Transition Behavior in the Use of Complementary and Alternative Medicine during Follow-up after Radical Prostatectomy: A Multicenter Survey in Japan

doi:10.4236/health.2010.212217

Paper Menu >>

Journal Menu >>

Vol.2, No.12, 1460-1465 (2010) Health

doi:10.4236/health.2010.212217

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

ABSTRACT

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;

Epidemiology

1. INTRODUCTION

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

1461

2. METHOD

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

ascertained.

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

variables.

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. RESULTS

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

survey.

K. Yoshimura et al. / Health 2 (2010) 1460-14 65

1462

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>1475838.55134.753.41610.91711.6

65 or 65<22911449.86126.620.93816.6146.1

e at surve

376 0.025

70>20781*39.173*35.352.42813.5209.7

70 or 70<16991*53.839*23.121.22615.4116.5

PSA at prostatectomy3760.60

10>24911947.87128.541.63514.1208.0

10 or 10<1275341.74132.332.41915.0118.7

Gleason's sum3760.84

6 or 6>973940.23334.033.11515.577.2

721210248.15927.820.92813.2219.9

8 or 8<673146.32029.923.01116.434.5

pT stege3760.50

pT226813048.57728.741.53613.4217.8

pT31084238.93532.432.81816.7109.3

pN stage376

pN035816345.410529.372.05415.1298.10.63

pN16233.3350.000.000.0116.7

pNx12758.3433.300.000.018.3

Biochemical recurrenc

376 0.20

yes822935.32935.411.21315.91012.2

no29414348.68328.262.04113.9217.1

Secondary teatment3760.11

yes632234.92031.711.61015.91015.9

no31315047.99229.461.94414.1216.7

Final Education3710.020

below university271127#46.987$32.162.229#$10.7228.1

university10042#42.024$24.011.024#$24.099.0

Income 3100.15

<￥5,000,000/

1778447.5 5631.631.72212.4 126.8

≧￥5,000,000/

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

Internal22.843.2822.583.4522.433.2122.663.4622.572.740.97

Family21.774.2522.443.8320.295.5021.653.8221.634.240.48

Professional22.763.4822.403.3320.574.5821.983.8722.034.090.34

Chance15.384.5516.194.6316.433.9916.544.7014.274.400.13

Supernatural11.954.0612.664.0113.294.6512.174.9811.313.220.42

SF-8

General health

erce

tio

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

Vitality52.446.6651.427.4954.644.7952.456.6852.056.550.63

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

1463

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

use.

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.

4. DISCUSSION

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

1464

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.

5. CONCLUSIONS

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

“maintenance”.

6. ACKNOWLEDGEMENTS

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-

tion.

REFERENCES

[1] Eisenberg, D.M., Kessler, R.C., Foster, C., Norlock, F.E.,

Calkins, D.R. and Delbanco, T.L. (1993) Unconventional

medicine in the United States: Prevalence, costs, and

patterns of use. New England Journal of Medicine, 328,

246-252.

[2] Lippert, M.C., McClain, R., Boyd, J.C. and Theodorescu,

D. (1999) Alternative medicine use in patients with loca-

lized prostate carcinoma treated with curative intent.

Cancer , 86, 2642-2648

[3] Kao, G.D. and Devine, P. (2000) Use of complementary

health practices by prostate carcinoma patients under-

going radiation therapy. Cancer, 88, 615-619.

[4] Nam, R.K., Fleshner, N., Rakovitch, E., et al. (1999)

Prevalence and patterns of the use of complementary

therapies among prostate cancer patients: An epidemio-

logical analysis. Journal of Urology, 161, 1521-1524.

[5] Wilkinson, S., Gomella, L.G., Smith, J.A., et al. (2002)

Attitudes and use of complementary medicine in men

with prostate cancer. Journal of Urology, 168, 2505-2509

[6] Boon, H., Westlake, K., Stewart, M., et al. (2003) Use of

complementary/alternative medicine by men diagnosed

with prostate cancer: Prevalence and characteristics.

Urology, 62, 849-853

[7] Diefenbach, M.A., Hamrick, N., Uzzo, R., et al. (2003)

Clinical, demographic and psychosocial correlates of

complementary and alternative medicine use by men di-

agnosed with localized prostate cancer. Journal of Urol-

ogy, 170, 166-169.

[8] Ponholzer, A., Struhal, G. and Madersbacher, S. (2003)

Frequent use of complementary medicine by prostate

cancer patients. European Urology, 43, 604-608.

[9] Hall, J.D., Bissonette, E.A., Boyd, J.C. and Theodorescu,

D. (2003) Motivations and influences on the use of com-

plementary medicine in patients with localized prostate

cancer treated with curative intent: Results of a pilot

study. British Journal of Urology International, 91:

603-607.

[10] Beebe-Dimmer, J.L., Wood Jr., D.P., Gruber, S.B., et al.

K. Yoshimura et al. / Health 2 (2010) 1460-14 65

1465

(2004) Use of complementary and alternative medicine

in men with family history of prostate cancer: A pilot

study. Urology, 63, 282-287.

[11] Eng, J., Ramsum, D., Verfoef, M., Guns, E., Davison, J,

and Gallagher, R. (2003) A population-based survey of

complementary and alternative medicine use in men re-

cently diagnosed with prostate cancer. Integrative Cancer

Therapies, 2, 212-216.

[12] Chan, J.M., Elkin, E.P., Silva, S.J., Broering, J.M., Latini,

D.M. and Carroll, P.R. (2005) Total and specific com-

plementary and alternative medicine use in a large cohort

of men with prostate cancer. Urology, 66, 1223-1228.

[13] Jones, R.A., Taylor, A.G., Bourguignon C., et al. (2007)

Complementary and alternative medicine modality use

and beliefs among African American prostate cancer sur-

vivors. Oncology Nursing Forum, 34, 359-364

[14] Yoshimura, K., Ichioka, K., Terada, N., Terai, A. and Arai,

Y. (2003) Use of complementary and alternative medi-

cine by patients with localized prostate carcinoma: study

at a single institute in Japan. International Journal of

Clinical Oncology, 8, 26-30.

[15] Yoshimura, K., Ueda, N., Ichioka, K., Matsui, Y., Terai,

A. and Arai, Y. (2005) Use of complementary and alter-

native medicine by patients with urologic cancer: A

prospective study at a single Japanese institution. Sup-

port Care Cancer , 13, 685-690

[16] Prochaska, J.O. and DiClemente, C.C. (1983) Stages and

processes of self-change of smoking: Toward an integral

model of change. Journal of Consulting & Clinical Psy-

chology, 51, 390-395.

[17] Horige, Y. (1991) Development of Japanese version of

health locus of control. Kenkoshinrigakukenkyu, 4, 1-7

(in Japanese).

[18] Fukuhara, S. and Suzukamo, Y. (2004) Manual of the

SF-8 Japanese version. Institute for Health Outcomes &

Process Evaluation Research, Kyoto.

[19] Sumiyoshi, Y., Hashine, K., Koizumi, T., Azuma, K. and

Hyodo, K. (2003) Use of complementary and alternative

medicine in prostate cancer patients. Nippon Hinyokika

Gakkaishi, 94, 328 (in Japanese).

[20] Hirai, K., Komura, K., Tokoro, A., et al. (2008) Psycho-

logical and behavioral mechanisms influencing the use of

complementary and alternative medicine (CAM) in can-

cer patients. Annals of Oncology, 19, 45-55.

[21] Cassileth, B.R., Lusk, E.J., Guerry, D., et al. (1991) Sur-

vival and quality of life among patients receiving unpro-

ven as compared with conventional cancer therapy. New

England Journal of Medicine, 324, 1180-1185.

[22] Boon, H., Westlake, K., Deber, R. and Moineddin, R.

(2005) Problem-solving and decision-making preferences:

no difference between complementary and alternative

medicine users and non-users. Complementary Therapies

in Medici ne, 13, 213-216.

[23] Steginga, S.K., Occhipinti, S., Gardiner, R.A.F., Yaxley, J.

and Heathcote, P. (2004) A prospective study of the use

of alternative therapies by men with localized prostate

cancer. Patient Education and Counseling, 55, 70-77.