Critical Considerations Regarding the Article “Association between Complementary and Alternative Medicine Use and Fear of Cancer Recurrence among Breast Cancer Survivors”

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Korean J Fam Med. 2023;44(1):66-67
Publication date (electronic) : 2023 January 19
doi :
1Department of Internal Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
2Department of Phytopharmaceuticals (Traditional Pharmacy), Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
3Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
Corresponding Author: Ehsan Amiri-Ardekani Tel: +98-9171465523, Fax: +98-07138309442, E-mail:
Received 2022 November 15; Accepted 2022 December 6.

Dear Editor

We are interested in a previously published article by Kim and Kang [1] in 2022 in the Korean Journal of Family Medicine. The paper highlighted the possible association between increased fear of cancer recurrence (FCR) and higher use of complementary and alternative medicine (CAM) among breast cancer survivors. Our comments on some essential pitfalls are as follows:

First, based on the definition presented by the Cochrane collaboration, “complementary and alternative medicine” refers to therapeutic methods applied to a society’s formal health system outside the borders of modern medicine [2]. The inclusion of vitamins, minerals, and probiotics to CAM may be misleading because physicians prescribe these agents routinely in many circumstances, such as in chemotherapy or cancer-induced complications, including anemia, diarrhea, and other conditions. If that is the case, perhaps they were not included in the CAM definition, and it was not clarified in the Methods section. For example, only high doses or special types of vitamins are categorized as CAM. Treatment of complications of chemotherapeutic agents and induced deficiencies does not fit the CAM methods. Therefore, the definition of CAM was not exactly identified by the writers. In addition, it is unclear whether the CAM definition was provided in the questionnaire or by the interviewers during the patient interview. A self-report bias was another limitation in the study design. In our opinion, failure to include the experiences of CAM professionals, such as oriental medicine experts, to improve the study design was a missed aspect that contributed to these challenges.

Second, while the amount of income affects CAM use, estimating socioeconomic status by educational level, as mentioned in the paper, does not seem satisfactory.

Third, categorization of religion in demographic variables is not suitable because people tend to strengthen their religious beliefs and behaviors after cancer diagnosis because they use religion as a coping mechanism [3]. Even prayer and faith are integrated into CAM [4].

Fourth, the presence of pain, physical symptoms, and cancer screening during the last year are cancer features associated with FCR [5-7]. It has been observed that suffering from pain and cancer-related physical symptoms are associated with higher FCR. During the last year, ultrasound and mammograms contributed to a lower FCR among breast cancer survivors. None of these factors were identified in this study.

Fifth, by determining the value of 0.05 as the threshold of statistical significance, the difference in CAM use between groups based on receiving hormone therapy should not be considered significant (P=0.057).

Sixth, although it was said that the assessment of psychological status was only limited to FCR anxious features, the lack of information regarding baseline psychological disorders is a source of error, whereas both FCR and CAM are affected by psychological disorders [7-9]. Also, patients’ emotional status plays a significant role in FCR, which was not considered in the study design [10].

Seventh, the frequency of CAM use was not pre-tested in the target population. Did the patients believe in CAM before cancer diagnosis and were using it routinely? If they were habitual users, then analysis of its association with any other variable seems unreliable.

Eighth, knowledge, attitude, and practice of CAM were not evaluated, but they were an important issue affecting CAM use. How many percent of the patients were aware of CAM? How was CAM introduced to patients? Was the medication self-medicated or prescribed by a physician? The above questions were not addressed in this study. However, they have been reported as a routine part of similar previous studies.

Ninth, introducing the article as the first paper published on this subject in the Discussion section is doubtful [1]. A result comparison and reference to previous studies have been mentioned several times throughout the paper.

Tenth, CAM use as a psychological stimulus leading to overthinking regarding cancer recurrence was mentioned in the second paragraph of column 2 on page 7 of the original article [1]. The temporality is questionable; perhaps the patients were interested in using CAM as a rescue method to overcome their increased fear instead of the mentioned explanation in the article.

Although conducting such studies is valuable, different aspects of CAM should be considered and applied to the study design. Then, with a complete awareness of the different factors, an accurate functional interpretation of the results should be reported.



No potential conflict of interest relevant to this article was reported.


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