Diseases that are difficult to cure, chronic and progressive, lead to the use of complementary and alternative medicine (CAM) in varying rates. CAM interventions may also be an adjunct to medical therapy ⁽¹⁾. The general proportion of patients using CAM interventions are reported to be 40-60 % and it is common among women,^(2,3) and physicians' reactions to alternative medicine may not be positive when compared with other health care workers ⁽³⁾. The rapid growth in CAM use is the result of the popularity of alternative methods among the patients and because of out-of-pocket payment.

Patients do not give information to their doctors about the alternative methods that they have used or are actually using, unless their doctors investigate. ⁽⁴⁾ Complementary and alternative therapies may sometimes be a reason for delay in seeking medical therapy.

Consumption of some kind of food and herbal products that are cheap and easy to reach is popular in Turkey. Certain types of herbs are also used for certain diseases. Oncologists' lack of reliable information about herbal remedies or products, and their belief that these products are ineffective, leads to lack of communication with their patients.

The extent and type of complementary and alternative therapy for specific diseases is unknown in Turkey. Cancers and chronic diseases are considered to be the well-known causes of CAM use. This study was conducted to evaluate the attitudes of patients with gynaecological cancer, on alternative and conventional therapies and detect the type of herbal remedies used.

Selection of patients

Participants of this study are all patients with gynecological malignancy and who have completed their surgical therapy, chemotherapeutic or radio-therapeutic cures and who are followed up by the department of Gynecologic Oncology in Erciyes University at least 3 months ago, over twelve consecutive months. Residents of the gynaecological oncology department filled out the research questionnaires after receiving oral informed consent from patients. Participants were asked the diagnosis of their disease and this was checked later from their patient files to determine if they knew the exact diagnosis. Patients were considered to be aware of their diagnosis if a doctor or their relatives knew that they had a malignant disease and if possible prognosis of this disease was explained to them intentionally. Patients were considered to be unaware of their diseases if they were not informed by anybody intentionally that they had a malignant disease, but just given indirect information about their disease and prognosis.

The questionnaires were composed of questions about demographic characteristics (educational and marital status, income, age), diagnosis and therapy of cancer, details about CAM methods used before and after having the diagnosis. A list of alternative therapy methods was given and patients were asked to choose which methods they have used or used to use, before and after their diagnosis was made. These alternative methods were all kinds of herbal medicine, acupuncture, spiritual or faith healing, special diets, spa. In the same question there was another open-ended choice in which patients asked to write down any other method that they had used.

Statistical analysis

X2 test was used and p values equal to or less than 0.05 were accepted as significant.

Fifty-two of 63 women who have the diagnosis of gynaecological cancer and who had completed their therapy gave consent and were recruited in this study. They were 52.92±12.86 (Mean: 53 Minimum 27-Maximum 80) years old. Thirty of these patients (56.6%) were aware of their diagnosis and 23 (43.4%) of them were not aware of their diagnosis or they were informed about the characteristics of their illnesses but the specific diagnosis was not mentioned by their doctors or relatives

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Five patients (9.6%) were found to use alternative therapies before they were diagnosed as having cancer. The alternative methods that were used by cancer patients before their diagnosis was established were herbal medicine, spiritual or faith healing and special diets. Thirteen patients who used CAM therapy after the diagnosis of cancer considered that this therapy would be useful for their diseases (25.0%).

There was non significant difference between patients who have a monthly income of more than $200 and less than $200 in using alternative methods (X2 =0.432, p=0.511). Educational level was not detected to be a significant factor in using alternative methods (X2 =0.408, p=0.523). Awareness of the diagnosis as a malignant disease was detected to be significant in using alternative methods (X2 =7.248, p=0.007).

Patients were asked if their doctors investigated if they are receiving CAM therapy and just four of them (%7.7) said that their doctors investigated for CAM therapy. Five of the patients also informed their doctors that they have used CAM therapy after they were informed about their diagnosis. The alternative method that was used by patients was herbal therapy (11 patients 44.0%), special diet (6 patients 24.0%) and herbal therapy and special diet together (8 patients 32.0%). Urtica dioica L was the choice of ten patients out of eleven, who used herbal therapy and special diet and herbal therapy was detected to be the mixture of honey and urtica dioica L. When this herb was used alone, patients stated that it was boiled in water and they consumed the boiled water of Urtica dioica The main reason that was mentioned by cancer patients for using alternative methods, was supportive therapy and increasing hope for cure (17 patients 63.7%).

Complementary and alternative medicine is used widely for various kinds of disorders in similar rates ^(5,6,7). Studies conducted on unconventional treatments used by patients with cancer are focusing on gathering information of user profiles and the type of the therapy used, since local properties may have influences on the type of the selected therapy. Conventional medical therapies are not satisfying patients and expenditure of these subjects is growing substantially ⁽⁸⁾. Either the medical physician does not ask his/her patients or their patients do not give information to their physicians about the alternative therapies that they are receiving. Although there are continuing advances in conventional medicine a great proportion of cancer patients reported to be using unconventional therapies (13-63%)⁽⁹⁾. Physicians are offering just a limited proportion of these therapies, or they may not be aware if their patients are using some kind of therapy, which can interfere with their conventional therapy ⁽⁹⁾. The main reason for planning this study was to detect the extent and types of unconventional therapies in patients, who have gynecological cancer.

Female patients reported to using CAM therapies more often than male patients so we planned to perform our study in the gynaecology department ⁽⁶⁾. In a study performed in oncology and hematology departments it was revealed that the majority of patients (61.0%) use CAM therapy and these patients are born in rural areas, have less education and live in large families. These findings are inconsistent with some other studies in the world ^(2,7) since more educated patients are more prone to use alternative therapies. Patients desire to get involved in their therapy; intense Internet marketing efforts and dissatisfaction with conventional cancer therapy may be some important reasons for unconventional interventions. Patients' consideration that alternative treatments have fewer side effects may also be the reason for choosing these methods ⁽¹⁰⁾. Ethnicity, marital status, religious affiliation, educational level, place of residence., were found to be not important in CAM use but age, sex, financial income and the type of previous therapy, are found to be important in CAM use ⁽¹¹⁾.

We consider that interactions of conventional therapy and CAM therapies, are very important, since if physicians are not informed about these interventions morbidity and mortality rates can increase ⁽³⁾. Interactions may sometimes not be important. Also physicians must be aware of the product used and to be able to communicate with his/her patient and give information which would satisfy his/her patient. Herbs used by patients in unconventional therapies, must be defined to inform doctors dealing with cancer patients.

In this study one out of five patients were using Urtica dioica and more than one third of them were using this herb with honey. Urtica dioica is a common plant in temperate climates. Fresh leaves of this plant contain acetylcholine, serotonin and histamine. Antirheumatic antiarthritic and immunostimulating abilities were demonstrated ^(12,13). Mode of administration is infusions and other galenic preparations of both the root and flowering plant ^(12,13). Adverse effects reported for Urtica dioica were gastric irritation, gingivostomatitis and strong diuretic effect ^(12,13). Tannin content of this plant can result in unabsorbable complex with iron. This therapy is mentioned in publications of folk medications and endemic medical herbs ^(14,15). Boiled extract (infusion) of Urtica dioica in water is used for cancer therapy and it can be supplied (grown) even in patients' own gardens. Physicians must take into consideration that herbal therapies with conventional therapies are common and are readily available. Patients must be investigated for non-conventional therapies to plan their medical therapy. In the Turkish population Urtica dioica is a common plant used for both its immuno-stimulating and anti-inflammatory effects

Physicians or relatives of cancer patients used to conceal the diagnosis from patients. This is consistent with our study and 42.3% of patients were not aware of their exact diagnosis. This may sometimes be considered as denial of the disease by patients but sometimes their relatives' decision to keep the diagnosis as secret.

Although other types of CAM therapies were mentioned in the questionnaire, interestingly, we determined that Urtica dioica alone or Urtica dioica with honey, was used in our study group. These interventions are also used along with their conventional therapies and none of the patients in the study group stated that they gave up medical therapy to use alternative interventions. They also do not believe that alternative interventions are superior to medical therapy. Increasing hope for cure and considering it as supportive therapy was the major reasons for using CAM therapy in conjunction with medical therapies and this is consistent with other studies ^(2,10,16).

Alternative, complementary or unconventional medical interventions do not appear in Turkish medical curriculum. Adverse effects and drug interactions also do not appear in the medical curriculum also. Description of these common interventions may lead us to understand patients' agenda more comprehensively, and plan our therapy more accurately than before.

Table 1. Characteristics of the study population

* They did not give information about their monthly income

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