Skip to main content
Download PDF

Conventional health care service utilization among cancer survivors that visit traditional and complementary providers in the Tromsø study: a cross-sectional study

BMC Health Services Research volume 22, Article number: 53 (2022) Cite this article

Abstract

Background

Traditional and complementary medicine (T&CM) is commonly used among cancer patients worldwide. Cancer patients in Norway mainly visit T&CM providers in addition to conventional health care services. It is not known how their utilization of T&CM providers influences their use of conventional health care services. The aim of this study was to investigate the difference between the utilization of conventional health care services among cancer survivors that visit T&CM providers and those that do not, and their associated factors.

Method

Health care service utilization data were obtained from cancer survivors 40 years and above participating in the Tromsø Study: Tromsø 7 conducted in 2015–2016. Data were collected from self-administered questionnaires. Pearson chi-square tests, Fisher exact tests, t-test, and logistic regression were used, with the significance level considered at p < 0.05.

Results

Of 1553 individuals, 10% (n = 155) reported visiting T&CM providers in the past 12 months. As both cancer survivors visiting and not visiting T&CM providers were frequent users of conventional health care, no significant differences were found in the overall use of conventional health care (98.1vs.94.5%, p = .056). Users of T&CM providers were however more likely to visit physiotherapists (40.1% vs 25%, p < .001), emergency rooms (29.2% vs 16.5%, p < .001), chiropractors (17% vs 6%, p < .001), and psychologist/psychiatrist (8.9% vs 3.4%, p < .001). They also had more frequent visits to conventional health care (11.45 vs 8.31 yearly visits, p = 0.014), particularly to general practitioners (5.21 visits vs. 3.94 visits, p = .002).

Conclusion

Results from this study show that visits to T&CM providers are associated with more visits to conventional health care services among cancer survivors. Further studies are needed to investigate the reasons for this high use behavior.

Peer Review reports

Background

Cancer is the second most common cause of death globally [1] and the leading cause of death in Norway [2]. Its incidence is relatively stable, with a small increase each year due to an aging population [3]. By the end of 2019, there were about 300,000 cancer survivors in Norway [4]. Cancer survivorship can be described as the period from diagnosis until the end of life [5]. Almost 3 out of 4 individuals with cancer survive for 5 years or more [6].

Upon cancer suspicion, the general practitioner (GP) who is often the first encounter for patients, will refer the patient to a cancer patient pathway [7]. The pathway contributes to rapid assessment and treatment initiation [8]. Different types of cancer treatments are offered, such as surgery, chemotherapy, radiotherapy, hormonal therapy, stem cell therapy, immune therapies, and palliation [9]. Differences in healthcare models [10] make international comparisons of health service utilization complicated. Norway has universal health coverage, and GP and specialist outpatient consultations are co-paid with a small user fee. Furthermore, the majority of cancer treatments are free for patients [11] and hospital admissions are also free of charge [12].

Following active treatment, cancer survivors have healthcare surveillance needs related to cancer [13,14,15], cancer treatment [13, 16], and other medical [17] and psychological comorbidities [18, 19]. Post-treatment follow-up is provided by GPs, oncologists, and other specialists, [18, 20] as well as rehabilitation providers such as physiotherapists and chiropractors [21]. Even though cancer survivors were found to have poorer physical [22] and mental health-related quality of life than non-cancer patients [23, 24], studies show that they often do not receive the appropriate follow-up care despite evidence of high-use of services [25,26,27].

Cancer survivors have on average 7 contacts to specialist health care annually, with some reaching up to 50 contacts. The total number of specialist health service contacts for cancer survivors (admissions, day treatment, outpatient visits) amounted to approximately 139,000 in 2017 [28]. In the same year, the median number of GP contacts was 5 per cancer survivor, varying from 1 to 40 compared to 2.7 contacts by non-cancer patients [17]. Furthermore, cancer survivors are sevenfold more likely to be high-users of out-of-hours centers (medical services for immediate medical assistance [29]) than non-cancer patients [30].

In addition to conventional medical therapies (CM), cancer survivors are increasingly seeking out traditional and complementary medicine (T&CM) [31,32,33]. The World Health Organization describes traditional medicine as “the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness” [34]. Further, complementary medicine is described as “a broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health-care system” [34]. In Norway, provider or non-provider-based T&CM use falls under the alternative treatment act of illness where alternative means, “health-related treatment which is practiced outside the established health services, and which is not practiced by authorized health personnel. However, treatment practiced within the scope of the established health services or by authorized health personnel is also covered by the term alternative treatment when the methods used are essentially methods that are used outside the established health services” [35]. The most common reasons given for T&CM utilization among cancer patients are improvement of physical and emotional wellbeing, as well as strengthening the body’s ability to fight cancer [33]. Earlier studies have shown that factors like gender, higher education, and poorer self-reported health [36] are predictors of T&CM use, while mental health [37], phase of survivorship [38], as well as gender [39], are predictors of high utilization of conventional health care services.

In Europe in general, and in Norway specifically, over a third of cancer survivors reported using some form of T&CM, with small variation across countries [40,41,42]. The most common therapies are dietary supplements, herbal medicines, and homeopathy, followed by spiritual and relaxation therapies [43,44,45]. Some Norwegian public hospitals have provisions for T&CM for cancer survivors [46, 47], mainly through the six Varde centers [48] that offer counseling, massage, yoga, dietary advice, and physical activities to cancer survivors and their families [49]. However, most T&CM treatments are offered outside hospitals and are paid for out-of-pocket [50].

Cancer patients in Norway mainly visit T&CM providers in addition to conventional health care services [36]. In a systematic review that looked at T&CM use in Australia, Reid et al. found that users of T&CM had higher use of conventional services [51]. In a study that looked at the health care utilization in general practice patients using T&CM, Kersnik found that they had more use of acute, primary, and secondary health care services [52]. To the authors’ knowledge, conventional health care utilization by cancer survivors that use T&CM providers has not been explored in Norway. The aim of this study is to investigate the difference between utilization of conventional health care services among cancer survivors that visit T&CM providers and those that do not, and their associated factors.

Method

The Tromsø study

The data used in this study were abstracted from The Tromsø Study: Tromsø 7. The Tromsø study is an ongoing longitudinal, cross-sectional cohort study that was initiated in 1974 to study cardiovascular risk factors in the Tromsø population. Tromsø is the largest city and municipality in Northern Norway with 73,480 inhabitants at the time of the study [53]. The study consists of 7 surveys to date. The seventh survey was conducted in 2015 – 2016 [54]. Based on the official population registry, inhabitants aged 40 years and above were invited to participate (n = 35,591) of whom 21,083 (10,009 men and 11,074 women) agreed to participate yielding an attendance rate of 65% with higher attendance rate among women (67%) than men (62.4%) [54]. Non-attendees tend to be younger and male [55]. Further detailed information about the age and sex distribution according to attendance is also available [55].

Eighteen thousand seven hundred ninety-two participants who never had cancer were excluded, as well as 655 participants who did not provide information regarding cancer. A further 83 participants that did not answer any question regarding the use of T&CM providers at all were excluded. The final study sample consisted of 1553 participants who met our inclusion criteria of self-reported present or previous cancer and information on the use of T&CM providers (Fig. 1).

Fig. 1
figure 1

Flowchart of study participants

Full size image

Data collection

Invitations to participate were sent through postal letters and included a study information brochure and a paper four-page questionnaire, Q1, and a date for a clinical examination. A username and password for a digital version of Q1, and a more comprehensive digital questionnaire (Q2), with expanded questions regarding diseases, health status, socio-economic status, use of health care services, etc., were also included [55].

Variables

The participants’ basic characteristics, state of health, and use of health care services used in this study were collected from Q1 and Q2.

Basic characteristics of participants

Age was measured continuously and reported as mean age with standard deviation (SD) per 31.12.2015. It was then grouped into three groups: “40-60 years”, “61-70 years” and “71 years and above”.

The “male” and “female” categories were collected through the national identity number. The Norwegian national identity number consists of 11 digits, where the ninth digit indicates assigned sex at birth [56].

Living arrangement was assessed through the question “Do you live with a spouse/partner?” with “Yes” and “No” as answer options.

Household income was collected through 7 response categories (“Less than NOK 150’/€ 15’”, “NOK 150’-250’/€ 15’-25’”, “NOK 251’-350’/€ 25.1’-35’”, “NOK 351’-450’/€ 35.1’-45’”, “NOK 451’-550’/ € 45.1’-55’”, “NOK 551’-750’/€ 55.1’-75’”,“NOK 751′-1000′/€ 75.1′-100′” and “more than NOK 1,000’/€ 100’”). These were re-categorized into: “low income” (less than NOK 450′/€ 45′), “middle income” (NOK 450′-750′/€ 45′-75′) and “high income” (more than NOK 750′ /€ 75′).

“What is the highest level of education you have completed?” assessed level of education with 4 categories: “Primary education (up to 10 years of schooling)”, “Secondary education: (a minimum of 3 years)”, “College/university less than 4 years”, “College/university 4 years or more”.

Health status

Data about self-reported cancer were collected from Q1 through the question: “Have you ever had, or do you have cancer?” with the alternatives “No”, “Yes, now” and “Previously, not now”.

Self-reported health was measured through a categorical variable with five categories in Q1 and a 100-point Likert scale in Q2. The question from Q1: “How do you in general consider your own health to be?” had the following answer options, “very bad”, “bad”, “neither good nor bad”, “good”, and “excellent”. These were compressed to, “bad” (very bad and bad), “neither good nor bad” and “good” (good and excellent). The question from Q2 stated; “We would like to know how good or bad your health is today” and was measured by a scale numbered from 0 to 100, with 100 representing best possible health.

For assessment of pain/discomfort and anxiety/depression, five categories were used in Q2, where respondents were to mark only one statement that described their health at the time of the survey. For “pain/discomfort” the alternatives were “I have no pain or discomfort”, “I have slight pain or discomfort”, “I have moderate pain or discomfort”, “I have severe pain or discomfort”, and “I have extreme pain or discomfort”. For anxiety/depression their alternatives were, “I am not anxious or depressed”, “I am slightly anxious or depressed”, “I am moderately anxious or depressed”, “I am severely anxious or depressed”, and “I am extremely anxious or depressed”.

Questions on self-reported health, pain/discomfort, and anxiety/depression were taken from a modified quality of life EQ-5D instrument [57].

Utilization of health care services

The use of a T&CM provider was based on a “yes” response to either of these three questions: “Have you during the past year visited a traditional healer (helper, “reader”, etc.?)”, “Have you during the past year visited an acupuncturist?” or “Have you during the past year visited a CM provider (homeopath, reflexologist, spiritual healer, etc.?)”.

To each of the questions above, participants were to report the number of times they had visited each provider. Visits to each T&CM provider were summed and presented as “mean overall number of visits to T&CM provider”.

Participants were to answer “yes” or “no” to the questions “Have you during the past 12 months visited; “a general practitioner (GP)”, “emergency room”, “psychiatrist/psychologist”, “another medical specialist than a general practitioner (GP)”, a “psychologist or psychiatrist (not at a hospital)”, “physiotherapist”, or “chiropractor”? Data on hospital visits was gathered through the “yes” or “no” questions; “Have you during the past year been admitted to a hospital?”, “Have you during the past 12 months visited a psychiatric out-patient clinic”, and “Have you during the past 12 months visited other out-patient clinics, (not psychiatric department)”. Where applicable, respondents were to report the number of times they had used each service during the last 12 months and were summed and presented as mean number of visits.

Questions on the use of T&CM providers were taken from the first level of the international CAM questionnaire (I-CAM-Q) which measures T&CM use [58].

“Overall use of conventional health care” was obtained by merging users of general practitioners, emergency rooms (ER), medical specialists, psychologists, psychiatrists, physiotherapists, chiropractors, as well as out-patient clinics and hospital admissions.

Missing data on one or more, but not all, of the health care provider questions, was interpreted as “no/not having visited the particular provider”.

Statistics and data analysis

Data were summarized using frequencies and descriptive analyses. To calculate differences between cancer survivors that visited T&CM providers and cancer survivors that did not Pearson chi-square tests, and Fisher exact tests were used for categorical values while binary logistic regression and linear regression were used for adjusted values. Continuous variables were analyzed using independent sample t-test with Levene’s test used to access homogeneity of variance in the tested variables. All calculations were conducted using SPSS for Windows (version 26.0, SPSS, Inc., Chicago, IL) and the significance level was considered at p < 0.05.

Results

Characteristics and associations of the participants

The mean age of the cancer survivors included in the study was 65.33 years. There were significantly more females than males among the cancer survivors who visited T&CM providers than those that did not, 63.9% females and 36.1% males vs 51.4% females and 48.6% males, respectively, p = .003 (Table 1). Most participants lived with a spouse/partner (72.6%), with no significant differences between cancer survivors that visited T&CM providers and those that did not (p = .437). There were no significant differences found between groups regarding the level of education (p = .213) and a marginal difference in household income, but not at a significant level, p = .050. However, a significance was found when adjusted for living with a spouse/partner, p = 0.048.

Table 1 Basic characteristics of cancer survivors that visit T&CM providers and cancer survivors that do not visit T&CM providers
Full size table

While most of the participants reported middle and high income in both groups, 41.1% reported low income among the cancer survivors who visited T&CM providers compared to only 31.2% among those that did not (Table 1). Most participants (88.4%) reported good health, with a mean score of 71.28 on a 100-point scale where 100 was the best possible health, with no significant differences between the two groups. A Pearson Chi-square test revealed that visitors to T&CM providers were more likely to have cancer currently (cancer at the time of participation, 33.5%) compared to those that did not visit T&CM providers (23.1%). This difference was significant at the p = .004 level (Table 2).

Table 2 Cancer survivors’ self-reported health and use of health care services
Full size table

Though most participants reported none/slight levels of anxiety/depression, there were significant differences between the groups. 30.7% of the cancer survivors with visits to T&CM reported moderate to severe anxiety/depression in comparison to 20.5% with no visits to T&CM providers, p = .015. Cancer currently (p = .004) and anxiety/depression (p = .015) were more common among cancer survivors that visited T&CM providers than those that did not, even though there was similar self-reported health among the two groups, p = .633 (Table 2).

Visits to T&CM providers

10% of all the participants (n = 155) reported visiting T&CM providers during the last 12 months, with a mean number of 5.64 visits (median 3, range 1-60). The most frequently visited T&CM providers were acupuncturists, visited by 4.5% of the participants (n = 69) with a mean number of visits of 7.24, followed by visits to other CM providers (4.0%, n = 62) with a mean number of visits of 4.96. Traditional healers were visited by 3.8% of the participants (n = 59) with a mean of 1.54 visits.

Visits to conventional health care services

Most of the participants (94.8%, n = 1472) had visited some form of conventional health care services in the past 12 months, with a mean/median number of visits of 8.63/5 (see Table 2 for the specific therapies).

Cancer survivors that visited T&CM providers were just as likely to have visited conventional health care services as cancer survivors that did not (98% vs. 95% respectively, p = .056). However, there was a significant positive correlation between visits to T&CM providers and a high frequency of visits to conventional health care providers, 11.45 vs 8.31 visits, p = .004. Those who had visits to T&CM providers were more likely to have visited physiotherapist (40% vs 25%, p < .001), emergency room (ER) (29% vs 17%, p < .001), chiropractors (17% vs 6%, p < .001), and psychologist/psychiatrist (9% vs 3%, p = .001). Even though there was no significant difference in having seen a GP, users of T&CM providers reported more frequent visits to GPs, 5.21 vs 3.94 visits, p = .002 (Table 2).

Total use of health care services (traditional, complementary, and conventional health care)

Three cancer survivors reported visits to T&CM providers only. A small group of cancer survivors that did not visit T&CM providers reported no visits to conventional health care services either (n = 77, 5.5%), while the majority that did not visit T&CM providers reported utilization of conventional health care services (n = 1320, 94.5%). This led to a significant difference in total use of health care services last 12 months among cancer patients that visited T&CM providers and those that did not, 100% vs 94.5% respectively, p = .003. Nearly all cancer survivors who visited T&CM providers (98.1%, n = 152), reported visits to conventional health care services with a mean number of 5.6 visits to T&CM providers and 11.45 visits to conventional health care services. Consequently, cancer survivors who visited T&CM providers had significantly more health care service visits than those that did not, with a mean of 16.04 vs 8.31 visits, respectively, p < .001 (Table 2).

In summary, these results show that visits to T&CM providers were associated with more frequent visits to conventional health services among cancer survivors. These results remained when adjusted for factors associated with higher use of T&CM providers; gender, cancer currently/previously, and anxiety/depression (Tables 1 and 2), (p = .010).

Discussion

This study revealed that visits to T&CM providers were associated with more visits to conventional health care services, particularly visits to walk-in services where a referral from a doctor is not required, but also hospital admissions. However, there were no differences in self-reported health, a driving factor in seeking and utilizing health care services [59], between those visiting T&CM providers and those that did not.

Being female was associated with more visits to conventional health care services among those visiting T&CM providers. Studies on gender differences on the utilization of health care have shown that women have higher health care utilization than men [39]. A 2019 study found that female cancer survivors had more doctor visits and hospital admissions than male cancer survivors [60]. Prior research has also shown that in women with breast cancer, the most diagnosed type of cancer among women [61], side-effects of treatments and impairments may persist up to a decade, influencing women’s use of health care services [62, 63]. However, this only partly explains the differences in health care utilization as the differences remain when adjusted for sex.

Another associated factor of increased visits to conventional health care services among T&CM users was a current cancer diagnosis. Cancer survivors with a current cancer diagnosis have been shown to have higher health care utilization than those not recently diagnosed [38]. Wong et al. found that the number of contacts to different health care providers was generally higher in the first 9 months of diagnosis [64]. Likewise, Low et al. found that a greater period post-diagnosis was associated with lower odds of following up medical appointments [65].

Contrary to other findings [66], visitors of T&CM providers of this study did not report poorer health status. Comparable self-reported health among visitors and non-visitors, and more visits to conventional services among visitors of T&CM providers could lay grounds for interpretation as high-use behavior. However, more cancer survivors visiting T&CM providers reported moderate and severe anxiety/depression. A recent study showed that severe depression was associated with increased visits to specialist health care [37]. Furthermore, depression and anxiety disorders are associated with a higher likelihood of utilization of acute health services like ER visits, hospitalization, and readmission [19, 67]. Our findings reflected similar findings.

Even though chiropractic is part of many countries’ conventional healthcare, [68], including Norway, its principles can resemble those of some complementary therapies based on concepts of holistic health, vitalism, and non-invasive manipulation to restore and preserve health [69]. Likewise, even though physiotherapy is a conventional treatment, some physiotherapists use complementary modalities like acupuncture and massage [70]. It is therefore unsurprising that more cancer survivors that visit T&CM providers visit chiropractors than cancer survivors that do not visit T&CM providers.

Though not exploring causal mechanisms, our findings show an unambiguous relationship between the use of T&CM, its associated use, and higher visitation rates to conventional health care services, in line with previous studies [36, 51, 52, 71,72,73,74].

Strengths and limitations

One of the main strengths of this study is that the data was collected outside a hospital or other health care service setting. This helps bypass the challenge of provider-patient communication, so participants likely disclosed their actual utilization of T&CM providers. For the same reason, cancer survivors who did not use conventional health care services in the last 12 months were able to participate. T&CM providers are grouped in this study, and this minimizes misinterpretation of the concepts. The study not only evaluated the utilization of different health care services, but also frequency of utilization. Although the study was conducted among a Tromsø population, the health care services evaluated, both conventional and T&CM, are available across Norway. Additionally, access to conventional health care was equal among the participants.

The study is not without limitations. Only the “healthiest” cancer survivors likely responded to the Tromsø Study 7 invitation, as shown by their self-reported health. This could affect the number of T&CM provider users participating in this study as poorer health and/or poor prognosis is associated with more use of T&CM providers [75]. The questionnaires used in this study were not validated as a whole but consisted of individual validated parts. The validity of self-reported data as such may be questioned, although self-report has been shown to be a valid estimate of health care utilization [76].

Self-reported cancer was intentionally not validated as authors were interested in participants’ perception of a cancer diagnosis. Even with studies showing high reproducibility and validity of self-reported findings from the Tromsø study, [77, 78], a possibility of a non-medical confirmation of diagnosis remains. There were no specifications of what “cancer now/cancer previously” meant. This could lead to people not choosing the most appropriate category for their phase of cancer, which would impact parts of the data analysis. Recall bias would affect the validity of health care service utilization and the frequency of use, which is integral to our study. However, this would be expected to be equally distributed among the groups and not influence between-group comparison. Prior health care utilization before diagnosis was not evaluated here and could potentially influence the interpretation of the results as a cancer diagnosis could impact utilization of health care services. This study looks at cancer survivors as a somewhat homogenous group. The reader should bear in mind that type [79], location [15], stage, time since diagnosis, and treatment [13,14,15,16, 79] lead to different health care needs for the survivor. Therefore, transferability of these findings to a cancer survivor population is affected. The study also only invited individuals 40 years and above. This could have an impact on our findings as age influences the use of health care services [80].

Implications of the findings

Our findings highlight associations of increased visits to conventional health care services among cancer survivors that visit T&CM providers. As the survivorship period lengthens due to better screening and treatment, future health care service research should focus on reasons for the high use of services. Understanding this group can lead to the development of more appropriate/integrated health care surveillance, to improve health-related quality of life for cancer survivors. This could also prove cost-effective as it can lead to the implementation of preventative measures.

Conclusion

This study provides an insight into the behavior of cancer survivors and their use of health care services. Cancer survivors that visited T&CM providers had more frequent visits to conventional health care services than those that did not, despite similarities in self-reported health.

Availability of data and materials

The raw dataset is not available due to Norwegian privacy regulations. Applicants for any data must be prepared to conform to Norwegian privacy regulations. Access to data files can be applied for upon reasonable request at tromsous@uit.no. For more information visit https://uit.no/research/tromsostudy/project?pid=709148.

Abbreviations

T&CM:

Traditional and Complementary Medicine

TM:

Traditional Medicine

CM:

Complementary Medicine

CAM:

Complementary and Alternative Medicine

GP:

General Practitioner

ER:

Emergency Room

NOK:

Norwegian Kroner

€:

Euro

SD:

Standard Deviation

REK:

Regional Committee of Medical and Health Research Ethics

UiT:

University of Tromsø

References

  1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–86. https://doi.org/10.1002/ijc.29210. Epub 2014 Oct 9.

  2. Dødsårsaksregisteret. Tall fra Dødsårsaksregisteret for 2020. https://www.fhi.no/hn/helseregistre-og-registre/dodsarsaksregisteret/tall-fra-dodsarsaksregisteret-for-2020/. Accessed 2 Feb 2021.

  3. Cancer Registry of Norway. Cancer in Norway 2018 - cancer incidence, mortality, survival and prevalence in Norway. Oslo: Cancer Registry of Norway; 2019.

    Google Scholar 

  4. Kreft i Norge. https://kreftforeningen.no/om-kreft/kreft-i-norge/. Accessed 6 Oct 2020.

  5. Marzorati C, Riva S, Pravettoni G. Who is a cancer survivor? A systematic review of published definitions. J Cancer Educ. 2017;32(2):228–37.

    Article  PubMed  Google Scholar 

  6. Nøkkeltall om kreft. https://www.kreftregisteret.no/Temasider/om-kreft/. Accessed 8 Dec 2020.

  7. Helsedirektoratet. 'Pakkeforløp for kreft'. https://www.helsenorge.no/sykdom/kreft/pakkeforlop-for-kreft/. Accessed 25 Nov 2020.

  8. Jacobs LA, Shulman LN. Follow-up care of cancer survivors: challenges and solutions. Lancet Oncol. 2017;18(1):e19–29.

    Article  PubMed  Google Scholar 

  9. Behandling. https://kreftforeningen.no/om-kreft/behandling/. Accessed 25 Nov 2020.

  10. Wallace LS. A view of health care around the world. Ann Fam Med. 2013;11(1):–84.

  11. Økonomisk støtte til pasienter. https://kreftforeningen.no/rad-og-rettigheter/okonomi/okonomisk-stotte-til-pasienter/. Accessed 25 Jan 2021.

  12. Din rett til helsehjelp. https://www.helsenorge.no/rettigheter/rett-til-helsehjelp/. Accessed 6 Nov 2020.

  13. Prince RM, Atenafu EG, Krzyzanowska MK. Hospitalizations during systemic therapy for metastatic lung cancer: a systematic review of real world vs clinical trial outcomes. JAMA Oncol. 2015;1(9):1333–9.

    Article  PubMed  Google Scholar 

  14. Hazell SZ, Mai N, Fu W, Hu C, Friedes C, Negron A, et al. Hospitalization and definitive radiotherapy in lung cancer: incidence, risk factors and survival impact. BMC Cancer. 2020;20(1):334.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Bateni SB, Gingrich AA, Stewart SL, Meyers FJ, Bold RJ, Canter RJ. Hospital utilization and disposition among patients with malignant bowel obstruction: a population-based comparison of surgical to medical management. BMC Cancer. 2018;18(1):1–10.

    Article  Google Scholar 

  16. Feliu J, Espinosa E, Basterretxea L, Paredero I, Llabrés E, Jiménez-Munárriz B, et al. Prediction of unplanned hospitalizations in older patients treated with chemotherapy. Cancers (Basel). 2021;13(6):1437.

    Article  Google Scholar 

  17. Fidjeland HL, Vistad I, Gjelstad S, Brekke M. Exploring why patients with cancer consult GPs: a 1-year data extraction. BJGP Open. 2019;3(4):bjgpopen19X101663.

    Article  PubMed Central  Google Scholar 

  18. Institute of Medicine and National Research Council. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington: The National Academies Press; 2006. https://doi.org/10.17226/11468.

  19. Nipp RD, El-Jawahri A, Moran SM, D'Arpino SM, Johnson PC, Lage DE, et al. The relationship between physical and psychological symptoms and health care utilization in hospitalized patients with advanced cancer. Cancer. 2017;123(23):4720–7.

    Article  PubMed  Google Scholar 

  20. Earle CC, Neville BA, Fletcher R. Mental health service utilization among long-term cancer survivors. J Cancer Surviv. 2007;1(2):156–60.

    Article  PubMed  Google Scholar 

  21. Montgomery M, Huang S, Cox CL, Leisenring WM, Oeffinger KC, Hudson MM, et al. Physical therapy and chiropractic use among childhood cancer survivors with chronic disease: impact on health-related quality of life. J Cancer Surviv. 2011;5(1):73–81.

    Article  PubMed  Google Scholar 

  22. Fagervoll JS, Sund AM, Zeltzer LK, Ådnanes M, Jensberg H, Eikemo TA, et al. Health-related quality of life and psychological distress in young adult survivors of childhood cancer and their association with treatment, education, and demographic factors; 2017.

    Google Scholar 

  23. Rodriguez JL, Hawkins NA, Berkowitz Z, Li C. Factors associated with health-related quality of life among colorectal cancer survivors. Am J Prev Med. 2015;49(6):S518–27.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Weaver KE, Forsythe LP, Reeve BB, Alfano CM, Rodriguez JL, Sabatino SA, et al. Mental and physical health–related quality of life among US cancer survivors: population estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Prev Biomark. 2012;21(11):2108–17.

    Article  Google Scholar 

  25. Salloum RG, Hornbrook MC, Fishman PA, Ritzwoller DP, O'Keeffe Rossetti MC, Elston Lafata J. Adherence to surveillance care guidelines after breast and colorectal cancer treatment with curative intent. Cancer. 2012;118(22):5644–51.

    Article  PubMed  Google Scholar 

  26. Keating NL, Landrum MB, Guadagnoli E, Winer EP, Ayanian JZ. Surveillance testing among survivors of early-stage breast cancer. J Clin Oncol. 2007;25(9):1074–81.

    Article  PubMed  Google Scholar 

  27. Elston Lafata J, Simpkins J, Schultz L, Chase GA, Johnson CC, Yood MU, et al. Routine surveillance care after cancer treatment with curative intent. Med Care. 2005;43(6):592–9.

    Article  PubMed  Google Scholar 

  28. Fremtidens kreftkostnader - Utvikling i kreftkostnader over tid — Årsaker og utfordringer. Edited by Oslo Economics. 2019. https://osloeconomics.no/rapport-om-fremtidens-kreftkostnader/.

  29. Legevakt. Helsedirektoratet. https://www.helsenorge.no/hjelpetilbud-i-kommunene/legevakt/. Accessed 3 Nov 2021.

  30. Sandvik H, Hunskaar S. Frequent attenders at primary care out-of-hours services: a registry-based observational study in Norway. BMC Health Serv Res. 2018;18(1):1–10.

    Article  Google Scholar 

  31. Buckner C, Lafrenie R, Dénommée J, Caswell J, Want D. Complementary and alternative medicine use in patients before and after a cancer diagnosis. Curr Oncol. 2018;25(4):e275.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Horneber M, Bueschel G, Dennert G, Less D, Ritter E, Zwahlen M. How many cancer patients use complementary and alternative medicine: a systematic review and metaanalysis. Integr Cancer Ther. 2012;11(3):187–203.

    Article  PubMed  Google Scholar 

  33. Wode K, Henriksson R, Sharp L, Stoltenberg A, Nordberg JH. Cancer patients’ use of complementary and alternative medicine in Sweden: a cross-sectional study. BMC Complement Altern Med. 2019;19(1):62.

    Article  PubMed  PubMed Central  Google Scholar 

  34. WHO. Traditional, Complementary and Integrative Medicine. https://www.who.int/health-topics/traditional-complementary-and-integrative-medicine#tab=tab_1. Accessed 2 Nov 2020.

  35. Act No. 64 of 27 June 2003 relating to the alternative treatment of disease, illness, etc. https://app.uio.no/ub/ujur/oversatte-lover/data/lov-20030627-064-eng.pdf. Accessed 3 Nov 2020.

  36. Hanssen B, Grimsgaard S, Launsø L, Fønnebø V, Falkenberg T, Rasmussen NK. Use of complementary and alternative medicine in the Scandinavian countries. Scand J Prim Health Care. 2005;23(1):57–62.

    Article  PubMed  Google Scholar 

  37. Yim J, Shaw J, Viney R, Arora S, Ezendam N, Pearce A. Investigating the association between self-reported comorbid anxiety and depression and health service use in cancer survivors. Pharmacoeconomics. 2021;39(6):681–90.

    Article  PubMed  Google Scholar 

  38. Maddams J, Utley M, Møller H. Levels of acute health service use among cancer survivors in the United Kingdom. Eur J Cancer. 2011;47(14):2211–20.

    Article  PubMed  Google Scholar 

  39. Thompson AE, Anisimowicz Y, Miedema B, Hogg W, Wodchis WP, Aubrey-Bassler K. The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study. BMC Fam Pract. 2016;17(1):38.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Jeppesen EJL. Komplementær og alternativ behandling for pasienter med kreft. In: Rapport fra Kunnskapssenteret nr 12-2011. Oslo: Nasjonalt kunnskapssenter for helsetjenesten; 2011.

    Google Scholar 

  41. Kristoffersen AE, Norheim AJ, Fønnebø VM. Complementary and alternative medicine use among Norwegian cancer survivors: gender-specific prevalence and associations for use. Evid Based Complement Alternat Med. 2013;2013:318781.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Molassiotis A, Fernandez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, et al. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005;16(4):655–63.

    Article  CAS  PubMed  Google Scholar 

  43. Bennett M, Lengacher C. Use of complementary therapies in a rural cancer population. In: Oncology Nursing Forum-Oncology Nursing Society: 1999. Pittsburgh: Oncology Nursing Society; 1999. p. 1287–94.

    Google Scholar 

  44. Richardson MA, Sanders T, Palmer JL, Greisinger A, Singletary SE. Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. J Clin Oncol. 2000;18(13):2505–14.

    Article  CAS  PubMed  Google Scholar 

  45. Bernstein BJ, Grasso T. Prevalence of complementary and alternative medicine use in cancer patients. Oncology (Williston Park, NY). 2001;15(10):1267–72 discussion 1272.

    CAS  Google Scholar 

  46. Salomonsen LJ, Skovgaard L, la Cour S, Nyborg L, Launso L, Fonnebo V. Use of complementary and alternative medicine at Norwegian and Danish hospitals. BMC Complement Altern Med. 2011;11:4.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Jacobsen R, Fønnebø V, Foss N, Kristoffersen AE. Use of complementary and alternative medicine within Norwegian hospitals. BMC Complement Altern Med. 2015;15(1):275.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Vardesenteret. https://kreftforeningen.no/vardesenteret/. Accessed 8 Dec 2020.

  49. Tilbud og aktiviteter. https://kreftforeningen.no/vardesenteret/tilbud/. Accessed 8 Dec 2020.

  50. Kristoffersen AE, Norheim AJ, Fønnebø VM. Any difference? Use of a CAM provider among cancer patients, coronary heart disease (CHD) patients and individuals with no cancer/CHD. BMC Complement Altern Med. 2012;12(1):1–8.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Reid R, Steel A, Wardle J, Trubody A, Adams J. Complementary medicine use by the Australian population: a critical mixed studies systematic review of utilisation, perceptions and factors associated with use. BMC Complement Altern Med. 2016;16(1):1–23.

    Article  Google Scholar 

  52. Kersnik J. Predictive characteristics of users of alternative medicine. Schweiz Med Wochenschr. 2000;130(11):390–4.

    CAS  PubMed  Google Scholar 

  53. Fylkesmannen i Troms. Folketallsutviklingen i Troms i 2016. https://www.statsforvalteren.no/siteassets/utgatt/fm-troms/bilder-fmtr/jusa/folketallsutviklingen-i-troms-2016-rettet.pdf. Accessed 5 Feb 2021.

  54. The seventh survey of the Tromsø Study. https://uit.no/research/tromsostudy/project?pid=708909. Accessed 5 Feb 2021.

  55. Jacobsen BK, Eggen AE, Mathiesen EB, Wilsgaard T, Njølstad I. Cohort profile: the Tromso study. Int J Epidemiol. 2012;41(4):961–7.

    Article  PubMed  Google Scholar 

  56. Norwegian national identity number. The Norwegian Tax Administration. https://www.skatteetaten.no/en/person/national-registry/birth-and-name-selection/children-born-in-norway/national-id-number/. Accessed 2 Feb 2020.

  57. Devlin N, Parkin D, Janssen MF. An introduction to EQ-5D instruments and their applications; 2020. p. 1–22.

    Google Scholar 

  58. Quandt SA, Verhoef MJ, Arcury TA, Lewith GT, Steinsbekk A, Kristoffersen AE, et al. Development of an international questionnaire to measure use of complementary and alternative medicine (I-CAM-Q). J Altern Complement Med. 2009;15(4):331–9.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Xu F, Johnston JM. Self-rated health and health service utilization: a systematic review. Int J Epidemiol. 2015;44(suppl_1):i180.

    Article  Google Scholar 

  60. Rana RH, Alam K, Gow J, Ralph N. Predictors of health care use in Australian cancer patients. Cancer Manag Res. 2019;11:6941.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Ferlay J, Colombet M, Soerjomataram I, Parkin DM, Piñeros M, Znaor A, et al. Cancer statistics for the year 2020: an overview. Int J Cancer. 2021. https://doi.org/10.1002/ijc.33588.

  62. DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500–15.

    Article  PubMed  Google Scholar 

  63. Rietman JS, Dijkstra PU, Debreczeni R, Geertzen JH, Robinson DP, De Vries J. Impairments, disabilities and health related quality of life after treatment for breast cancer: a follow-up study 2.7 years after surgery. Disabil Rehabil. 2004;26(2):78–84.

    Article  PubMed  Google Scholar 

  64. Lo-Fo-Wong DN, de Haes HC, Aaronson NK, van Abbema DL, Admiraal JM, den Boer MD, et al. Health care use and remaining needs for support among women with breast cancer in the first 15 months after diagnosis: the role of the GP. Fam Pract. 2019;37(1):103–9.

    Article  PubMed Central  Google Scholar 

  65. Low CA, Beckjord E, Bovbjerg DH, Dew MA, Posluszny DM, Schmidt JE, et al. Correlates of positive health behaviors in cancer survivors: results from the 2010 LIVESTRONG survey. J Psychosoc Oncol. 2014;32(6):678–95.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Steinsbekk A, Adams J, Sibbritt D, Johnsen R. Complementary and alternative medicine practitioner consultations among those who have or have had cancer in a Norwegian total population (Nord-Trøndelag Health Study): prevalence, socio-demographics and health perceptions. Eur J Cancer Care. 2010;19(3):346–51. https://doi.org/10.1111/j.1365-2354.2008.01049.x.

  67. Mausbach BT, Irwin SA. Depression and healthcare service utilization in patients with cancer. Psychooncology. 2017;26(8):1133–9.

    Article  PubMed  Google Scholar 

  68. World Health Organization. WHO guidelines on basic training and safety in chiropractic. World Health Organization; 2005. https://apps.who.int/iris/handle/10665/43352.

  69. Gatterman MI. Foundations of chiropractic: subluxation. St. Louis: Elsevier Health Sciences; 2005.

  70. Hughes C, Quinn F, Baxter G. Complementary and alternative medicine: perception and use by physiotherapists in the management of low back pain. Complement Ther Med. 2011;19(3):149–54.

    Article  CAS  PubMed  Google Scholar 

  71. Busato A, Dönges A, Herren S, Widmer M, Marian F. Health status and health care utilisation of patients in complementary and conventional primary care in Switzerland—an observational study. Fam Pract. 2005;23(1):116–24.

    Article  PubMed  Google Scholar 

  72. Al-Windi A. Determinants of complementary alternative medicine (CAM) use. Complement Ther Med. 2004;12(2-3):99–111.

    Article  PubMed  Google Scholar 

  73. Li JZ, Quinn JV, McCulloch CE, Jacobs BP, Chan PV. Patterns of complementary and alternative medicine use in ED patients and its association with health care utilization. Am J Emerg Med. 2004;22(3):187–91.

    Article  CAS  PubMed  Google Scholar 

  74. Strömbom Y, Magnusson P, Karlsson J, Fredrikson M. Health-related quality of life among frequent attenders in Swedish primary care: a cross-sectional observational study. BMJ Open. 2019;9(7):e026855.

    Article  PubMed  PubMed Central  Google Scholar 

  75. Kristoffersen AE, Fønnebø V, Norheim AJ. Do cancer patients with a poor prognosis use complementary and alternative medicine more often than others? J Altern Complement Med. 2009;15(1):35–40.

    Article  PubMed  Google Scholar 

  76. Reijneveld SA, Stronks K. The validity of self-reported use of health care across socioeconomic strata: a comparison of survey and registration data. Int J Epidemiol. 2001;30(6):1407–14.

    Article  CAS  PubMed  Google Scholar 

  77. Engstad T, Bonaa KH, Viitanen M. Validity of self-reported stroke: the Tromso study. Stroke. 2000;31(7):1602–7.

    Article  CAS  PubMed  Google Scholar 

  78. Lundblad MW, Jacobsen BK. The reproducibility of self-reported age at menarche: the Tromsø study. BMC Womens Health. 2017;17(1):62.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Johansson BB, Holmberg L, Berglund IG, Sjödén P, Glimelius BL. Determinants of cancer patients’ utilization of hospital care within two years after diagnosis. Acta Oncol. 2004;43(6):536–44.

    Article  PubMed  Google Scholar 

  80. Gerich J, Moosbrugger R, Heigl C. Health literacy and age-related health-care utilisation: a multi-dimensional approach. Ageing Soc. 2020:1–22. https://doi.org/10.1017/S0144686X20001609.

Download references

Acknowledgments

We thank the people of Tromsø and the Tromsø Study for giving data to this study.

Funding

The publication charges for this article have been funded by a grant from the publication fund of UiT The Arctic University of Norway. No further funding was received.

Author information

Authors and Affiliations

  1. National Research Center in Complementary and Alternative Medicine (NAFKAM), Faculty of Health Sciences, Department of Community Medicine, UiT The Arctic University of Norway, N-9037, Tromsø, Norway

    Kiwumulo Nakandi, Dana Mora, Trine Stub & Agnete E. Kristoffersen

Authors
  1. Kiwumulo Nakandi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dana Mora
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Trine Stub
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Agnete E. Kristoffersen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

KN and AEK conceived the study, conducted the initial and final analyses, and drafted the initial version of the paper. DM and TS gave input on how to interpret and structure the findings, reviewed subsequent versions. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Kiwumulo Nakandi.

Ethics declarations

Ethics approval and consent to participate

The study has been approved by the Regional Committee for Medical and Health Research Ethics, REK nord, (REK 2014/940) and was conducted in accordance with the Declaration of Helsinki Ethical Principles involving human subjects.

Written informed consent was obtained from all participants. This sub-project was approved by the Norwegian Centre for Research Data, NSD, under the reference number 750871.

Consent for publication

Not applicable.

Competing interests

None.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Nakandi, K., Mora, D., Stub, T. et al. Conventional health care service utilization among cancer survivors that visit traditional and complementary providers in the Tromsø study: a cross-sectional study. BMC Health Serv Res 22, 53 (2022). https://doi.org/10.1186/s12913-021-07445-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12913-021-07445-6

Keywords

  • Cancer
  • Health service
  • Complementary and alternative medicine
  • CAM
  • Traditional and complementary medicine
  • T&CM
  • Complementary therapies
  • Norway
  • The Tromsø study

BMC Health Services Research

ISSN: 1472-6963

Contact us