Vol.2, No.12, 1460-1465 (2010) Health
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Transition behavior in the use of complementary and
alternative medicine during follow-up after radical
prostatectomy: a multicente r su rv ey i n Ja pan
Koji Yoshimura1*, Yoshiteru Sumiyoshi2, Toshiyuki Kamoto1, Osamu Ogawa1, Yoichi Arai3,
Yoshiyuki Kakehi4, Akito Terai5, Hiroshi Kanamaru6, Mutsushi Kawakita7, Naoko Kinukawa8
1Department of Urology, Kyoto University Graduate School of Medicine, Kyoto, Japan;
*Corresponding Author: ky7527@kuhp.kyoto-u.ac.jp;
2Department of Urology, Shikoku Cancer Center, Matsuyama, Japan;
3Department of Urology, Tohoku University Graduate School of Medicine, Sendai, Japan;
4Department of Urology, Kagawa University of Medicine, Takamatsu, Japan;
5Department of Urology, Kurashiki Central Hospital, Kurashiki, Japan;
6Department of Urology, Kitano Hospital, Ohgimachi, Japan;
7Department of Urology, Kobe City Medical Center General Hospital, Kobe, Japan;
8Department of Medical Information Science, Kyushu University Hospital, Fukuoka, Japan.
Received 25 August 2010; revised 12 October 2010; accepted 29 October 2010
Objectives: We evaluated the prevalence of use
of complementary and alternative medicine
(CAM), as well as the transitional nature of its use,
before and after radical prostatectomy in Japa-
nese patients with localized prostate cancer.
Methods: We enrolled 376 patients, who ans-
wered a self-administered questionnaire on
CAM use, psychological health locus of control
(HLC), and general-health-related quality of life
(GHQL). Detailed information regarding CAM use
according to the transtheoretical model, and the
time at initiation and abandonment of CAM use
were assessed. Medical information was also
extracted from patient charts. Results: 45.7% of
patients belonged to the “precontemplation”
stage, 29.8% to the “contemplation” stage, 1.9%
to the “preparation” stage, 14.4% to the “action”
st age, and 8.2% to the “relapse” stage. Although
patient age and educational status had a signif-
icant impact on stage of CAM use, HLC and
GHQL were not associated with them. The
time-course of prevalence of CAM use during
follow-up was divided into three phases: “ini-
tial,” “rapid-increase,” and “maintenance”. Con-
clusions: Among patients undergoing radical
prostatectomy, non-users can be classified into
several behavioral stages, while users do not
use CAM constantly during follow-up.
Keywords: Prostate Cancer; Alternative Medicine;
Health Survey; Health Locus of Control;
Complementary and alternative medicine (CAM) has
gradually gained in popularity worldwide since the study
of Eisenberg et al. in 1993 [1]. In urology, many studies
have been conducted to elucidate the prevalence and
associated background of CAM use in patients with
prostate cancer [2-14]. Most of these have been cross-
sectional studies, and the question about CAM use was
all-or-nothing, i.e., yes or no. However, patients with
cancer initiate CAM use at various times during fol-
low-up involving conventional treatments. They also
occasionally abandon CAM for various reasons. Non-
CAM users can be divided into several behavioral stages
according to their degree of interest in CAM use.
We conducted a multicenter cross-sectional survey to
explore the detailed behavioral stages for CAM use in
patients with localized prostate cancer undergoing radi-
cal prostatectomy. We focused our study on patients who
had undergone radical prostatectomy without any peri-
operative treatment, which ensured the homogeneity of
the population. First, we explored the behavioral transi-
tion involved with CAM use hoping to better understand
the background associated with this. Second, we inves-
tigated the timing of the initiation and termination of
CAM use in patients in the action/maintenance or re-
lapse stages. Finally, we estimated the reliability of the
study outcomes, namely, the recall bias suffered in this
retrospective study.
K. Yoshimura et al. / Health 2 (2010) 1460-14 65
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
This questionnaire-based cross-sectional study was
conducted at 10 Japanese institutions between January
2007 to December 2007, and all institutional review
boards approved the study.
2.1. Participants
A total of 471 patients, who had undergone radical
prostatectomy for localized prostate cancer and then
followed-up for at least one year, were selected as can-
didates for this study. No patients received any neoadju-
vant or adjuvant therapy perioperatively. We explained
the main purpose of the study to the patients and ob-
tained their informed consent. No financial reimburse-
ment was given to the patients for filling out the ques-
tionnaire. Simultaneously, we obtained medical informa-
tion from urologists at each institution, including patient
age (at prostatectomy and at this survey), date of prosta-
tectomy, clinical and pathological stage of cancer, Glea-
son’s score, preoperative serum prostate-specific antigen
(PSA) level, biological recurrence, clinical recurrence,
secondary treatment, and past history of other medical
problems. Though information extracted from charts and
questionnaires was anonymous, it was possible to link
information from charts to questionnaires.
2.2. Self-Report Questionnaire
In the first part of the questionnaire, we simply de-
fined CAM as non-orthodox medicine and listed the
various types available in Japan; these were identical to
those used in our earlier studies [14,15].
Regarding CAM use, the question was based on the
stages of the transtheoretical model (TTM) [16], which
was modified for this study: precontemplation (“I have
no interest in using CAM”), contemplation (“I have been
thinking that I might want to use CAM”), preparation (“I
am preparing to use CAM”), action (“I have already
used CAM”), and relapse (“I have abandoned CAM use,
although I previously used it). If a responder belonged to
the action stage, he was asked the type of CAM used,
and the timing and motivation for initiation of CAM use.
If the patient abandoned any type of CAM use, the tim-
ing and reasons for termination of CAM use were also
The Japanese version of the multidimensional health
locus of control (HLC) scale assessed five control di-
mensions: internal, family, professional (powerful oth-
ers), chance, and supernatural [17]. Each control dimen-
sion was assessed with five items. Participants were
asked to indicate their extent of agreement with each
item on a six-point response scale of 1 (strongly disagree)
to 6 (strongly agree).
To assess general-health-related quality of life
(GHQL), we used the Medical Outcome Study
Short-Form 8 (SF-8) [18]. The SF-8 consists of eight
component scores of general health perception, physical
function, role-physical, bodily pain, vitality, social func-
tion, mental health, and role-emotional. The Japanese
version of SF-8 was validated for use and higher scores
represented greater quality of life.
Other than the TTM, the HLC and the SF-8, age at
survey, times of diagnosis of prostate cancer and prosta-
tectomy, educational background, income, and past
medical history of eight chronic diseases including
hypertension, diabetes mellitus, stroke (cerebral infarc-
tion and cerebral hemorrhage), arrhythmia, coronary
artery disease, renal disease, pulmonary disease, and
malignant disease other than prostate cancer were as-
sessed. Thus, data about age at survey and time of pros-
tatectomy were obtained both from urologists and pa-
tients. Finally, we estimated recall bias, using these two
2.3. Statistical Analysis
The factors predicting stage of CAM use were ana-
lyzed using the χ2 test and ANOVA. If these analyses
exhibited statistical significance, multiple comparisons
for 10 available pairs of groups were performed using
the Bonferroni method. Since these analyses revealed
significant differences between various stages, we did
not perform multivariate analysis. For estimation of re-
call bias, we used ratio of correct answers with 95%
confidence intervals and intraclass correlation coeffi-
cients (ICCs). P<0.05 were considered significant.
3.1. Demographic Characteristics
Of the 471 candidates, 386 patients returned the ques-
tionnaire (response rate 82.0%), and 376 questionnaires
were valid for statistical analysis. The remaining 10
were invalid because of lack of important information
such as the stage of CAM use according to the TTM; the
rate of valid replies was thus 79.8%. Ages at prosta-
tectomy and survey were 66.2 ± 6.0 (mean ± SD) and
69.2 ± 6.1 years, respectively. Mean follow-up period
from prostatectomy to this survey was 47.3 ± 15.4
months. Pathologically locally confined disease and
lymph-node metastasis were observed in 268 (71.3%)
and six patients (1.6%), respectively. In this survey, 82
patients (21.8%) had experienced biochemical failure
and 63 (16.5%) had undergone secondary treatments. No
patients suffered from clinical recurrence during the
K. Yoshimura et al. / Health 2 (2010) 1460-14 65
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
3.2. Stages and Predictors of CAM use
Of the 376 patients, 172 (45.7%) belonged to the pre-
contemplation stage, 112 (29.8%) to the contemplation
stage, seven (1.9%) to the preparation stage, 54 (14.4%)
to the action stage, and 31 (8.2%) to the relapse stage.
Users had tried 1-8 types of CAM (average 1.8), and
quitters had abandoned 1-5 types (average 1.6). The five
stages of CAM use did not show statistical correlation
with follow-up period (ANOVA, P = 0.78).
Ta bl e 1 shows association of demographic and diag-
nostic variables according to stages of CAM use. Patient
age, both at prostatectomy and at the time of this survey,
and higher final education status had a significant asso-
ciation with stage of CAM use (P = 0.025, 0.015, and
0.020, respectively). Considering age at the time of sur-
vey, younger patients had more interest in CAM use
(precontemplation versus contemplation, P = 0.0028).
Patients who had graduated from university tried CAM
more than those with lower educational status (precon-
templation versus action, P = 0.0045; contemplation ver-
sus action, P = 0.0018). Other variables, including serum
PSA values at prostatectomy, Gleason’s sum, pT stage, pN
stage, biochemical recurrence, secondary treatment, and
income, had no association with stages of CAM use.
Table 2 shows association of HLC and GHQL with
stages of CAM use. No parameters of HLC and SF-8
Table 1. Association between patients’ characteristics and stages of CAM use Age at survey: *Precontemplation vs
Contemplation, p = 0.0028 Education: #Precontemplation vs Action, p = 0.0045, $Contemplation vs Action, p=0.0018.
TotalPrecontemplation ContemplationPreparationActionAbandonmentP-values
N N%N%N%N%N%
Total376172 45.711229.871.95414.4318.2
Age at prostatectomy3760.015
65 or 65<22911449.86126.620.93816.6146.1
e at surve
376 0.025
70 or 70<16991*53.839*23.121.22615.4116.5
PSA at prostatectomy3760.60
10 or 10<1275341.74132.332.41915.0118.7
Gleason's sum3760.84
6 or 6>973940.23334.033.11515.577.2
8 or 8<673146.32029.923.01116.434.5
pT stege3760.50
pN stage376
Biochemical recurrenc
376 0.20
Secondary teatment3760.11
Final Education3710.020
below university271127#46.987$32.162.229#$10.7228.1
Income 3100.15
1778447.5 5631.631.72212.4 126.8
r13355 41.435 26.310.82619.516 12.0
Table 2. Association between HLC, GHQL and stages of CAM use.
Precontemplation ContemplationPreparationActionAbandonmentP-values
Mean SDMean SDMean SDMean SDMean SD
Health locus of control
General health
51.05 6.5250.06 6.2551.85 3.0251.89 5.5751.48 5.820.42
Physical function49.857.8249.536.8750.504.4949.976.7249.858.120.99
Role physical48.888.5048.528.1550.734.4150.165.7350.185.150.61
Bodily pain54.447.7953.977.7250.608.0453.907.2155.177.070.67
Social function49.548.5748.589.3049.696.6949.537.8250.337.730.84
Mental health52.086.1150.447.1750.825.1152.035.6851.655.370.29
Role emotional49.908.3049.418.3252.062.8049.519.6851.353.600.74
K. Yoshimura et al. / Health 2 (2010) 1460-14 65
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
had a significant association with stages of CAM use.
3.3. Initiation and Termination of CAM use
Figure 1 depicts transition of CAM use in all study
patients, based on diagnosis of prostate cancer and pros-
tatectomy. Approximately 5% of patients had used some
form of CAM, regardless of cancer diagnosis or surgery.
From 6 months before diagnosis or a year before prosta-
tectomy, the rate of CAM use rapidly increased; though
some patients abandoned CAM during these periods.
From a year after diagnosis or 6 months after prosta-
tectomy, the number of new CAM users gradually in-
creased, but nearly the same number of patients aban-
doned CAM use. Thus, the overall prevalence of CAM
use appeared steady during this period. Although 85
(22.6%) of the 376 patients tried CAM during the fol-
low-up period, the highest prevalence of CAM use was
observed at 29-30 months after diagnosis (17.5%) and
24-25 months after prostatectomy (16.9%).
The most common reason for the initiation of CAM
was “recommendation by family or friends” (75 res-
ponses, 52.9%), followed by “research by themselves”
(21.4%), “information by chance” (15.0%), and others
(10.0%). The most prevalent reason for abandonment of
CAM use was “expense” (15 responses, 29.4%), fol-
lowed by “lack of expected efficacy” (23.5%), “lack of
interest” (13.7%), and others (33.3%). No patient gave
“adverse effects” as a reason for abandonment.
Figure 1. Transition of CAM use among all patients, based
on cancer diagnosis and prostatectomy. Asterisks indicate the
timings of the highest percentage of CAM users. accumu-
lated rate of initiation of CAM use; prevalence of CAM
use by month; accumulated rate of termination of CAM
3.4. Estimation of Recall Bias
Regarding age at time of survey, the difference be-
tween that obtained from charts and that from question-
naires was a mean 0.195 years. In the questionnaires, 19
patients gave a younger age and 72 an older one than
their actual age, while 285 patients (75.8%: 95% confi-
dence interval, 71.2-79.8%) gave an accurate age. ICC
was 0.940. Regarding date of prostatectomy (calendar
year and month), the mean difference between that ob-
tained from charts and that from questionnaire was 0.186
months. Three hundred and thirteen patients (83.2%:
95% confidence interval, 79.1-86.7%) gave accurate
date. Based on the period from prostatectomy to this
survey, ICC was 0.919.
Generally, 18-43% of prostate cancer patients are re-
ported to be using some type of CAM [2-14,19]. In the
current study, which focused on patients undergoing
radical prostatectomy, 22.6% of patients had experience
of some type of CAM during the follow-up period; this
observation was compatible with previous studies in our
country [14,19]. This study also revealed that these pa-
tients did not use CAM consistently throughout the fol-
low-up period, and about one-third of users had already
abandoned some type of CAM at the time of this survey.
As well as CAM users, non-CAM users could be classi-
fied into several behavioral stages. Namely, half of pa-
tients had no interest in CAM (precontemplation stage),
and ~30% of patients had been interested in CAM use
but did not actually use it (contemplation and prepara-
tion stages). These percentages were considerably dif-
ferent from those recently reported by Hirai et al. [20],
which suggested that patients with non-metastatic pros-
tate cancer treated radically were less interested in CAM
than those with other active cancers, as we have reported
previously [14].
While several predictors of CAM use among prostate
cancer patients have been reported so far [2-5,14], in-
cluding younger age, no recurrence after prostatectomy,
higher income, and higher education, our study pre-
sented more detailed information. Patient age had an
impact on transition from precontemplation to contem-
plation, with higher aged patients tending to have no
interest in CAM. On the other hand, educational status
had an impact on actual CAM use.
Although several previous studies have demonstrated
a correlation between CAM use and GHQL in prostate
cancer patients [8,14], one study exhibited no such cor-
relation [7]. While many studies, since that of Cassileth
[21], have reported that GHQL has a significant associa-
tion with CAM use in patients with malignant disease
K. Yoshimura et al. / Health 2 (2010) 1460-14 65
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
other than prostate cancer, the differences, if any, among
patients with localized prostate cancer belonging to the
five stages of CAM use might not be large. As well as
GHQL, HLC had no impact on the stages of CAM use in
this study, and this finding is compatible with previous
reports [21,22]. Over half of our CAM users responded
that they had tried CAM because of a recommendation
by their family or friends, which suggests that superna-
tural beliefs or internal control had little association with
CAM use, similar to other study populations.
The three phases of CAM use were the most impor-
tant finding of the present study. The period 6 months
before diagnosis and operation represented the initial
phase, during which about 5-7% of patients had already
used CAM, regardless of there being any identified
prostate cancer. From the end of the initial phase to just
after diagnosis and operation represented the rap-
id-increase phase, which was obviously related to pros-
tate cancer. In our country, elevation of serum PSA level
measured at a health screening is the most frequent mo-
tive for consulting an urologist for a biopsy examination.
There is a time lag between finding elevated PSA level
at screening and cancer diagnosis, and this is presumably
the reason why the prevalence of CAM use begins to
increase before cancer diagnosis. Finally, the mainten-
ance phase is the period after the end of the rap-
id-increase phase, during which new CAM users gradu-
ally increase, but abandonment of CAM use similarly
increases, resulting in relatively constant prevalence of
CAM use. Overall prevalence of CAM use inevitably
depends on the clinical and sociodemographic characte-
ristics of patients, as reported by Chan et al. [12]. Ste-
ginga et al. reported a prospective study of patients with
prostate cancer, determining that CAM use decreased
after treatment [23]. Our study’s different outcome to
that of Steginga et al. indicates a fundamental discre-
pancy between the role of CAM in oriental and in west-
ern cultures; this seems an important issue that could be
investigated in future.
The present study has several limitations. The most
important is that it was retrospective, and was thus open
to a recall bias. Therefore, we examined the reliability of
this study using two statistical methods. Rates of correct
answers on the two parameters of age and calendar
year/month of prostatectomy were ~80%, and ICCs
were >0.9. These results suggested that the outcomes of
the study were permissibly reliable, while the replies
from patients did not completely correspond with those
from doctors. Another limitation is the relatively small
size of the study population. Despite these limitations,
the study presents clinically useful information regarding
CAM use of patients undergoing radical prostatectomy.
The present study has shown that, among patients un-
dergoing radical prostatectomy, non-CAM users can be
classified into several behavioral stages, while users do
not use CAM constantly during follow-up. The time-
course of prevalence of CAM use during follow-up was
divided into three phases: “initial,” “rapid-increase,” and
We thank Prof. Shunichi Fukuhara and Dr. Yasuaki Hayashino for
their assistance in the development of our questionnaire, and Drs.
Katsuyoshi Hashine, Shunichi Namiki, Kazuhiko Orikasa, Mikio Su-
gimoto, Teruyoshi Aoyama, Masakazu Yamamoto, Noriaki Utsuno-
miya, Takuya Okada, Satoshi Ishitoya, Kenji Mitsumori, Hiroyuki
Onishi, Kazuhiro Okumura, and Kazuo Nishimura for their coopera-
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