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Use and Perceived Benefits of Complementary Therapies by Cancer Patients Receiving Conventional Treatment in Italy

Open AccessPublished:August 02, 2013DOI:https://doi.org/10.1016/j.jpainsymman.2013.03.014

      Abstract

      Context

      In Italy, data regarding the use of complementary therapies (CTs) among patients with cancer are sparse and discordant.

      Objectives

      The present study aimed to investigate the demographic and psychological characteristics of Italian cancer patients who use CTs and the perceived benefit of users.

      Methods

      Eight hundred three patients from six Italian oncology departments were interviewed about CT use and completed two questionnaires to explore psychological distress and the resilience trait called sense of coherence (SOC). Patients included in the study had different primary tumor sites and were in different phases of the disease and care process.

      Results

      At the time of measurement, 37.9% of patients were using one or more types of CTs. The most commonly used CTs were diets and dietary supplements (27.5%), herbs (10.8%), homeopathy (6.4%), and mind-body therapies (5.5%). The Italian context is characterized by a high percentage of patients who informed their physicians about CT use (66.3%) and who experienced benefits (89.6%); 75.2% of the patients had used CTs in the past. Multivariate analysis revealed that young, female patients, who previously used complementary and alternative medicine in the past, appear more likely to use at least one type of CT in the present. Predictors of the use of CTs varied according to the type of CT. Among psychological factors, SOC was positively associated with both past and present CT use.

      Conclusion

      Overall prevalence of CTs among Italian cancer patients is high and is in accordance with the European average. In addition to clinical and sociodemographic factors, the resilience trait SOC also was associated with CT use.

      Key Words

      Introduction

      The term complementary and alternative medicine (CAM) refers to any medical system, practice, or product that is not thought of as standard care. The most commonly noted CAM therapies include mind-body approaches (e.g., meditation, relaxation, hypnotherapy, visualization), botanical preparations, homeopathy, acupuncture, dietary approaches and food supplements, Chinese and other traditional medications, and spiritual healing.
      • Cassileth B.R.
      Complementary and alternative cancer medicine.
      • Klafke N.
      • Eliott J.A.
      • Wittert G.A.
      • Olver I.N.
      Prevalence and predictors of complementary and alternative medicine (CAM) use by men in Australian cancer outpatient services.
      The use of CAM therapies by cancer patients is common and widespread.
      • Ernst E.
      • Cassileth B.R.
      The prevalence of complementary/alternative medicine in cancer—a systematic review.
      • Cassileth B.R.
      • Deng G.
      Complementary and alternative therapies for cancer.
      CAM can be separated into alternative medicine and complementary therapies (CTs), where alternative medicine includes CAM therapies used in place of standard treatments that are unproved or were studied and found ineffective,
      • Cassileth B.R.
      Alternative therapies: learning from patients who choose them.
      • Vickers A.
      Alternative cancer cures: “unproven” or “disproven”?.
      and CTs refer to those used along with mainstream treatment. The present study was carried out in Italian hospitals of the Public Health Care System of Tuscany. Thus, the unconventional therapies investigated were used alongside conventional medicine and categorized as CTs.
      Research on the use of CTs among cancer patients is highly relevant for several reasons: the increasing use of CTs in Europe and the U.S.;
      • Molassiotis A.
      • Fernadez-Ortega P.
      • Pud D.
      • et al.
      Use of complementary and alternative medicine in cancer patients: a European survey.
      • Boon H.S.
      • Olatunde F.
      • Zick S.M.
      Trends in complementary/alternative medicine use by breast cancer survivors: comparing survey data from 1998 and 2005.
      • Eisemberg D.M.
      • Davis R.B.
      • Ettner S.L.
      • et al.
      Trends in alternative medicine use in the United States, 1990-1997.
      the possible harmful interactions between mainstream and complementary cancer treatments, the importance of which is made more significant by the fact that oncologists often are not informed about the use of CTs by their patients;
      • Sparreboom A.
      • Cox M.
      • Acharya M.
      • Figg W.D.
      Herbal remedies in the United States: potential adverse interactions with anticancer drugs.
      • Mannel M.
      Drug interactions with St John's wort: mechanisms and clinical implications.
      • Malekzadeh F.
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      Natural remedies and hormone preparations—potential risk for breast cancer patients. A study surveys the use of agents which possibly counteract with the treatment.
      the tendency of some European countries or regions to introduce some CTs in addition to the resources available to patients in the public health system; and the psychological traits and the unmet needs that underlie the choice of CTs should be known and, when possible, taken into account in oncology clinical practice to improve the care process and the efficacy of the relationship between the patient and medical staff.
      Some interesting findings have come to light through recent studies focused on psychological factors related to CAM use among patients with cancer. These include higher desire of control over disease,
      • Richardson M.A.
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      • Singletary S.E.
      Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology.
      greater optimism,
      • Wyatt G.K.
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      • Given C.W.
      • Given B.A.
      • Beckrow K.C.
      Complementary therapy use among older cancer patients.
      and a mental adjustment characterized by significantly higher levels of anxious preoccupation and fighting spirit.
      • Davidson R.
      • Geoghegan L.
      • McLaughlin L.
      • Woodward R.
      Psychological characteristics of cancer patients who use complementary therapies.
      There are conflicting reports on the existence of a correlation between distress or psychopathology and the use of CAM in cancer patients. Some studies have shown a correlation between distress, anxiety, or depression and the use of CAM;
      • Montazeri A.
      • Sajadian A.
      • Ebrahimi M.
      • Akbari M.E.
      Depression and the use of complementary medicine among breast cancer patients.
      • Burstein H.J.
      • Gelber S.
      • Guadagnoli E.
      • Weeks J.C.
      Use of alternative medicine by women with early-stage breast cancer.
      others do not.
      • Davidson R.
      • Geoghegan L.
      • McLaughlin L.
      • Woodward R.
      Psychological characteristics of cancer patients who use complementary therapies.
      • Söllner W.
      • Maislinger S.
      • DeVries A.
      • et al.
      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 behaviour: a survey.
      Therefore, further research is needed to clarify this point.
      Among salutogenic and psychological resilience factors, the Sense of Coherence (SOC) appears to play a primary role.
      • Eriksson M.
      Unravelling the mystery of salutogenesis.
      SOC is a personality trait concerning the ability to understand, give meaning to, and face stressful events in life.
      • Antonovsky A.
      Health, stress and coping.
      • Antonovsky A.
      Unraveling the mystery of health.
      SOC scales have been widely used in a considerable number of studies on health, health care, and psychological well-being. To date, the SOC questionnaires have been used in 32 countries and 33 languages.
      • Eriksson M.
      • Lindström B.
      Validity of Antonovosky's Sense of Coherence Scale: a systematic review.
      The relationship between SOC and CAM use has not yet been investigated.
      Recent research also has clarified several sociodemographic characteristics related to the use of CAM; in particular, studies from industrialized countries have suggested that cancer patients using CTs are younger, have a higher socioeconomic status than non-users, and are more likely to be female and previous users of CTs.
      • Downer S.M.
      • Cody M.M.
      • McCluskey P.
      • et al.
      Pursuit and practice of complementary therapies by cancer patients receiving conventional treatment.
      To date, sparse and discordant epidemiological data are available on CAM use in Italy. Crocetti et al.
      • Crocetti E.
      • Crotti N.
      • Feltrin A.
      • et al.
      The use of complementary therapies by breast cancer patients attending conventional treatment.
      found that only 16.5% of female breast cancer patients receiving conventional treatment used CTs after cancer diagnosis and only 8.7% before. In 2008, Johannessen et al.
      • Johannessen H.
      • von Bornemann Hjelmborg J.
      • Pasquarelli E.
      • et al.
      Prevalence in the use of complementary medicine among cancer patients in Tuscany, Italy.
      published preliminary research carried out with 128 day hospital patients, which showed that 17% of them had used CTs after cancer diagnosis. A European study by Molassiotis et al.
      • Molassiotis A.
      • Fernadez-Ortega P.
      • Pud D.
      • et al.
      Use of complementary and alternative medicine in cancer patients: a European survey.
      found a prevalence of 73.1% in the use of CAM among 52 cancer patients from a single palliative care unit in Italy compared with a European average of 35.9%.
      The present study aimed to investigate, in Italy, the prevalence of CT use among cancer patients and establish the clinical and demographic characteristics of CT users. This is the first study on this topic in Italy involving a large number of cancer patients from different care settings. Another aim was to examine some of the personality and psychopathological traits associated with the decision to opt for CTs. In particular, we evaluated, for the first time to our knowledge, the relationship between personal SOC and CT use.

      Methods

      Study Sample

      The present study involved patients from six different oncology medical units in Tuscany, Italy: 1) Centro Riabilitazione Oncologica (CERION) of the Istituto per lo Studio e la Prevenzione Oncologica (ISPO), Firenze; 2) Oncologia Medica Aziendale AUSL 10, Firenze; 3) Oncologia Medica AUSL 4, Prato; 4) Oncologia Medica AUSL 1, Massa Carrara; 5) Oncologia Medica, Azienda Ospedaliero Universitaria, Careggi-Firenze; and 6) SOD Oncologia Medica 2, DAI Oncologia, Azienda Ospedaliero Universitaria Careggi-Firenze.
      During the study period, participation was proposed to all patients consecutively attending outpatient clinics or admitted to oncology wards, regardless of site or stage of the tumor. The study was proposed by the unit psycho-oncologist to inpatients two days after admission and to outpatients excluding their first day hospital treatment or their first ambulatory visit. Particular care was given to avoid any appearance of coercion to join the study, emphasizing to patients that participation was totally free and voluntary and that nonadherence did not alter care received from the ward staff.
      Exclusion criteria were age under 18 or over 90, cognitive impairment, comorbid psychotic illness, learning disability, and severe symptoms caused by illness or side effects of therapy that precluded because of physical limitation, the ability to fill in questionnaires autonomously.
      Nine hundred eighty patients were invited to participate in the study; 803 patients agreed and were interviewed. Basic demographic and clinical characteristics of the participating patients are summarized in Table 1. The percentage of patients who agreed to participate ranged from 71.0% of CERION-ISPO (rehabilitation unit) and 95.4% of Oncologia Medica AUSL 4 Prato (oncology ward, day hospital, and ambulatory).
      Table 1Basic Demographic and Clinical Characteristics of Participants (N = 803)
      Characteristics of ParticipantsParticipantsActual CT UsersPPast CT UseP
      n%n% (Within Category)n% (Within Category)
      CT users30437.960475.2
      Age (mean)
       18–4912315.45948.0<0.00110484.5<0.001
       50–5918523.29450.815382.7
       60–6925231.57830.918272.2
       ≥7023929.97230.116267.8
      Gender
       Female52265.123344.8<0.00141880.4<0.001
       Male28134.97025.118365.6
      Marital status
       Single759.53749.30.0336586.70.045
       Married56271.421337.941373.5
       Divorced486.12143.74083.3
       Widowed10213.02928.47573.5
      Educational level
       Primary school25032.96425.6<0.00115562.0<0.001
       Secondary school17723.37039.614079.1
       High school22229.210045.117880.2
       University11214.76154.510291.1
      Occupation
       Office worker668.63756.10.0255786.40.109
       Dealer202.6945.01575.0
       Freelancer334.31648.52884.8
       Manual worker162.1743.71275.0
       Retired35546.412434.925471.6
       Housewife7810.22430.85671.8
       Other19725.77437.615578.7
      Oncology care settings
       Ward201255627.9<0.00114371.1<0.001
       Day hospital19824.76532.813568.2
       Ambulatory18222.76937.913875.8
       Rehabilitation unit22227.611451.418884.7
      Primary tumor site
       Breast32442.615347.20.00226782.40.001
       Lung10513.83331.47470.5
       Colon-rectum8611.32832.66474.4
       Pancreas293.81034.52586.2
       Stomach263.41038.52076.9
       Lymphoma131.7430.8646.1
       Other17723.35128.812067.8
      Phase of the disease and care process
       Diagnosis and treatments30042.39632.00.01721471.30.060
       Follow-up and/or rehabilitation30442.913544.424580.6
       Relapse/recurrence4343.11841.93274.4
       Progression of disease and palliative care618.62236.14878.7
      Treatment received
       Chemotherapy52369.920639.40.03839375.10.521
       Radiotherapy27837.312946.4<0.00121878.40.210
      Months from diagnosis
       0–619028.35629.50.02813571.00.275
       7–2417926.67642.514078.2
       45–6014521.66242.811478.6
       >6015823.56440.512377.8
      PDI score
       ≤2944860.016737.30.58433775.20.297
       >3029840.011739.323478.5
      SOC score
       ≤454471.219636.00.05040674.60.023
       >422028.89643.618182.3
      CT=complementary therapy; PDI = Psychological Distress Inventory; SOC = Sense of Coherence Scale.

      Data Collection

      A semi-structured interview was developed for Italian participants by translating and adapting items from similar questionnaires used in recent studies.
      • Molassiotis A.
      • Fernadez-Ortega P.
      • Pud D.
      • et al.
      Use of complementary and alternative medicine in cancer patients: a European survey.
      • Johannessen H.
      • von Bornemann Hjelmborg J.
      • Pasquarelli E.
      • et al.
      Prevalence in the use of complementary medicine among cancer patients in Tuscany, Italy.
      Each patient was initially interviewed by the psycho-oncologist. The interviewer asked about the use of CTs (reasons for present use, perceived benefits, sources of information, and physician/relative knowledge about the use of CTs, annual cost). Clinical data were provided by oncologists. Additional questionnaires were administered to evaluate psychological factors potentially related to CT use:
      Psychological Distress Inventory: a multiple choice test comprising 13 items, giving a general score of psychological distress in cancer patients, developed and validated in Italy;
      • Morasso G.
      • Costantini M.
      • Baracco G.
      • Borreani C.
      • Capelli M.
      Assessing psychological distress in cancer patients: validation of a self-administered questionnaire.
      Sense of Coherence-3: a brief, three-item scale evaluating SOC.
      • Lundberg O.
      • Nystrom Peck M.
      A simplified way of measuring sense of coherence.

      Statistical Analysis

      Analyses using the Pearson χ2-test were performed to evaluate bivariate associations between CT past (or CT actual, i.e., at the moment of the study) use and sociodemographic, clinical, and psychological variables.
      We report aspects of the present use of CTs (reasons for present use, perceived benefits, sources of information, physician/relative knowledge about the use of CTs, annual cost) for 196 patients out of 304 current users because of organizational limitations. Time constraints in particular care settings prevented interviewing all participants about actual CT use, particularly in the day hospital and ambulatory care.
      Separate multivariate logistic regression analyses have been done to identify independent predictors of the following outcomes: using at least one CT, using diets and dietary supplements, mind-body techniques, and other main types of CTs. A backward stepwise procedure was followed using the significance level for removal from the model of 0.1. All sociodemographic and clinical variables listed in Table 1 were tested. Odds ratios, 95% CIs, and P-values for statistically significant covariates are reported. Analyses were performed using Stata/SE 12.1 (StataCorp LP, College Station, TX).

      Ethical Approval

      The study received the approval of the local ethics committees of Careggi Hospital, of AUSL 10 in Florence, of AUSL 4 in Prato and of AUSL 1 in Massa Carrara. Patients gave written informed consent and received an information sheet on the study.

      Results

      Use of CTs

      The use of at least one type of CT at the time of the interview was reported by 37.9% of patients. In the past, 75.2% of the patients had used CTs. Several demographic and clinical factors were shown to be associated with the current and previous use of CT. Younger, female and well-educated patients were more likely to report the use of CTs in the past or at the time of the study (P < 0.001); patients in a rehabilitation setting had more likelihood to use CTs, perhaps because the main goal of rehabilitation is focused on general health status (P < 0.001) (Table 1). The most commonly used CTs in the present study were diets and dietary supplements (27.5%), mind-body therapies (5.5%), herbs (10.8%), and homeopathy (6.4%) (Table 2).
      Table 2Present and Past Use of CTs
      Types of CTsPresent Use of CTsPast Use of CTs
      n%n%
      Diets and dietary supplements22127.550462.8
       Diets465.725231.4
       Dietary supplements19324.037246.3
      Mind-body therapies445.516921.0
       Yoga192.410613.2
       Meditation162.0435.4
       Autogenic training162.0769.5
       Others types of mind-body therapies less commonly used111.4273.4
      Unconventional cancer treatment101.2
      Other types of CTs16120.040650.6
       Herbs8710.817221.4
       Homeopathy516.418322.8
       Acupuncture81.012715.8
       Bach flowers121.59712.1
       Massage243.015218.9
       Other types of CTs less commonly used273.412315.3
      Total users of at least one CT30437.960475.2
      CT = complementary therapy.
      Characteristics of the present use of CTs are summarized in Table 3. A reason for actual use of CTs is rarely “to treat cancer” (11.2%); a high percentage of patients informed their physicians about CT use (66.3%), and almost all relatives (95.3%) were aware of CT use.
      Table 3Characteristics of the Present Use of CTs (N = 196)
      Users of CTs
      N%
      Reasons for using CTs (more than one possible option)
       To improve general health conditions11860.5
       To support medical treatments6935.4
       To treat physical symptoms4623.6
       To treat psychological distress2311.8
       To treat cancer2311.8
       Other reasons105.1
      Perceived benefits
       Excellent3618.9
       Good8041.9
       Fairly good5528.8
       Poor136.8
       Absent73.7
      Sources of information (more than one possible option)
       Physician8242.0
       Friends6131.3
       Relatives3618.5
       Mass media2613.3
       Pharmacist84.1
       Other patients52.6
       Other126.1
      Physician informed about the use of CTs
       Yes12866.3
       No6536.7
      Relative knowledge about the use of CTs
       Yes18195.3
       No94.7
      Annual cost for CTs
       <250 Euro11660.7
       >250 and <500 Euro5126.7
       >500 and <1000 Euro2010.5
       >1000 Euro42.1
      CT = complementary therapy.

      Independent Predictors of CT Use at the Time of the Study

      Using logistic regression analysis, we evaluated the independent association of each variable significantly associated during the bivariate analysis with CT use at the time of the study, adjusting for the influence of the other variables considered in the model. Results are shown in Table 4. Age, gender, and previous use of CTs were found to be independent predictors of the use of at least one type of CT at the time of the study. Assuming that different types of CTs could have different predictors, we carried out a separate logistic regression analysis for each different type of CT. Results (Table 4) confirmed that predictors of the use of different types of CTs may vary according to the type of CT taken into consideration.
      Table 4Predictors of CT Use
      OR95% CI
      Use of at least one type of CT
       Previous use of CTP < 0.001
      Not previous user1
      Previous user6.13.8–9.8
       GenderP = 0.001
      Male1
      Female1.81.3–2.6
       AgeP < 0.001
      ≥601
      <601.81.3–2.4
      Diet and dietary supplement users
       Previous use of diet and dietary supplementsP < 0.001
      Not previous user1
      Previous user3.52.3–5.3
       AgeP = 0.007
      ≥601
      <601.61.1–2.4
       RTP = 0.019
      No1
      Yes1.51.1–2.1
      Mind-body techniques users
       Previous use of mind-body techniquesP < 0.001
      Not previous user1
      Previous user48.817.2–138.9
      Other CT users
       Previous use of other CTsP < 0.001
      Not previous user1
      Previous user13.37.3–24.3
       AgeP = 0.003
      ≥601
      <601.91.2–2.8
       Phase of the care processP = 0.012
      Diagnosis and treatments1
      Follow-up and/or rehabilitation2.11.3–3.3
      Relapse/recurrence1.00.4–2.4
      Progression of disease and palliative care1.60.7–3.5
      OR = odds ratio; CT = complementary therapy; RT = radiotherapy.

      Psychological Characteristics of Patients Using CTs at the Time of the Study

      In the present study, both the current and past use of CTs were not related to the presence of psychological distress (Table 1). On the contrary, the actual use of CTs and the use of CTs in the past were both positively associated with the resilience trait SOC (P = 0.050 and P = 0.023, respectively).
      In the multivariate logistic regression analysis, SOC was not an independent predictor of the current use of at least one CT, whereas it was significantly associated with the past use of CTs (data not shown; adjusted odds ratio 1.6; 95% CI 1.1–2.5).

      Discussion

      The present study is the first thorough survey of CT use among cancer patients in Italy. In our survey, we found a 37.9% prevalence of the present use of CTs. This is consistent with previous findings by Molassiotis et al. who developed a European survey (14 countries) and found that 35.9% of cancer patients were using some form of CAM.
      • Molassiotis A.
      • Fernadez-Ortega P.
      • Pud D.
      • et al.
      Use of complementary and alternative medicine in cancer patients: a European survey.
      Laengler et al.
      • Laengler A.
      • Spix C.
      • Seifert G.
      • et al.
      Complementary and alternative treatment methods in children with cancer: a population-based retrospective survey on the prevalence of use in Germany.
      also recently found a similar prevalence (35%) in the use of CAM in Germany by children with cancer, usually administered by the parents. In our sample, 75.2% of patients had used CAM at least once in the past. In Italy, the most frequently used types of CTs are similar to those observed in other countries
      • Ernst E.
      • Cassileth B.R.
      The prevalence of complementary/alternative medicine in cancer—a systematic review.
      • Molassiotis A.
      • Fernadez-Ortega P.
      • Pud D.
      • et al.
      Use of complementary and alternative medicine in cancer patients: a European survey.
      and include diets and dietary supplements, herbs, homeopathy, and mind-body therapies. This research provides Italian data on the use of CTs in oncology, which is helpful not only to make comparisons with other countries but also to track changes over time in the future.
      An interesting aspect of our data was that only a small proportion of patients used CAM with curative intent; this finding has been mirrored in a large number of studies.
      • Field K.M.
      • Jenkins M.A.
      • Friedlander M.L.
      • et al.
      Predictors of the use of complementary and alternative medicine (CAM) by women at high risk for breast cancer.
      It suggests that in Italy, as in other countries, many cancer patients turn to CTs to satisfy needs other than curative ones. In particular, patients seek CTs for purposes of support that include improving general health conditions, supporting medical treatments, or treating psychological distress. We can observe that the majority of patients with cancer experienced benefits from the use of CTs and, therefore, that they found in this type of treatment satisfaction of their supportive needs and expectations.
      An interesting finding of our study is that, in Italy, the use of CTs was higher in specific phases of the disease and care process, particularly in the follow-up/rehabilitation phase and the relapse/recurrence phase of the care process. Particularly during the phases of diagnosis and treatment, patients are probably more focused on conventional treatments for cancer and less aware of unmet needs. The supportive goals that motivate patients to use CTs help in explaining the increased use of these therapies, particularly in the rehabilitation phase.
      We found that 66.3% of patients using CTs informed their physicians. This percentage is higher than that observed in other countries where less than 50% of cancer patients using CAM received information on this subject from their conventional health care providers;
      • Ernst E.
      • Cassileth B.R.
      The prevalence of complementary/alternative medicine in cancer—a systematic review.
      • Molassiotis A.
      • Fernadez-Ortega P.
      • Pud D.
      • et al.
      Use of complementary and alternative medicine in cancer patients: a European survey.
      • Ernst E.
      The current position of complementary/alternative medicine in cancer.
      therefore, in Italy, the communication between patients and physicians regarding CTs seems to be better than in other European countries, with a possible positive impact on prevention of negative interactions between mainstream and complementary cancer treatments. Moreover, in Italy, physicians are the source of information on CTs for 42% of users.
      In our sample, relatives were almost always informed about the choice of patients using CTs, and in most cases, they agreed with this choice. This fact suggests that families are privileged by the patients to participate in their treatment choices and that, facing a disease such as cancer, families deeply share beliefs and values. Accordingly, health care systems could better take into account, at least as regards treatment choices, the “family system.”
      In Western countries, CAM represents a considerable industry; this was confirmed in Italy where 39.3% of cancer patients who are CT users have faced an annual expense higher than 250 Euros. This highlights the importance of including CTs in oncology research projects aimed at evaluating cost/benefit ratios and effectiveness.
      As expected, there were sociodemographic and clinical differences between the groups of CT users and non-users. In accordance with previous studies,
      • Davidson R.
      • Geoghegan L.
      • McLaughlin L.
      • Woodward R.
      Psychological characteristics of cancer patients who use complementary therapies.
      • Crocetti E.
      • Crotti N.
      • Feltrin A.
      • et al.
      The use of complementary therapies by breast cancer patients attending conventional treatment.
      we observed that young, female patients, with a higher educational level, and who have previously used CAM, appear more likely to use CTs. As Pedersen et al.
      • Pedersen C.G.
      • Christensen S.
      • Jensen A.B.
      • Zachariae R.
      Prevalence, socio-demographic and clinical predictors of post-diagnostic utilisation of different types of complementary and alternative medicine (CAM) in a nationwide cohort of Danish women treated for primary breast cancer.
      suggested, patients with a higher education are more aware of the availability of CTs and more resourceful in terms of seeking out possible additional support in relation to their illness. Predictors of the use of different types of CTs varied according to the type of CT being considered, suggesting that the large and heterogeneous group of CTs actually includes various groupings of therapies whose features are, at least partly, different.
      With regard to the mind-body CTs (e.g., yoga, meditation, autogenic training), it is interesting to note that their use at the time of the study had as a single predictor the use of the same therapies in the past. It is probable that the mind-body therapies are, more than other CT types, closely associated with a lifestyle that is rooted in some spiritual beliefs and personality characteristics such as self-transcendence.
      • Coninger C.R.
      Feeling good—The science of well-being.
      Our survey aimed to contribute to the study of psychological factors related to CT use. In our study, CT use was not related to psychological distress. Conversely, we found that a higher SOC was related to the use of CTs during cancer illness and that it was an independent predictor of previous use of CTs. SOC is considered an individual's flexible and adaptive dispositional orientation, enabling successful coping with adverse experiences.
      • Eriksson M.
      • Lindström B.
      Antonovsky's sense of coherence scale and the relation with health: a systematic review.
      • Surtees P.G.
      • Wainwright N.W.
      • Khaw K.T.
      Resilience, misfortune, and mortality: evidence that sense of coherence is a marker of social stress adaptive capacity.
      • Surtees P.G.
      • Wainwright N.W.
      • Luben R.
      • Khaw K.T.
      • Day N.E.
      Mastery, sense of coherence, and mortality: evidence of independent associations from the EPIC-Norfolk Prospective Cohort Study.
      Cancer patients with a higher SOC could have available a resource of resilience, which facilitates the choice of integrating conventional treatment with CTs, with the main purposes of improving quality of life and seeking answers to unmet needs.
      A limitation of the present study is the fact that patients who were receiving cancer care in settings other than the national health system and who may have been receiving alternatives to mainstream care were not represented. Another limitation is that the data came from cancer centers all located in Tuscany. Different Italian regions might have different social and cultural contexts that could affect a different use of CTs; this aspect should be explored in future studies.
      In conclusion, our study has shown that overall prevalence of CT use among Italian cancer patients in Tuscany is high and is in accordance with the European average. The Italian context is characterized by a high percentage of patients who informed their physicians about CT use and who experienced benefits. Our study also demonstrated that, in addition to clinical and sociodemographic factors, the psychological factor, SOC, also was associated with CT use.

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