Pediatric Hematology and Oncology, 29:335344, 2012

Copyright C
Informa Healthcare USA, Inc.
ISSN: 0888-0018 print / 1521-0669 online
DOI: 10.3109/08880018.2012.670368
ORIGINAL ARTICLE
Use Of Complementary and Alternative Medicine in
Children With Cancer: Effect on Survival
Yasin Karal, MD,
1
Metin Demirkaya, MD,
2
and Bet ul Sevinir, MD
2
1
Department of Pediatrics, Uludag University, Medical Faculty, Bursa, Turkey;
2
Division of
Pediatric Oncology, Department of Pediatrics, Uludag University, Medical Faculty, Bursa,
Turkey
The objective of the present study was to determine the type, frequency, the reason why com-
plementary and alternative medicine (CAM) treatments are used, the factors related with their
use, and the eects of CAM usage on long-term survival. Families of a total of 120 children with
cancer between 018 years of age, including 50 (41.7%) girls and 70 (58.3%) boys, participated in
our study. The authors found that 88 patients (73.3%) used at least one CAM method, the most
common (95.5%) of which was biologically based therapies. Most frequently used biologically
based therapies were dietary supplements and herbal products. The most commonly used di-
etary supplement or herbal product was honey (43.2%) or stinging nettle (43.2%), respectively.
We found that patients used such CAM methods as complementary to, but not instead of, con-
ventional therapy. Sixty-nine out of 88 patient families (78.4%) shared the CAMmethod they used
with their physicians. No statistically signicant relation was found between socioeconomic, so-
ciodemographic, or other factors or items and CAM use. The mean follow-up period of the CAM
users and nonusers groups was 79.4 36.7 (21.3217.9) and 90.9 50.3 (27.4193.7) months, re-
spectively. Five-year survival rates for CAM users and nonusers were found as 81.5% and 86.5%,
respectively (P > .05). In conclusion, families of children with cancer use complementary and al-
ternative treatment frequently. They do not attempt to replace conventional treatment with CAM.
Higher rates of CAM use was found in families with higher educational level. CAM usage did not
aect the long-term survival.
Keywords alternative treatment, cancer, children, complementary medicine
Complementary and alternative medicine (CAM) treatments are defned as medi-
cal health care systems, practices, and products that are not considered a part of con-
ventional treatment [1].
Te US National Institute of Health Center for Complementary and Alternative
Medicine (NCCAM) classifed CAM treatments in 5 categories: (i) alternative med-
ical systems (such as homeopathy or traditional Chinese medicine); ii) mind-body
medicine (activities suchas meditation, prayer, art, dance, andmusic); iii) biologically
based therapies (such as plants, diet supplements); (iv) manipulative and body-based
therapies (such as chiropractic message); and (v) energy therapies (such as Qi gong,
Reiki, healing touch) [2].
CAM treatments are mostly used to decrease the side efects of traditional cancer
treatment. Unfavorable prognosis, previous use of CAM treatment, parents with high
Received 29 September 2011; accepted 23 February 2012.
Address correspondence to Metin Demirkaya, MD, Division of Pediatric Oncology, Department of
Pediatrics, Uludag University, Medical Faculty, 16059 G or ukle, Bursa, Turkey. E-mail:
demirkayametin@hotmail.com
{{,
{{ Y. Karal et al.
educational level, advanced age, and religious belief are factors associated with the
use of CAM treatment in children with cancer [3].
Te prevalence of CAMis reported to be between 24%and 90%in these patients. In
various studies, it was established that CAM treatments were used as complementary
to conventional treatment [3, 4]. In studies carried out in Turkey, the prevalence of us-
ingCAMtreatments has beenaround50%inpediatric patients and22%to53%inadult
patients. Te most frequently used method is treatment with plants, most commonly
the stinging nettle [58].
Tere are only a fewstudies evaluating CAMusage onthe long-termsurvival incan-
cer patients [9, 10]. Tese limited data primarily include adult patients and reveal that
CAM usage does not contribute to long-term survival.
Te objective of the present study was to determine the type, frequency, the con-
tributing factors, and the efect on long-term survival of CAM treatment in children
with cancer.
METHODS
Tis study was carried out between July 2007 and October 2007 with parents of pedi-
atric patients (aged0to18years) inthePediatric Oncology Department of UludagUni-
versity Hospital. However, the patient population was followed up for approximately
4 years to evaluate the efect of CAM on long-term survival.
CAM treatments were defned as any treatment not included in the biomedical
framework in the management of cancer patients. Patients families were frst in-
formed about CAM, and then about the study. Te questionnaire developed for the
study was completed by either one or both of the parents.
Te questionnaire was divided into the following parts: (i) sociodemographic data
(eg, age, sex, occupation of the parents, monthly income of the family, educational
level of the parents, number of siblings, social security, and place of residence); (ii)
information on the disease (diagnosis, date of the diagnosis, cancer history in family
members, treatments administered to the patient, etc); (iii) the use of CAM and the
methods used; (iv) the reason for the use of CAM; (v) time of initiating CAM use; (vi)
expected benefts and/or side efects of CAM; (vii) physician awareness of the familys
use of CAM; and (viii) changes in the way of life of the family after the diagnosis of
cancer.
Educational status of the family was classifed into 4 groups: (i) no school atten-
dance; (ii) primary or secondary school; (iii) high school graduate; and (iv) university
graduate.
Families with monthly income lower than 500 Turkish Liras (TL) were classifed as
low income, those between 500 and 1000 TL as middle income, and those over 1000
TL as high income according to poverty limits of Turkish Institution of Statistic.
Demography of the families was classifed into province, county, and rural areas.
Te study was approved by the ethical committee of Uludag University. Written in-
formed consent was obtained from either or both of the parents of cancer patients
participating in the study.
Statistical Analysis
Statistical analysis was performed using SPSS 13.0 for Windows (SPSS, Chicago, IL,
USA) software. Categorical variables were given with mean, standard deviation, and
minimummaximum values. Te Kolmogorov-Smirnov test was used if continuous
variables were distributed normally. Te intergroup comparison of variables dis-
tributed normally was carried out with an independent t test; comparison of the vari-
ables not distributed normally was carried out with the Mann-Whitney U test. In
Pediatric Hematology and Oncology
Complementary and Alternatlve Vedlclne {{;
TABLE 1 Distribution of Diagnosis (n =120)
Diagnosis n (%)
Lymphoma 47 (39.2)
Non-Hodgkin lymphoma 33 (27.5)
Hodgkin lymphoma 14 (11.7)
Nervous system tumors 30 (25)
CNS tumor 24 (20)
Neuroblastoma 6 (5)
Sarcoma 16 (13.3)
Soft tissue sarcomas 9 (7.5)
Bone sarcomas 7 (5.8)
Wilms tumor 14 (11.7)
Other 13 (10.8)
Note. CNS =central nervous system.
the intergroup comparison of categorical variables, a chi-square test was used. Te
Kaplan-Meier test was used for survival analysis. Survival periods were compared be-
tween groups by a log-rank test. P value of <.05 was considered signifcant.
RESULTS
One hundred twenty parents of pediatric patients participated in the study. Question-
naires were answered, 74 (61%) by only the mothers, 32 (26.7%) by only fathers, and
14 (11.7%) by both parents together.
When the study was initiated, treatment of 69 patients (57.5%) was completed and
that of 51patients (42.5%) was continuing. Of thelatter, 15(12.5%) werereceivingtreat-
ment for cancer relapse. Table 1 shows the distribution of the diagnoses.
Of 120 patients included in the study, 88 (73.3%) were found to use a method of
CAM. Table 2 shows the classifcation of CAM treatment into major groups and man-
ner of use.
TABLE 2 Te Distribution of CAM Use Within Major Groups of CAM and Mode of Use
n (%)

CAM group

Biologically based therapies 84 (95.5)

Mind-body practices 38 (43.2)
Manipulative and body-based methods 2 (2.3)
Energy therapies 2 (2.3)
Alternative medical systems 0 (0)
Modes of use of CAM
Only biologically based therapy 49 (55.7)
Mind-body practice +biologically based therapy 32 (36.4)
Only mind-body practices 4 (4.6)
Mind-body practice +biologically based therapy +manipulative and body-based
therapies
1 (1.1)
Mind-body practice +biologically based therapy +energy therapies 1 (1.1)
Mind-body practice +biologically based therapy +manipulative and body-based
therapies +energy therapies
1 (1.1)
Note. CAM=complementary and alternative medicine.

More than 1 answer.

Percentage was calculated over 88 patients using CAM.

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Of families using CAM, 53 (60%) stated that they began after the disease was con-
trolled, 32 (36.3%) chose to do so from the moment of diagnosis, and 3 (3.7%) began
when the disease recurred.
Of CAM methods, biologically based treatments were the most commonly used
(95.5%). Of the biologically based treatments, 51 patients (58%) used an herbal treat-
ment, to which 45 of these patients added at least one food or drink. Of herbal prod-
ucts, 38 patients (43.2%) used stinging nettle and 25 (28.4%) drank herbal teas. Other
frequently usedproducts of plant originwere rose hip, black seed, artichoke, andbroc-
coli. In addition to herbal products, the most frequently ingested products in decreas-
ing order of frequency were honey (43.2%), grape molasses (28.4%), and bee pollen
(18.2%). Bee milk, carob molasses, and mulberry molasses were also commonly used
products. Four other patients used metabolic products containing gluconate-cesium,
dimethyl sulfoxide (DMSO), shark cartilage, and turtle blood, respectively.
Tirty-eight families (43.2%) used body-mind practices such as oferings, animal
sacrifce, amulets, referring to a prayer leaders, and visiting tombs.
Two families (2.3%) did exercise and other activities such as manipulative body
treatment.
Two families (2.3%) referred to a bioenergy center for energy therapy.
No patients used alternative medical systems such as homeopathy, naturopathy,
Ayurveda, or Chinese medicine.
Stated reasons for using CAM included obtaining better blood values (23 families,
26.1%), improvement ingeneral condition(20 families, 22.7%), pressure fromrelatives
(17 families, 19.3%), and to ease the conscience (12 families, 13.6%).
Of families who used and claimed beneft from CAM, 25 (28.4%) stated that
blood values of their children increased, 23 (26.1%) stated that appetite increased, 16
(18.1%) stated that general conditionimproved, and16 (18.1%) statedthat morale was
boosted. None observed any side efects from the use of CAM.
Of families using CAM, 53 (60.2%) changed their nutritional habits, and 74 (84.1%)
started to protect their children from exposure to cigarette smoke. Parents in 13
(14.8%) families started to smoke due to anxiety and/or stress. In 17 families (19.2%),
religious practices increased. Only 4 families experienced no change in lifestyle.
When comparing families using CAM to those who do not, no signifcant difer-
ence was found in terms of the age of parents, age of patients, and number of siblings
(P >.05) (Table 3).
Tables 4 and 5 show sociodemographic and other factors efecting CAM usage.
Tere were no statistically signifcant diference between those who used CAM and
those who do not with respect to sociodemographic (educational levels of parents
and place of residence) and other (diagnosis, treatment, recurrence, cancer history
in the family, belief in recovery, and confdence in medical treatment) factors (P >
.05). Table 6 demonstrates the relation between socioeconomic variables and the use
TABLE 3 Use of CAM With Regard to Ages of Patients, Mothers, and Fathers, and Number of
Siblings
CAM use
Age of the patient

(year)
Age of the mother

(year)
Age of the father

(year)
Number of
siblings

Yes (n =88) 8.7 (218) 35.0 (2350) 38.0 (2455) 1.0 (06)
No (n =32) 10.0 (0.518) 35.0 (2350) 37.5 (2753) 1.0 (06)
P >.05 >.05 >.05 >.05
Note. CAM=complementary and alternative medicine.

Median (minmax).
Pediatric Hematology and Oncology
Complementary and Alternatlve Vedlclne {{
TABLE 4 Sociodemographic Variables and the Use of CAM
Te use of CAM
Yes No
n (%) n (%)
Mothers education level
Primary or secondary school 67 (76.1) 23 (71.9)
High school 12 (13.6) 5 (15.6)
No education 5 (5.7) 3 (9.4)
University 4 (4.5) 1 (3.1)
P >.05 >.05
Fathers education level
Primary or secondary school 53 (60.2) 23 (71.9)
High school 19 (21.6)
University 16 (18.2) 2 (6.2)
No education 0 0
P >.05 >.05
Place of residence
Providence 46 (52.3) 16 (50.0)
County 31 (35.2) 12 (37.5)
Rural area (town, village, etc) 11 (12.5) 4 (12.5)
P >.05 >.05
Note. CAM=complementary and alternative medicine.
of CAM. Te working status of parents and socioeconomic status of the family did not
change the CAM usage (P >.05)
Te mean follow-up period of the using CAM and other groups was 79.4 36.7
(21.3217.9) and 90.9 50.3 (27.4193.7) months, respectively. Tere was no statisti-
cally signifcant diferenceinfollow-uptimes betweenthe2groups. Whensurvival was
analyzed, the overall survival at the end of 5 years of follow-up was 81.5% and 86.5%
for the CAM users and nonusers, respectively (P >.05) (Figure 1).
250,00 200,00 150,00 100,00 50,00 0,00
time (months)
1,0
0,8
0,6
0,4
0,2
0,0
S
u
r
v
i
v
a
l
users
nonusers
FIGURE 1 Overall survival of CAM users and nonusers.
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TABLE 5 Other Factors or Items and the Use of CAM
Te use of CAM
Yes No
n (%) n (%)
Diagnosis group
Lymphoma 35 (39.8) 12 (37.5)
Nervous system tumors 21 (23.9) 9 (28.1)
Sarcomas 10 (11.4) 6 (18.7)
Wilms tumor 12 (13.6) 2 (6.2)
Others 10 (11.4) 3 (9.4)
P >.05 >.05
Treatment status
Finished 49 (55.7) 20 (62.5)
Ongoing 39 (44.3) 12 (37.5)
P >.05 >.05
Status of recurrence
No 80 (90.9) 25 (78.1)
Yes 8 (9.1) 7 (21.9)
P >.05 >.05
Treatment administered
Chemotherapy 84 (95.5) 29 (90.6)
Surgery 50 (56.8) 22 (68.7)
Radiotherapy 42 (47.7) 11 (34.4)
Cancer history in the family
Absent 46 (52.3) 23 (71.9)
Present 42 (47.7) 9 (28.1)
P >.05 >.05
Belief in recovery
Yes 79 (89.8) 29 (90.6)
No idea 3 (3.4) 2 (6.2)
Partly 4 (4.5) 0 (0)
No 2 (2.3) 1 (3.1)
Confdence in medical treatment
Yes 83 (94.3) 31 (96.9)
Partly 4 (4.5) 1 (3.1)
No idea 1 (1.1) 0 (0)
No 0 (0) 0 (0)
Note. CAM=complementary and alternative medicine.
TABLE 6 Socioeconomic Variables and the Use of CAM
Te use of CAM
Yes No
n (%) n (%)
Working status of the mother (n =118)
Housewife 77 (88.5) 29 (93.5)
Works 10 (11.5) 2 (6.5)
P >.05 >.05
Working status of the father (n =118)
Works 83 (95.4) 27 (87.1)
Retired (does not work) 4 (4.6) 4 (12.9)
P >.05 >.05
Socioeconomic status
Medium 54 (61.4) 17 (53.1)
High 24 (27.2) 7 (21.9)
Low 10 (11.4) 8 (25.0)
P >.05 >.05
Note. CAM=complementary and alternative medicine.
Pediatric Hematology and Oncology
Complementary and Alternatlve Vedlclne {|+
DISCUSSION
In pediatric oncology patients, CAM is commonly employed by the families. Parents
administer CAMtreatment basedoninformationobtainedfromfamily, friends, or the
Internet rather than that obtained from health care providers. CAM use is generally
kept secret fromphysicians administering conventional treatment. CAMmethods are
a source of concern for oncologists, as they are usually used without being subjected
to investigations [11].
Although survival rates from childhood cancer have recently increased, it is still
a cause of mortality. Incomplete information on the source of the diseaseand
physical and psychological symptoms emerging during conventional treatmentled
the children and their families to seek diferent treatment approaches. Te use of
CAM treatments in pediatric cancer patients varies from country to country and
is reported to range from 24% to 90% [3, 4, 12]. In a 1970s study carried out in the
USA, rate of the use of CAM treatment was found to be 9%, with recently determined
regional diferences ranging from 18% to 84% [1214]. Te corresponding rates in the
other 2 countries of North America were found to be 42.649% and 70% in Canada
and Mexico, respectively [1517]. In studies carried out in Europe, for example, in
Germany and England, the rates were found around 35% [18, 19]. In the study of
Grootenhuis et al in the Netherlands [20], the use of CAM was found to be higher in
patients with relapsing disease (46%) than in those in remission (16%). In Southeast
Asian countries still under the infuence of traditional Chinese medicine, the rates of
CAM use are higher, being 67% and 73% in Singapore and Taiwan, respectively [21,
22]. Tese data indicate that CAM methods are used at diferent rates in diferent
countries and that recently the administration of CAM has tended to be increased.
Two diferent studies performed in 1999 and 2004 in diferent parts of Turkey show
the use of CAM to be around 50% in this patient population [5, 6]. In the present
study, which was performed in 2007, the rate of the use of at least one CAM method
was found to be higher (73.3%) compared with other studies carried out in Turkey
and other countries. Since approximately two third of the population in our region
has been reported to be moved from other regions of Turkey, we believe that our
fgures represent the general pediatric oncology patient of Turkey. Te noticeably
large diferences in the rates of the use of CAM between diferent countries may
be ascribed to methodological diferences plus the lack of standard defnitions and
criteria for CAM. In addition, individual factors and sociocultural characteristics of
the style and adequacy of health services also infuence the rates of CAM use.
CAM methods vary by country, geographical region, ethnic group, socioeconomic
status, and religion [7]. Herbal treatment and nutritional supplements are most
frequently used CAM methods. Mind-body practices such as belief therapy, imagina-
tion, hypnosis, meditation and spiritual recovery, relaxation therapy, aromatherapy,
music, and massage therapy are among the CAM practices established in various
studies. Other CAM options include homeopathy, naturopathy, acupuncture, chiro-
practic, and reiki [12, 1417, 19, 20, 2327]. In the evaluation of the world as a whole,
the most frequently used CAM methods are praying, exercise, and spiritual recovery
[24]. Cancer centers in England most frequently used multivitamins, aromatherapy
massage, diet, and music [19]. For children in Australia, relaxation through hyp-
notherapy and similar imaging techniques is the CAM treatment most commonly
used [28]. In Canada, the rate of the use of chiropractic, homeopathy, naturopathy,
and acupuncture is 84% [29].
CAM methods used in western countries show great variance elsewhere. In
Pakistan, herbal therapy is the most commonly used [30]. Southeast Asians prefer
alterations in diet or packaged fuids or powders to enhance the immune system
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(48%) or alterations in diet. Spiritual and traditional Chinese medicine is also used
commonly [21, 22]. In Turkey, Karadeniz et al [6] reported that the most frequently
used CAM method in children with cancer was biologically based therapy, with a
rate of 71.4% (mostly stinging nettle, but also plant essences and Anzer honey, a
honey specifc to the Anzer region in the Black Sea), followed by belief therapy at
40.8% (prayer, oferings, and tomb visits). In the study of G oz um et al [5], herbal
products were the most frequently used methods in Erzurum in eastern Turkey
(90.7%), usually stinging nettle and its seed. In the present study, the most commonly
used complementary and alternative therapies were dietary supplements and herbal
products. Of patients using CAM, 86.3%used at least one dietary supplement (food or
drink other than herbal medicine), whereas 58% used at least one herbal product. Of
dietary supplements, the most commonly usedwere honey, molasses, andbee pollen.
Te most preferred herbal product was stinging nettle (43.2%), followed by herbal
teas (33.3%). Mind-body practices (ofering, sacrifcing animals, amulets, referring to
prayer leader, visiting tombs, etc) were the secondmost frequently usedCAMmethod.
Temost commonreasonfor usingCAMwas toprevent thefall inbloodvalues after
chemotherapy. A 14.1%of the families stated that they used CAMbecause of pressure
fromclose relatives. Indeed, the rate of the use of CAMwas higher among those whose
relatives have a history of cancer (82.3%vs 66.7%). In the study of Fernandez et al [15],
including366families, reasons oferedfor usingCAMwas toenhancetheimmunesys-
tem and the general health condition of the cancer patient. Additional reported aims
were to cure the cancer, to obtain a cure with fewer problems and complications, and
to slowthe progression of the disease. In many other studies, the reasons for CAMuse
were reported to be similar [5, 6, 12, 17, 19, 2123, 25, 26].
In the present study, no serious efects of CAM use were reported, although some
plants may lead to side efects in children whose conventional treatment continued.
For example, when used concurrently with grapefruit, the efect of steroids, irinote-
cans, some chemotherapy agents, and calciumchannel blockers may vary [31]. Other
side afects of herbal therapies as reported by Ernst [32] were bradycardia, brain dam-
age, cardiogenic shock, diabetic coma, encephalopathy, heart rupture, intravascular
hemolysis, liver failure, respiratory failure, toxic hepatitis, and death.
Te present study established that patients used CAM methods to supplement but
not replace conventional treatment, which is similar to the fndings of other studies
carried out in Turkey [5, 6]. In the study of Fernandez et al [15], only 8 of 366 families
used CAMinstead of conventional treatment. Inanother study with44 families partic-
ipating, only 1 used CAM as an alternative to conventional treatment [23].
In various studies, rates of how often families admitted to their physicians that
they used CAM ranged from 9% to 92% [5, 6, 12, 15, 18, 21, 24, 28]. In the present
study, 78.4%of the families using CAMinformed their physicians of the methods they
usedbecause the families of patients were asked to clearly state CAM use. Family
members were then informed as to possible side efects.
Te rate of CAMuse incancer patients was foundtobe higher among those patients
whose parents are employed and/or university graduates. Because the majority was
at a low educational and economic level, however, the diference between parents in
terms of the above rates was not signifcant.
Studies evaluating the efect of CAM usage on overall survival are limited and gen-
erally performed in adult patients. Risberg et al [9] investigated the efect of alterna-
tive medicine (AM) on the long-term survival in their study with a follow-up period
of 8 years, including 515 cancer patients aged above 15 years and found that death
rates were higher in AM users (79%) than in those who did not use AM (65%). Sen-
sitivity analyses strengthened the negative association between AM use and survival.
Tey concluded that the use of AM seems to predict a shorter survival from cancer.
Pediatric Hematology and Oncology
Complementary and Alternatlve Vedlclne {|{
Richardsonet al [10] reportedthat of the 342cancer patients attending 2diferent CAM
clinics (approximately 60% of whom attended after surgery, chemotherapy, or radio-
therapy), only 16.8%survivedat the endof 5years. Buiatti et al [33] reportedthat 5-year
survival rate in 248 pediatric and adult leukemia patients receiving Di Bella multither-
apy (MDB), whichis analternative treatment method, was 29.4%. Tis ratio was found
as statistically lower than those of the patients included in Italian Cancer Registry.
Our study is one of the very limited numbers of studies investigating the relation-
ship between CAM usage and survival rates. In PubMed database, we were unable to
detect any study evaluating the efect of CAM usage on long-term survival in children
withlymphoma or solidtumors. Although5-year survival rate was lower inCAMusers
thannonusers, this was statistically insignifcant. Our patients usedat least one of con-
ventional treatment modalities including surgery, chemotherapy, and radiotherapy.
For this reason, we were reasonably unable to compare the patients solely using CAM
with those solely using conventional treatments.
Inconclusion, the rates andmethods of CAMuse inour patients difer fromthose in
Western countries. Our data indicate that around 75% of our patients use at least one
method of CAM, most commonly therapies that are biologically based (dietary sup-
plements and herbal products). Our fgures suggest that CAM use in our country has
increasedrecently. None of our patients employedCAMtoreplace conventional treat-
ment owingtotheconfdenceinconventional treatments andtothebelief intheharm-
lessness of CAM when used in conjunction with conventional treatments. It was also
established that CAM was used at higher rates in members of families with a profes-
sion and/or high educational level. Informing the families about CAM will contribute
tothe regular use of conventional treatment. Generally usedinadditiontothe conven-
tional treatments, CAM usage does not seem to contribute on the long-term survival
in pediatric cancer patients.
Declaration of Interest
Te authors report no conficts of interest. Te authors alone are responsible for the
content and writing of the paper.
REFERENCES
[1] Kelly KM. Bringing evidence to complementary and alternative medicine in children with cancer:
focus on nutrition-related therapies. Pediatr Blood Cancer. 2008;50:490493.
[2] National Center for Complementary and Alternative Medicine. What Is Complementary and Alter-
native Medicine (2002). Available at: http://nccam.nih.gov/health/whatiscam/D156.pdf. Accessed
November 24, 2006.
[3] Kelly KM. Complementary and alternative medicines for use in supportive care in pediatric cancer.
Support Care Cancer. 2007;15:457460.
[4] Kelly KM. Complementary and alternative medical therapies for children with cancer. Eur J Cancer.
2004;40:20412046.
[5] G oz um S, Arikan D, Buyukavc M. Complementary and alternative medicine use in pediatric oncol-
ogy patients in eastern Turkey. Cancer Nurs. 2007;30:3844.
[6] Karadeniz C, Pinarli FG, Oguz A, et al. Complementary/alternative medicine use in a pediatric on-
cology unit in Turkey. Pediatr Blood Cancer. 2007;48:540543.
[7] Samur M, Bozcuk HS, Kara A, et al. Factors associatedwithutilizationof nonprovencancer therapies
in Turkey: a study of 135 patients from a single center. Support Care Cancer. 2001;9:452458.
[8] Ceylan S, Hamzaoglu O, Komurcu S, et al. Survey of the use of complementary and alternative
medicine among Turkish cancer patients. Complement Ther Med. 2002;10:9499.
[9] Risberg T, Vickers A, Bremnes RM, et al. Does use of alternative medicine predict survival from can-
cer? Eur J Cancer. 2003;39:372377.
[10] RichardsonMA, Russell NC, Sanders T, et al. Assessment of outcomes at alternative medicine cancer
clinics: a feasibility study. J Altern Complement Med. 2001;7:1932.
Copyrlght C
lnforma lealthcare uSA, lnc.
{|| Y. Karal et al.
[11] Sencer SF, Kelly KM. Complementary and alternative therapies in pediatric oncology. Pediatr Clin
North Am. 2007;54:10431060.
[12] McCurdy EA, Spangler JG, WofordMM, et al. Religiosity is associatedwiththe use of complementary
medical therapies by pediatric oncology patients. J Pediatr Hematol Oncol. 2003;25:125129.
[13] Faw C, Ballentine R, Ballentine L, et al. Unproved cancer remedies. A survey of use in pediatric out-
patients. JAMA. 1977;238:15361538.
[14] Nathanson I, Sandler E, Ramirez-Garnica G, et al. Factors infuencing complementary and al-
ternative medicine use in a multisite pediatric oncology practice. J Pediatr Hematol Oncol.
2007;29:705708.
[15] Fernandez CV, Stutzer CA, MacWilliamL, et al. Alternative and complementary therapy use in pedi-
atric oncology patients inBritishColumbia: prevalence andreasons for use andnonuse. J ClinOncol.
1998;16:12791286.
[16] Martel D, Bussieres JF, Teoret Y, et al. Use of alternative and complementary therapies in children
with cancer. Pediatr Blood Cancer. 2005;44:660668.
[17] Gomez-Martinez R, Tlacuilo-Parra A, Garibaldi-Covarrubias R. Use of complementary and alterna-
tive medicine in children with cancer in Occidental, Mexico. Pediatr Blood Cancer. 2007;49:820823.
[18] Langler A, Spix C, Gottschling S, et al. Parents-interview on use of complementary and alternative
medicine in pediatric oncology in Germany. Klin Padiatr. 2005;217:357364.
[19] Molassiotis A, Cubbin D. Tinking outside the box: complementary and alternative therapies use
in pediatric oncology patients. Eur J Oncol Nurs. 2004;8:5060.
[20] Grootenhuis MA, Last BF, de Graf-Nijkerk JH, et al. Use of alternative treatment in pediatric oncol-
ogy. Cancer Nurs. 1998;21:282288.
[21] Yeh CH, Tsai JL, Li W, et al. Use of alternative therapy among pediatric oncology patients in Taiwan.
Pediatr Hematol Oncol. 2000;17:5565.
[22] LimJ, Wong M, Chan MY, et al. Use of complementary and alternative medicine in paediatric oncol-
ogy patients in Singapore. Ann Acad Med Singapore. 2006;35:753758.
[23] Bold J, Leis A. Unconventional therapy use among children with cancer in Saskatchewan. J Pediatr
Oncol Nurs. 2001;18:1625.
[24] Friedman T, Slayton WB, Allen LS, et al. Use of alternative therapies for children with cancer. Pedi-
atrics. 1997;100(6):E1.
[25] Neuhouser ML, PattersonRE, Schwartz SM, et al. Use of alternative medicine by childrenwithcancer
in Washington State. Prev Med. 2001;33:347354.
[26] Fletcher PC, Clarke J. Te use of complementary and alternative medicine among pediatric patients.
Cancer Nurs. 2004;27:9399.
[27] Loman DG. Te use of complementary and alternative health care practices among children. J Pedi-
atr Health Care. 2003;17:5863.
[28] Sawyer MG, Gannoni AF, Toogood IR, et al. Te use of alternative therapies by children with cancer.
Med J Aust. 1994;160:320322.
[29] Spigelblatt L, Laine-Ammara G, Pless IB, et al. Te use of alternative medicine by children. Pediatrics.
1994;94:811814.
[30] Malik IA, Khan NA, Khan W. Use of unconventional methods of therapy by cancer patients in Pak-
istan. Eur J Epidemiol. 2000;16:155160.
[31] Marchetti S, Mazzanti R, Beijnen JH, et al. Concise review: clinical relevance of drug-drug and
herb-drug interactions mediated by the ABC transporter ABCB1 (MDR1, P-glycoprotein). Oncolo-
gist. 2007;12:927941.
[32] Ernst E. Serious adverse efects of unconventional therapies for children and adolescents: a system-
atic review of recent evidence. Eur J Pediatr. 2003;162:7280.
[33] Buiatti E, Arniani S, Verdecchia A, et al. Results from a historical survey of the survival of cancer
patients given Di Bella multitherapy. Cancer. 1999;86:21432149.
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