Radiation Therapists’ Experiences with Complementary AlternativeMedicine Use by their Patients: A Preliminary Study

Amanda Bolderston, MRT(T), BSc, MSc, FCAMRTa,*, Fiona Mitchell, ACT, CMS, BSc (Hons),MA, FCAMRTb, Bonnie Cowan, MRT(T), BSc, CNHPc, and Christie Mawson, MRT(T), BScd

a Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontariob Radiation Therapy Department, Vancouver Cancer Centre, Vancouver, British Columbia

c Medical Radiation Sciences Program, The Michener Institute, Toronto, Ontariod Radiation Therapy Department, R. S. McLaughlin Regional Cancer Centre, Oshawa, Ontario

Journal of Medical Imaging and Radiation Sciences 39 (2008) 128-134

Journal of Medical Imaging and Radiation Sciences

Journal de l’imagerie médicaleet des sciences de la radiation

www.elsevier.com/locate/jmir

ABSTRACT

Complementary and alternative medicine (CAM) is increasingly pop-ular among patients receiving radiation therapy. However, there is little

empirical evidence relating to the interactions of radiation therapistsand their patients regarding the use of CAM during treatment. Thestudy objectives were to quantify how often the issue of CAM use arises

in the therapists’ daily practice, to explore radiation therapists’ knowl-edge and attitudes about CAM use by their patients, and to identifyareas for future education and development for therapists.

This article describes a two-centre survey conducted at the Vancou-ver Cancer Centre in British Columbia and Princess Margaret Hos-pital in Ontario. The survey used an email survey instrument,

‘‘SurveyMonkey,’’ which was emailed to all therapists working atboth centres (n ¼ 230). The survey had a 5-point Likert scale rang-ing from ‘‘strongly disagree’’ to ‘‘strongly agree.’’ There were also as-

sociated open-ended questions to allow for individual comments.

The total response rate from the two centres was 49%. Results indi-

cated that the topic of CAM does arise, although the frequency ofinteraction between patient and therapist varies between centres.Therapists reported feeling comfortable with their knowledge of 3

from a list of 27 common CAM therapies. They would recom-mend/support their patients’ use of 11 CAM therapies in total. Ther-apists and patients use a variety of information sources about CAM,

but would welcome more information/education in this area. Over-all, therapists felt that the radiation oncologist was the most appro-priate person to discuss the use of CAM with patients.

Radiation therapists need more information about CAM in the formof continuing education to meet the needs of their patients. Further

research is warranted, as this is a very preliminary look at a large andsomewhat controversial topic.

* Corresponding author. Tel.: 416-946-4501; Fax: 416-946-2019.

E-mail address: amanda.bolderston@rmp.uhn.on.ca (A. Bolderston).

1939-8654/08/$ - see front matter � 2008 Elsevier Inc. All rights reserved.

doi: 10.1016/j.jmir.2008.07.004

RESUME

La medecine complementaire et parallele (MCP) augmente en popu-larite aupres des patients qui recoivent de la radiotherapie. Cependant,

nous possedons peu de donnees empiriques sur l’interaction des radio-therapeutes et de leurs patients concernant l’utilisation de la MCP du-rant les traitements. L’etude visait a quantifier le nombre de fois ou la

question de la MCP a ete soulevee dans le cours de la pratique courantedes therapeutes, a explorer les connaissances et les attitudes des thera-peutes relatifs a l’utilisation de la MCP aupres de leurs patients et a re-censer les secteurs necessitant de la formation et du perfectionnement

pour les therapeutes.

L’article constitue un compte-rendu d’une etude effectuee dans 2 cen-

tres, soit le Vancouver Cancer Centre en Colombie-Britannique etl’hopital Princess Margaret en Ontario. Elle a ete menee par courrielau moyen d’un instrument de sondage, le SurveyMonkey; tous les ther-

apeutes des centres ont recu le sondage (n ¼ 230). L’evaluation a etefaite au moyen d’une echelle Likert de 5 points, allant de « fortementen desaccord » a « fortement d’accord ». Suivaient des questions

ouvertes permettant de recueillir les commentaires individuels.

Le taux de reponse des deux centres a atteint 49 %. Les resultats indi-

quaient que la question de la MCP est abordee mais que la frequencevarie entre les centres. Les therapeutes faisaient confiance a leurs con-naissances de 3 des 27 formes de therapies courantes citees. Ils accept-

aient de recommander ou d’appuyer 11 des therapies de MCP citeespour leurs patients. Dans l’ensemble, les therapeutes estimaient que lesradiooncologues etaient les personnes les mieux placees pour discuter

du recours a la MCP avec leurs patients. Les therapeutes comme les pa-tients utilisent diverses sources d’information sur la MCP mais souhai-teraient pouvoir recevoir plus d’information et de formation sur le sujet.

Les radiotherapeutes ont besoin de plus de formation continue enMCP. La recherche doit etre approfondie puisque nous disposonsd’un apercu seulement sur un sujet vaste et plutot controverse.

Introduction

In recent years, complementary and alternative medicine(CAM) has moved from the fringes of the health care systemto take a more central role. The terminology used to describeCAM reflects this shift, moving away from previous termssuch as ‘‘unsound,’’ ‘‘alternative,’’ ‘‘unconventional,’’ and‘‘non-traditional’’ to more contemporary and positive expres-sions such as ‘‘Eastern,’’ ‘‘integral,’’ ‘‘holistic,’’ and ‘‘integra-tive’’ [1]. In this article, we will employ the definition ofCAM used by the National Centre for Complementary andAlternative Medicine, that is, as a group of diverse medicaland health care systems, practices and products not presentlyconsidered as conventional medicine [2]. The use of CAM iscommon among patients who have cancer, although there islittle empirical evidence relating to the interactions of radia-tion therapists and their patients regarding CAM use duringradiation treatment. This article reports the results of a two-centre survey conducted with the radiation therapists at theVancouver Cancer Centre in British Columbia and PrincessMargaret Hospital in Ontario. The survey was designed toquantify how often the issue of CAM use arises in the thera-pists’ daily practice, to explore radiation therapists’ knowledgeand attitudes about CAM use in their patients, and to identifyareas for future education and development for therapists.

Background

CAM practices cover a broad range of treatments, from themainstream, such as massage and psychotherapy, to the ratherunorthodox, such as Laetrile. It is well known that patientswho have cancer frequently use CAM. A literature review of26 studies of varying countries, methodologies, and patientgroups reported that 7% to 64% of patients who have canceruse CAM [3]. A survey conducted at the University of TexasM.D. Anderson Cancer Center revealed that 83% of patientsin their clinics across a spectrum of disease stages and sitesused complementary health practices. In addition, each patientused an average of four to five different CAM therapies [4].

Reasons commonly cited by patients for CAM use in theliterature include promoting an improved quality of life, re-lieving cancer or treatment-related symptoms, boosting theimmune system and increasing life expectancy [5]. Patientsmay also seek ‘‘relief of emotional and existential discomfort’’[5] by engaging actively in their own health care. They seekpractitioners who use a holistic and highly patient-centred ap-proach. The most common use of CAM is to ‘‘complement’’the conventional therapies of radiotherapy, chemotherapy,hormone therapy, and surgery [6]. There seems to be little ev-idence to suggest that patients are choosing CAM instead ofstandard medical care [7].

According to the literature, patients who use CAM tend tobe young, female, educated, and from a high socioeconomicclass [8]. There is still a certain amount of stigma attached tothe use of CAM. A literature search identified 12 studies pub-lished between 1993 and 2002 that demonstrated a rate of

A. Bolderston et al./Journal of Medical Imagin

nondisclosure of CAM use to medical practitioners as high as77%. Principal reasons cited for nondisclosure were concernsabout a negative response by the practitioners, the belief thatthe practitioner did not need to know about their CAM use,and that the practitioner did not ask [9]. In addition, physiciansconsistently underestimate the number of their patients usingCAM [10]. They may not bring the subject up with their pa-tients, relying instead on patient self-disclosure.

Patients may seek information about CAM from healthcare professionals, friends and family, and from the Internet[3]. Patients will often ask oncology nurses for informationabout CAM, as illustrated in one study in which nurseswere having conversations with their patients about CAM atleast once a week [11]. It is shown in nursing and medicalstudies that that the health care professional’s attitude can af-fect his or her patient’s trust and may influence future com-munication [12]. As radiation therapists deal with patients’informational needs on a daily basis, often for a protractedcourse of treatment, it can be hypothesized that they havean important role to play in alleviating their patients’ concernsabout CAM use. Although the authors could find no informa-tion in the literature on radiation therapists’ interactions withtheir patients regarding CAM use, they were aware from pro-fessional experience that these exchanges do occur.

Methods

A two-centre survey was conducted at the Vancouver Can-cer Centre (VCC) in British Columbia and Princess MargaretHospital (PMH) in Ontario. The survey was developed usingthe email survey instrument ‘‘SurveyMonkey.’’ The e-mailsurvey allowed for anonymous collection of data and was e-mailed to all therapists working at both centres (n ¼ 230).Face validity of the survey was tested using a group of radia-tion therapists and nurses with experience and interest inCAM therapies. The survey was piloted with a small groupof therapists at PMH, and several changes were made to im-prove clarity. Appropriate ethics approval was obtained fromeach institution beforehand. A message attached to the surveyinformed the participant that the survey was voluntary andconfidential and provided contact details for the researchers,as well as the study objectives.

Demographic information (sex, education level, and areaof specialty) was gathered. The main survey questions probedthe radiation therapists’ knowledge of, and comfort level with,their patients using 27 CAM therapies. The therapies weredistilled from an extensive literature review of CAM therapiesin cancer and the collective expertise of the authors. Thesetherapies consisted of:

� Acupressure� Acupuncture� Aromatherapy� Ayurvedic remedies� Body work (such as yoga, tai chi, or chi gong)� Chiropractic

g and Radiation Sciences 39 (2008) 128-134 129

� Essiac� Exercise� Homeopathy� Hypnosis,� Imagery and visualization,� Journaling,� Laetrile,� Massage,� Meditation,� Megavitamins,� Mistletoe,� Music therapy,� Naturopathy,� Osteopathic manipulation,� Prayer or spirituality,� Psychotherapy (such as support groups, social work and

psychiatry),� Reflexology,� Shark or bovine cartilage,� Special diets (such as macrobiotics and veganism),� Therapeutic touch or energy healing, and� Traditional Chinese medicine.

Radiation therapists were also asked how often the CAMissue arose in their practice, who should discuss CAM withpatients, what resources are available for staff and patientsat their centre, and whether they desired more informationabout CAM. Questions were posed using a 5-point Likertscale ranging from ‘‘strongly disagree’’ to ‘‘strongly agree.’’There were also associated open-ended questions to allowfor individual comments.

Results

Results indicated that the topic of CAM does arise in dis-cussion with patients, although the frequency of interactionvaries between centres.

Participant Demographics

There was a significantly higher response rate at VCC,with 80% of the 60 radiation therapists responding to the sur-vey. At PMH, 36% of the 170 radiation therapists respondedto the survey. The total response rate from both centres was49%. At both centres, the female to male responders’ genderratio was 8:2, which is a fair representation of the profession.

The most common highest level of completed educationwas an undergraduate degree (60%) followed by a diploma(16%). There were some differences using Fisher’s exact testbetween the survey populations in this area. There werea higher percentage of respondents with an undergraduate de-gree at PMH (68% vs 50% at VCC) and 8% of respondentsheld a postgraduate degree at PMH compared with 2% atVCC (P ¼ .003).

Interestingly, the most common range of experience was0 to 5 years at both centres, indicating a high level of fairlynew graduates (Figure 1). The majority of the participants

130 A. Bolderston et al./Journal of Medical Imagin

(85%) were in clinical practice, namely treatment, planning,or simulation. A smaller percentage held nonclinical positionssuch as management, educational, or research roles (13%).Again, this differed significantly between the two centres us-ing Fisher’s exact test; there were fewer people in clinical prac-tice at PMH (79%) compared with VCC (98%).

How Often Does the Issue of CAM Arise with Patients?

PMH radiation therapists reported a higher frequency ofinteraction with their patients about CAM than participantsat VCC; interactions occurred twice per month at PMH com-pared to twice per year at VCC. However, frequencies of in-teraction reported ranged from daily interaction (3.5% atPMH) to never (10.5% at PMH, 4.2% at VCC). See Figure 2for more details.

Do You Have a Comfortable Level of Knowledge aboutthis CAM Therapy and Would You Recommend/Supportyour Patients Using It?

Results indicated that radiation therapists did not feelcomfortable with their knowledge about the majority ofCAM therapies. Exceptions were exercise, massage, and psy-chotherapy. Despite this lack of familiarity, they wouldrecommend/support their patients using the followingCAM therapies: aromatherapy, body work (such as yoga,tai chi, or chi gong), imagery and visualization, journaling,

0

5

10

15

20

25

30

35

0 to 5 6 to 10 11 to 15 16 to 20 21 to 25 26 plus

VCC

PMH

Figure 1. DemographicsdYears Qualified.

0

2

4

6

8

10

12

14

16

18

20

VCC

PMH

Daily >2 x wk 1 x wk >2 x mth 1 x mth > 2 x yr Never

Figure 2. Frequency of Interaction.

g and Radiation Sciences 39 (2008) 128-134

meditation, music therapy, prayer or spirituality, and thera-peutic touch or energy healing (Table 1).

The only statistically significant therapy that was recom-mended more commonly in VCC than PMH was therapeutictouch or energy healing (P ¼ .003). Table 2 shows the differ-ences between the two centres in recommending therapieswithout the accompanying comfortable level of knowledge.

Whose Responsibility is it to Discuss CAM Use?

Radiation therapists at both centres felt that the radiationoncologist was the most appropriate person to discuss CAMuse with patients (Figure 3). The second choice was ‘‘all mem-bers of the team.’’ A few respondents commented that anymember with sufficient expertise should be able to talk to pa-tients about CAM use. Examples given included nutritionists,social workers, and members of the clergy.

What Resources are Available for Staff and Patient Use?

Educational materials from their centre and the Internethave been the most common sources of information aboutCAM for both staff and patients (Figures 4 and 5). PMHtherapists used departmental materials and Internet resources

Table 1

Comparison Between the Questions ‘‘Do you Have a Comfortable Level

of Knowledge about this CAM Therapy?’’ and ‘‘Would you Recommend/

Support your Patients using it’’

Have Comfortable Knowledge Of Would Recommend/

Support Patient Use

Exercise Exercise

Massage Massage

Psychotherapy such as support

groups, social work,

and psychiatry

Psychotherapy such as support

groups, social work,

and psychiatry

Aromatherapy

Body work such as yoga, tai chi,

or chi gong

Imagery and visualization

Journaling

Meditation

Music therapy

Prayer or spirituality

Therapeutic touch or energy

healing

Table 2

Comparison of Recommendations versus Knowledge between PMH and

VCC

Princess

Margaret Hospital

Vancouver

Cancer Centre P

Recommended at least

one therapy without

enough knowledge

.54

Yes 46 (74%) 38 (79%)

No 16 (26%) 10 (21%)

Recommended at least

three therapies without

enough knowledge

>.9

Yes 38 (61%) 29 (60%)

No 24 (39%) 19 (40%)

A. Bolderston et al./Journal of Medical Imaging

equally, but VCC used departmental materials more than theInternet. Therapists used a wide range of resources, includingdiscussion with experts, continuing education opportunitiessuch as conferences and in-services, articles, and referencebooks. Other resources cited included the Center for Inte-grated Healing in Vancouver and departmental patient andfamily services.

Would You Like to Know More about CAM?

There was a strongly positive reply to this question, witha response average of 4.17 between ‘‘agree’’ and ‘‘stronglyagree’’ on a 5-point scale. One respondent commented that:

As a therapist you often briefly hear about CAM at a confer-ence or using a pamphlet, but I found it’s not reinforced/used/discussed enough so you can’t remember the details of the use

clearly enough to advise your patient on it.

Discussion

The difference in the survey response rate between the twocentres may be due to the higher volume of survey-based re-search conducted at PMH compared with VCC, leading toa somewhat lower level of participation at PMH. From thesurvey results, we can see that radiation therapists are discus-sing CAM use with patients, albeit relatively infrequently. Weknow from the literature that a high proportion of patientsuse CAM, and that patients’ desire for information aboutCAM is generally high [4].

0

5

10

15

20

25

30

35

40

RO RN RTT Pharm All No one Other

VCC

PMH

Figure 3. Who Should Discuss CAM Use?

0

5

10

15

20

25

30

35

Dept ed

material

WWW People None Other

VCC

PMH

Figure 4. What Resources do Patients Use?

and Radiation Sciences 39 (2008) 128-134 131

In a wide-scale study of physicians in the United Kingdom[13], 41% referred patients to CAM practitioners. In Canada,an Ontario-based study of 28 oncology nurses [11] estimatedthat the nurses had conversations at least once a week with pa-tients about CAM, and 18 of 28 nurses routinely initiatedconversations with patients themselves. In light of this, it issomewhat surprising that the radiation therapists in this studydeal with this issue as seldom as the results suggest. In addi-tion, one question that was unasked is whether patients or ra-diation therapists are initiating conversations about CAM.We have seen that patients may not reveal their CAM useto physicians [9] and this may be a similar situation. Further-more, radiation therapists may feel uncomfortable raising theissue of CAM use if they feel they lack the knowledge to dealwith questions from patients.

There would seem to be more discussions about CAMhappening at PMH compared with VCC. Why this is thecase can only be a matter of speculationdperhaps Vancouverpatients obtain CAM information from other sources. For ex-ample, Vancouver is home to the Centre for Integrative Heal-ing, which provides a comprehensive integrated cancer careprogram for people with cancer and their families.

Despite the differences in education, position, and qualifi-cation between the respondents at the two centres, the thera-pists tend to recommend therapies that they feel they do nothave enough knowledge about. This is obviously a seriousconcern, as there is the risk of erroneous information beinggiven to patients if the practitioner is misinformed or lackingaccurate information. It may be that radiation therapists per-ceive therapies such as aromatherapy and therapeutic touch as‘‘harmless’’ (causing no physiological effect but perhaps hav-ing a positive effect on the patient’s quality of life). Thusthey feel it is safe to recommend therapies to patients, eventhough they know little about them.

In reality, there is some empirical evidence to suggest ben-efits for the recommended therapies in this study: namelymassage, exercise, and psychotherapy. According to a reviewof 10 randomized or controlled studies [14], physical activityappears to be a good way of combating fatigue induced byvarious cancer therapies. Massage has demonstrated short-term benefits in terms of psychological wellbeing and

0

5

10

15

20

25

30

35

40

Dept ed

materials

WWW One-on

-one with

Experts

Confs. Inservices

VCC

PMH

Literature Ref

Books

None Other

Figure 5. What Resources do Therapists Use?

132 A. Bolderston et al./Journal of Medical Imagin

reduction of some symptoms for patients who have cancer[15]. In addition, a 2004 Cochrane review [16] of aromather-apy-massage called for more randomized trials, but allowedthere were short-term benefits on psychological wellbeing,with the positive effect on the reduction of anxiety supportedby limited evidence. The review stated that evidence is mixedas to whether the addition of aromatherapy enhances the ef-fects of massage. Psychosocial interventions (such as supportgroups, social work, and psychiatry) have proven efficacy inalleviating distress in patients being treated for cancer [17], al-though their effects on disease processes, morbidity, and mor-tality are not yet well established. Finally, in many studies,there is often a clear distinction made between ingestedCAM therapies and other modalities [18]. This also seemsto be the case here, as radiation therapists are likely wary ofpotentially harmful effects from administered CAM treat-ments and toxic interactions with conventional therapies.

A US survey of physicians examined participants’ views offive of the most prominent CAM therapies and found consid-erable variations in the perceived effectiveness of the differentmodalities. Approximately half believed that acupuncture,chiropractic, and massage were effective, compared with26% for homeopathy and 13% for herbal approaches [19].In the previously mentioned UK study, 41% of respondentsreferred patients to CAM, although only 13% of the samplehad received any education about the use and application ofCAM [13]. This trend is in line with the results of this study.

To sound a note of caution, some therapies listed in thisstudy may indeed be harmless, but a number have been con-traindicated in other publications because of their interactionswith allopathic cancer treatments or general toxicity. For ex-ample, Laetrile (also known as Amygdalin or Vitamin B17)is a chemical found in the pits of many fruits, raw nuts,and plants, which can cause severe cyanide poisoning [20].Megavitamin and antioxidant use during radiation therapyis also hotly debated and is often the only CAM topic withinformation available to patients in departments [21]. Thetraditional view is that antioxidants should not be taken dur-ing treatment [22], but there is a vocal minority asserting thatthey can ameliorate the side effects of treatment without min-imizing the effect of the radiation therapy on the cancer cells[23–25].

Radiation therapists in this study seem to rely on the radi-ation oncologist to address CAM use, and this may be whythe interaction frequency with patients is relatively low. In ad-dition, patients with questions may be referred to the oncol-ogist instead of discussing the issue with the radiationtherapist [21].

Information sources used by staff and patients were wide-ranging, but mainly consisted of departmental resources andthe Internet. A recent survey-based study revealed that manyOntario radiation therapy departments do not have adequatepolicies dealing with CAM use in radiation therapy patients.Their patient education literature is often limited to informa-tion about antioxidant use [21]. The concern with Internetinformation seeking is that many Web sites may not be

g and Radiation Sciences 39 (2008) 128-134

evidence-based and perhaps such information may be inaccu-rate or biased. Common primary sources of information forpatients about CAM in the literature are the mass media,which includes television, newspaper, magazine, videotapes,and the Internet, as well as friends or family members.

The clear need for more information evinced by the re-spondents reflects the literature [26]. A recent US surveyfound that 61% of doctors felt they had inadequate knowl-edge about the safety and efficacy of CAM therapies, and81% believed that more education was required in this field[27]. In an Ontario study, the radiation therapist respondentsindicated that they strongly desire more education aboutCAM [21]. CAM is being introduced into the undergraduatecurricula for physicians in some universities, often in the formof optional special study modules [28]. For radiation thera-pists, CAM is poorly covered in the existing undergraduatecurriculum and many therapists rely on information fromcontinuing education events such as departmental in-servicesor a continuing education course [21].

Study Limitations and Directions for Further Study

Because the study was conducted at two centres only, itmay not be possible to make generalizations. This projectwas a preliminary look at the issue, prompted by a lack of em-pirical evidence about radiation therapists’ interactions withtheir patients regarding use of CAM. There are many issuesthat can be identified for further study, including a widerqualitative study looking more closely at therapists’ attitudesand beliefs regarding CAM use, and an examination of ther-apists’ preferred methods of education about their patients’use of CAM.

Conclusion

It seems that radiation therapists are discussing CAM usewith their patients. There is a strong indication from thisstudy that more information is needed for radiation therapistsin the form of continuing professional education, althoughpractitioners are currently using material provided by their or-ganization and various Web sites. It is a concern that thera-pists feel they are uninformed and that there is the potentialrisk of misinformation being given to patients. In addition,radiation therapists should be aware of patients’ CAM useand their information sources. Given the potential riskswith some CAM therapies, and the data suggesting that ther-apists rely on the physicians to discuss CAM with patients,physicians should actively ask patients whether they useCAM and provide appropriate counselling. This informationneeds to be shared with, and supported by the entire treat-ment team. How radiation therapists respond to their pa-tient’s questions will most likely have an impact on thedecision the patient makes about pursuing a particular ther-apy or whether the patient feels they are supported. Thusa nonjudgemental, supportive attitude is important as wellas a good working knowledge of the more common CAM

A. Bolderston et al./Journal of Medical Imaging

therapies; particularly in this era of patient-centered medicinewhere patient choice is paramount. In the words of onerespondent:

It’s my personal belief that patients should do what they need

to do to heal and feel better about their condition, however itis our responsibility to ensure they are not doing anything po-tentially harmful to themselves and we can’t leave it up to the

CAM experts to be fully aware of the effects of radiotherapy.

Further research is warranted, as this is a very preliminarylook at a large and somewhat controversial topic.

Acknowledgements

The authors would like to thank Lisa Wang, Departmentof Clinical Study Coordination and Biostatistics at PrincessMargaret Hospital for her help with statistical analysis andJessica Wong for her invaluable help in editing this article.

About the Authors

Amanda Bolderston trained at the Oxford RegionalSchool of Radiography in the United Kingdom and movedto Canada in 1990. Her current position is at PMH in Tor-onto where she is the Clinical Education Manager. Her pro-fessional interests are the development, demonstration, andassessment of clinical expertise and the management of radio-therapy side effects.

Fiona Mitchell is the Professional Practice Leader for ra-diation therapy at the BC Cancer Agency. She holds anMA in Leadership and has an interest in professional practiceand patient care.

Bonnie Cowan is a radiation therapist and a CertifiedNatural Health Professional who has completed instructionand certification in the field of Natural Health. She currentlyteaches the Fundamentals of Complementary/IntegrativeMedicine elective course at the Michener Institute in Torontoand gives lectures and presentations on complementary alter-native medicine at various conferences.

Christie Mawson obtained a BSc in Kinesiology at theUniversity of Waterloo and a BSc in Radiation Science atthe University of Toronto. She has worked at Princess Mar-garet Hospital and currently works in dosimetry at the Dur-ham Regional Cancer Centre.

References

[1] Fontaine, K. (2005). Complementary & Alternative Therapies for NursingPractice (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

[2] National Centre for Complementary and Alternative Medicine. (2005).

What is complementary and alternative medicine (CAM)? Retrieved

June 1, 2007, from National Institutes of Health Web site: http://

nccam.nih.gov/health/whatiscam.

[3] Eng, J., Ramsum, D., Verhoef, M., Guns, E., Davison, J., &

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

and alternative medicine use in men recently diagnosed with prostate

cancer. Integr Cancer Ther 2, 212–216.

[4] Richardson, M. A., Saders, T., Palmer, J. L., Greisinger, A., &

Singletary, S. E. (2000). Complementary/alternative medicine use in

and Radiation Sciences 39 (2008) 128-134 133

a comprehensive cancer centre and the implications for oncology. J Clin

Oncol 18, 2505–2514.

[5] Burstein, H. (2000). Discussing complementary therapies with cancer

patients: what should we be talking about? J Clin Oncol 18, 2501–

2504.

[6] Adams, M., & Jewell, A. P. (2007). The use of complementary and al-

ternative medicine by patients who have cancer. Int Semin Surg Oncol

4, 10.

[7] Druss, B., & Rosenheck, R. A. (1999). Association between use of un-

conventional therapies and conventional medical services. JAMA 282,

651–656.

[8] Tascilar, M., de Jong, F. A., Verweij, J., & Mathijssen, R. H. (2006).

Complementary and alternative medicine during cancer treatment:

beyond innocence. Oncologist 11, 732–741.

[9] Robinson, A., & McGrail, M. R. (2004). Disclosure of CAM use to

medical practitioners: a review of qualitative and quantitative studies.

Compl Ther Med 12, 90–98.

[10] Roberts, C. S., Baker, F., Hann, D., Runfola, J., Witt, C., &

McDonald, J., et al. (2005). Patient-physician communication regard-

ing use of complementary therapies during cancer treatment. J Psycho-

soc Oncol 23, 35–60.

[11] Fitch, M., Pavlin, M., Gabel, N., & Freedhoff, S. (2002). Oncology

nurses’ experiences regarding patients’ use of complementary and alter-

native therapies. Can Oncol Nurs J 12, 20–33.

[12] Stephenson, F., Britten, N., Barry, C. A., Bradley, C. P., &

Barber, N. (2003). Self-treatment and its discussion in medical consul-

tations: how is medical pluralism managed in practice? Soc Sci Med

57, 513–527.

[13] Lewith, G. T., Hyland, M., & Gray, S. F. (2001). Attitudes to and use

of complementary medicine among physicians in the United Kingdom.

Compl Ther Med 9, 167–172.

[14] Lawrence, D. P., Kupelnick, B., Miller, K., Devine, D., & Lau, J.

(2004). Evidence report on the occurrence, assessment, and treatment

of fatigue in patients who have cancer. J Natl Cancer Inst Monogr

32, 40–50.

[15] Sagar, S. M., Dryden, T., & Wong, R. K. (2007). Massage therapy for

patients who have cancer: a reciprocal relationship between body and

mind. Curr Oncol 14, 45–56.

134 A. Bolderston et al./Journal of Medical Imaging

[16] Fellowes, D., Barnes, K., & Wilkinson, S. (2004). Aromatherapy and

massage for symptom relief in patients with cancer. Cochr Database

Syst Rev 2, CD002287.

[17] Fekete, E. M., Antoni, M. H., & Schneiderman, N. (2007). Psychoso-

cial and behavioral interventions for chronic medical conditions. Curr

Opin Psychiatry 20, 152–157.

[18] Shen, J., Andersen, R., Albert, P. S., Wenger, N., Glaspy, J., & Cole, M.,

et al. (2002). Use of complementary/alternative therapies by women with

advanced-stage breast cancer. BMC Compl Altern Med 2, 8.

[19] Astin, J. A., Marie, A., Pelletier, K. R., Hansen, E., & Haskell, W. L.

(1998). A review of the incorporation of complementary and alternative

medicine by mainstream physicians. Arch Intern Med 158, 2303–2310.

[20] O’Brien, B., Quigg, C., & Leong, T. (2005). Severe cyanide toxicity

from ’vitamin supplements’. Eur J Emerg Med 12, 257–258.

[21] Wong, J., & Bolderston, A. (2007). A descriptive study of departmental

policies regarding patients’ use of complementary and alternative med-

icine in Ontario radiation therapy centres. Can J Med Radiat Technol

38, 32–38.

[22] D’Andrea, G. M. (2005). Use of antioxidants during chemotherapy and

radiotherapy should be avoided. Cancer J Clin 55, 319–321.

[23] Simone, C. B., Simone, N. L., Simone, V., & Simone, C. B. (2007).

Antioxidants and other nutrients do not interfere with chemotherapy

or radiation therapy and can increase kill and increase survival, part 1.

Alt Ther Health Med 13, 22–28.

[24] Borek, C. (2004). Dietary antioxidants and human cancer. Integr Can-

cer Ther 3, 333–341.

[25] Sagar, S. M. (2005). Should patients take or avoid antioxidant supple-

ments during anticancer therapy? An evidence based review. Curr Oncol

12, 44–54.

[26] Hessig, R. E., Arcand, L. L., & Frost, M. H. (2004). The effects of an

educational intervention on oncology nurses’ attitude, perceived knowl-

edge, and self-reported application of complementary therapies. Oncol

Nurs Forum 31, 71–78.

[27] Milden, S. P., & Stokols, D. (2004). Physicians’ attitudes and practices re-

garding complementary and alternative medicine. Behav Med 30, 73–82.

[28] Owen, D., Lewith, G., & Stephens, C. (2001). Can doctors respond to

patients’ increasing interest in complementary and alternative medicine?

Br Med J 322, 154–158.

and Radiation Sciences 39 (2008) 128-134