Type o CA(M %) n (%) n (%*)
Pain Fatigue Sleep disruptions Multiple symptoms
Massage 3(23.1) 3(100) -- 8(66.7)
Chiropractic 1 (7.7) 1 (100) 3 (25)
Acupuncture 0 -2 (16.7)
Acupressure 1(7.7) 1(100) 2 (16.7)
Energy healing 0 -3 (27.3)
Guided imagery 1(7.7) 1(100) -- 1(8.3)
Meditation 4(30.8) 1(25) 1(25) 1(25) 1(25) 5(41.7)
Reflexology 1(7.7) 1(100) 2 (16.7)
Hypnosis 0 2(16.7)
Biofeedback 0 5(41.7)
Prayer 7(53.8) 1(14.3) 6 (85.8) 4 (33.3)
Spiritual healing 3(23.1) -- 3(100) 2(16.7)
Music therapy 3 (23.1) 1(33.3) 2 (66.6) 2 (16.7)
Herbal/folk remedies 1(7.7) 1(100) 3(25)
Megavitamins 2 (15.4) 1(50) 1(50) 3 (25)
Yoga/tai chi 0 4(33.3)
TENS 0 -- 3 (25)
* Valid percent reported


RESULTS

Prevalence of Sleep Disruptions

The most commonly reported symptom was sleep
disruptions, with 76.9% (n = 10) experiencing sleep
disruptions over the last week (Figure 1). Thirty-eight
percent reported difficulty falling asleep at night, while


84.6% reported having moderate to very severe difficulty
staying asleep. The majority of participants (53.8%) stated
that they are dissatisfied with their sleeping patterns, and
76.9% reported that they worry and/or are distressed about
their sleep. According to the Insomnia Severity Index, 75%
(n = 9) of the participants had some degree of clinically
significant insomnia.


University of Florida I Journal of Undergraduate Research I Volume 12, Issue 3 1 Summer 2011
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COMPLEMENTARY AND ALTERNATIVE THERAPIES TO MANAGE CANCER-RELATED SYMPTOMS


Pain Fatigue Sleep Disruptions
Figure 1: Percent of patients reporting pain, fatigue, and sleep disruptions.


Most Commonly Used CAM


More than half of the participants (53.8%) reported
experiencing pain in the last 24 hours. The majority of pain
experienced (76.9%) was reported in the upper body,
including head, neck, shoulders, back, and abdomen. On
average, participants reported their worst pain intensity as a
5 (mean = 4.9), and 46.2% reported pain scores of 6 or
higher. With regard to pain relief from current medical
treatments, 3 (23.1%) reported complete relief, 3 (23.1%)
reported no relief, and the remainder reported little relief
(15.4%) or some relief (26.1%). Pain interfered primarily
with patients' work (69.2%), mood (61.5%), and sleep
(69.2%). Most participants reported no interference with
social relationships (61.5%) or walking (69.2%).

Prevalence of Fatigue

The majority of study participants (69.2%) reported
experiencing fatigue. On average, participants reported that
their worst fatigue intensity was a 5 (mean = 4.9), and the
usual level of fatigue was a 4 (mean = 3.9). Respondents
reported that fatigue interfered primarily with their ability
to work (mean intensity = 4.5), but there was also moderate
interference with general activity (mean = 3.6), mood
(mean = 3.31) and enjoyment with life (mean = 3.5).


Of the 17 types of CAM assessed, prayer was the most
commonly reported CAM therapy used (53.8%) (see Table
2). Of those using prayer (n = 7), most respondents
(85.8%) reported using prayer for multiple symptoms. Use
of spiritual healing was also reported by 23.1% to heal
multiple symptoms. Participants reported using meditation
(30.8%) for pain, fatigue, and sleep disturbances. Massage
was reported for pain by 23.1% reported. Participants in
this study did not report the use of the following therapies:
acupuncture, energy healing, hypnosis, biofeedback, yoga,
or transcutaneous electrical nerve stimulation (TENS).

Interest in Types of CAM

Patients expressed interest in learning about massage
(66.7%), biofeedback (41.7%), and meditation (41.7%)
(see Table 3). Mind-body practices generated the most
interest, with study participants reporting biofeedback,
meditation, prayer, and yoga/tai chi among the top ten
CAM therapies that they are interested in learning about.
Study participants reported that they were least interested
in imagery (8.3%).


University of Florida I Journal of Undergraduate Research I Volume 12, Issue 3 I Summer 2011
5


Prevalence of Pain





JENNIFER JONAS, DR. ANN HORGAS, & DR. SAUN-JOO YOON


CAM Therapies
Massage
Biofeedback
Meditation
Prayer
Yoga/tai chi
Energy healing
Chiropractic
Herbal/folk remedies
Megavitamins
TENS


a Valid percent reported


DISCUSSION

The results of this study confirm that pain, fatigue, and
sleep disruptions are common symptoms among cancer
patients undergoing treatment. The majority of hospitalized
patients in this sample reported experiencing at least one of
these symptoms. Not surprisingly, pain, fatigue, and sleep
disruptions interfered with participants' daily lives.
Notably, very few patients reported complete pain relief
from conventional therapies. Thus, it is not surprising that
many turn to complementary and alternative therapies to
help manage their symptoms.
Prayer was the most commonly used CAM therapy.
Prayer is often used to relieve stress and to cope with the
issues of daily life (Dunn & Horgas, 2000). Pain, fatigue,
and sleep disruptions can cause a considerable amount of
distress in one's life, and the high prevalence of prayer is
not surprising in this context. This finding is consistent
with prior studies that have documented the high use of
prayer to cope with pain among older adults (Dunn &
Horgas, 2000).
These findings illustrate the fact that many cancer
patients suffer from multiple symptoms during their
treatment, most notably pain, fatigue, and sleep
disruptions. These symptoms negatively influence their
quality of life. Not surprisingly, patients report using CAM
to help manage their pain, and expressed interest in
learning about other therapies. These findings have
important implications for nurses, since they are in a key
position to assess and manage symptoms among
hospitalized patients. Nurses should recognize that


Table 3: Top Ten Interesting CAM Therapies to Patients


University of Florida I Journal of Undergraduate Research I Volume 12, Issue 3 | Summer 2011
6


Patient Interest in CAM
n (% a)
8 (66.6)
5(41.7)
5(41.6)
4 (33.4)
4 (33.3)
3 (27.3)
3(25)
3 (25.0)
3 (25.0)
3 (25.0)


symptoms are not always relieved by conventional medical
therapy and should help patients consider CAM therapies.
Nurses play an important role in educating patients and
their families about symptom management and should be
knowledgeable about the various forms of CAM therapies
that are available. Nurses can use this knowledge to help
patients use CAM safely. It is also important that nurses
and other health care professionals be aware of what
patients are currently using, so that they can assess for
potential interactions or contraindications. Finally, with
regard to prayer, nurses should be aware of its importance
to many patients and be prepared to acknowledge it with
their patients and/or make referrals as necessary.
While this study yields some interesting preliminary
results, several limitations should be noted. First, the
sample size was small. Only 13 patients from Shands @
UF completed and returned the questionnaire to date. Thus,
the sample may be biased towards patients who are well
enough to complete the survey or those who use CAM.
Other potential participants may have declined
participation based on the purpose of the study. The study
assessed CAM use, and if patients didn't use it or weren't
interested, they may not have responded. Unfortunately,
because the study was an anonymous survey, it is
impossible for us to know how many patients were eligible
to participate or why some did not respond. Second, the
sample consisted of only Caucasians. Thus, the extent to
which the results would vary in different racial groups is
not known. Further study is necessary to obtain a larger
and more diverse sample size. Third, the study used an
anonymous survey methodology. This approach, however,
relied heavily on the nurses and unit clerks to distribute
surveys to newly admitted patients. The hectic and busy
environment of the hospital may have caused these surveys
to be overlooked. In further studies, it may be beneficial to
conduct interviews with patients instead of distributing
surveys. This might yield a more representative sample that
would enable more in-depth analyses of the symptom
experience and CAM use in cancer patients.
Despite these limitations, this study highlights the
continuing problem of pain, fatigue, and sleep disruptions
among cancer patients. Patients' symptoms are not relieved
during their hospitalization, and this is an important issue
for nurses and other health care professionals to address.
Further, patients use and seek information about CAM
therapies to help them manage their symptoms and disease.
Nurses should be aware of patients' interest and be
knowledgeable about CAM so that they can be in the best
position to appropriately assist and educate patients.





COMPLEMENTARY AND ALTERNATIVE THERAPIES TO MANAGE CANCER-RELATED SYMPTOMS


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