Knowledge of and attitudes toward complementary and alternative therapies: a national multicentre study of oncology professionals in Norway T. Risberga,*, A. Kolstadb, Y. Bremnesa, H. Holteb, E.A. Wistc, O. Mellad, O. Kleppe, T. Wilsgaardf, B.R. Cassilethg aDepartment of Oncology, University Hospital of Troms��, N-9038 Troms��, Norway bThe Norwegian Radium Hospital, Oslo, Norway cDepartment of Oncology, Ulleva��l University Hospital, Oslo, Norway dDepartment of Oncology, Haukeland Hospital, Bergen, Norway eDepartment of Oncology, St. Olav Hospital, Trondheim, Norway fInstitute of Community Medicine, Biostatistics Service, University of Troms��, Norway gIntegrative Medicine Service, Memorial Sloan-Kettering Cancer Center, New York 10021, USA Received 4 November 2003 accepted 7 November 2003 Abstract This study reports on oncology professionals��� knowledge and attitude toward complementary and alternative medicines (CAM), classified according to their primary application as complementary or alternative methods. In June 2002, we conducted a national, multicentre survey of 828 Norwegian oncologists, nurses, clerks and therapeutic radiographers. A response rate of 61% was achieved. Only a few physicians (4%) described their reactions to alternative medicine as positive compared with nurses (33%), therapeutic radiographers (32%) and clerks (55%) (P 0.0001). Females showed a more positive view than males (33% versus 14%, P 0.0001). More participants expressed a positive attitude to complementary versus alternative medicines. Most respondents regarded healing by hand or prayer, homeopathy, and Iscador (mistletoe) as alternative therapies. In contrast, most respondents classified acupuncture, meditation, reflexology, music/art-therapy, aromatherapy and massage as complementary therapies. This survey demonstrates major differences, by gender as well as oncology health profession in views about and the classification of various CAM methods # 2003 Elsevier Ltd. All rights reserved. Keywords: Alternative medicine Complementary medicine Cancer oncology professionals 1. Introduction Surveys of complementary and alternative therapy use among cancer patients conducted in Scandinavia and internationally during the last 5���10 years report a prevalence ranging from less than 10% to over 50% [1��� 3]. Methodological problems hinder comparison of results across these studies, as they involve different instruments, patient samples, and definitions of com- plementary and alternative therapies. Thus, one reason for an apparent increase in the use of CAM may be a broadening of the definition of CAM to include self- care techniques such as care of routine problems, efforts to maintain fitness, and ordinary lifestyle activities [4]. Definitions based on the promoted benefit or action of the particular method have been proposed [2,4]. ���Alternative therapies��� may be defined as unproven treatments promoted to treat the disease itself, whereas ���complementary therapies��� represent adjunctive thera- pies aimed at symptom management and enhancement of quality of life. The Norwegian Ministry of Health and Social Affairs appointed a Committee in April 1997 to report on var- ious aspects of alternative medicine (this term was used instead of CAM by the Ministry). The Alternative Medicine Committee delivered their report in December 0959-8049/$ - see front matter # 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejca.2003.11.011 European Journal of Cancer 40 (2004) 529���535 www.ejconline.com * Corresponding author. Tel.: +47-1147-7762-6000 fax: +47- 1147-7762-6779. E-mail address: terje.risberg@unn.no (T. Risberg).

1998 [5]. One of their proposals was to repeal the ���Medical Quackery Act of 1936���, the law regulating use of alternative medicine in serious disease, and to incor- porate a new law covering use of alternative medicine in the new Health Personnel Act. The new law is now under discussion in the Norwegian parliament. There is little research addressing health care workers��� use of and attitudes toward CAM. A report in 2000 [6] describing the attitudes of oncologists towards uncon- ventional cancer therapies identified only six original articles on the subject. Studies conducted in Europe suggest that few oncologists have su���cient knowledge about CAM [7]. A Norwegian study [8] of opinions and use of alternative medicine among different health workers (physicians, nurses and clerks) indicated that nurses held more positive attitudes than did the other two groups. That study was limited to six hospitals in the northern part of Norway, and personnel in general surgical and medical departments, using a questionnaire that did not distinguish between complementary and alternative therapies. The term CAM includes a vast collection of unrelated modalities, from simple relaxation techniques to unpro- ven, potentially harmful cancer treatments. It seems necessary, clinically and conceptually, to distinguish between these two categories, especially in situations where increasing numbers of hospitals incorporate ���departments of integrative medicine��� for the benefit of their patients. At the Memorial Sloan-Kettering Cancer Center in New York city, such a department was intro- duced in 1999 [9]. Particularly because the Norwegian government has proposed a new law on the use of such therapies, it is important to understand the knowledge and opinions of health care workers who are responsible for the treat- ment of cancer patients in Norway. Therefore, we undertook a national, multi-centre comparative study of physicians, nurses, therapeutic radiographers and clerks responsible for the care of cancer patients. Here, we report data from a survey of oncology caregivers to determine their knowledge and attitudes toward various CAM therapies. We focused on differences by the respondent���s gender, age and occupation. 2. Patients and methods An anonymous questionnaire-based study was per- formed in June 2002. The questionnaire was designed by a consensus of experts. Items included were determined by a review of the literature regarding cancer patients��� and healthcare professionals��� use of CAM. A pilot study involved nurses, clerks and physicians at the University Hospital of Troms�� and scientists at the Institute of Community Medicine at the University of Troms��. Based on this feedback, the questionnaire was revised and readied for distribution. The questionnaire was designed to differentiate between complementary and alternative medicine. Thus, definitions were introduced to the participants at the beginning of the questionnaire. ���Complementary��� thera- pies were defined as unconventional approaches aimed at managing symptoms and improving quality of life. ���Alternative��� therapies were defined as unproved unconventional therapies aimed at treating the cancer itself. Participants were asked whether they were famil- Table 1 Attitudes toward alternative therapies Univariate Multivariatea Positive to complementary medicine Variables (n) Positive Neutral Negative Odds ratio (95% confidence interval) (%) (%) (%) P value Gender Female (382) 33 22 45 P 0.0001 1.6 0.7���3.3 Male (102) 14 18 68 1.0 Reference Age (years) 35 (182) 36 23 44 P=0.140 1.0 Reference 35���49 (218) 25 20 55 0.6 (0.4���1.0) 550 (84) 29 21 50 0.8 (0.4���1.5) Religion Christian (315) 33 23 45 P=0.003 1.0 Reference Other (143) 22 16 62 1.4 (0.8���2.2) Profession Physicians (100) 4 15 81 P 0.0001 1.0 Reference Nurses (237) 33 22 45 8.8 (3.0���26.4) Clerks (47) 55 23 22 20.8 (6.1���70.6) Radiotherapists (100) 32 23 45 10.0 (3.3���30.7) a All variables were mutually adjusted for each other. 530 T. Risberg et al. / European Journal of Cancer 40 (2004) 529���535