Canadian integrative oncology research priorities: results of a consensus-building process

BACKGROUND

In Canada, many diverse models of integrative oncology care have emerged in response to the growing number of cancer patients who combine complementary therapies with their conventional medical treatments. The increasing interest in integrative oncology emphasizes the need to engage stakeholders and to work toward consensus on research priorities and a collaborative research agenda. The Integrative Canadian Oncology Research Initiative initiated a consensus-building process to meet that need and to develop an action plan that will implement a Canadian research agenda.

METHODS

A two-day consensus workshop was held after completion of a Delphi survey and stakeholder interviews.

RESULTS

FIVE INTERRELATED PRIORITY RESEARCH AREAS WERE IDENTIFIED AS THE FOUNDATION FOR A CANADIAN RESEARCH AGENDA: EffectivenessSafetyResource and health services utilizationKnowledge translationDeveloping integrative oncology models Research is needed within each priority area from a range of different perspectives (for example, patient, practitioner, health system) and in a way that reflects a continuum of integration from the addition of a single complementary intervention within conventional cancer care to systemic change. Strategies to implement a Canadian integrative oncology research agenda were identified, and working groups are actively developing projects in line with those strategic areas. Of note is the intention to develop a national network for integrative oncology research and knowledge translation.

CONCLUSIONS

The identified research priorities reflect the needs and perspectives of a spectrum of integrative oncology stakeholders. Ongoing stakeholder consultation, including engagement from new stakeholders, is needed to ensure appropriate uptake and implementation of a Canadian research agenda.

Understanding coronary artery disease patients' decisions regarding the use of chelation therapy for coronary artery disease: descriptive decision modeling

BACKGROUND

A considerable number of patients receive chelation therapy to treat their coronary artery disease. However, there is no current empirical evidence to support its use.

AIM

To better understand patient's decision-making processes regarding the use of chelation therapy as a treatment for coronary artery disease.

METHODS

Based on qualitative interviews with 32 coronary artery disease patients, a taxonomy of decision-related issues, hierarchical decision-model, and survey based on the model were developed. The model was then pilot tested with another group of 30 patients and revised accordingly. The final model was tested with another group of 167 patients (27 current users, 72 previous users, and 68 never users of chelation therapy). The primary examination of the model was to determine the degree to which it successfully identified people who fell within each behavioral group. This was done by dividing the total number of successes by the total number of cases on all paths (or questions in the questionnaire).

RESULTS

The most important elements in the decision to use or not use chelation therapy were: previous experience with or learning about chelation therapy, openness to alternative treatments, satisfaction with current level of (traditional) care, physician opinion regarding chelation therapy, costs associated with chelation therapy, perceived access to chelation therapy provider, current state of health (good or bad), and wanting to do 'all one can' for heart health. When tested, the ability of the model to predict the appropriate outcome was nearly 93%. The most salient junctures in the model that led participants to different behavioral outcomes were: considering using non-traditional treatments; perceptions regarding potential risks and benefits; cost; and believing that using chelation therapy was 'doing all that they can' to help their heart health.

CONCLUSIONS

Descriptive decision-modeling is a useful method to depict cardiac patients' decision-making concerning the use of chelation therapy. It can also assist healthcare providers and policy makers in directing interventions and policy aimed at enhancing the use of evidence-based therapies for cardiac patients.

Chiropractic treatment of patients younger than 18 years of age: Frequency, patterns and chiropractors' beliefs

OBJECTIVES

To explore how and when chiropractors are involved in the care of patients younger than 18 years of age, and to examine chiropractors' beliefs about treating paediatric patients.

DESIGN

A cross-sectional survey of a random sample of 140 chiropractors practising in Alberta. Data were collected by means of a mailed questionnaire, which elicited practice information and chiropractors' beliefs, and included closed-and open-ended questions related to six vignettes of paediatric health problems.

RESULTS

Fifty-seven per cent of chiropractors responded to the questionnaire. All chiropractors indicated that they treat patients younger than 18 years of age. Nine per cent of respondents do not treat patients younger than age two years, and 4% do not treat patients from ages six to 11 years. On average, 13% of chiropractors' total patient load over the month preceding the completion of the questionnaires consisted of patients younger than the age of 18 years. With increasing age, patients are more likely to present with musculoskeletal problems (23% of patients younger than age two years, 84% of those aged 14 to 17 years). Chiropractors reported that they provided musculoskeletal treatment regardless of the cause of the problem. A high percentage of chiropractors refer to physicians and reported that they would like to provide concomitant care with physicians.

CONCLUSION

The present study has shown that chiropractors do treat children and that their opinions about this practice vary by specific condition. In addition, substantial percentages of chiropractors indicated that they would like to work with physicians in treating patients with nonmusculoskeletal conditions.

Principles to guide integrative oncology and the development of an evidence base

Background

Integrative oncology uses both conventional and complementary medicine to meet the needs of individual patients and to focus on the whole person. The core principles of integrative oncology include individualization, holism, dynamism, synergism, and collaboration, but the nature of the evidence to guide the development of integrative oncology has been given little attention.

Objectives

To discuss the need for evidence to support the integration of complementary therapies for integrative oncology care.

To emphasize that the evidence base must be valid and respect the underlying principles of individual complementary therapies and integrative oncology practice.

To suggest ways to begin developing the evidence base.

Review and Discussion

Although the evidence for safety and efficacy seems paramount for supporting the integration of an individual complementary therapy into mainstream cancer care, the need for evidence to support the overall practice of integrative oncology has to be considered as well.

We argue that developing an evidence base for integrative oncology requires a contextual and comprehensive research approach that assesses a range of outcomes over a suitable period of time that the patient and the patient’s family, in addition to the health care providers, deem important.

Conclusion

A whole-systems framework to the development of the evidence base for integrative oncology can guide the development of evidence that respects the complex nature of many complementary and integrative practices and their underlying principles of care delivery.

Talking to cancer patients about complementary therapies: is it the physician's responsibility?

Background

To ensure the safety and effectiveness of cancer management, it is important for physicians treating cancer patients to know whether their patients are using complementary and alternative medicine (cam) and if so, why.

Objective

Here, we discuss the ethical and legal obligations of physicians to discuss cam use in an oncology setting, and we provide practical advice on how patient–provider communication about cam can be improved.

Results

Physicians have both ethical and legal obligations to their patients, including the obligation to respect patient autonomy. This latter obligation extends to use of cam by patients and needs to be addressed beginning early in the patient–provider relationship. Because lack of education in this field and lack of time during patient consultations are barriers to talking with patients about cam, we provide resources to facilitate such discussions. These resources include suggestions on how to discuss the topic of cam and a wide range of information sources.

Conclusions

Discussing cam with patients is the physician’s responsibility, and such discussion will facilitate evidence-based, patient-centred cancer care.

Declining conventional cancer treatment and using complementary and alternative medicine: a problem or a challenge?

Background

Several studies have shown that a small but significant percentage of cancer patients decline one or more conventional cancer treatments and use complementary and alternative medicine (cam) instead.

Objectives

Here, drawing on the literature and on our own ongoing research, we describe why cancer patients decide to decline conventional cancer treatments, who those patients are, and the response by physicians to patients who make such decisions.

Results

Poor doctor–patient communication, the emotional impact of the cancer diagnosis, perceived severity of conventional treatment side effects, a high need for decision-making control, and strong beliefs in holistic healing appear to affect the decision by patients to decline some or all conventional cancer treatments. Many patients indicate that they value ongoing follow-up care from their oncologists provided that the oncologists respect their beliefs. Patients declining conventional treatments have a strong sense of internal control and prefer to make the final treatment decisions after considering the opinions of their doctors. Few studies have looked at the response by physicians to patients making such a decision. Where research has been done, it found that a tendency by doctors to dichotomize patient decisions as rational or irrational may interfere with the ability of the doctors to respond with sensitivity and understanding.

Conclusions

Declining conventional treatment is not necessarily an indicator of distrust of the medical system, but rather a reflection of many personal factors. Accepting and respecting such decisions may be instrumental in “keeping the door open.”

Women's needs for CAM information to manage menopausal symptoms

OBJECTIVE

To identify the information needs of women regarding complementary and alternative medicine (CAM) treatment options to alleviate menopausal symptoms.

METHODS

Self-administered questionnaires were mailed to women responding to notices posted in family physicians' offices and a women's health center. Survey questions addressed preferred topics, formats and sources of information; experiences with information searching; and what signified good, trustworthy information.

RESULTS

The women in this study (n = 413) indicated several challenges including a lack of time to gather information, gaps in, and lack of, relevant information, and poor information quality. They expressed interest in information about the menopausal process, conventional and CAM treatment options, and the safety of treatments. Personal consultation with health-care professionals was the preferred way for obtaining information. The majority of women preferred evidence-based information but there was also a substantial number of women who chose to rely on 'softer' evidence such as personal accounts. These results suggested two different subgroups; however, the data indicate that these are not mutually exclusive since many respondents showed a preference for both types of information.

CONCLUSIONS

Women feel they are not sufficiently informed to make safe decisions regarding CAM treatment options to alleviate menopausal symptoms. Family physicians are a trusted information source and have an important role in providing women with that information. Brochures containing evidence-based information and a list of newsletters or books that include personal accounts, available in physician's offices and during personal consultations at women's health centers, are offered as a possible solution. A website is another possibility for distributing this information.

Complementary therapies for cancer patients: assessing information use and needs

Many cancer patients seek complementary therapies (CTs) for cancer management; however, relatively little is known about patients' CT information seeking behaviour. Therefore, we assessed: 1) cancer patients' use of the types and sources of CT information; 2) their information preferences; and 3) their understanding of the phrase "scientific evidence or proof that a therapy works." We collected data from 404 patients attending the Tom Baker Cancer Centre (TBCC) in Calgary and 303 patients calling the Cancer Information Service (CIS) helpline. In most cases, patients wanted information on the safety of CTs, how CTs work and their potential side effects. Physicians and conventional cancer centres were the most desired sources of CT information, but relatively few patients obtained information via these sources. Although patients were aware of the meaning of scientific evidence, they often used information based on non-scientific evidence, such as patient testimonials. The creation of a supportive care environment in conventional cancer treatment centres, by providing CT information, may help address cancer patients' concerns and alleviate some of the stress that may have been caused by the cancer diagnosis.

Talking to Cancer Patients about Complementary Therapies: Is It the Physician’s Responsibility?

Background: To ensure the safety and effectiveness of cancer management, it is important for physicians treating cancer patients to know whether their patients are using complementary and alternative medicine (cam) and if so, why. Objective: Here, we discuss the ethical and legal obligations of physicians to discuss cam use in an oncology setting, and we provide practical advice on how patient–provider communication about cam can be improved. Results: Physicians have both ethical and legal obligations to their patients, including the obligation to respect patient autonomy. This latter obligation extends to use of cam by patients and needs to be addressed beginning early in the patient–provider relationship. Because lack of education in this field and lack of time during patient consultations are barriers to talking with patients about cam, we provide resources to facilitate such discussions. These resources include suggestions on how to discuss the topic of cam and a wide range of information sources. Conclusions: Discussing cam with patients is the physician’s responsibility, and such discussion will facilitate evidence-based, patient-centred cancer care.

Qualitative research in inflammatory bowel disease: dispelling the myths of an unknown entity

The potential for qualitative research in the field of inflammatory bowel disease has been overlooked due to a misunderstanding of the methods and intent of this approach. In this paper, we provide a brief overview of qualitative research and address some of the misconceptions and criticisms that we have come across during our use of qualitative research methods in inflammatory bowel disease research.

Response rates for surveys of chiropractors

BACKGROUND

Survey response rates may vary by type of practitioner studied and may have declined over time. Response rates for surveys of complementary practitioners have not been studied.

OBJECTIVE

To describe the response rates in published surveys of chiropractors and explore for secular trends in response rates and for methodologic and geographic correlates of response rates.

METHODS

Secondary analysis of data extracted from published English language reports of surveys of chiropractors. Response rates were calculated as the total number of persons from whom a questionnaire was returned divided by the total number of persons who were sent a questionnaire.

RESULTS

Sixty-two surveys represented by 79 articles published in the interval 1980 to 2000 met inclusion criteria for analysis. We were able to calculate a response rate for 46 postal surveys. The mean response rate was 52.7%. There was no significant association between geographic setting and response rate, and there was no evidence of secular trend in response rates. None of the studies employed incentives. The strongest predictor of response rate was number of contacts with the target population.

CONCLUSION

Response rates for surveys of chiropractors are similar to those observed for surveys of medical doctors. The key to obtaining high response rates is the use of evidence-based methods in design and conduct of the surveys.

Cannabis use as described by people with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is one of the most common neurological diseases affecting young adults. The prevalence of MS in Alberta has been described as among the highest reported in the world, estimated at 217 per 100,000. Numerous anecdotal reports, and a few small empirical investigations have suggested that cannabis use may relieve the symptom experience of those with MS. The present study was undertaken to describe cannabis use by this patient group. Information on peoples' beliefs, practices and experiences related to use were investigated.

METHODS

A questionnaire was mailed to a sample of 780 adults with MS in southern Alberta, Canada.

RESULTS

Completed questionnaires were returned by 420/673 eligible subjects (response rate 62%). Mean sample age was 48 years and 75% were women. Respondents ranged from mildly to severely impaired. The majority of respondents (96%) was aware cannabis was potentially therapeutically useful for MS and most (72%) supported legalization for medicinal purposes. Forty-three percent had tried cannabis at some point in their lives, 16% for medicinal purposes. Symptoms reported to be ameliorated included anxiety/depression, spasticity and chronic pain. Reasons given for not trying cannabis were the fact that it is an illegal substance, concern about side effects and lack of knowledge on how to obtain it.

CONCLUSIONS

Subjective improvements in symptom experience were reported by the majority of people with MS who currently use cannabis. Further evaluation of this substance is warranted.

Inflammatory bowel disease patients' decisions to use complementary therapies: links to existing models of care

OBJECTIVE

In this paper we present emergent categories of factors that influence inflammatory bowel disease patients' decisions to use complementary therapies and discuss similarities between this work and existing models of care.

METHODS

This combined methods study consisted of a quantitative survey followed by qualitative interviews. The results of the qualitative interviews are reported in this article.

RESULTS

Major categories that emerged during qualitative analysis were the personal context (i.e. contextual issues that influenced the individual's experience of illness), impact (i.e. the impact that the experience of illness had on the individual), and action (i.e. actions taken to manage the individual's illness).

DISCUSSION

Research in the areas if complementary therapy, biopsychosocial models, and patient-centered care, point to the importance of patient-physician communication. Our findings with people who have inflammatory bowel disease are in alignment with this previous body of work. By investigating the reasons for using complementary therapies among people who have a chronic illness, we make a substantive contribution to a growing body of literature that supports the need for continued emphasis on strengthening patient-physician relationships.

Use of chelation therapy after coronary angiography

PURPOSE

Among patients who had undergone coronary angiography, we sought to determine the proportion of chelation therapy users, their sociodemographic and clinical characteristics, and the association of chelation therapy with subsequent revascularization.

METHODS

We studied all patients who underwent coronary angiography in the province of Alberta, Canada, during 1995 and 1996. The cohort was followed for up to 6 years to determine subsequent revascularization status. Use of chelation therapy was determined by a mailed survey 1 year after angiography.

RESULTS

Among the 5854 patients who responded to the mail survey (70% response rate), 210 (3.6%) reported current use of chelation therapy and 252 (4.3%) reported past use. Current use of chelation therapy was associated with extensive coronary artery disease (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI]: 1.9 to 5.7 for 3-vessel disease; and OR = 2.7; 95% CI: 1.2 to 6.0 for left main disease, as compared with those with normal anatomy) and the absence of diabetes (OR = 0.6; 95% CI: 0.4 to 0.9). Current users were less likely to have undergone percutaneous transluminal coronary angioplasty (OR = 0.7; 95% CI: 0.5 to 0.9) and coronary artery bypass graft (CABG) surgery (OR = 0.3; 95% CI: 0.2 to 0.5) in the first year after angiography, but were as likely as nonusers of chelation therapy to have undergone CABG surgery in the subsequent 3- to 5-year period (adjusted hazard ratio [HR] = 1.1; 95% CI: 0.7 to 1.9). Past use of chelation therapy was associated with a history of CABG surgery before coronary angiography (OR = 1.6; 95% CI: 1.1 to 2.3) and extensive coronary artery disease. Past users were also more likely to have undergone CABG surgery in the follow-up period (HR = 1.7; 95% CI: 1.1 to 2.6).

CONCLUSIONS

About 8% of patients who underwent cardiac catheterization for coronary artery disease were using or had previously tried chelation therapy. Users may have foregone revascularization in favor of this less invasive yet unproven treatment, with some users subsequently undergoing conventional treatment after chelation. Alternatively, some patients may have turned to chelation as a "last resort" after having been judged unsuitable for revascularization.

Attitudes toward smoking and smoking behaviors of patients with Crohn's disease

OBJECTIVE

To examine the smoking behaviors of people with Crohn's disease. In active smokers, we measured their willingness to quit, their degree of nicotine dependence, and the proportion that made a quit attempt within 6 months to determine if they were refractory to smoking cessation in comparison to the general population. We also examined factors that were important in their decision to smoke.

METHODS

We conducted a cross-sectional survey of out-patients, supplemented by telephone interviews and a 6-month follow-up questionnaire of active smokers. Measures included disease activity, current smoking behaviors, intentions (stage of change), Fagerstrom Test for Nicotine Dependence, and factors related to their decision to smoke (decisional balance).

RESULTS

The questionnaire was completed by 115 patients (78% response rate). Forty percent were active smokers. Of active smokers, 59% were considering quitting within the next 6 months, and of these, 15% were planning on quitting within the next 30 days. Those with moderate disease activity were more likely to be considering quitting than those with mild or severe activity. Nicotine dependence was rated as high in 33% and as moderate in 43%. Factors unrelated to Crohn's disease were more important in their decision to smoke than were Crohn's disease-related factors. After 6 months, 23% had made an attempt to quit and this attempt was strongly associated with their stated intentions at the baseline questionnaire. Two of three patients who had recently quit at baseline had resumed smoking.

CONCLUSION

When compared to similar data for the general population, patients with Crohn's disease are no more refractory to smoking cessation.

Attitudes toward smoking and smoking behaviors of patients with Crohn's disease

OBJECTIVE

To examine the smoking behaviors of people with Crohn's disease. In active smokers, we measured their willingness to quit, their degree of nicotine dependence, and the proportion that made a quit attempt within 6 months to determine if they were refractory to smoking cessation in comparison to the general population. We also examined factors that were important in their decision to smoke.

METHODS

We conducted a cross-sectional survey of out-patients, supplemented by telephone interviews and a 6-month follow-up questionnaire of active smokers. Measures included disease activity, current smoking behaviors, intentions (stage of change), Fagerstrom Test for Nicotine Dependence, and factors related to their decision to smoke (decisional balance).

RESULTS

The questionnaire was completed by 115 patients (78% response rate). Forty percent were active smokers. Of active smokers, 59% were considering quitting within the next 6 months, and of these, 15% were planning on quitting within the next 30 days. Those with moderate disease activity were more likely to be considering quitting than those with mild or severe activity. Nicotine dependence was rated as high in 33% and as moderate in 43%. Factors unrelated to Crohn's disease were more important in their decision to smoke than were Crohn's disease-related factors. After 6 months, 23% had made an attempt to quit and this attempt was strongly associated with their stated intentions at the baseline questionnaire. Two of three patients who had recently quit at baseline had resumed smoking.

CONCLUSION

When compared to similar data for the general population, patients with Crohn's disease are no more refractory to smoking cessation.

Canadian Cancer Society Information Services: lessons learned about complementary medicine information needs

The use of complementary and alternative medicine (CAM) in cancer patients is very common. However, currently valid and reliable information on CAM treatments for cancer is limited. The purpose of this study was to identify the information needs those who called the Canadian Cancer Society's Cancer Information Service (CIS) requesting information on CAM. CIS Information Specialists completed two-page questionnaires for 109 callers who inquired about CAM therapies. Findings show that the majority of callers were women between the ages of 30 and 59, and that most of their questions concerned the safety and/or effectiveness of herbs and compounds like Essiac and 714X. Information Specialists generally utilized one or more of four resources upon receiving a CAM-related call. These resources, while mostly Canadian and reviewed by content experts, are not specific to the type of cancer and are no longer the most up- to-date. To address this issue we have included an appendix that outlines some current CAM resources and websites for cancer patients.

Patient outcomes related to percutaneous endoscopic gastrostomy placement

Although many aspects of percutaneous endoscopic gastrostomy (PEG) have been addressed in the literature, attention to psychologic and social outcomes of PEG has been limited. Our goal was to assess a range of physical, psychologic, and social outcomes related to PEG feeding. This study is a follow-up survey of patients undergoing PEG and/or their surrogates. Data were collected by semistructured interviews in two tertiary hospitals in Alberta, Canada. Measurements consisted of PEG status at 1-year follow-up, quality of life, impact on caregivers, and opinions about long-term support via PEG. We included 71 patients in the study. Of all 39% of patients died, 32% had the PEG still in place, and for 28% the PEG was removed at the end of the 1-year follow-up. The prognosis of the attending physician at the initial visit and the underlying disease were significantly related to the outcome (p < 0.05). After 1 year, 85% of all patients whose PEGs were still in place, were not working or studying or managing their own household in any capacity, 67% were not managing personal care, and 19% were feeling very ill. Fifty-two percent of the caregivers spent 15 hours or more per week visiting and caring for the patient. At the 1-year follow-up, all ten surviving patients who could be interviewed agreed they would have a PEG again. Seventy percent of the caregivers said that they would want the same decision to be made. Although a majority of patients and caregivers did not regret the decision to place a PEG, this did not necessarily mean enhanced quality of life. Developing strategies to select patients who will benefit from long-term nutritional support could improve patient outcomes.

Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding

OBJECTIVE

This study was done to determine whether sigmoidoscopy could theoretically constitute sufficient investigation for some patients with bright red rectal bleeding.

METHODS

One hundred and forty-three patients undergoing investigative colonoscopy for bright red rectal bleeding and whose source of bleeding was identified were studied. The investigation took place in a large urban hospital over an 11-month period. Data obtained included changes in stool pattern, characteristics of the bleeding, lesions identified, and the distance of the lesion from the anus.

RESULTS

In patients younger than 55 yr, all serious lesions except for one malignancy in a patient with massive bleeding lay within 60 cm of the anus and theoretically within reach of the fiberoptic sigmoidoscope. The mixing of red blood with stool was commonly due to distal lesions, especially hemorrhoids.

CONCLUSIONS

In young persons with bright red rectal bleeding, fiberoptic sigmoidoscopy may prove to constitute appropriate initial investigation.

Gastric cancer and other endoscopic diagnoses in patients with benign dyspepsia

BACKGROUND

It has been suggested that endoscopy could be replaced with non-invasive assessment of helicobacter status in the initial work up of young dyspeptic patients without sinister symptoms.

AIMS

To determine the incidence of gastro-oesophageal malignancy in young dyspeptic patients.

METHODS

The Alberta Endoscopy Project captured clinical and demographic data on all endoscopies performed from April 1993 to February 1996 at four major adult hospitals in Alberta. The endoscopic and histological diagnosis in a subgroup of patients under 45 years of age without alarm symptoms that had undergone gastroscopy was reviewed. In addition, a random list of 200 patients was generated and their medical records reviewed in order to assess the proportion with symptoms suitable for a non-invasive management strategy.

RESULTS

Gastroscopy was performed in 7004 patients under 45 years. In 3634 patients (56% female) alarm type symptoms were absent; 78.9% of patients had symptoms amenable to a non-invasive initial approach, giving a corrected sample size of 2867 patients (correction factor 0.789). Three gastric cancers, one case of moderate dysplasia, 10 biopsy proved cases of Barrett's oesophagus, and 19 oesophageal strictures/rings were detected within this sample. The corrected prevalence of gastric cancer in this select population was 1.05 per thousand patients.

DISCUSSION

Endoscopy yielded three gastric cancers in this sample of under 45 year old dyspeptic patients without sinister symptoms. While initial non-invasive screening with one-week triple therapy for helicobacter positive individuals is unlikely to have a detrimental outcome the physician is advised to consider endoscopy in patients with persisting, recurrent, or sinister symptoms.

How are decisions made about the use of percutaneous endoscopic gastrostomy for long-term nutritional support?

OBJECTIVE

We sought to study the process by which decisions to commit individuals to long-term nutritional support via percutaneous endoscopic gastrostomy (PEG) are made.

METHODS

A semistructured questionnaire was administered to surrogates and patients in 73 cases of persons undergoing PEG.

RESULTS

Such decisions are often made with inadequate information regarding the PEG and its possible impact on the future clinical course, sometimes with an overly optimistic view of the prognosis. Several factors may influence this process. In cases in which the underlying illness was severe, 30% of surrogate decisionmakers expressed some uncertainty that a right decision was made.

CONCLUSIONS

The decision to commit patients to long-term nutritional support via PEG is often difficult and the implications of such a commitment may have major implications for patients and their families. Strategies to optimize this decisionmaking process are recommended.

Complementary therapies and cancer care: an overview

The use of complementary therapies by patients with cancer is increasingly common, despite limited evidence for their efficacy and safety. The widespread use of complementary therapies has major implications for research and practice. In this paper, we provide an overview of the current state of knowledge regarding issues related to the use of complementary therapies by patients with cancer. So far, complementary therapies have not been defined very well, which makes it difficult to assess the precise extent of their use. The difference in philosophy underlying conventional and complementary treatments appears to contribute to the attractiveness of complementary therapies. Conventional medical practitioners are beginning to recognize the importance of many of the elements of this philosophy, which is evidenced in the patient-centered model. Explaining how patients with cancer make the decision to use complementary therapies has been the subject of many studies. However, as yet, no formal theory of decision making has been developed. Communication between patients and physicians about complementary therapies is an important part of the patients' decision-making process. Many gaps can be identified in knowledge of complementary therapy use by patients with cancer. Not only is there a need to increase knowledge by conducting more research and improving the research infrastructure, but attention should also be paid to information dissemination, education, and planning and development of health policies.

Complementary therapies: evaluating their effectiveness in cancer

The use of complementary therapies is common among cancer patients. However, a major concern is that very few of these therapies have been appropriately evaluated and, thus, little is known about their safety and efficacy. The gold standard for evaluating cancer treatments is the randomized controlled trial (RCT). However, there are several issues inherent to the nature and practice of complementary therapies that interfere with the straightforward use of RCTs. Alternative approaches are often highly individualized and attempt to respond to patients' needs. They are often holistic, taking into account many facets of a patient's life. Placebo effects and the role of the provider are frequently recognized as an important part of treatment. Outcomes of complementary therapies are often subjective, rather than being more objective outcomes, such as increased survival time. Although it is important to evaluate complementary therapies, it is mandatory that studies be sensitive to these issues and that existing research methods be adjusted and modified for this purpose.

Determinants of Canadian physicians' opinions about legalized physician-assisted suicide: a national survey

OBJECTIVES

To ascertain the opinions of practising Canadian physicians about their willingness to participate in legalized physician-assisted suicide; and to seek possible associations between willingness to practise legalized assisted suicide, and personal and medical professional determinants.

DESIGN

Cross-sectional, mailed survey of a random sample of Canadian physicians, stratified non-proportionally with respect to five geographic regions, and proportionally for type of practice (general practitioner or specialist).

RESULTS

Useable responses came from 2,010 (59 per cent) physicians (regional range 53 to 64 per cent), of whom 1,855 were in clinical practice. Respondents' gender and type of practice did not deviate from national reference data; 57 per cent were unwilling to practice legalized assisted suicide, but 40 per cent would wish it for themselves. Significantly different associations were found between opinions about willingness to practise legalized assisted suicide and the personal determinants of age, geographic regions, country of graduation, and religious activity, but not for gender, and type or experience in practice and terminal care.

CONCLUSIONS

The opinions of Canadian physicians about the practice of legalized physician-assisted suicide are more strongly influenced by personal determinants than by medical professional determinants. This reveals potential conflicts between physicians' professional and personal preferences. In this context, a plurality of Canadian physicians supports legislated change, but most would not practise legalized physician-assisted suicide at this time in Canada.

Cancer patients' expectations of the role of family physicians in communication about complementary therapies

OBJECTIVE

To explore cancer patients' experiences with and expectations of the role of family physicians in communication about complementary therapies.

DESIGN

Focus group interviews.

SETTING

British Columbia Cancer Agency and the University of Calgary.

PARTICIPANTS

Sample of 14 cancer patients using complementary therapies comprising 3 focus groups (2 in BC and 1 in Alberta).

RESULTS

The role of family physicians in discussing complementary therapies varied from being extraneous to patients' decision making to being a partner in making decisions about cancer treatments. Patients expected their physicians to be supportive, caring, kind and to show an interest in them. They also expected their physicians to be accepting and nonjudgmental regarding complementary therapy use and to reinforce a sense of hope. Most patients did not expect their doctors to have extensive knowledge about these therapies. All patients strongly felt the need to seek information themselves. In addition, they felt that believing in the type of therapies they were using was very important.

CONCLUSION

Family physicians can play an important role in exploring and discussing complementary therapies with their patients. It is important that they are made aware of their patients' needs in this area.

Complementary and alternative medicine use by patients with inflammatory bowel disease: An Internet survey

OBJECTIVES

To determine the degree and determinants of the use of complementary and alternative medicine (CAM) by patients with inflammatory bowel disease (IBD) with the use of the Internet and to compare the results with those found by using a similar survey in patients attending gastroenterology clinics in Calgary, Alberta.

SUBJECTS AND METHODS

A cross-sectional survey of 263 patients with IBD with the use of a World Wide Web-based, structured questionnaire was conducted.

RESULTS

Complementary therapies had been used by 46% of patients in the previous two years. Current use was reported by 34%. Vitamins, herbal products and natural health practices were the most commonly reported therapies. Side effects and lack of effectiveness of standard therapies were the most commonly cited reasons for seeking complementary medicine. However, despite this, respondents who had previously received surgery, or intravenous or oral steroids were less likely to be current CAM users. Important differences between the determinants of and reasons for CAM use in the present study and those of a similar study of IBD patients in a local tertiary care setting were noted.

CONCLUSIONS

Complementary medicine use is common in patients with IBD. Differences in the determinants of and reasons for CAM use noted between the present Internet sample and a gastroenterology clinic sample suggest that conclusions from the present study and from previous studies based only on clinic samples provide a limited view of CAM use by people with IBD. More comprehensive assessments are needed.

Alternative therapy use in neurologic diseases: use in brain tumor patients

BACKGROUND

The extent of alternative therapy use in brain tumor patients is unknown, but it may be frequent and seems important to those who use it.

OBJECTIVE

To characterize alternative therapy use in brain tumor patients.

METHODS

Prospective questionnaire-based survey of 167 brain tumor patients who attended a cancer center in Southern Alberta. Physicians completed forms describing clinical information such as disease status.

RESULTS

The response rate was 91% (167/184). Twenty-four percent of patients used alternative therapies and often more than one therapy at the same time. Motivation to use these therapies was influenced by the desire for patient-focused treatment and a perceived need to take charge. Alternative therapy users were younger (p = 0.04) and more likely to be on sick or disability leave (p = 0.02), to come in for repeat visits (p = 0.05), and to have received conventional treatments (p = 0.01). Users tended to have lower quality of life with respect to physical well-being, functional well-being, and a specific brain tumor subscale. Clinical variables, such as disease status, tumor type, and Karnofsky Performance Score, were not related to alternative therapy use. Major changes in number and types of alternative therapy use occurred during the study period. No major side effects or tumor responses were seen with alternative therapies.

CONCLUSIONS

Alternative therapy use in brain tumor patients is common and may reflect unmet patient needs with respect to their cancer care within the current model of health care delivery.

The utility of endoscopy in the management of patients with gastroesophageal reflux symptoms

OBJECTIVE

The utility of endoscopy in the management of patients with symptoms of gastroesophageal reflux disease (GERD) is unclear. The purpose of this prospective study was to assess the impact of endoscopy on the subsequent management of patients with uncomplicated reflux symptoms.

METHODS

A total of 742 patients underwent endoscopy for symptoms of GERD. Endoscopists recorded the therapy before endoscopy, the findings of endoscopy, and the treatment recommendations after endoscopy.

RESULTS

There was no difference in pre-endoscopy therapy or grade of esophagitis in subjects undergoing endoscopy for failed therapy versus GERD symptoms alone. After endoscopy, the most common strategy for patients taking omeprazole was to maintain or increase the dose. For those taking an H2 blocker before endoscopy, the most common outcome was to switch the patient to omeprazole, independent of the grade of esophagitis.

CONCLUSIONS

Most patients undergoing endoscopy for symptoms of GERD were switched to omeprazole regardless of the endoscopic findings. No esophageal cancer was identified and the incidence of Barrett's esophagus was low. It appears that endoscopy itself did not change the management of patients receiving H2-blocker therapy. A trial of a proton pump inhibitor before endoscopy should be considered.

Complementary and alternative medicine: evaluating its effectiveness in inflammatory bowel disease

The use of complementary and alternative medicine (CAM) by patients with inflammatory bowel disease (IBD) is common. Physicians and scientists believe that the randomized controlled trial (RCT) provides the best evidence of an intervention's efficacy. However, there are only a few controlled trials that have assessed these therapies in IBD and all contain methodological problems. The RCT does not always fit well with the underlying principles of disease causation and treatment of CAM. Many forms of CAM take a holistic approach to the diagnosis and treatment of disease, where the patient plays an active and key role in healing and treatments are often highly individualized. Therefore, the use of placebos, blinding, and random allocation to structured treatment protocols in an RCT setting is often contradictory to the principles of CAM. We still know relatively little about the use of CAM in IBD. Prior to embarking upon a program of clinical trials to evaluate these therapies, a better understanding of the specific therapies being used, reasons for their use, and their potential side effects is required. We also need to understand how the CAM practitioners use their therapies, what they view as the appropriate indications, and how treatments are best administered.

Complementary and alternative medicine: evaluating its effectiveness in inflammatory bowel disease

The use of complementary and alternative medicine (CAM) by patients with inflammatory bowel disease (IBD) is common. Physicians and scientists believe that the randomized controlled trial (RCT) provides the best evidence of an intervention's efficacy. However, there are only a few controlled trials that have assessed these therapies in IBD and all contain methodological problems. The RCT does not always fit well with the underlying principles of disease causation and treatment of CAM. Many forms of CAM take a holistic approach to the diagnosis and treatment of disease, where the patient plays an active and key role in healing and treatments are often highly individualized. Therefore, the use of placebos, blinding, and random allocation to structured treatment protocols in an RCT setting is often contradictory to the principles of CAM. We still know relatively little about the use of CAM in IBD. Prior to embarking upon a program of clinical trials to evaluate these therapies, a better understanding of the specific therapies being used, reasons for their use, and their potential side effects is required. We also need to understand how the CAM practitioners use their therapies, what they view as the appropriate indications, and how treatments are best administered.

A multimethod research study on the use of complementary therapies among patients with inflammatory bowel disease

CONTEXT

The purpose of this study was to gain a better understanding of the use of complementary therapies among patients with inflammatory bowel disease.

OBJECTIVE

To examine factors influencing the use of complementary therapies, to explore patient-physician communication concerning those therapies, and to assess the effect of combining qualitative with quantitative research.

DESIGN

In-depth qualitative interviews.

PARTICIPANTS

Fourteen patients were selected from a quantitative study in which the use of complementary therapies among patients with inflammatory bowel disease was assessed.

RESULTS

Patients reported using complementary therapies because of the serious side effects of medical treatment, because they felt conventional treatments did not help, and because complementary therapies were thought to be safe. Psychological and social factors for using complementary therapies must be considered and understood. Patients cited many reasons for not discussing the use of complementary therapies with their doctors. Adding qualitative data to quantitative research greatly increased the authors' understanding of factors that contribute to complementary therapy use.

CONCLUSIONS

Multiple factors contribute to the decision to use complementary therapies among those with inflammatory bowel disease. Identifying these factors is important for educating physicians regarding their patients' use of complementary therapies and may contribute to improved patient-physician communication.

Physicians' perspectives on massage therapy

OBJECTIVE

To examine the knowledge, opinions, and referral behaviour of family physicians with respect to massage therapy and to explore factors associated with referral.

DESIGN

A random, cross-sectional mailed survey.

SETTING

Alberta family practices.

PARTICIPANTS

Family physicians (n = 300).

MAIN OUTCOME MEASURES

A self-report survey was developed for the study. This survey contained questions about sociodemographic and practice characteristics, perceived knowledge of massage therapy, opinions about the usefulness and legislation (government regulations) of massage therapy, and referral behaviour.

RESULTS

Fifty-four percent of physicians (n = 161) completed the questionnaire. Sixty-eight percent of respondents indicated they had minimal or no knowledge of massage therapy. Despite this low level of knowledge, most (83%) believed massage therapy was a useful adjunct to their own practice. Moreover, 71% had referred patients to massage therapists and most (72%) perceived increasing demand from their patients for massage therapy. Approximately half of physicians surveyed supported government regulation of massage therapy.

CONCLUSIONS

Physicians demonstrated a discrepancy between their knowledge of massage therapy and their opinions of, and referrals to, the profession. Physicians who referred patients to massage therapists generally held more positive opinions and had more knowledge of the discipline.

Complementary medicine use by patients with inflammatory bowel disease

OBJECTIVE

The purpose of this study was to establish the degree and determinants of the use of complementary therapies by patients with inflammatory bowel disease (IBD) and their reasons for seeking them.

METHODS

The first phase was a cross-sectional survey of 134 patients with IBD (98 with Crohn's disease, 34 with ulcerative colitis, and two indeterminate) using a mailed, structured questionnaire (response rate 70%). Determinants of complementary medicine use were examined using logistic regression. The second phase was an in-depth exploration using personal interviews of the beliefs and perceptions of 14 complementary medicine users about the management of their disease. Analysis was performed using standard qualitative techniques and the identification of important, patient-identified themes about the management of IBD.

RESULTS

Complementary therapies had been used by 51% of patients in the previous 2 yr. Current use was reported by 33%, of whom one-half were using it for their IBD. Vitamins and herbal products were the most commonly reported therapies. In multivariate analysis, duration of disease > 10 yr and a history of hospitalization were independent predictors of complementary medicine use. The side effects and lack of effectiveness of standard therapies were the most commonly cited reasons for seeking complementary medicine. Sixty-two percent had told their doctor about their use of complementary medicine.

CONCLUSION

Complementary medicine use is common in patients with IBD, especially among those with a longer duration of disease or a history of hospitalization.

Anxious attachment and self-reported depressive symptomatology in women

OBJECTIVE

Lack of intimacy has been identified as an important provoking agent that increases the risk of depressive symptoms in women. This study precisely characterized lack of intimacy by assessing a woman's attachment style and investigated the specificity of association between depressive symptoms and an anxious attachment pattern.

METHOD

Four hundred and twenty women participated in this cross-sectional study of depressive symptomatology and anxious attachment. All participants completed the following measures: a sociodemographic questionnaire, the Centre for Epidemiological Studies Depression Scale (CES-D), the Reciprocal Attachment Questionnaire, the Social Support Questionnaire, the Rosenberg Self-Esteem Scale, and the Global Assessment of Recent Stress Scale.

RESULTS

A score of 16 or above on the CES-D, which indicates the presence of depressive symptoms, was used to divide the sample into 2 groups: a depressed group (N = 129) and a nondepressed group (N = 291). We found that women in the depressive symptomatology group were more likely than women in the nondepressive symptomatology group to exhibit anxious attachment and adverse social and cognitive characteristics. Lower levels of self-esteem and higher levels of recent stress were also predictive of depressive symptomatology. Feared loss of the attachment figure and a lack of use of the attachment figure were independent predictors of depressive symptomatology in the same model.

CONCLUSION

The feared loss of security associated with an attachment figure seems to be related to an increased likelihood of depressive symptoms.

Combining qualitative and quantitative research methods: considering the possibilities for enhancing the study of chronic diseases

This paper discusses some of the underlying reasons why health researchers have historically had difficulty working collaboratively across qualitative and quantitative research paradigms and argues why it is imperative that researchers move beyond traditional adherence to particular methods of inquiry. Chronic illnesses are prime examples of conditions that by their very nature need to be studied from a combination of perspectives, using both qualitative and quantitative methods. We suggest that the success of health research on managing these conditions lies in the shared application of both qualitative and quantitative research perspectives, methods and tools. In addition, we argue that effective research into long-term chronic illnesses requires not only combined research efforts but also longitudinal programs of study, so that the experience of managing chronic conditions can be captured over time.

The Chiropractic Outcome Study: pain, functional ability and satisfaction with care

OBJECTIVE

To examine changes in pain experienced, changes in functional ability and degree of patient satisfaction with chiropractic care. Patient characteristics influencing these parameters were also explored.

DESIGN

A follow-up study consisting of a questionnaire to be completed at the beginning of treatment and a mailed questionnaire 6 wk later.

SETTING

Non-random sample of 13 chiropractic practices in Calgary and Red Deer, Alberta, Canada.

PATIENTS

Three hundred sixty-nine patients presenting with neck and/or back pain who saw a chiropractor for the first time or who had not seen a chiropractor for a period for 6 months before the first visit.

RESULTS

Pain relief and changes in functional ability were greatest among patients whose initial pain or disability level was moderate or severe. No significant improvement was found among those whose initial level of pain or disability was mild. Pain relief and improved functional ability was greatest among those with an acute condition and those who saw no one other than the chiropractor during treatment. In addition, pain relief was highest among men, those who perceived themselves to be in good or excellent health and those who had completed treatment in 6 wk. Patients positively endorsed all items on the satisfaction questionnaire, indicating a high level of satisfaction with the care they received. Patients were most satisfied with access to chiropractic care and least satisfied with financial aspects. Improvement in pain and in back and neck disability were significantly related to general satisfaction.

CONCLUSION

Based on these results, it seems that patients suffering from back and/or neck complaints experience chiropractic care as an effective means of resolving or ameliorating pain and functional impairments, thus reinforcing previous results showing the benefits of chiropractic treatment for back and neck pain.

Endoscopists' opinions of indications for upper gastrointestinal endoscopy

OBJECTIVE

To determine whether endoscopists and general internists agreed with the characterization of appropriateness for endoscopy of various clinical scenarios, as previously reported by the RAND Corporation.

DESIGN

Mail survey.

STUDY SAMPLE

All endoscopists in western Canada and a random sample of general internists who did not perform endoscopy.

METHODS

Questionnaires were sent to 179 endoscopists in western Canada who were asked to rate the 53 scenarios for endoscopy on a nine-point scale ranging from most appropriate to most inappropriate. A similar questionnaire was sent to 39 general internists practising in the province of Alberta.

RESULTS

Response rate was 72% of endoscopists (n = 128) and 64% of general internists (n = 25). Among the endoscopists, there was agreement with the RAND classification for 32 scenarios. All 18 indications previously thought to be appropriate were considered to be appropriate. However, endoscopists agreed with only six of 16 equivocal and eight of 19 indications considered inappropriate. Discrepancies were reviewed by five experienced endoscopists and most appeared to be related to a concern regarding possible malignancy linked in part with the definition of failure to respond to medical therapy; and to a refusal to request a barium meal before endoscopy. Among general internists, there was agreement with RAND in 26 scenarios. When the appropriateness rankings of endoscopists and general internists were compared, there was agreement in 40 of 53 scenarios. Significant discrepancies in ratings were identified in scenarios in which barium studies were described as being normal, known or not done.

CONCLUSIONS

The equivocal and inappropriate ratings developed by the RAND Corporation are not uniformly accepted by the endoscopy community or general internists. Use of the RAND indications for assessing quality assurance can be challenged.

Decision-making and outcomes for percutaneous endoscopic gastrostomy: a pilot study

We undertook a retrospective review of 25 patients who had undergone percutaneous endoscopic gastrostomy (PEG). Data regarding the clinical courses were collected, and a questionnaire was administered to patients when possible; in most cases the individual responsible for care answered questions. We pinpointed concerns relevant to the decision-making process. In a substantial proportion of cases, the clinical courses subsequent to PEG were poor. Of 21 surrogates interviewed, 33% were uncertain that proceeding to nutritional support via PEG had been the right decision. Findings indicate a need to improve the process by which decisions to treat by PEG are made, ideally including better prognostic information.

Euthanasia in family practice in The Netherlands. Toward a better understanding

OBJECTIVE

To describe the incidence of euthanasia and assisted suicide in family practice in the Netherlands, the reasons for its practice, and the characteristics of patients and physicians involved.

DESIGN

Cross-sectional survey of a random sample of Dutch family physicians.

SETTING

General practices in The Netherlands.

PARTICIPANTS

An anonymous questionnaire was mailed to 1042 general practitioners. Of the 996 eligible physicians, 667 (67%) completed the questionnaire.

MAIN OUTCOME MEASURES

Reported practices and beliefs concerning euthanasia and assisted suicide.

RESULTS

In the course of an average year, 24% of Dutch family physicians had practised euthanasia or assisted suicide. Most deaths took place at home in the presence of others. According to the physicians, the most important reasons for the request were futile suffering, fear or avoidance of loss of dignity, and unbearable suffering. Euthanasia or assisted suicide was mostly (85%) administered to patients with malignant neoplasms. Physicians were more opposed to euthanasia and assisted suicide if they had never practised it, if they had a religious affiliation, and if they were older.

CONCLUSIONS

This study presents empiric data about euthanasia and assisted suicide in the context of a permissive euthanasia policy. Understanding Dutch practices could be helpful for Canadians. However, each country needs to resolve these issues in its own way.

Alberta Euthanasia Survey: 3-year follow-up

OBJECTIVE

To determine whether the opinions of Alberta physicians about active euthanasia had changed and to assess the determinants of potential changes in opinion.

DESIGN

Follow-up survey (mailed questionnaire) of physicians included in the 1991 Alberta Euthanasia Survey.

SETTING

Alberta.

PARTICIPANTS

Of the 1391 physicians who participated in the 1991 survey 1291 (93%) had indicated that they were willing to take part in a follow-up survey. A follow-up questionnaire was mailed in 1994 to 1146 physicians who could be traced through the 1994 Medical Directory of the provincial college of physicians and surgeons; 25 questionnaires were returned because they could not be delivered.

OUTCOME MEASURES

Physicians' opinions about (a) the morality of active euthanasia, (b) changes in the law to permit active euthanasia and (c) the practice of legalized euthanasia.

RESULTS

Of the 1121 physicians sent a follow-up questionnaire 866 (77%) returned it completed. The responses of these same 866 physicians in 1991 provided a basis for comparison. Of the 866, 360 (42%) stated in the 1994 survey that it is sometimes right to practise active euthanasia; a similar proportion (384 [44%]) gave this response in 1991. However, other opinions changed significantly. In 1991, 250 of the respondents (29%) indicated that they would practise active euthanasia if it were legalized, as compared with 128 (15%) in 1994 (p < 0.01). In 1991, 429 (50%) of the respondents thought that the law should be changed to permit active euthanasia, as compared with 316 (37%) in 1994 (p < 0.01). Religious activity was the most important characteristic associated with changes in opinion. Despite the decrease in support for the practice and legalization of active euthanasia between 1991 and 1994, in both surveys at least 70% of those who responded to this question indicated that active euthanasia, if it were legalized, should be performed only by physicians and should be taught at medical sites.

CONCLUSION

Alberta physicians' support for the practice and legalization of active euthanasia decreased considerably between 1991 and 1994. However, most physicians remain in favour of restricting active euthanasia, if it were legalized, to the medical profession. These results suggest a need for caution and deliberation when changes in the law concerning active euthanasia are examined.