Research Article Use of Self-Care and Practitioner-Based Forms of Complementary and Alternative Medicine before and after a Diagnosis of Breast Cancer

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1 Hindwi Publishing Corportion Evidence-Bsed Complementry nd Alterntive Medicine Volume 2013, Article ID , 16 pges Reserch Article Use of Self-Cre nd Prctitioner-Bsed Forms of Complementry nd Alterntive Medicine before nd fter Dignosis of Brest Cncer Aliss R. Link, 1 Mrilie D. Gmmon, 2 Judith S. Jcobson, 1 Pge Abrhmson, 2 Ptrick T. Brdshw, 3 Mry Beth Terry, 1 Susn Teitelbum, 4 Alfred Neugut, 1,5 nd Hether Greenlee 1,5 1 Deprtment of Epidemiology, Milmn School of Public Helth, Columbi University, 722 West 168th Street, New York, NY 10032, USA 2 Deprtment of Epidemiology, University of North Crolin, 2101 McGvrn-Greenberg Hll, CB No Chpel Hill, NC 27599, USA 3 Deprtment of Nutrition, Deprtment of Epidemiology, University of North Crolin, 2200 McGvrn-Greenberg Hll, CB No Chpel Hill, NC 27599, USA 4 Deprtment of Preventive Medicine, Mount Sini School of Medicine, 17 E 102nd Street, New York, NY 10029, USA 5 Deprtment of Medicine, College of Physicins nd Surgeons, Columbi University, 722 West 168th Street, New York, NY 10032, USA Correspondence should be ddressed to Aliss R. Link; liss.link@gmil.com Received 17 April 2013; Revised 21 June 2013; Accepted 7 July 2013 Acdemic Editor: Holger Crmer Copyright 2013 Aliss R. Link et l. This is n open ccess rticle distributed under the Cretive Commons Attribution License, which permits unrestricted use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Purpose. We exmine fctors ssocited with self-cre, use of prctitioner-bsed complementry nd lterntive medicine (CAM), nd their timing in cohort of women with brest cncer. Methods. Study prticipnts were women with brest cncer who prticipted in the Long Islnd Brest Cncer Study Project. Self-cre is defined s the use of multivitmins, single vitmins, botnicls, other dietry supplements, mind-body prctices, specil diets, support groups, nd pryer. Within ech modlity, study prticipnts were ctegorized s continuous users (before nd fter dignosis), strters (only fter dignosis), quitters (only before dignosis), or never users. Multivrible logistic regression ws used for the min nlyses. Results. Of 764 women who provided complete dt, 513 (67.2%) initited new form of self-cre following brest cncer dignosis. The most populr modlities were those tht re ingestible, nd they were commonly used in combintion. The strongest predictor of continuous use of one type of self-cre ws continuous use of other types of self-cre. Helthy behviors, including high fruit/vegetble intke nd exercise, were more strongly ssocited with continuously using self-cre thn strting self-cre fter dignosis. Conclusions. Brest cncer dignosis ws ssocited with subsequent behviorl chnges, nd the mjority of women undertook new forms of self-cre fter dignosis. Few women discontinued use of modlities they used prior to dignosis. 1. Introduction Over the pst two decdes, the use of complementry nd lterntive medicine (CAM) prctices modlities used for helth nd wellbeing tht re considered outside the relm of conventionl medicine hs been stedily rising in the United Sttes [1 3]. Ptients with cncer nd other chronic diseses re more likely to use CAM thn re those without chronic illness [4], nd brest cncer ptients re more likely to use CAM thn ptients with colon [5], prostte [5], or gynecologicl [6] cncers. Estimtes of CAM use mong women with brest cncer rnge from 48% to 86% [7 9]. The frequency of CAM use mong brest cncer ptients is not surprising in the light of the physicl nd emotionl burden tht brest cncer entils. Brest cncer ptients report using CAM for recovery, heling, improving helth, strengthening the immune system, reducing side effects of cncer tretments, reducing physicl nd psychologicl

2 2 Evidence-Bsed Complementry nd Alterntive Medicine distress [10], nd incresing feelings of control [10, 11]. CAM encompsses vst rry of modlities, some of which require CAM prctitioner or provider, commitment of ptient nd prctitioner time, nd prctitioner pyment; only some sttes in the US mndte helth insurnce coverge of CAM prctitioners. Other modlities fll into the ctegory of self-cre, rnge of ctivities in which individuls engge utonomously nd regulrly to mintin or improve helth, beuty, spiritul connection, or generl wellbeing. Due to the fct tht lrge numbers of cncer ptients use CAM, it is incresingly importnt to develop epidemiologicl methods to both describe nd nlyze CAM use ptterns. Historiclly, most nlyses of CAM use mong cncer popultions hve focused on use fter dignosis. However, it is importnt to consider postdignosis CAM use in context of the ptient s behvior prior to cncer dignosis. In this pper, we present novel pproch to describe chnges in CAM use before nd fter brest cncer dignosis. Furthermore, since CAM encompsses wide vriety of individul modlities tht hve different implictions on pthophysiology nd tretment course, we propose tht it is importnt to consider chnges in CAM use cross specific ctegories of CAM. Using follow-up dt from the Long Islnd Brest Cncer Study Project, we nlyzed predictors of self-cre prctices nd prctitioner-bsed modlities of CAM before nd fter first brest cncer dignosis. Most studies of CAM use do not seprte self-cre (i.e., modlities tht ptients cn ccess nd use on their own) from prctitioner-bsed modlities. Our primry im ws to nlyze the determinnts of self-cre versus prctitioner-bsed modlities; other ims were to determine how use of these modlities chnged fter the brest cncer dignosis nd how use of self-cre nd prctitionerbsed modlities might be ssocited with helth-relted behviors such s exercise, smoking, nd lcohol intke. 2. Methods 2.1. Prticipnts. The Long Islnd Brest Cncer Study Project (LIBCSP) originted s popultion-bsed, csecontrol study of women residing in Nssu or Suffolk county, New York, USA [12]. The LIBCSP ws federlly mndted to investigte the possibility of ssocitions between environmentl toxicnts nd the high incidence of brest cncer on Long Islnd. Eligible cses were women dignosed with first primry in situ or invsive brest cncer between August 1996 nd July Potentil cses were identified through frequent communiction with pthology deprtments t every hospitl on Long Islnd, nd 3 mjor tertiry cre fcilities in New York City. The physicins of potentilly eligiblewomenconfirmeddignosesndgvepermission to contct eligible cses; 82.1% of eligible subjects with consenting physicin greed to prticipte in the study. The study enrolled 1508 cses [12]. Between 2002 nd 2004, follow-up study ws conducted mong the LIBCSP cses [13]. Of the 1414 cses (93.8%) who greed to future contct, 1098 (77.4%) prticipted in the follow-up, but 334 (23.6%) completed only short-form interview or hd proxy interview (completed by reltive on their behlf). Only those who completed the full followup telephone interview [14] were included in the nlysis reported here. Institutionl review bords t ll prticipting institutions pproved the study protocol, nd ll prticipnts provided written informed consent prior to the in-person bseline interview nd verbl consent prior to the telephone followup interview Dt Collection Bseline Questionnire. The bseline questionnire ws dministered to cses by trined interviewer in the respondent shomesoonfterfirstprimrybrestcncerdignosis (men = 89 dys mong the subsmple with full followup telephone interview). Women responded to detiled questionnire tht took on verge 100 minutes to complete nd covered known nd suspected risk fctors for brest cncer, including environmentl exposures, reproductive nd menstrul histories, medicl history, nd demogrphic chrcteristics. Women were lso sked bout lifestyle nd helth behviors cross the life course, including cigrette nd lcohol use [12] nd recretionl physicl ctivity using modifiction of the instrument developed by Bernstein et l. [15]. Dt on usul dietry intke in the yer prior to the bseline interview were collected using self-completed modified Block food frequency questionnire [16] Follow-Up Questionnire. The full-length follow-up questionnire, which ws dministered by telephone by trined interviewer nd lsted bout 45 minutes, ssessed tretment detils for the first primry brest cncer dignosis, fctors ssocited with brest cncer prognosis, postdignosis medicl history, nd helth behviors. The followup interview included detiled questions bout CAM used, specificlly, before brest cncer dignosis, fter dignosis, nd during brest cncer tretment. The CAM questionnire covered use of multivitmins, single vitmins, minerls, herbs nd botnicls, other dietry supplements, mind-body prctices, support groups, pryer nd specil diets, nd visits to CAM prctitioners [14]. Tble 1 lists the single gents nd modlities within ech ctegory Medicl Records. Medicl records obtined t the time of bseline nd follow-up were used to confirm disese chrcteristics nd tretment course. For cse women for whom complete medicl records were vilble (n = 598), informtion bstrcted from the records ws in excellent greement (κ = ) with the women s responses to questions bout tretment in the follow-up questionnire; we therefore relied on the follow-up questionnire dt for informtion bout cncer tretment [13] Dt Anlysis Dt Ctegoriztion. In this nlysis, we defined selfcresuseofmultivitmins,singlevitmins,botnicls,other

3 Evidence-Bsed Complementry nd Alterntive Medicine 3 Tble 1: List of individul modlities within ech ctegory of self-cre nd prctitioner-bsed CAM, reported in the LIBCSP follow-up interview ( ). Ctegory Multivitmins Single vitmins Botnicls Other dietry supplements Products Mind-body Specil diets Prctitioner-bsed Individul modlities Multivitmin with minerls, Multivitmin without minerls, ntioxidnt combintion type (A, C, E), stress-tbs, women s formul (MV), multivitmin with Herbs, other multi-vitmin Vitmin A with bet crotene, vitmin A without bet crotene, bet crotene (lone), vitmin B1/thimin, vitmin B3/nicin, vitmin B6, vitmin B12, B complex vitmins, vitmin C, vitmin D nd clcium, vitmin D, vitmin E (lph-tocopherol), mgnesium, clcium, rolids, tums, dolomite, folic cid/folte, selenium, iron, zinc, lutein, chromium Aloe ver, Ashwgndh, Atrctylodes, Astrglus root, Bee pollen, Bilberry, Blck cohosh, clue cohosh, blue-green lge, borge seed oil, bromelin, Burdock, Clendul, Cscr sgrd, ct s clw, chmomile, chste tree, Vitex, or chste berry, crnberry, Dndelion,dongqui,Echince,elder,ephedr,essicor floressence, evening primrose oil, Fennel, feverfew, grlic, ginger, Ginkgo bilob, ginseng, goldensel, grpe seed oil, green te, hwthorne, horse chestnut, kv kv, kelp, lvender, mitke mushroom, milk thistle, Nettle,pud rco, pronthocynidin, pycnogenol, red clover, reishi mushroom, shiitke mushroom, slippery elm, soy supplements or isoflvones, St. John s Wort, vlerin, wild ym, willow brk Fiber supplement, coenzyme Q10 (CoQ10),shrk crtilge, meltonin, flx seed oil, fish oil/epa/omeg-3/cod liver oil, glucosmine, chondroitin, DHEA, cidophilus, rginine, leucine Medittion, visuliztion/imgery, ti chi, qi gong, yog, dnce therpy, rt therpy, music therpy, poetry therpy or journling, biofeedbck Vegn diet, vegetrin diet, no red met, orgnic fruits nd vegetbles, mcrobiotic diet, low-ft diet, high-fiber diet, chnged your consumption of soy products, diet or progrm designed to lose weight Mssge, wter tretment or hydrotherpy, reiki, heling touch, or other energy therpy, bioeletromgnetic therpy, cupuncture, yurvedic medicine, Chinese medicine, chiroprctic therpy, herblist, homeopthy, ntive mericn Medicine, nturopthic physicin, nutritionist or dieticin, tibetn, other CAM prctitioner, hypnosis, psychotherpy dietry supplements, mind-body prctices, pryer, support groups, nd use of specil diets. We distinguished self-cre from visits to CAM prctitioners, which usully entil time commitment, n encounter, nd fee for the services of nother individul. Within ech ctegory or type of self-cre nd prctitionerbsedcam,wegroupedthewomeninto4distinctgroups bytimingofuseinreltiontotheirbrestcncerdignosis: continuous users used 1 modlity within the ctegory both before nd fter dignosis; strters strted using 1 modlity from within ctegory fter dignosis nd hd never used nything from tht ctegory before dignosis; quitters stopped using everything they hd previously used in tht ctegory fter dignosis; nd never users never used nymodlitywithinctegory Sttisticl Anlyses. First, univrite regression nlyses were performed to identify the vribles tht were independently ssocited with use of self-cre/prctitioner-bsed CAM before nd fter dignosis. Then, 2 sets of multivrible logistic regression models were developed to identify fctors independently ssocited with (1) continuously using nd (2) strting to use ctegory of modlity fter dignosis [17]. Age, income, eduction, nd stge t dignosis s reported t the bseline interview, were selected s priori confounders. All fctors found to be sttisticlly ssocited with lwys using CAM before nd fter dignosis (with P vlue of <0.05 in t lest one of the ctegories) were included in the full models so tht the odds rtios would be comprble cross ll models. The independent vribles tested in univrite regression models tht were not included in the finl multivrible models (P > 0.05) were orl contrceptive use, hormone replcement therpy, stge t dignosis, nd hormone receptor sttus. The finl models were djusted for ge t dignosis, rce, income, eduction, body mss index (BMI, defined s weight in kilogrms divided by height in meters squred), helth behviors (including mmmogrm within 5 yers prior to dignosis, cigrette smoking, lcohol use, physicl ctivity, nd fruit nd vegetble intke) s reported t bseline, continuoususeofothercamctegories,ndfirstcourseofbrest cncer tretment type, s reported t the follow-up interview. 3. Results Among LIBCSP cses, 764 completed the full follow-up questionnire nd were included in this nlysis. Differences

4 4 Evidence-Bsed Complementry nd Alterntive Medicine betweenthemndthe724whodidnothvefullfollowup dt hve been previously reported [14]. Among those included in this nlysis (n = 764), men ge t dignosis ws 56.3yers;94%werenon-Hispnicwhite;59%hdnnnul householdincomebove$50,000;61%hdttendedcollege; nd 44.1% hd never smoked cigrettes. At bseline, 36.8% te t lest 35 servings of fruits nd vegetbles per week, nd 23.7% exercised t lest 2.7 hours week (Tble 2) Use of Self-Cre nd Prctitioner-Bsed CAM before nd fter Dignosis. More thn 95% of our study prticipnts used self-cre fter dignosis; most did so before s well. About 75% used multi- or single vitmin, nd bout 40% used pryer, botnicls, or prctitioner-bsed CAM (dt not shown) Continuous Users. Both before nd fter dignosis, 55.5% of women used multivitmins; 57.3% used single vitmins; 35.5% used pryer, 29.2% botnicls, 21.6% specil diets, nd 16.6% mind-body prctices. 25.4% of women used t lest one prctitioner-bsed modlity both before nd fter dignosis (Tble 3) Strters. 67.2% of women strted some form of selfcre fter dignosis. The modlities most commonly strted fter dignosis were multivitmins (20.5%), single vitmins (19.1%), support groups (17.4%), other dietry supplements (12.3%), nd mind-body prctices (11.6%). 14.8% of women begn using prctitioner-bsed modlity fter dignosis. The prticulr modlities most commonly initited fter brest cncer dignosis were clcium (25.3%), vitmin E (22.6%), green te (20.9%), support groups (17.4%), vitmin C (16.5%), low-ft diet (11.0%), nd glucosmine (10.3%) (Tble 3) Quitters. 10.6% of women stopped using multivitmins fter dignosis. The most common modlities stopped fter dignosis were iron (11.9%) nd vitmin C (9.3%). A smll proportion of women (7.2%) stopped using ll prctitionerbsed modlities. Chiroprctic, the most common everused prctitioner-bsed modlity (210 users or 27.5%), ws the modlity most commonly discontinued fter dignosis (14.5%) (Tble 3) CAM Use nd Self-Cre during Adjuvnt Tretment Use during Tretment. As previously reported [14], ll 764 respondents who prticipted in the complete followup study reported undergoing surgery for their brest cncer; 310 (40.6%) lso received chemotherpy, 464 (60.7%) rdition therpy, nd 462 (60.5%) tmoxifen tretment. The forms of self-cre most frequently used during chemotherpy were pryer (48.7%), multivitmins (37.42%), single vitmins (33.2%), mind-body (28.4%), nd support groups (23.9%); 21.6% of women used prctitioner-bsed modlities. The forms of self-cre most commonly used during rdition therpy were multivitmins (55.2%), single vitmins (48.7%), pryer (39.9%), mind-body (31.0%), nd specil diets (29.0%); 17.4% of women used prctitioner-bsed modlities. The self-cre modlities most commonly used during tmoxifen tretment were multivitmins (80.7%), pryer (38.1%), single vitmins (23.6%), mind-body (22.9%), nd specil diets (26.0%); 26.0% of women used prctitioner-bsed modlities (Tble 4) Fctors Associted with Self-Cre nd Prctitioner-Bsed CAMbeforendfterDignosis Demogrphics. Higher eduction ws strong predictorofbothstrtingmind-bodyprcticesfterdignosisnd using such prctices before nd fter dignosis (continuous use); eduction ws lso ssocited with continuous use of botnicls nd dietry supplements. Income ws ssocited directly with continuous single vitmin use nd inversely with continuous use of other dietry supplements (Tble 5); income ws inversely ssocited with beginning prctitionerbsed CAM fter dignosis (Tble 6). Rce ws the demogrphic vrible most strongly ssocited with strting selfcre fter dignosis; women of minority rce/ethnicity were bout3.5timesslikelytostrtusingbotniclsorspecil dietssnon-hispnicwhites(tble 6). Younger women nd women with more eduction were more likely thn older nd less educted women to strt using noningestible forms of self-cre or prctitioner-bsed CAM fter dignosis (Tble 6) Helth Behviors. Helthy behviors reported t the bseline interview were more strongly ssocited with continuously using self-cre thn with strting self-cre fter dignosis with first primry brest cncer. Those with the highest level of physicl ctivity (>2.7 hr/week) were 2.4 times s likely to use mind-body modlities before nd fter dignosis s those who reported no physicl ctivity. Women who hd mmmogrm within 5 yers before dignosis were 2 times s likely to be continuous users of single vitmins swomenwhohdnothdrecentmmmogrm.women whoseintkeoffruitsndvegetbleswshighwere50%more likely to use multivitmins nd/or botnicls continuously thn those whose intke ws low (Tble 5). Current smokers hd 60% lower odds of following specil diet before nd fter dignosis thn never smokers (Tble 5). Women with body mss index (BMI) 30hd 60% lower odds of lwys using other dietry supplements nd women with BMI between hd 50% lower odds of continuously using mind-body prctices thn women with BMI<25.WomenwithBMI 30were twice s likely to strtmind-bodyprcticesswomenwithbmi< 25 but nerly 80% less likely to strt specil diet (Tble 6). High BMI ws lso ssocited with continuous use of prctitioner-bsed modlities (OR = 2.5); high fruit nd vegetble intke ws ssocited with strting prctitionerbsed CAM fter dignosis (OR =1.8) Continuous Use of Other Self-Cre nd Prctitioner- Bsed CAM. In our multivrible logistic regression models, mong women with dignosis of first primry brest cncer, the strongest nd most common predictors of continuous

5 Evidence-Bsed Complementry nd Alterntive Medicine 5 Tble 2: Demogrphics, helth behviors, nd disese chrcteristics, by ctegory of self-cre nd prctitioner-bsed CAM used fter dignosis mong women in the LIBCSP. TOTAL (n = 764) Multivitmins b (n = 581, 76%) Single vitmins/ minerls b (n = 584, 76.4%) Botnicls b (n = 303, 39.7%) Demogrphics Other dietry supplements b (n = 188, 24.6%) Mindbody b (n = 216, 28.3%) Specil diets b (n= 248, 32.5%) Pryer b (n = 302, 39.5%) Support groups b (n = 161, 21.1%) CAM prctitioners b (n = 307, 40.2%) Age t dignosis Continuous (Men ± SD) 56.3 ± ± ± ± ± ± ± ± ± ± 10.7 < % 18.6% 17.3% 21.5% 12.8% 25.9% 17.7% 21.9% 29.8% 22.8% % 31.2% 32.0% 32.3% 38.3% 35.6% 30.6% 36.1% 34.2% 37.5% % 26.9% 27.2% 29.0% 29.3% 26.9% 27.4% 27.5% 27.3% 24.4% % 23.4% 23.5% 17.2% 19.7% 11.6% 24.2% 14.6% 8.7% 15.3% Rce Non-Hispnic white 94.0% 93.5% 93.8% 93.1% 96.3% 92.6% 89.5% 92.1% 93.8% 93.8% All other 6.0% 6.5% 6.2% 6.9% 3.7% 7.4% 10.5% 7.9% 6.2% 6.2% Religion,c Protestnt 22.6% 23.1% 21.1% 20.5% 25.0% 24.1% 21.4% 22.2% 24.2% 20.5% Ctholic 55.5% 55.1% 55.5% 54.5% 48.4% 55.6% 50.8% 64.2% 53.4% 54.1% Jewish 20.0% 20.5% 21.7% 23.8% 24.5% 19.0% 25.4% 12.3% 21.7% 23.1% Annul household income <$25k 10.3% 9.3% 7.5% 6.9% 8.0% 7.9% 10.5% 8.6% 3.7% 9.1% $25k $49, % 30.6% 30.0% 25.7% 24.5% 25.0% 26.2% 30.1% 24.8% 21.5% $50k $89, % 35.6% 36.0% 38.0% 38.3% 40.7% 34.7% 38.7% 37.9% 37.8% $90k 24.2% 24.4% 26.5% 29.4% 29.3% 26.4% 28.6% 22.5% 33.5% 31.6% Eduction High school grd 39.4% 36.3% 35.8% 26.1% 27.1% 20.8% 32.3% 32.8% 23.0% 28.3% Some college 25.5% 26.7% 26.0% 27.7% 26.1% 30.6% 27.4% 29.8% 24.8% 25.4% College grdute 14.5% 15.0% 15.2% 18.5% 15.4% 15.7% 16.5% 13.9% 23.0% 18.9% Postgrdute 20.5% 22.0% 22.9% 27.7% 31.4% 32.9% 23.8% 23.5% 29.2% 27.4% BMI t dignosis < % 51.3% 51.0% 53.8% 53.7% 56.0% 52.0% 52.6% 50.9% 48.2% % 30.8% 31.8% 30.7% 30.3% 25.0% 32.3% 27.2% 32.3% 30.6% % 17.9% 17.1% 15.5% 16.0% 19.0% 15.7% 20.2% 16.8% 21.2% Menopusl sttus Premenopusl 36.5% 37.7% 37.8% 43.2% 34.6% 52.3% 38.7% 45.4% 50.9% 46.6% Postmenopusl 60.9% 59.7% 59.4% 53.8% 60.6% 44.4% 57.7% 51.3% 47.8% 49.8% Helth behviors Orl contrceptives Never 49.2% 47.3% 47.6% 46.5% 44.1% 38.9% 47.6% 45.4% 36.6% 43.0% Ever 50.5% 52.5% 52.1% 53.5% 55.3% 60.6% 52.0% 54.6% 63.4% 57.0% Hormone replcement therpy Never 66.9% 67.1% 65.1% 64.0% 52.7% 67.6% 64.1% 68.2% 64.6% 65.5% Ever 33.1% 32.9% 34.9% 36.0% 47.3% 32.4% 35.9% 31.8% 35.4% 34.5%

6 6 Evidence-Bsed Complementry nd Alterntive Medicine TOTAL (n = 764) Multivitmins b (n = 581, 76%) Single vitmins/ minerls b (n = 584, 76.4%) Tble 2: Continued. Botnicls b (n = 303, 39.7%) Other dietry supplements b (n = 188, 24.6%) Mindbody b (n = 216, 28.3%) Specil diets b (n= 248, 32.5%) Pryer b (n = 302, 39.5%) Support groups b (n = 161, 21.1%) CAM prctitioners b (n = 307, 40.2%) Mmmogrm Never or >5yrs go 4.2% 4.1% 3.3% 3.0% d 3.7% 3.2% 4.3% 5.0% 4.2% <5yrsgo 94.4% 94.3% 95.4% 96.0% 96.8% 96.3% 96.8% 95.4% 94.4% 94.8% Cigrette smoking sttus Never 44.1% 44.9% 45.9% 48.2% 45.7% 47.7% 48.8% 49.0% 49.1% 45.0% Current 18.6% 17.2% 17.0% 18.2% 14.4% 15.7% 11.3% 17.5% 13.7% 17.6% Former 37.3% 37.9% 37.2% 33.7% 39.9% 36.6% 39.9% 33.4% 37.3% 37.5% Alcohol use Never 33.8% 33.7% 31.8% 31.0% 30.9% 33.3% 33.9% 34.1% 32.3% 33.9% Ever 66.2% 66.3% 68.2% 69.0% 69.1% 66.7% 66.1% 65.9% 67.7% 66.1% Averge lifetime lcohol intke (g/dy) % 34.1% 32.4% 31.4% 31.4% 34.3% 34.3% 34.8% 32.9% 34.5% < % 50.8% 51.2% 52.5% 47.3% 47.7% 48.0% 50.0% 46.0% 51.5% % 11.0% 11.8% 11.6% 12.8% 11.6% 12.1% 10.3% 11.8% 9.4% % 4.1% 4.6% 4.6% 8.5% 6.5% 5.6% 5.0% 9.3% 4.6% Physicl ctivity (h/wk) % 22.9% 22.3% 17.5% 18.6% 13.4% 16.1% 19.2% 17.4% 19.2% % 21.3% 22.1% 22.4% 23.9% 23.1% 23.8% 22.5% 18.6% 20.8% % 26.2% 25.2% 24.4% 22.9% 26.9% 24.6% 24.8% 29.2% 24.1% % 24.3% 24.8% 29.7% 27.7% 31.5% 29.8% 27.2% 26.7% 29.3% Fruit nd vegetble intke (servings/wk) % 60.1% 61.0% 54.5% 57.4% 55.6% 57.3% 58.3% 55.3% 57.7% % 38.7% 37.8% 44.6% 41.5% 44.0% 42.7% 40.7% 42.9% 41.4% CAM Use before dignosis b Multivitmins 55.5% 73.0% 62.8% 70.3% 66.5% 64.8% 60.1% 62.9% 64.0% 61.2% Single vitmins 57.3% 64.2% 75.0% 75.6% 74.5% 68.1% 66.5% 63.6% 67.7% 67.8% Botnicls 29.2% 33.7% 34.8% 73.6% 40.4% 42.1% 40.7% 39.7% 38.5% 40.4% Other diet. supp. 12.3% 14.1% 14.6% 19.1% 50.0% 24.1% 16.1% 16.9% 23.0% 20.8% Mind-body 16.6% 18.8% 18.2% 24.4% 30.9% 58.8% 24.2% 33.4% 35.4% 26.1% Specil diets 21.6% 21.9% 23.5% 29.0% 30.9% 33.8% 66.5% 27.5% 28.6% 27.4% CAM prctitioner 25.4% 27.7% 28.8% 38.3% 40.4% 45.4% 33.1% 36.4% 43.5% 63.2% Disese chrcteristics Stge t dignosis In situ 17.9% 18.8% 18.7% 20.1% 23.4% 19.4% 20.6% 18.5% 14.3% 21.2% Invsive 82.1% 81.2% 81.3% 79.9% 76.6% 80.6% 79.4% 81.5% 85.7% 78.8% Hormone receptor sttus ER /PR 13.0% 13.3% 12.3% 13.5% 11.2% 12.0% 12.5% 14.6% 12.4% 10.1% ER+ or PR+ 49.2% 48.2% 46.1% 45.9% 43.1% 50.5% 47.2% 47.7% 52.2% 50.2% missing 37.8% 38.6% 41.6% 40.6% 45.7% 37.5% 40.3% 37.7% 35.4% 39.7%

7 Evidence-Bsed Complementry nd Alterntive Medicine 7 TOTAL (n = 764) Multivitmins b (n = 581, 76%) Single vitmins/ minerls b (n = 584, 76.4%) Botnicls b (n = 303, 39.7%) Tble 2: Continued. Other dietry supplements b (n = 188, 24.6%) Mindbody b (n = 216, 28.3%) Specil diets b (n= 248, 32.5%) Pryer b (n = 302, 39.5%) Support groups b (n = 161, 21.1%) CAM prctitioners b (n = 307, 40.2%) Tretment received b Chemotherpy 40.6% 40.6% 39.7% 45.9% 38.3% 51.4% 43.1% 48.3% 57.1% 44.0% Rdition 60.7% 61.4% 61.8% 60.4% 59.6% 61.1% 57.3% 59.9% 55.9% 58.0% Tmoxifen 60.5% 60.6% 59.6% 55.8% 57.4% 58.8% 60.1% 60.9% 60.2% 55.4% Dt collected t bseline, b Dt collected t follow-up, c Dt for no religion/other religion re not displyed becuse cell size <5. d Dt re not displyed becuse cell size <5.

8 8 Evidence-Bsed Complementry nd Alterntive Medicine Tble 3: Timing of the top 6 self-cre nd prctitioner bsed modlities per ctegory mong women in the LIBCSP follow-up interview ( ). Strters Continuers Quitters Never users Multivitmins (ny) 20.5% 55.5% 10.6% 13.4% Single Vitmins 19.1% 57.3% 5.0% 18.6% Clcium 25.3% 20.9% 4.1% 49.7% Vitmin E 22.6% 24.7% 4.2% 48.4% Vitmin C 16.5% 32.7% 9.3% 41.5% B12 8.9% 3.5% 5.2% 82.3% B Complex vitmins 7.9% 7.1% 4.5% 80.6% Iron 3.7% 2.1% 11.9% 82.3% Botnicls 10.5% 29.2% 1.6% 58.8% Green te 20.9% 2.4% 76.3% Echince 9.8% 4.7% 1.2% 84.3% Ginkgo bilob 4.6% 1.6% 1.3% 92.5% Blck Cohosh 2.1% 97.5% St. John s Wort 1.3% 98.2% Chmomile 0.7% 1.6% 0.0% 97.8% Other OTC products 12.3% 12.3% 3.0% 72.4% Glucosmine 10.3% 0.7% 88.5% Chondroitin 8.8% 0.9% 89.8% Co-Q % 2.0% 89.4% Fish oil 5.5% 2.2% 3.3% 89.0% Fiber supplements 4.7% 5.0% 3.0% 87.3% Mind-body 11.6% 16.6% 1.4% 70.3% Visuliztion 7.7% 4.5% 0.7% 83.2% Medittion 6.9% 8.5% 1.2% 83.2% Yog 6.8% 3.3% 1.7% 83.2% Ti chi 3.3% 0.7% 1.4% 83.2% Poetry 2.6% 3.1% 83.2% Music therpy 1.8% 5.2% 0.0% 83.2% Pryer 4.80% 35.5% 0.0% 59.7% Support groups 17.40% 3.70% 0.8% 78.1% Specil diets 10.9% 21.6% 1.0% 66.5% Low-ft diet 11.0% 14.9% 1.0% 72.1% Weight loss 8.8% 4.1% 3.5% 83.1% Chnge consumption of soy 6.9% 1.2% 91.6% No red met 6.4% 3.8% 89.3% Orgnic 5.9% 1.4% 92.5% High fiber 5.1% 3.0% 91.6% Prctitioner-bsed 14.8% 25.4% 7.2% 52.6% Mssge 9.4% 7.6% 0.7% 81.9% Chiroprctor 6.2% 12.0% 8.9% 72.5% Acupuncture 6.0% 1.4% 2.8% 89.7% Reiki, heling touch, other energy 5.5% 0.9% 92.9% psychotherpy 5.5% 8.1% 2.1% 84.3% Nutritionist or dieticin 3.5% 0.7% 95.7% Dt re not displyed due to cell sizes <5. use of one type of self-cre were continuous use of other typesofself-cre.inprticulr,usersofonetypeofingestible self-creweremorelikelytouseotheringestiblegents. Women who continuously used single vitmins were nerly 4 times s likely to use multivitmins nd/or use other dietry supplements nd 1.6 times s likely to use botnicls before nd fter dignosis s other women. Similrly, women who used botnicls before nd fter dignosis were nerly twice

9 Evidence-Bsed Complementry nd Alterntive Medicine 9 Tble 4: Proportion of CAM use during tretment, by tretment type, mong women in the LIBCSP follow-up interview ( ). Chemotherpy (n = 310) Rdition(n = 464) Tmoxifen (n = 462) Multivitmins (ny) 37.4% 55.2% 80.7% Single vitmins 33.2% 48.7% 54.1% Vitmin E 18.1% 18.8% 34.6% Vitmin C 18.1% 19.0% 32.3% Clcium 12.3% 12.3% 28.8% Selenium 6.5% 6.3% 8.4% B-complex 4.8% 4.1% 8.2% Herbs nd botnicls 13.2% 12.6% 23.6% Green te 8.1% 4.3% 13.6% Echince 3.5% 1.1% 7.6% Ginkgo bilob 3.7% Chmomile 1.5% Grlic 1.1% Blck cohosh 0.0% 0.0% 1.1% Astrglus root Other OTC Products 8.1% 10.0% 16.2% Glucosmine 0.0% 6.3% Co-Q % 2.4% 5.6% Chondroitin 0.0% 5.4% Lxtives 3.2% 1.9% 5.4% Flx seed oil 3.7% Fish oil/epa/omeg-3 1.5% 3.5% Meltonin 2.2% Mind-body 28.4% 31.0% 22.9% Medittion 16.1% 12.3% 13.0% Visuliztion 14.5% 9.9% 8.0% Yog 1.5% 6.9% Music therpy 8.7% 5.8% 6.3% Poetry therpy or journling 7.1% 3.9% 3.7% Ti chi 1.6% 2.6% Support groups 23.9% 11.2% 12.8% Pryer 48.7% 39.9% 38.1% Prctitioner bsed 21.6% 17.4% 26.0% Chiroprctor 4.5% 2.8% 11.3% Psychotherpy 11.3% 5.8% 9.1% Mssge 5.5% 1.9% 8.7% Reiki 4.2% 1.7% 3.7% Acupuncture 2.6% Nutritionist 2.6% 1.3% 1.5% Specil diets 22.9% 29.0% 26.0% Low-ft 17.4% 15.9% 22.1% No red met 7.4% 6.5% 8.0% Weight loss 1.6% 2.6% 8.0% High fiber diet 5.2% 4.5% 5.8% Orgnic fruits nd vegetbles 6.8% 4.7% 4.3% Chnged consumption of soy 4.2% 3.0% 3.7% Dt re not displyed due to cell sizes <5.

10 10 Evidence-Bsed Complementry nd Alterntive Medicine Tble 5: Fctors ssocited with continuing (vs. strting, stopping, or never using) self-cre nd prctitioner-bsed CAM mong women in the LIBCSP, multivrible nlyses, OR (95% Confidence Intervl). Multivitmins b Single vitmins/ Botnicls b Other dietry Mind-body b Specil diets b Pryer b Support groups b CAM minerls b supplements b prctitioners b Age Continuous 0.98 ( ) 1.01 ( ) 1.00 ( ) 0.98 ( ) 1.00 ( ) 1.00 ( ) 0.97 ( ) 1.01 ( ) 0.99 ( ) Rce Non-Hispnic white 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) All Other 0.78 ( ) 1.09 ( ) 0.60 ( ) 0.40 ( ) 1.89 ( ) 2.18 ( ) 1.10 ( ) 1.74 ( ) 0.95 ( ) Annul household income <$25k 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) $25k $49, ( ) 2.37 ( ) 1.38 ( ) 0.38 ( ) 0.78 ( ) 0.56 ( ) 1.79 ( ) 0.76 ( ) $50k $89, ( ) 2.61 ( ) 1.12 ( ) 0.40 ( ) 0.50 ( ) 0.73 ( ) 1.38 ( ) 0.79 ( ) $90k 0.87 ( ) 2.09 ( ) 1.11 ( ) 0.31 ( ) 0.45 ( ) 0.96 ( ) 1.00 ( ) 0.82 ( ) Eduction Highschoolgrd 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) Some college 1.25 ( ) 1.00 ( ) 1.82 ( ) 0.86 ( ) 2.38 ( ) 1.26 ( ) 1.02 ( ) 0.91 ( ) 1.26 ( ) College grdute 1.17 ( ) 1.00 ( ) 2.72 ( ) 2.17 ( ) 1.36 ( ) 1.25 ( ) 0.76 ( ) 1.31 ( ) 1.83 ( ) Postgrdute 0.85 ( ) 1.12 ( ) 2.25 ( ) 2.60 ( ) 2.44 ( ) 1.07 ( ) 0.80 ( ) 0.73 ( ) 1.54 ( ) BMI t dignosis <25 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) ( ) 1.10 ( ) 1.00 ( ) 0.74 ( ) 0.53 ( ) 1.21 ( ) 0.96 ( ) 0.74 ( ) 1.58 ( ) ( ) 0.76 ( ) 0.58 ( ) 0.40 ( ) 0.76 ( ) 1.11 ( ) 1.27 ( ) 1.90 ( ) 2.52 ( ) Menopusl (meno.) sttus Premeno. 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) Postmeno ( ) 0.86 ( ) 0.94 ( ) 2.81 ( ) 0.94 ( ) 0.98 ( ) 1.03 ( ) 0.70 ( ) 0.66 ( ) Mmmogrm Never/>5 yrs go 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) <5 yrs go 0.85 ( ) 1.95 ( ) 1.10 ( ) 2.26 ( ) 1.43 ( ) 2.01 ( ) 1.09 ( ) 0.85 ( ) 0.70 ( ) Physicl ctivity (h/wk) 0 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) ( ) 0.68 ( ) 1.51 ( ) 1.30 ( ) 1.80 ( ) 1.64 ( ) 1.09 ( ) 0.66 ( ) 1.25 ( ) ( ) 1.00 ( ) 1.17 ( ) 1.26 ( ) 1.70 ( ) 0.95 ( ) 1.12 ( ) 1.49 ( ) 1.28 ( ) ( ) 1.13 ( ) 1.46 ( ) 0.97 ( ) 2.44 ( ) 1.38 ( ) 0.98 ( ) 0.67 ( ) 1.54 ( )

11 Evidence-Bsed Complementry nd Alterntive Medicine 11 Tble 5: Continued. Multivitmins b Single vitmins/ Botnicls b Other dietry Mind-body b Specil diets b Pryer b Support groups b CAM minerls b supplements b prctitioners b Cigrette smoking sttus Never 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) Current 0.94 ( ) 0.79 ( ) 1.17 ( ) 1.03 ( ) 0.83 ( ) 0.44 ( ) 0.75 ( ) 0.85 ( ) 1.00 ( ) Former 1.25 ( ) 0.82 ( ) 0.77 ( ) 0.66 ( ) 1.24 ( ) 1.10 ( ) 0.78 ( ) 2.16 ( ) 1.23 ( ) Alcohol use Never 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) Ever 1.01 ( ) 1.51 ( ) 0.79 ( ) 1.05 ( ) 0.97 ( ) 1.01 ( ) 0.91 ( ) 0.55 ( ) 1.43 ( ) Fruit nd vegetble intke (servings/ wk) (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1 (Ref) 1 (Ref) ( ) 1.18 ( ) 1.46 ( ) 0.87 ( ) 1.44 ( ) 1.23 ( ) 1.24 ( ) 0.69 ( ) 0.82 ( ) Stge t dignosis In situ (1 Ref) (1 Ref) (1 Ref) (1 Ref) (1 Ref) (1 Ref) (1 Ref) (1 Ref) (1 Ref) Invsive 0.80 ( ) 1.47 ( ) 0.66 ( ) 0.88 ( ) 0.99 ( ) 0.90 ( ) 0.93 ( ) 0.76 ( ) 0.73 ( ) Tretments received b Chemo. (no/yes) 0.82 ( ) 0.83 ( ) 1.92 ( ) 1.46 ( ) 1.51 ( ) 1.15 ( ) 1.06 ( ) 2.04 ( ) 1.08 ( ) Tmoxifen (no/yes) 1.14 ( ) 0.60 ( ) 0.84 ( ) 0.60 ( ) 1.05 ( ) 1.26 ( ) 1.38 ( ) 0.94 ( ) 0.82 ( ) Continuous CAM Use before dignosis b Multivit. N/A 3.60 ( ) 1.85 ( ) 1.53 ( ) 1.63 ( ) 0.93 ( ) 1.43 ( ) 1.04 ( ) 1.05 ( ) Single vit ( ) N/A 1.58 ( ) 3.87 ( ) 0.98 ( ) 1.74 ( ) 1.06 ( ) 0.82 ( ) 2.13 ( ) Botnicls 1.79 ( ) 1.59 ( ) N/A 0.70 ( ) 1.13 ( ) 1.32 ( ) 1.69 ( ) 1.29 ( ) 1.73 ( ) Other diet. supp ( ) 3.38 ( ) 0.75 ( ) N/A 2.86 ( ) 1.12 ( ) 1.00 ( ) 1.23 ( ) 3.55 ( ) Mind-body 1.58 ( ) 0.98 ( ) 1.04 ( ) 2.64 ( ) N/A 1.71 ( ) 7.53 ( ) 5.43 ( ) 2.41 ( ) Specil diet 0.93 ( ) 1.65 ( ) 1.31 ( ) 1.26 ( ) 1.66 ( ) N/A 1.24 ( ) 1.17 ( ) 1.55 ( ) CAM prctitioner 1.11 ( ) 2.00 ( ) 1.74 ( ) 3.94 ( ) 2.34 ( ) 1.53 ( ) 1.54 ( ) 2.17 ( ) N/A Dt collected t bseline, ; b Dt collected t follow-up, Bold text indictes sttisticlly significnt odds rtio (P < 0.05).

12 12 Evidence-Bsed Complementry nd Alterntive Medicine Tble 6: Fctors ssocited withstrting (vs. continuing, stopping or never using) self-cre nd prctitioner-bsed CAM fter dignosis mong women in the LIBCSP, multivrible nlyses, OR (95% Confidence Intervl). Multivitmins b Single vitmins/ Botnicls b Other dietry Mind-body b Specil diets b Pryer b Support groups b CAM minerls b supplements b prctitioners b Age Continuous 1.00 ( ) 1.01 ( ) 0.99 ( ) 0.99 ( ) 0.93 ( ) 1.01 ( ) 0.92 ( ) 0.96 ( ) 0.96 ( ) Rce Non-Hispnic white 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) All Other 2.09 ( ) 1.37 ( ) 3.46 ( ) 0.76 ( ) 0.93 ( ) 3.63 ( ) 3.52 ( ) 0.87 ( ) 1.18 ( ) Annul household income <$25k 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) $25k $49, ( ) 1.30 ( ) 0.41 ( ) 0.93 ( ) 0.84 ( ) 1.17 ( ) 0.30 ( ) 1.39 ( ) 0.31 ( ) $50k $89, ( ) 1.49 ( ) 0.47 ( ) 1.23 ( ) 0.71 ( ) 0.74 ( ) 0.39 ( ) 1.89 ( ) 0.39 ( ) $90k 1.02 ( ) 2.00 ( ) 0.70 ( ) 1.41 ( ) 0.33 ( ) 0.75 ( ) 0.29 ( ) 1.75 ( ) 0.59 ( ) Eduction High school grd. 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) Some college 0.96 ( ) 1.03 ( ) 1.89 ( ) 1.64 ( ) 2.02 ( ) 1.13 ( ) 2.26 ( ) 1.24 ( ) 1.47 ( ) College grdute 0.82 ( ) 0.89 ( ) 0.82 ( ) 0.93 ( ) 1.76 ( ) 0.86 ( ) 0.87 ( ) 2.27 ( ) 1.05 ( ) Postgrdute 1.54 ( ) 0.97 ( ) 1.57 ( ) 1.36 ( ) 3.90 ( ) 0.87 ( ) 2.01 ( ) 1.75 ( ) 1.49 ( ) BMI t dignosis <25 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) ( ) 0.86 ( ) 1.02 ( ) 1.10 ( ) 1.27 ( ) 0.73 ( ) 0.38 ( ) 1.35 ( ) 1.07 ( ) ( ) 1.06 ( ) 1.54 ( ) 1.28 ( ) 2.11 ( ) 0.23 ( ) 1.31 ( ) 0.89 ( ) 1.30 ( ) Menopusl (meno.) sttus Premeno. 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) Postmeno ( ) 0.83 ( ) 0.85 ( ) 1.12 ( ) 0.52 ( ) 0.84 ( ) 0.81 ( ) 1.20 ( ) 0.90 ( ) Mmmogrm Never/>5 yrs go 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) <5 yrs go 1.06 ( ) 0.91 ( ) 1.07 ( ) 1.53 ( ) 1.20 ( ) 0.86 ( ) 1.70 ( ) 0.97 ( ) 1.66 ( ) Physicl ctivity (h/wk) 0 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) ( ) 1.44 ( ) 1.03 ( ) 1.07 ( ) 1.39 ( ) 1.57 ( ) 0.47 ( ) 0.71 ( ) 0.89 ( ) ( ) 1.16 ( ) 1.28 ( ) 0.57 ( ) 1.34 ( ) 1.99 ( ) 0.70 ( ) 1.22 ( ) 0.82 ( ) ( ) 0.85 ( ) 1.37 ( ) 1.06 ( ) 1.16 ( ) 1.81 ( ) 0.94 ( ) 0.90 ( ) 1.14 ( )

13 Evidence-Bsed Complementry nd Alterntive Medicine 13 Tble 6: Continued. Multivitmins b Single vitmins/ Botnicls b Other dietry Mind-body b Specil diets b Pryer b Support groups b CAM minerls b supplements b prctitioners b Cigrette smoking sttus Never 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) Current 0.69 ( ) 0.81 ( ) 1.47 ( ) 0.72 ( ) 0.92 ( ) 0.77 ( ) 1.04 ( ) 0.72 ( ) 1.23 ( ) Former 0.83 ( ) 0.80 ( ) 1.32 ( ) 1.23 ( ) 0.93 ( ) 1.13 ( ) 0.49 ( ) 0.63 ( ) 1.12 ( ) Alcohol use Never 1 (Ref) 1 (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) Ever 0.80 ( ) 0.85 ( ) 1.08 ( ) 1.13 ( ) 0.77 ( ) 0.88 ( ) 1.66 ( ) 1.11 ( ) 0.50 ( ) Fruit nd vegetble intke (servings/wk) (Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) ( ) 0.77 ( ) 0.92 ( ) 1.04 ( ) 0.89 ( ) 0.93 ( ) 0.56 ( ) 1.20 ( ) 1.75 ( ) Stge t dignosis Insitu 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) 1(Ref) Invsive 0.85 ( ) 0.58 ( ) 0.96 ( ) 0.73 ( ) 0.84 ( ) 0.82 ( ) 0.51 ( ) 2.14 ( ) 1.02 ( ) Tretments received b Chemo. (no/yes) 1.00 ( ) 1.12 ( ) 0.88 ( ) 0.58 ( ) 1.04 ( ) 1.08 ( ) 1.78 ( ) 1.24 ( ) 0.75 ( ) Tmoxifen (no/yes) 1.39 ( ) 1.86 ( ) 0.92 ( ) 1.54 ( ) 1.41 ( ) 0.69 ( ) 1.32 ( ) 1.17 ( ) 1.04 ( ) Continuous CAM Use before dignosis b Multivit. N/A 0.51 ( ) 1.23 ( ) 1.12 ( ) 0.57 ( ) 0.97 ( ) 0.59 ( ) 0.99 ( ) 0.85 ( ) Single vit ( ) N/A 9.92 ( ) 1.17 ( ) 1.49 ( ) 0.92 ( ) 0.63 ( ) 1.23 ( ) 0.93 ( ) Botnicls 1.13 ( ) 1.62 ( ) N/A 2.02 ( ) 1.98 ( ) 2.42 ( ) 1.65 ( ) 1.26 ( ) 1.49 ( ) Other diet. supp ( ) 0.39 ( ) 2.72 ( ) N/A 1.19 ( ) 1.04 ( ) 1.55 ( ) 1.72 ( ) 0.88 ( ) Mind-body 0.68 ( ) 0.88 ( ) 1.36 ( ) 1.69 ( ) N/A 0.58 ( ) 0.66 ( ) 2.39 ( ) 0.80 ( ) Specil diet 0.69 ( ) 0.58 ( ) 1.09 ( ) 1.17 ( ) 1.12 ( ) N/A 0.95 ( ) 1.12 ( ) 0.63 ( ) CAM prctitioner 0.93 ( ) 0.55 ( ) 0.93 ( ) 0.50 ( ) 1.13 ( ) 0.68 ( ) 1.00 ( ) 1.35 ( ) N/A Dt collected t bseline, ; b Dt collected t follow-up, Bold text indictes sttisticlly significnt odds rtio (P < 0.05).

14 14 Evidence-Bsed Complementry nd Alterntive Medicine slikelytousemultivitminsndsinglevitminsbeforend fter dignosis s never users of botnicls (Tble 5). Women who used ingestible forms of self-cre were lso more likely to begin using new ctegories of ingestible selfcre fter dignosis with first primry brest cncer. Women who used single vitmins before nd fter dignosis were 10timesslikelytostrtuseofbotniclsfterdignosis s never users; women who used other dietry supplements before nd fter dignosis were 3 times more likely to strt using botnicls fter dignosis thn never users (Tble 6). Continuous users of mind-body modlities were more thn 7 times s likely to use pryer, 5 times s likely to use support groups, nd more thn twice s likely to use prctitioner-bsed modlities continuously s non-users Disese Chrcteristics. Neither stge of disese nor hormone receptor sttus ws ssocited with continuous or new use of self-cre ctegories. The only clinicl vrible ssocited with self-cre ws tretment type: women who received tmoxifen tretment hd 1.7 times greter odds of strting use of single vitmins fter dignosis thn women who were not treted with tmoxifen (Tble 6). 4. Discussion We present novel method to describe chnges in CAM use before nd fter cncer dignosis by compring those who strted using, stopped using, continued using, or never used ctegory of CAM following dignosis. Cncer survivors ccess multiple forms of CAM nd we specificlly exmined differences in ptterns of CAM tht involved self-cre s compred to those tht were bsed on prctitioner-cre. Among women dignosed with first primry brest cncer who self-reported their use of complementry nd lterntive medicine modlities in the follow-up components of the Long Islnd Brest Cncer Study Project, the fctors most commonly nd strongly ssocited with using self-cre nd CAM modlities were use of other ctegories of self-cre. In prticulr, women who used one form of ingestible self-cre (multind single vitmins, botnicls, other dietry supplements, or specildiets)weremorelikelythnotherwomeneitherto continue or to strt using other ingestible self-cre. Helthy behviorsweressocitedwithself-creprcticesthtwere used before dignosis nd continued fterwrds. Behviorl fctors were more predictive of self-cre use fter brest cncer dignosis thn were indictors of disese prognosis. In ntionlly representtive survey conducted in 1997, which is close to the period when the LIBCSP cses were dignosed with brest cncer, 42% of dults reported using t lest 1 of 16 CAM modlities (these dt did not include dily vitmins) [2]. Of those who used CAM, 46% reported visiting CAM prctitioner within the pst yer [2]. The prevlence of CAMprctitionervisitsmongthe1997smpleiscomprble to tht mong the LIBCSP cses. Among the dults surveyed in the 2002 Ntionl Helth Interview Survey, 62% of dults reported using CAM, lthough this dropped to 36% when helth-relted pryer ws excluded; nturl products nd brething/medittion were the most commonly used forms of CAM [3]. 95% of LIBCSP cse women included in this nlysis used self-cre fter brest cncer dignosis, nd 90% used self-cre fter dignosis if multivitmins re excluded, which is much higher thn in ntionl smples of dults. A recent cross-sectionl study reported tht 75% of dult cncer ptients used CAM nd of those, close to 60% begn using CAM fter their cncer dignosis [18]. It hs been well documented tht women with brest cncer who use CAM re younger, better educted, nd more ffluent thn women with brest cncer who do not use CAM [2, 19 23]; our results re consistent with these findings. In the Women s Helthy Eting nd Living Study, 81% of brest cncer survivors reported using dietry supplements [24]. In the Pthwys Study, 29% of brest cncer ptients dignosed in in Northern Cliforni used specil diets fter dignosis, s compred with 33% of LIBCSP women. However, more of the prticipnts of the Pthwys Study thn of the LIBCSP used botnicls (48% versus 40%), mind-body heling (including support groups) (64% versus 49%), nd other dietry supplements (47% versus 25%) fter dignosis [9]. Differences in loction nd period of recruitment my ccountforthedifferencesincamuseinthetwosmples. It is not surprising tht the strongest predictor overll of using self-cre ctegory before nd fter dignosis with first primry brest cncer, nd of strting self-cre ctegory fter dignosis, ws using other forms of self-cre. Women who lredy use some form of CAM or self-cre prctice relikelytobewreofothercammodlities.itislsonot surprising tht ingestible forms of CAM were commonly used together. Women who lredy tke one type of supplement do not need to mke much dditionl effort or to undergo significnt chnge in behvior to try new supplements. Continuous use of botnicls ws the fctor most commonly ssocited with strting new forms of self-cre, including single vitmins, mind-body, other dietry supplements, nd specil diets. However, strting prctitioner-bsed CAM ws notssocitedwithprioruseofself-cremodlities. High intke of fruits nd vegetbles t the bseline interview ws ssocited with the use of multivitmins before nd fter dignosis. High recretionl physicl ctivity level reportedtthebselineinterviewwspositivelyssocited with continuous use of mind-body prctices, nd high BMI t bseline ws negtively ssocited with continuous use of botnicls, other dietry supplements, nd mind-body modlities. However, helthy behviors were not strongly ssocited with strting self-cre prctices fter dignosis; most women who engged in helthy behviors were lredy using self-cre. Neither stge of disese nor hormone receptor sttus ws ssocited with strting either self-cre or prctitionerbsed modlities. Most self-cre nd prctitioner-bsed CAM use occurred during tmoxifen tretment, perhps becuse tmoxifen is n orl gent tht ptients use for 5 yers, wheres chemotherpy nd rdition tretments hve usul durtion of severl months or weeks. In ddition, women whousedtmoxifenmyhvebeenmorewillingtouse otherorloringestiblegentsthnwomenwhodidnotuse tmoxifen. Mind-body prctices were lso common during djuvnt tretment, perhps becuse women who were told

15 Evidence-Bsed Complementry nd Alterntive Medicine 15 not to tke dietry supplements during those tretments used noningestible forms of self-cre insted. The modlities tht were most commonly initited fter dignosis with brest cncer mong women in our study were lso the modlities most frequently used during djuvnt tretment. Although our study prticipnts were not sked why they used the modlities they chose, dt from other studies suggest tht ptients initite self-cre fter brest cncer dignosis due to fer or experience of tretmentrelted side effects[25 27]. A recent study tht exmined CAM use mong brest cncer ptients fter djuvnt therpy similrly compred self-cre (or self-directed ) CAM with provider-directed CAM [28]. Of those women who used self-directed CAM, over hlf reported using it to influence thecourseofcncerfterdjuvnttherpy, while95%of women who used self-directed CAM nd ll women who used provider-directed CAM used it to improve wellbeing [28]. This study highlights the importnce of discussing CAM use with brest cncer ptients, prticulrly in the context of djuvnt therpy. Among the limittions of our study, the follow-up dt were collected nerly decde go; CAM nd self-cre prcticesmybedifferentnow.andbecusethedtwere collected more thn 5 yers fter dignosis nd tretment, ptients my not hve ccurtely reclled their prior CAM use. Although minority rce/ethnicity ws ssocited with beginning prctitioner-bsed CAM, only 6% of the smple were non-white, nd thus the ssocitions observed re unstble nd must be interpreted with cution. In ddition, lthough two-thirds of the cse women who prticipted in the originl LIBCSP cse-control study provided some follow-up dt, only 55.4% personlly completed the full follow-up questionnire, including the instrument developed byourtemtossessuseofcam.wepreviouslyreported tht nonrespondents to the full follow-up were of lower socioeconomic sttus thn respondents (response bis) [14]. The well-estblished ssocition of higher income with CAM use my prtilly explin the high prevlence of CAM use in our study popultion. Growing evidence suggests tht CAM nd other self-cre modlitiesmybeeffectiveinreducingtretment-reltedside effects, including nuse nd vomiting, s well s in reducing stress nd esing pin [26, 29]. Further, enggement in selfcre prctices helps individuls with cncer to mintin some sense of control over their personl wellbeing. Self-efficcy nd feelings of control re predictive of improved coping, emotionl wellbeing, physicl helth, immune function, nd qulity of life mong cncer ptients [30 33]. Henderson nd Dontelle found tht higher perceptions of control predicted CAM use mong brest cncer ptients [11]. The connection between self-cre during cncer nd vriety of physicl nd psychologicl outcomes should be further explored. 5. Conclusions Wefoundthtdignosisofbrestcncerwsssocited with subsequent behviorl chnges nd tht more ptients undertook new forms of self-cre thn bndoned the forms theyhdbeenusing.themostpopulrmodlitieswerethose tht re ingestible nd redily vilble without gtekeeper, nd they were commonly used in combintion. These findings re importnt becuse they identify ptterns of CAM use in well-chrcterized popultion of cncer ptients, including how CAM use chnged fter dignosis nd during tretment. Bsed on reserch conducted to dte, evidencebsed guidelines re vilble for providers nd ptients bout the sfety nd effects of vrious CAM modlities in the oncology setting [34 36] nd cn inform how nd when clinicins counsel their ptients on CAM use. However, more reserch is needed to understnd the specific effects of mny CAM therpies on cncer outcomes nd qulity of life, nd further reserch is needed to understnd the motivtions for nd ptterns of CAM use so tht broder spectrum of ptient needs cn be met. Abbrevitions CAM: Complementry nd lterntive medicine LIBCSP: Long Islnd Brest Cncer Study Project BMI: Body mss index. Acknowledgments This work ws supported by contrcts U01CA/ES66572, U01CA66572, nd P30ES10126 from the Ntionl Cncer Institute, the Ntionl Institute for Environmentl Helth Sciences, nd the Lnce Armstrong Foundtion. References [1] P. M. Brnes, B. Bloom, nd R. L. Nhin, Complementry nd lterntive medicine use mong dults nd children: United Sttes, 2007, Ntionl Helth Sttistics Reports, no. 12, pp. 1 23, [2]D.M.Eisenberg,R.B.Dvis,S.L.Ettneretl., Trendsin lterntive medicine use in the United Sttes, : results of follow-up ntionl survey, JournloftheAmericnMedicl Assocition,vol.280,no.18,pp ,1998. [3] P. M. Brnes, E. Powell-Griner, K. McFnn, nd R. L. Nhin, Complementry nd lterntive medicine use mong dults: United Sttes, 2002, Advnce Dt, no.343, pp. 1 19,2004. [4] S. H. Sydh nd M. S. Eberhrdt, Use of complementry nd lterntive medicine mong dults with chronic diseses: United Sttes 2002, Journl of Alterntive nd Complementry Medicine, vol. 12, no. 8, pp , [5]R.E.Ptterson,M.L.Neuhouser,M.M.Heddersonetl., Types of lterntive medicine used by ptients with brest, colon, or prostte cncer: predictors, motives, nd costs, Journl of Alterntive nd Complementry Medicine, vol.8,no. 4, pp , [6] P. A. Fsching, F. Thiel, K. Nicolisen-Murmnn et l., Assocition of complementry methods with qulity of life nd life stisfction in ptients with gynecologic nd brest mlignncies, Supportive Cre in Cncer, vol. 15, no. 11, pp , [7] Z. Nhleh nd I. A. Tbbr, Complementry nd lterntive medicine in brest cncer ptients, Pllitive & Supportive Cre,vol.1,no.3,pp ,2003.