Oncologists’ and specialist cancer nurses’ approaches to complementary and alternative medicine and their impact on patient action

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Abstract

High levels of use of complementary and alternative medicine (CAM) have been consistently reported amongst cancer patients over recent years. This is occurring in the context of an apparent increase in sources of information on therapeutic alternatives and a growth in the range of those claiming professional expertise in the field. To date there has been little research on patient experience of discussions about CAM with biomedical cancer specialists in this increasingly complex social environment. This paper addresses three issues: patient experience with cancer specialists; the significance of that experience for patient engagement with CAM; and the nature and significance of inter-professional dynamics. It draws on the results of a qualitative study with cancer patients in the UK. In-depth interviews with 80 purposively sampled patients, incorporating a range of disease types and stages, were conducted. Patients reported three main types of approach by oncologists: explicit or implicit negativity; supportive ambivalence; and, pragmatic acceptance. Crucially, patients’ accounts suggest that the type of approach adopted influences (though does not determine) patient action. Specialist cancer nurses emerged as potentially powerful mediators between oncologists and patients. Despite the apparent potential for influence from multiple information sources and ‘experts’, on the basis of this study we would argue that oncologists remain crucial to patient engagement with CAM. However, this is not to argue that the influence is a simplistic one. Where patient and medical perspectives diverge, strategic alignment with specialist nurses may help patients make choices which conflict with perceived advice.

Introduction

The dynamics between complementary and alternative medicine (CAM) and biomedicine have been regularly examined within the sociological literature (e.g. Hirschkorn & Bourgeau, 2005; Mizrachi, Shuval, & Gross, 2005). Such analyses have focused on the management of professional boundaries and the centrality of notions of evidence, efficacy and professionalism in shaping inter-professional dynamics. However, little is known about how inter- and intra-professional dynamics are manifested at a grassroots level in clinical contexts, and importantly, how patients make sense of these and how they may impact on patient action. This paucity of research is particularly evident in cancer care, where ironically, CAM use seems to be most prolific (e.g. Ernst & Cassileth, 1998; Lewith, Broomfield, & Prescott, 2002; Rees et al., 2000). In this specific disease context the responses of biomedical clinicians to patients’ treatment preferences are of particular importance given the level of emotion and anxiety reported in treatment decision-making processes (see Arora, 2003; Hack, Degnera, & Parker, 2005). Moreover, effective communication about CAM has been reported by both cancer patients and clinicians to enhance the patient/practitioner relationship (Roberts et al., 2005).

Such patient-practitioner exchanges do not exist in a vacuum. Indeed, drawing on work from other areas of health research, the actual extent to which biomedical clinicians are actually pivotal to contemporary patient action on CAM is open to question. A plurality of information sources, such as the Internet (Broom, 2005), the influence of friends and family (Maly, Umezawa, Ratliff, & Leake, 2006), and the ‘plurality of experts’ (Giddens, 2001), evident in the CAM field are all characteristic of a multi-dimensional decision-making environment. In this context the impact and influence of those at the apex of formal legitimate authority (cancer specialists and, to a different extent, cancer nurses) requires fresh empirical examination. This paper presents the findings from a Department of Health-funded study with cancer patients in the UK. It addresses their interpretation of key processes (see Methods section). Specifically, the paper considers: (1) patient experience with cancer specialists and specialist cancer nurses about non-biomedical treatment options at this time of potential or actual ‘integration’; (2) the impact of the attitudes and approach of biomedical practitioners on patient engagement with CAM; (3) how processes are played out between oncologists and specialist nurses and how this impacts on patients.

Section snippets

Background

The inter-professional dynamics between CAM and biomedicine have received significant attention from health sociologists over the last two decades. Key concerns have been the occupational dominance of biomedicine and the ongoing peripherisation of many CAM modalities in the context of primary care (see Hirschkorn & Bourgeau, 2005). To a certain degree we have seen a gradual encroachment by CAM modalities such as acupuncture, chiropractic and osteopathy on biomedical territory for specific

Methods

After ethics approval was secured, we approached three NHS teaching hospitals and one partially NHS-funded hospice involved in cancer and palliative care services in the north of England. This project was a 30-month qualitative study utilising in-depth interviews. Patients were recruited via posters placed in oncology wards and patient information and support centres. The final sample included 80 cancer patients with a good distribution of ages from 20 to 87 and representation from all major

Results

Patients reported three distinct responses from their medical specialists regarding their CAM use or interest in using CAM—responses which had very specific impacts on patient action. These were: (a) explicit negativity; (b) supportive ambivalence; and, (c) pragmatic acceptance. We identify broad patterns of correspondence between specialists’ responses to CAM usage and patient action. Despite the theoretical possibility of a plurality of influences on patient action, oncologists’ reactions to

Discussion

The aim of this study was to examine cancer patients’ accounts of their clinicians’ attitudes towards CAM and the ways in which dialogue within the patient/practitioner encounter shapes their perceptions of and usage of CAM. Specifically, we were interested in the range of oncologists’ views encountered by patients; their apparent impact on action; and, the role of specialist cancer nurses as a further source of professional input for patients. As with all research, our methods clearly impacted

Acknowledgements

We would like to thank the anonymous referees for their helpful comments on an earlier draft of this paper. This work was funded by the UK Department of Health. Award no.: 09/02.

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