Is a Biopsychosocial–Spiritual Approach Relevant to Cancer Treatment? A Study of Patients and Oncology Staff Members on Issues of Complementary Medicine and Spirituality

Abstract

Complementary and alternative medicine (CAM) is increasingly being used by patients with cancer.
Our aim is to compare the attitudes of cancer patients who use CAM to those of nonusers, on issues of CAM, biopsychosocial considerations, and spiritual needs.
Questionnaires were administered to patients and medical care providers in a tertiary teaching hospital with a comprehensive cancer center.
Forty-nine percent of the study patients reported integrating CAM into their conventional care. Health care providers considered psychological and spiritual needs as major reasons for CAM use, while patients considered the familial-social aspect to be more important.
Cancer patients do not correlate CAM use with spiritual concerns but expect their physicians to attend to spiritual themes. Health care providers involved in oncology cancer care should emphasize spiritual as well as CAM themes. The integration of these themes into a biopsychosocial-spiritual approach may enrich the dialogue between patients and health providers.

Full text

Support Care Cancer (2006) 14: 147–152
DOI 10.1007/s00520-005-0866-8
ORIGINAL ARTICLE
Eran Ben-Arye
Gil Bar-Sela
Moshe Frenkel
Abraham Kuten
Doron Hermoni
Received: 4 April 2005
Accepted: 29 June 2005
Published online: 16 August 2005
# Springer-Verlag 2005
Is a biopsychosocial–spiritual approach
relevant to cancer treatment? A study
of patients and oncology staff members
on issues of complementary medicine
and spirituality
Abstract Background: Comple-
mentary and alternative medicine
(CAM) is increasingly being used by
patients with cancer. Objectives: Our
aim is to compare the attitudes of
cancer patients who use CAM to
those of nonusers, on issues of CAM,
biopsychosocial considerations, and
spiritual needs. Methods: Question-
naires were administered to patients
and medical care providers in a
tertiary teaching hospital with a
comprehensive cancer center.
Results: Forty-nine percent of the
study patients reported integrating
CAM into their conventional care.
Health care providers considered
psychological and spiritual needs as
major reasons for CAM use, while
patients considered the familial–social
aspect to be more important.
Conclusions: Cancer patients do not
correlate CAM use with spiritual
concerns but expect their physicians
to attend to spiritual themes. Health
care providers involved in oncology
cancer care should emphasize spiri-
tual as well as CAM themes. The
integration of these themes into a
biopsychosocial–spiritual approach
may enrich the dialogue between
patients and health providers.
Keywords Biopsychosocial model
.
Cancer
.
Complementary alternative
medicine (CAM)
.
Patient–doctor
relationship
.
Spiritual well-being
.
Spirituality
Background
Complementary and alternative medicine (CAM) is de-
fined by the Cochrane Complementary Medicine Field
Group as practices outside the domain of mainstream
medicine that complement it “by contributing to a com-
mon whole, satisfying a demand not met by conventional
practices and diversifying the conceptual framework of
medicine” [1].
CAM is increasingly being used by patients with cancer
in rates exceeding 30% and up to 83% [2–6]. CAM use for
cancer treatment is more prevalent among women and is
associated with younger age, higher education and socio-
economic status, advanced disease, active coping behavior,
and a change in life outlook and beliefs since the diagnosis
of cancer [3, 7–13]. Recent CAM use may as well be as-
sociated with greater psychosocial distress and a worse
quality of life [14]. In most cases, CAM users do not ex-
E. Ben-Arye
.
M. Frenkel
.
D. Hermoni
The Complementary and Traditional
Medicine Unit,
Department of Family Medicine,
Faculty of Medicine,
Technion-Israel Institute
of Technology,
Haifa, Israel
G. Bar-Sela
.
A. Kuten
Department of Oncology,
Rambam Medical Center and Faculty
of Medicine,
Technion-Israel Institute
of Technology,
Haifa, Israel
M. Frenkel
CAM Education Project,
Department of Family Medicine,
University of Texas,
Galveston, TX, USA
E. Ben-Arye (*)
Complementary and Traditional
Medicine Unit,
Department of Family Medicine,
Clalit Health Services,
6 Hasahaf Street,
Haifa, 35013, Israel
e-mail: eranben@netvision.net.il
Tel.: +972-52-8709282
Fax: +972-4-8513059

press disappointment or dissatisfaction with conventional
medicine but hope to do everything possible to regain
health, to gain more control in decision making, and to
improve the quality of life [3, 5, 7, 9, 12, 15–17].
During the last two decades, cancer care has been chal-
lenged with a call for a more patient-centered and holistic
view, as suggested by the biopsychosocial model of Engel
[18] and themes of patient centeredness [19], mindfulness
[20], psychoneuroimmunology [21], and salutogenesis [22].
Cassileth and Vickers [23] proposed the term “integrative
oncology, a synthesis of the best of cancer treatment and
evidence-based, supportive complementary modalities that
effectively relieve many of the physical and emotional
symptoms that cancer patients experience.” Nowadays,
cancer treatment not only emphasizes biomedical aspects
but also relates to issues of quality of life and spirituality,
especially in palliative care [24]. Spiritual well-being, de-
fined by McClain et al. [25] “as a sense of meaning and
purpose in life, faith, and comfort with existential con-
cerns,” is increasingly being acknowledged as an important
element in assessing the quality of life of terminally ill
patients. Increased psychological and spiritual well-being
was found to be related to reduced feelings of anxiety and
hopelessness and increased coping with illness in patients
with advanced cancer [26].
The increased use of CAM treatments by patients with
cancer and the emerging acknowledgement of spirituality
in cancer management raise a number of questions: Is
CAM use for cancer treatment associated with a quest for
more holistic–spiritual dimensions? Do patients and med-
ical practitioners share the same attitudes toward these
dimensions? How relevant is the biopsychosocial–spiritual
model in communicating with patients with cancer?
In order to address these questions, we conducted a
study in the largest oncology center in northern Israel.
Study design and methods
Study site and participants
This study was conducted in a tertiary teaching hospital
with a comprehensive cancer center. The sampling frame
included patients older than 18 years of age who were ad-
mitted for chemotherapy or radiation treatment (group A)
and medical care providers (oncologists and nurses) from
the oncology department (group B). Patients and care pro-
viders were recruited between April 2002 and November
2003. The study protocol was approved by the local Hel-
sinki committee.
Study design
Participants from both groups were asked to complete a
questionnaire addressing issues of CAM use and cancer
management. The questionnaire was based on prior ques-
tionnaires developed by the Complementary and Tradi-
tional Medicine Unit for both patients and conventional
therapists [27].
CAM treatment is defined as therapy not offered by
conventional medicine and is one or more of the following
treatments: folk and traditional medicine, medicinal herbs,
Chinese medicine (including acupuncture), homeopathy,
nutritional therapy (nutritional supplements and diets specif-
ically designed for cancer treatment), mind–body techniques
(meditation, guided imagery, and relaxation), therapeutic
touch (massage, shiatsu, and reflexology), movement and
manipulation therapies (chiropractic, yoga, and Alexander and
Feldenkrais methods), and anthroposophical medicine.
Spirituality was defined in accordance with McClain et
al.’s definition as “a sense of meaning and purpose in life,
faith, and comfort with existential concerns.” The authors
simplified this definition, adjusting it to local Israeli con-
text as “Discuss spiritual aspects (meaning of disease, life,
and death and making a mindful decision in choosing
treatment).”
Analysis
Data analysis was performed using the SPSS statistical
package. For sample size calculation, we assumed that the
cancer patients using CAM make up 40% (based on a pre-
vious unpublished survey). In order to estimate this pro-
portion with a 95% confidence interval and a 7% sampling
error, about 200 patients were required.
The relationships between CAM users and nonusers
and categorical variables, such as gender and ethnicity,
were examined using chi-square test. Statistical signifi-
cance was set at α=0.05. A comparison of continuous
variables between CAM users and nonusers was done
using t test.
Results
Questionnaires were offered to 220 patients and 60 staff
members of the Department of Oncology at the Rambam
Medical Center (Haifa, Israel). Data from 203 patients (group
A) and 48 health care providers (group B, 18 physicians and
30 nurses) were available for statistical analysis.
Of the 203 patients in group A, 138 (72%) were wo-
men and 53 (28%) were men (mean age 55.8 years [SD
13.2]). The mean number of years of education was 13.9
years (SD 2.8). Ninety-nine (49%) participants reported
current or past use of CAM for cancer treatment. The
most often practiced CAM modalities were nutritional
therapy (20.5%), medicinal herbs (19.5%), mind–body
techniques (13.8%), traditional Chinese medicine (11.3%),
homeopathy (10.3%), therapeutic touch (9.7%), and folk
and traditional medicine (8.2%).
148

A secondary analysis, which compared the attitudes of
CAM users (N=99) to those of nonusers (N=104), was
performed within group A. CAM users differed signifi-
cantly in age (mean age 53 years [SD 12.6] vs. 58 years
[SD 13.4]; t test, p=0.012) and sex (71 female users vs. 65
nonusers; chi-square test, p=0.043). No significant differ-
ence was noticed in educational level (p=0.268). When
asked why patients with cancer turn to CAM (Table 1),
significantly more users than nonusers desired to improve
quality of life (57 users [60% of responses] vs. 35 nonusers
[36.1%]; chi-square test, p=0.001) and to seek for a more
holistic treatment (37 users [38.9%] vs.. 21 nonusers
[21.6%]; chi-square test, p=0.009). No difference was
found in attributing disappointment with conventional
medicine as an important consideration (13.7 vs. 10.3% of
responses; chi-square test, p=0.472).
Table 2 illustrates participants’ attitudes toward the
relative importance of four components in cancer care:
biomedical (surgery, chemotherapy, and radiation), psycho-
logical, familial–social (including occupational aspects), and
CAM. CAM users considered CAM as a relatively more
important component in cancer care than nonusers (mean
15.4% [SD 12.3] vs. 9.3% [SD 10.3]; t test, p<0.001).
More than nonusers, CAM users reported either in-
itiating a talk about CAM with their practitioners (49 users
[51%] vs. 22 nonusers [21.6%]; chi-square test, p<0.001)
or being asked about it (20 users [20.8%] vs. 6 nonusers
[5.9%]; chi-square test, p=0.002).
A second set of analyses was made in which attitudes of
participants in group A (patients) were compared to those
of group B (staff members). Table 1 shows that, more than
group A, group B attributed CAM use by cancer patients to
addressing psychological distress (37.5% of responses in
group B vs. 21.1% responses in group A; chi-square test,
p=0.018) and spiritual/religious aspects (20.8 vs. 4.1%;
chi-square test, p<0.001). Group B participants attributed
Table 1 Why do you think patients with cancer address CAM?
Statement Group A (patients)
(N=203; %)
Group B
(staff members)
(N=48; %)
CAM users (N=99) Nonusers (N=104) Both (N=203)
To do everything
to cure cancer
85 83 84 79
To improve quality
of life
60* 36 48 42
Consider CAM as safer and “less toxic” 26 30 28 35
To address
psychological
distress
22 19 21 37**
To address spiritual
or religious aspects
4 4 4 21*
Disappointed with conventional
medicine
13.7 10.3 12 48*
To look for a more holistic treatment 39* 21.6
*p<0.01
**p<0.05
Table 2 What is the relative importance of each of the four components in cancer treatment?
Component Group A (patients)
(N=203; %)
Group B
(staff members)
(N=48; %)
CAM users (N=99) Nonusers (N=104) Both (N=203)
Biomedical (surgery, chemotherapy, and
radiation)
55.8 57.3 56.5 47.3*
Psychological 19.7 21.7 20.6 23.8
Familial–social
(including
occupational aspects)
9.8 11.7 10.7 17.2*
CAM 15.5* 9.3 12.5 13.5
*p<0.01
149

significantly more CAM use to disappointment with con-
ventional medicine (47.9 vs. 11 .9%; chi-square te st,
p<0.001). Table 2 shows that participants in group B con-
sidered addressing family–social aspects in cancer care as
relatively more important than did group A (mean 17.2%
[SD 7.4] vs. 10.7% [SD 10.5]; t test, p<0.001) and bio-
medical components as relatively less so (mean 47.3% [SD
17.6] vs. 9.3% [SD 56.5]; t test, p=0.004).
Figure 1 illustrates the attitudes of participants from both
groups to the following question: During a 10-min phy-
sician consultation with a patient with cancer, what pro-
portion of time should be spent on each of the following
topics? Patients (group A) considered as relatively more
significant a discussion on spiritual aspects, such as the
meaning of disease, life, and death and a mindful decision
on choosing treatments (group A mean 18.2% [SD 13.3]
vs. group B mean 12% [SD 9.2]; t test, p=0.007). On the
other hand, staff members (group B) ascribed importance
to asking patients about their condition in general (group A
mean 23.6% [SD 14.9] vs. group B mean 30.3% [SD 16];
t test, p=0.011) and explaining the technical issues of
treatment (mean 22.4% [SD 13.1] vs. 27.7% [SD 11.3];
t test, p=0.017). No difference was found between the two
groups on the importance of addressing quality-of-life is-
sues and discussing laboratory and imaging results.
Discussion
In this study, the authors examined the patients’ attitudes
toward psychosocial aspects, spiritual beliefs, and CAM
use related to cancer care. It was hypothesized that CAM
and spiritual issues may share common features. Indeed,
certain CAM modalities refer to spirituality as part of a
holistic conceptualization of the individual [ 28]. Oriental
philosophies such as traditional Chinese, Tibetan, and
Ayurvedic (Indian) medicine perceive health as a harmo-
nious equilibrium between fundamental elements that
coresponds to physical, emotional, and spiritual mani-
festations in humans [29]. Western modalities such as
homeopathy and anthroposophical medicine extend the
biomedical paradigm and view health and disease as
related either to “life force” (vital force) [30]ortothe
complexity of body, mind, and soul [31].
In this report, a possible connection between CAM use
and spirituality was explored. The results of the study sup-
ported findings from previous studies showing that CAM
use is common among patients with cancer. The authors
compared the attitudes of patients who use CAM to those
of nonusers and found no direct association between CAM
use and a search for spiritual needs. When asked why a
patient with cancer seeks CAM, CAM users pointed to
more a holistic treatment and quality-of-life aspects. This
emphasis on holism does not necessarily mean that CAM
use better addresses spiritual needs, but it testifies to a
yearning for a broader context in healing.
A comparison of staff members’ and patients’ attitudes
showed that psychological and spiritual needs and disap-
pointment with conventional medicine were ranked higher
by the former as reasons for cancer patients to turn to CAM
(Table 1). Moreover, staff members ranked relatively high-
er the familial–social aspect in cancer care and ranked rel-
atively lower the importance of biomedicine (Table 2).
These results indicated that staff members were highly
aware of psychosocial aspects in cancer care. However,
when their attitudes were compared to those of the patients
on the question of how time should be spent during a 10-
min consultation, staff members wished to spend less time
on spiritual issues than did patients (Fig. 1).
Fig. 1 During a 10-min physi-
cian consultation with a patient
with cancer, how much time
should be spent on each
of the following topics,
proportionally?
150

What is the meaning of these results? How can staff
members’ genera l awareness of psychoso cial themes be
settled with their tendency to assign relatively less time to
spiritual issues in a medical consultation? Future research
is warranted to examine the perceptions of staff members
when considering the importance of discussing spiritual
issues during a medical encounter. Further, they may be
asked who the preferred therapist is in relating to these
topics—need it be a staff member (physician, nurse, or
social worker) or therapists outside the mainstream do-
main, such as CAM practitioners. Moreover, future studies
may illuminate patients’ expectations on relating to spir-
itual themes, comparing them to their oncologists’ aware-
ness or willingness to do so. Successive research may study
a possible role for CAM in allowing patients and medical
care providers to openly discuss themes of meaningfulness,
self-awareness, and spirituality.
This study has various limitations. It used data from
a combined group of physicians and nurses. It may be
claimed that patients’ attitudes should not be compared
to a unanimous oncology team but to physicians and
nurses separately. Studies in Norway and the USA il-
lustrated differences in the attitudes of oncologists and
oncology nurses toward CAM [32, 33]. However, our
understanding was that daily work in the oncology de-
partment is characterized by team work and that phy-
sicians and nurses alike are identified as therapists from
the patient’s point of view. This view is supported by a
study conducted in Israel, which found that patients with
cancer had high expectations of communication skills
from both oncologists and oncology nurses [34].
Another limitation is the small and nonhomogenous
sample of patients recruited to the study. The inclusion
criteria did not address issues of cancer type and stage of
disease. Demographics did not assess the type and depth of
religion or other spiritual domains. The association be-
tween CAM and spirituality was not thoroughly examined.
Attitudes of patients and staff members toward the meaning
of spirituality were not addressed in depth.
The authors hope that this study enables a preliminary
understanding of the issues of CAM use and the signif-
icance of acknowledging spiritual issues in cancer c are.
We believe that this study supports the need f or acquiring
a biopsychosocial–spiritual attitude in cancer care that will
relate to the developing field of complementary medicine.
Conclusions
This study suggests that patients with cancer do not
correlate CAM use with spiritual concerns but expect their
physicians to attend to spiritual themes. Nonetheless, the
patients’ health providers view spiritual themes as an im-
portant reason for CAM use. The authors propose that
health care providers relate more to spiritual and CAM
issues during medical discussions. The integration of these
themes into a biopsychosocial –spiritual approach may en-
rich the dialogue between patients and health providers.
Acknowledgements The authors thanks Ms. Yael Bruno for
conceptualizing the themes of spirituality and CAM and for editing
the text; Ms. Idit Lavi for statistical design and workup; and Mrs.
Myrna Perlmutter for her help in the preparation of this paper.
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