Introduction
Cancer is a leading cause of death in China. Traditional Chinese medicine (TCM), with its well-established theoretical framework and unique treatments, is highly popular in mainland China. Studies have reported that 68–80% of Chinese cancer patients use TCM after diagnosis.1,2 For example, in a survey of 1,950 cancer patients in southern China, 54.61% (1,065 cases) opted for Chinese herbs as their initial treatment, while 14.46% (282 cases) used Chinese herbs as monotherapy.3 In China, the integration of TCM is not merely a supplementary option; it is often considered an essential component of the overall treatment strategy, aimed at enhancing the efficacy of conventional therapies while mitigating their side effects.4,5
TCM has long played a significant role in cancer treatment. However, previous research has primarily focused on its usage rates and types, with relatively little attention given to patients’ underlying motivations for choosing TCM or their communication with Western medical teams. Patients often seek TCM to alleviate symptoms associated with cancer treatment or to strengthen their immune systems. However, the specific cultural beliefs and personal experiences influencing these choices remain poorly understood.6–8 Patients’ beliefs about the efficacy of TCM and their prior experiences with it may significantly impact their current treatment decisions.9 Understanding why patients incorporate TCM into their cancer care could enhance personalized treatment approaches and facilitate better communication between patients and healthcare providers regarding treatment options.
Many cancer patients do not discuss or disclose their use of TCM to their Western medicine (WM) oncologists.10 For example, among Chinese immigrant cancer patients in New York City, only 13% of those who used herbal medicine disclosed their TCM use to a healthcare provider, even though 75% reported having used TCM at some point since their most recent primary cancer diagnosis.1 Similarly, in Singapore, TCM use was not routinely reported to WM doctors, despite the high risk of TCM-drug interactions.11 Notably, many Chinese oncologists trained in WM incorporate TCM into their practice, such as prescribing proprietary Chinese medicines alongside Western treatments—an approach that differs from oncologists in other countries. However, the reasons behind patients’ reluctance to communicate with their oncologists about TCM remain insufficiently explored. Multiple factors, including high workloads, time constraints, and inadequate resources, may hinder effective communication between cancer patients and their healthcare providers.12 As far as the authors are aware, minimal research has been conducted to examine whether Chinese cancer patients continue seeking separate TCM consultations while receiving both WM and TCM care from the same oncologist.
This study aimed to explore the primary reasons Chinese cancer patients adopt TCM and their communication with oncologists regarding TCM use.
Materials and methods
Research design and participant recruitment
This study employed a cross-sectional design to collect data. Eligible participants met the following criteria: (1) self-identify as Chinese, (2) be 18 years or older, (3) have a cancer diagnosis, and (4) be able to read simplified Chinese. A consecutive sampling method was used to recruit participants from an oncology outpatient clinic at a teaching hospital in central China between June and December 2019. Of the 362 eligible patients, 302 (83.4%) agreed to participate. After excluding 15 participants who withdrew or returned blank questionnaires, the final sample size was 287, resulting in a 95% completion rate.
This study protocol was approved by the Institutional Review Board of the Third Xiang-Ya Hospital of Central South University, Changsha, China (No: 2019-S442), and the Institutional Review Board of Adelphi University, Garden City, USA (No: 060419). A trained research assistant, independent of the hospital’s staff and interns, facilitated participant recruitment. Participants were fully informed about the study’s purpose, their role, potential benefits and risks, and the voluntary nature of their involvement.
Measurement
Each patient completed a self-report survey lasting approximately 20–25 m. Key variables included demographic and clinical information, as well as patients’ beliefs, perceived effectiveness, usage of TCM, cancer symptom distress, and quality of life. A portion of this study’s findings, specifically related to beliefs, perceived effectiveness, and TCM use, has already been published.13
Demographic and clinical information
The demographic and clinical characteristics assessed in this study included age, gender, health insurance coverage, ethnic background, income level, marital status, education, employment status, household income, presence of comorbid conditions, cancer type and stage, recurrence or metastasis status, and treatment details.
The primary reasons for using TCM
An open-ended question was included to explore the primary reason for using TCM in cancer treatment. All patients answered this question in one sentence, as a research assistant was on-site to review and ensure the completeness of almost all questionnaires before collection.
Communication with oncologists
Patients were asked whether they consulted another doctor at a different TCM hospital or clinic. If a patient answered “yes,” they were further asked whether they informed their current oncologist about the TCM prescription provided by another TCM doctor and whether their oncologist approved the continued use of the prescribed TCM treatment.
Data analysis methods
Deidentified data were imported into IBM SPSS 29 for statistical analysis. Descriptive statistics, including frequency, range, mean, standard deviation, and median, were utilized to summarize sociodemographic and clinical characteristics, as well as patient-provider communication regarding TCM use. For qualitative data, thematic analysis was employed to categorize the primary reasons for TCM use. This method followed a six-step process: (1) familiarizing with the data, (2) generating initial codes, (3) identifying potential themes, (4) reviewing themes for coherence, (5) defining and refining themes, and (6) composing the final analysis. Two researchers, Shan Liu and Yiyuan Sun, independently read and coded patients’ primary reasons for using TCM in cancer treatment, then met to discuss and reach a consensus on the final themes. Binary logistic regression was conducted to examine factors influencing whether patients communicated with their oncologist about TCM use.
Results
Sociodemographic, clinical characteristics, and use of TCM
The study included 287 participants, with a mean age of 58.8 years (standard deviation = 11.0) at the time of the study. The median duration since cancer diagnosis was five months, with a range spanning from less than one month to 14.5 years. TCM use was widespread, with 84.3% of patients reporting the use of herbal medicine. Additionally, 144 participants (50.3%) strongly believed in the efficacy of TCM for cancer treatment, while 121 (42%) held moderate beliefs, and 22 (7.7%) had minimal confidence in its effectiveness. No patients were without beliefs. Regarding the total number of TCM modalities used, the majority (222, 77.4%) used only one modality (herbal medicine), while only 20 patients (7%) used two or more TCM modalities. The median perceived effectiveness ratings were 1.6 for herbal medicine, 1.5 for acupuncture and/or moxibustion, and 1.3 for Qigong/Taiji. The responses ranged from 0 to 3, with 0 indicating “not at all” and 3 indicating “very effective”. Table 1 lists selected sociodemographic and clinical information. Comprehensive sociodemographic and clinical details have been reported elsewhere.13
Table 1Selected sociodemographic and clinical characteristics of the subjects
| Variables | N (%) |
|---|
| Gender | |
| Female | 151 (52.6) |
| Male | 136 (47.4) |
| Hometown | |
| Rural | 165 (57.5) |
| Urban | 122 (42.5) |
| Household monthly income (CNY*) | |
| 0–2,999 | 182 (63.1) |
| 3,000–4,999 | 82 (28.6) |
| 5,000 and above | 20 (8.4) |
| Working status | |
| Working | 146 (50.9) |
| Not working | 138 (48.1) |
| Cancer type | |
| Lung cancer | 93 (32.7) |
| Gastrointestinal cancer | 83 (27.2) |
| Breast and gynecologic cancer | 76 (26.8) |
| Others | 32 (11.2) |
| Stage of cancer | |
| III and IV | 152 (59.8) |
| I and II | 71 (27.9) |
| No stage | 31 (12.2) |
| Recurrence of cancer | |
| Yes | 56 (19.5) |
| No | 231 (80.5) |
| Active treatment | |
| Yes | 199 (69.3) |
| No | 88 (30.7) |
The primary reason for choosing TCM during cancer treatment
All patients answered the question, “What is the primary reason for choosing TCM?” Most patients provided only one reason, though 26 patients provided two reasons, as both were considered equally important. This resulted in a total of 311 primary reasons. Through thematic analysis, five main categories of reasons were identified (Table 2): belief in the benefits of TCM itself, recommendations from others (family/friends or oncologists), belief in the benefits of TCM combined with WM, personal previous positive TCM experiences, and the belief that WM does not work or that patients cannot tolerate WM.
Table 2Primary reasons for TCM use among Chinese cancer patients in outpatient care
| Five themes for the primary reasons for using TCM | Sub-themes | Frequency of reasons (total 311) |
|---|
| Belief in the benefits of TCM itself | Enhancing immunity, strengthening vital qi/the body, dredging the meridians | 60 |
| Fewer side effects and less damage to the body compared to WM
gentle effect | 67 |
| Eliminating pathogens, killing cancer cells | 13 |
| Low cost. TCM is cheaper than WM | 4 |
| Recommendation from others | Family/ friends’ recommendation | 47 |
| Oncologist’s recommendation | 48 |
| Belief in the benefits of a combination of WM (WM and TCM | Adjuvant effects of TCM: e.g., decreasing the side effects of WM Preventing the recurrence and metastasis after WM treatment | 23 |
| The combination of both WM and TCM is a more comprehensive treatment | 13 |
| Personal previous TCM experiences | Patients’ previous good experiences with TCM | 25 |
| WM doesn’t work/fit | Could not tolerate further chemo or surgery or WM drugs.
WM is not working. | 11 |
Communication with oncologist
One hundred and three patients reported seeing another doctor at a specific TCM hospital or clinic for TCM prescriptions to treat cancer. The names of the TCM hospitals/clinics were also collected in the questionnaires. Among these 103 patients, 67 (65%) informed their current oncologists about the TCM prescribed by another doctor. The oncologists’ responses are listed in Table 3.
Table 3Communication between patients and oncologists regarding TCM prescriptions
| Total patients | Patients told oncologists about TCM prescriptions | Oncologists’ response to other TCM prescriptions |
|---|
| 103 | 67 (65%) | Neither approved nor disapproved (36, 55%) |
| | Disapproved (15, 23%) |
| | Approved (14, 21%) |
Before conducting the binary logistic regression analysis, potential predictors (sociodemographic factors, clinical characteristics, and use of TCM) for patient communication with their oncologist were identified using T-tests, analysis of variance, and Spearman correlation analysis according to the levels of measurement. Length of diagnosis and working status were identified as the only potential predictors of patient communication with their oncologist in these bivariate analyses. These variables were then entered into the binary logistic regression model (Table 4). After controlling for all variables, both the length of diagnosis and working status continued to significantly predict patient communication with their oncologist. Specifically, patients with a longer duration since diagnosis were more likely to communicate with their oncologists about other TCM prescriptions. Patients who were working (compared to those who were not working) were less likely to inform their oncologists about other TCM prescriptions.
Table 4Predictors of communication with oncologists regarding other TCM prescriptions
| Variables | B | χ2 | P | OR (95% CI) |
|---|
| Length of diagnosis | 0.048 | 4.437 | 0.030 | 1.048 (1.005, 1.096) |
| Workinga | −1.222 | 7.105 | 0.008 | 0.295 (0.120, 0.724) |
| constant | 0.743 | 3.632 | 0.057 | 2.102 |
Discussion
In this study, a significant proportion of patients (57.5%) originated from rural areas of Hunan Province and traveled to Changsha City, the provincial capital, for cancer treatment. The distribution of cancer types and the prevalence of advanced-stage disease among participants were consistent with cancer incidence patterns observed in other rural Chinese populations.14,15 Multiple systemic reviews on the use of TCM during cancer treatment in China concluded that combining Western and TCM therapy could significantly improve the symptoms of cancer patients and enhance survival time.16,17 The Chinese government has actively promoted the integration of TCM and WM through initiatives such as the “14th Five-Year Plan,” which outlines strategies for developing clinical practice guidelines that reflect the strengths of both medical paradigms.18 This policy framework aims to enhance the collaborative practice of TCM and WM, thereby improving patient outcomes in oncology.
The most common primary reason for patients in this study to use TCM is the belief in the benefits of TCM itself, as we already know that patients in this study demonstrated strong beliefs in TCM.13 Around 50% of patients (n = 144) in this study believed that TCM could enhance immunity, strengthen vital qi/the body, dredge the meridians, and have fewer side effects and less damage to the body compared to WM. These beliefs are consistent with findings in the literature. Among 590 cancer patients from a patient-support group in Beijing, the majority of patients expected TCM to enhance their immune system (96%), improve overall physical health (96%), and alleviate symptoms (94%).6 This belief system is intertwined with the historical and cultural significance of TCM in Chinese society, where it has been practiced for thousands of years and is deeply embedded in the healthcare practices of the population.19
The relatively new finding from this study is that recommendations played a key role in choosing TCM during cancer treatment. Ninety-five patients (33%) considered recommendations as the primary reason for using TCM for cancer. Of these, 47 listened to recommendations from family and/or friends, while 48 followed the advice of their oncologists. China adheres to Confucian familism, in which collective family decisions are strongly preferred.20,21 It seems that both collective family decisions and patient-clinician shared decision-making influenced patients’ choice of TCM in this study.
The third most common reason in this study was that patients (n = 36) believed in the benefits of combining WM and TCM. They believed that TCM could decrease the side effects of WM and prevent cancer recurrence and metastasis, a view supported by numerous studies on integrative oncology in China. In contrast, many studies conducted in Western countries show that healthcare providers are most concerned about drug-herb interactions or toxicities.22,23 In China, the situation is quite different. Most studies reported that TCM, particularly herbs, was significantly beneficial, and the majority of WM oncologists in China prescribed TCM alongside WM treatment. Both healthcare providers and patients in China consider combining WM and TCM to be more beneficial than dangerous.2
Over one-third of patients (n = 103) in this study actively sought additional TCM care from a TCM-specific hospital or clinic. The majority of these patients (n = 67) disclosed to their WM oncologists the other TCM advice/prescriptions they had received. The rate of voluntary communication (65%) with oncologists regarding other TCM prescriptions was relatively high compared to the rate of cancer patients communicating with WM oncologists about TCM in Western countries. For example, despite the high prevalence of concurrent TCM use (75%) among Chinese cancer patients undergoing conventional cancer treatment, the rate of communication with healthcare providers regarding TCM use remained notably low (13%) in New York.1 It is interesting to note that 36 oncologists (55%) neither approved nor disapproved of the TCM prescriptions by another doctor. Yang et al.24 reported that both oncologists and patients anticipated that TCM could enhance the immune system. However, cancer patients were generally more likely to believe in TCM’s effectiveness, while oncologists were more cautious, expressing greater concerns about potential adverse effects.24 Chinese oncologists may have mixed views on TCM during cancer treatment, which could explain why many of them neither approve nor disapprove of the use of additional TCM prescriptions.
In this study, we found that the longer the time since cancer diagnosis, the more likely the patient was to discuss other TCM prescriptions with their current oncologists. Multiple studies have shown that TCM users had a higher survival rate in cancer treatment compared to non-TCM users.9,17 Patients with a longer time since diagnosis or a longer survival time may feel more comfortable disclosing other TCM prescriptions to their oncologists. More studies are needed to examine the relationship between cancer survival time, TCM use, and communication between patients and clinicians. Our study also found that if a patient was working, they were less likely to discuss another TCM prescription. Possible reasons behind this, such as busy work schedules leading to less communication or the non-working status providing more time to focus on health issues, are supported by the literature.12 Since patients who are working are less willing to communicate, future research should examine the nature of patients’ work, work pressure, and medical experience during disease progression to explain why these factors affect communication behavior. This will provide more targeted guidance for clinical intervention. In Western countries, oncologists should also enhance their awareness of TCM when treating Chinese immigrant patients, fostering open discussions and exploring potential integration with WM to provide more culturally responsive and patient-centered care.
Limitations of the study
Firstly, the research sample is limited to outpatient patients in the oncology department of a teaching hospital in central China, which may not fully represent the usage and communication patterns of TCM among cancer patients in all regions and different medical environments in China. In the future, the sample size could be expanded to cover more regions and different types of medical institutions to improve the generalizability of the research results. Secondly, the study adopts a cross-sectional design, which can only reflect the situation at a specific time point and cannot determine the causal relationship between variables. Subsequent research could consider using a longitudinal study design to track the changes in TCM use and the dynamic process of communication with oncologists during cancer treatment and to deeply explore the interaction and influencing factors between the two. Thirdly, although the final sample size reached 287 cases, there were still 15 patients who withdrew or returned blank questionnaires, resulting in missing data. Although the completion rate was 95%, the reasons for the missing data were not thoroughly analyzed, which may affect the accuracy and completeness of the research results. For example, some patients may have withdrawn from the survey due to lack of interest in the research, low educational levels, difficulty understanding the questionnaire content, or poor physical condition, which may have led to certain selection bias in the sample. Fourthly, although bivariate analysis and binary logistic regression analysis were used to examine the factors that affect communication between patients and oncologists, some other potential confounding factors, such as the patient’s satisfaction with WM or the patient’s psychological concerns, were not fully considered and adjusted for. Finally, the main reasons for patients using TCM in the study were qualitatively analyzed using thematic analysis. Although this approach can reveal some key themes, the depth and detailed description of each theme may be limited. Future research could combine quantitative methods to conduct a more detailed quantitative analysis of each theme to more accurately evaluate the impact of different reasons on patients’ choice of TCM.
Conclusions
The primary reasons patients used TCM were the perceived benefits and recommendations from oncologists and family members. To enhance patient care, Chinese healthcare providers should receive training to better understand patients’ beliefs and cultural practices, enabling more personalized and culturally sensitive care. Western oncology practitioners must also understand the prevalence and motivations behind the use of TCM among Chinese immigrant patients. Such understanding fosters cultural competence and strengthens patient-provider rapport. Less than one-third of patients seek additional TCM care, and the majority of them have discussed the additional TCM treatment with their current oncologist. Addressing communication gaps through patient education programs is critical. These programs should emphasize the importance of disclosing TCM use to oncologists, thereby minimizing the risks associated with uncoordinated care. Oncologists should also be equipped to address misconceptions about TCM in a manner that respects its cultural significance, promoting a respectful and holistic approach to patient care. In addition, as highlighted in this manuscript, further research is necessary to examine the influence of family and social recommendations on treatment decisions. These findings reinforce the importance of integrating cultural practices into modern oncology to provide holistic and effective patient care.
Declarations
Acknowledgement
We thank the patients and staff at the oncology outpatient clinic for their participation and support.
Ethical statement
This study was approved by the Institutional Review Board of the Third Xiang-Ya Hospital of Central South University, Changsha, China (No: 2019-S442), and the Institutional Review Board of Adelphi University, Garden City, USA (No: 060419). All subjects gave written informed consent in accordance with the Declaration of Helsinki.
Data sharing statement
The data supporting the findings of this study are available from the corresponding author upon reasonable request.
Funding
This study was partially funded by the Adelphi University Faculty Development Grant.
Conflict of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Authors’ contributions
Conceptualization (SL, JL), methodology (SL, JL, JH), supervision (SL), writing - original draft (SL, YS, JL), writing - review & editing (SL, YS, JH), funding acquisition (SL), formal analysis (YS), data curation (YS), and investigation (JL, JH). All authors have approved the final version and publication of the manuscript.