Racial differences in familiarity, interest, and use of integrative medicine among patients with breast cancer

In the United States (U.S.), breast cancer is the most common cancer type in women, accounting for approximately 30% of all cancers in women and with more than 3.6 million people alive with breast cancer in 2020 [1]. Breast cancer and its treatment can be associated with numerous side effects and symptoms, from cancer pain to lymphedema to hot flashes, [2] that can negatively impact patients’ treatment adherence and quality of life [3]. Reduction of side effects and management of symptoms typically consists of further medications, which carry their own adverse effect profiles. In 2017, the Society for Integrative Oncology (SIO) performed a systemic review focusing on randomized controlled trials from 1990 through 2015 of the use of integrative medicine (IM) modalities during and after breast cancer treatment [4]. This resulted in a set of evidence-based practice guidelines on the use of IM in breast cancer, which was subsequently endorsed by the American Society of Clinical Oncology (ASCO) in 2018 [5]. IM modalities, including acupuncture, therapeutic massage, meditation therapy, music therapy, and yoga therapy all have received ASCO’s endorsement for the treatment or management of various side effects and symptoms, particularly: hot flashes, nausea, anxiety or stress reduction, depression or mood disorders, and improving quality of life [5].

A 2021 study documented that more than 50.0% of cancer patients and their caregivers are familiar with acupuncture, yoga therapy, and meditation therapy [6]. Multiple previous studies have reported breast and gynecological cancer patients’ growing interest in and demand for IM, however, these studies included only White female patients [7‐10]. Use of IM has increased in recent decades [11‐13]. A 2005 survey conducted in breast cancer survivors found that more than 80.0% of the survivors had either used a complementary and alternative therapy or visited a therapist in the past [11]. According to a study using the 2002 National Health Interview Survey, Black race and lower socioeconomic status (SES) have historically been associated with lower prevalence of IM utilization among U.S. adults [12]. Therefore, IM services are generally marketed toward White populations and those with higher SES. However, little is known about familiarity, interest, and use of IM among Black or African American patients with breast cancer and survivors.

To date, the best study about racial differences in interest and use of IM comes from a 2017 study at the University of Texas MD Anderson Cancer Center, which surveyed 165 cancer patients, 43% of which were Black or African Americans, at an urban community hospital about interest and use of complementary and alternative therapies [14]. The study found that 90.6% of the patients were interested in therapeutic massage, followed by 72.7% in meditation therapy, 69.8% in yoga therapy, and 49.7% in acupuncture [14]. However, most were unprofessionally guided use, and both past and current IM use were low. In this study, 13.8% of Black patients had used yoga therapy as compared to 42.9% of Asian and 25.7% of White patients, with no significant differences among these racial groups based on a Pearson’s Chi-square test. Moreover, the study did not perform multivariable regression analyses due to the small sample size [14].

Prior studies are small and descriptive, with the majority of cancer patients and survivors being White. Additionally, there is paucity of data on racial differences in familiarity, interest, and use of IM specifically among patients with breast cancer. To fill these gaps in the literature, we sought to assess racial differences in familiarity, interest, and use of five ASCO-endorsed IM modalities for breast cancer symptom management: acupuncture, therapeutic massage, meditation therapy, music therapy, and yoga therapy in a large cohort of patients with breast cancer having been treated at the University of Chicago Medicine.

To our knowledge, this is of the first and the largest study to examine racial differences in familiarity, interest, and use of five ASCO-endorsed IM modalities and to assess specific symptom-related facilitating factors for interest in, and key barriers to use of, these modalities among U.S. patients with breast cancer. In this diverse cohort of patients with breast cancer, familiarity of IM modalities was prevalent among Black and White patients. However, higher proportions, ranging from 26.9% to 48.6%, of the patients across the racial groups were still not familiar with these modalities. Black patients were less likely to be familiar with acupuncture than their White counterparts, but there were no differences between them in familiarity with therapeutic massage, meditation therapy, music therapy, and yoga therapy. These findings are somewhat consistent with a recent study of familiarity and interest in IM among cancer patients and their caregivers that non-White patients are less familiar with therapeutic massage than White patients, while levels of familiarity with acupuncture, meditation therapy, music therapy, and yoga therapy are similar between White and non-White patients [6]. Our findings suggest that patient education on IM and its associated benefits may be needed among patients with breast cancer in order to increase patients’ knowledge and awareness of IM. Future research may be needed to explore reasons related to level of familiarity and how the findings could help inform and tailor IM education campaigns and programs specifically toward patients with breast cancer and survivors.

We found that most patients across the two racial groups were interested in the use of IM modalities, and the percentages of interest of IM use also increased when the patients were asked if any of these modalities were treated for a particular symptom such as joint pains, back pain, fatigue, anxiety or stress reduction, hot flashes, and chemotherapy-induced neuropathy. Our finding in increased interest of IM use aligns with a published study that patients who experience back, joint, or other pain are more likely to use acupuncture and therapeutic massage, though racial differences were not assessed [16]. Further, Black patients were twice as likely as their White counterparts to have expressed interest in music therapy, yoga therapy, meditation therapy, and therapeutic massage, which is contrary to prior findings in the general population that conclude Black patients are less interested in IM services than White patients [12]. Patients with breast cancer may have unique needs, as a population-based research has indicated that cancer patients and survivors are more likely than the general population to have discussed IM use with a provider and have used these modalities in the past 12 months [17]. Our result also contradicts a recent study finding that levels of interest in IM are similar between non-White and White patients [6]. However, this study sample was relatively small, probably lacking statistical power. In addition, it included patients with different cancer types and their caregivers, and thus, the findings may not be comparable to our cohort of patients with breast cancer [6]. It is worth noting that approximately 21.6%–40.6% of the patients across the racial groups reported being not very interested or not interested at all in using these IM modalities, even when they were asked if these modalities addressed specific common cancer treatment-associated symptoms. It is also important to note that most patients expressed greater interest in IM use if recommended by their providers and were willing to pay no more than $19 out of pocket for a session. Our findings indicate that Black patients may be in greater need for IM and that both provision and coverage of these modalities should be integrated as part of standard cancer care and services at comprehensive cancer centers in the U.S.

The percentages of past use of IM modalities were low among Black and White patients with breast cancer; the majority of the patients, between 57.1% and 93.4%, had not used these modalities in the past. These results are in line with a previous study that both past and current use of acupuncture, meditation therapy, yoga therapy, and therapeutic massage were low, ranging from only 5.6% to 46.3% [14]. Compared with White patients, a higher proportion of Black patients reported cost, lack of access to services, unaware of the benefits of these services as major barriers to IM use. Less than 10.0% of both Black and White patients reported low confidence in the benefits of the five surveyed IM modalities. After adjusting for key demographic and clinical characteristics, Black patients in our cohort were significantly less likely than their White counterparts to have used acupuncture, while there were no differences between the racial groups in past use of therapeutic massage, meditation therapy, music therapy, or yoga therapy. Our finding is consistent with the previous study partially that use of yoga therapy was similar between Black and White patients, however, multivariable regression modeling was not performed due to the small sample size [14]. It is important to point out that we did not ask whether the patients had used these IM modalities before, during, and/or after their cancer therapies, which is worth doing in future research to evaluate whether there are racial and ethnic differences in IM utilization over time and how these differences would impact patients’ treatment adherence and quality of life. Our findings also suggest that providers at cancer centers should be promoting these IM services as recommended by ASCO guidelines to all patients which, as shown, may be likely to increase interest in patients with breast cancer and survivors.

Furthermore, Black patients with breast cancer more frequently report nonadherence to endocrine therapy than their White counterparts, with side effect profile being one of the main causes of discontinuation [18, 19]. Therefore, the use of IM modalities to reduce side effects from breast cancer treatment and to manage symptoms may lead to greater adherence to endocrine therapy in Black patients. As we have shown Black patients are just as interested, if not more interested, in IM as their White counterparts, and there are likely unmet needs of IM among patients with breast cancer, we should ensure equity to access these services for all our patients, regardless of race.

Several limitations of this study need to be noted. First, the data collected through the survey were self-reported, which were subject to recall error or social desirability bias. However, we expect such bias to be minimal since our research staff had little interaction with the patients. Therefore, their responses were unlikely influenced. Second, because we did not ask the participants whether they had use these services before their cancer diagnoses, during, and/or after their cancer treatment, with an approximately 47.0% response rate, the percentages of use of these IM modalities may have been either overestimated or underestimated. Third, we were not able to assess unmeasured characteristics, e.g., cultural background/influence, employment status, patient-provider discussion of IM, which might affect or help better explain the observed racial differences in familiarity, interest, and past use of IM. Thus, additional cultural and behavioral factors should be taken into consideration in future research. Lastly, participants in the ChiMEC may not be representative of all U.S. patients with breast cancer or other patient populations, and therefore, limiting the generalizability of our study findings.

Despite the above limitations, this study has several strengths. Our study is the largest to date examining racial differences in familiarity, interest, and use of the five ASCO-endorsed IM modalities among patients with breast cancer. Another strength of this study was the inclusion of a racially diverse cohort of patients with breast cancer and key clinical characteristics that previous research was not able to assess.

In conclusion, both Black and White patients with breast cancer were familiar with the five ASCO-endorsed IM modalities, but Black patients expressed greater interest in the use of these modalities. There were no racial differences in prior use of IM, except an increased use of acupuncture among White patients. However, Black patients reported more health care and services access-related barriers than did their White counterparts. Promoting benefits of IM among patients with breast cancer and facilitating patient-provider discussion of IM use may be needed. Furthermore, breast programs focused on health equity should provide access to these services for all patients.