Traditional Chinese medicine in cancer care: perspectives and experiences of patients and professionals in China

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1 Blackwell Publishing LtdOxford, UKECCEuropean Journal of Cancer Care Blackwell Publishing Ltd Original ArticleTraditional Chinese medicine in cancer carexu et al. Original article Traditional Chinese medicine in cancer care: perspectives and experiences of patients and professionals in China W. XU, md, msc, Department of Epidemiology & Biostatistics, McGill University, Montreal, Quebec, and Clinical Trial Unit, Center for Clinical Epidemiology and Community Study, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada, A.D. TOWERS, md, Palliative Care Division, McGill University Health Center, Montreal, Quebec, Canada, P. LI, md, Department of Traditional Chinese Medicine, Beijing Cancer Hospital, Peking University School of Oncology, Hai Dian District, Beijing, China, & J.-P. COLLET, md, phd, Department of Epidemiology & Biostatistics, McGill University, Montreal, Quebec, and Clinical Trial Unit, Center for Clinical Epidemiology and Community Study, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada XU W., TOWERS A.D., LI P. & COLLET J.-P. (2006) European Journal of Cancer Care 15, Traditional Chinese medicine in cancer care: perspectives and experiences of patients and professionals in China Although traditional Chinese medicine (TCM) is widely used in Chinese cancer centres, it is a brand new area for formal scientific evaluation. As the first step of developing a research programme on clinical evaluation of TCM for cancer patients, we conducted a qualitative study to explore the perspectives and experiences of Chinese cancer patients and TCM professionals. Twenty-eight persons participated in two cancer patient focus groups and one professional focus group. Semi-structured interviews were audiotaped, transcribed and translated. Textual transcripts and field notes underwent inductive thematic analysis. We found that patients decision to use TCM for cancer is a self-help process with a deep cultural grounding, which is related to the traditional Chinese philosophy of life. Participants perceived TCM to be an effective and harmless therapy. They highly valued the fact that TCM is tailored to patients, and believed it was the basis of an optimal and safe treatment. Participants also highlighted the long-term positive effects, the benefit of group interventions and the low cost as important features of TCM. Subjects believed that conducting clinical research would be crucial for the recognition and dissemination of TCM in Western countries. The findings of this study are expected to contribute to the knowledge base on the current TCM use for cancer in China, and to provide useful information for developing future clinical research in this area in Western countries. Keywords: traditional Chinese medicine, complementary and alternative medicine, cancer care, supportive care, symptom control, cross-cultural studies INTRODUCTION Correspondence address: Jean-Paul Collet, Suite 132, Center for Clinical Epidemiology and Community Study, Sir Mortimer B. Davis Jewish General Hospital, 3755 Côte Ste-Catherine, Montréal, Québec, Canada, H3T 1E2 ( jean-paul.collet@mcgill.ca. Correspondence address in China: Pingping Li, Department of Traditional Chinese Medicine, Beijing Cancer Hospital, Peking University School of Oncology, no. 52, Fu Cheng Road, Hai Dian District, Beijing, China, ( lppma123@yahoo.com.cn). Accepted 22 February 2006 DOI: /j x European Journal of Cancer Care, 2006, 15, There has been a large increase in complementary and alternative medicine (CAM) use by cancer patients in Western countries with a prevalence as high as 80% (Ernst & Cassileth 1998; Boon et al. 1999; Richardson et al. 2000). Among CAM modalities, traditional Chinese medicine (TCM) is particularly interesting because it is based on a clear rationale and a well-established theoretical framework, albeit on a different philosophical premise. TCM has been used for thousands of years in China and is 2006 Blackwell Publishing Ltd

2 XU et al. currently widely practised in Chinese cancer centres. Nevertheless, it is a brand new area for formal scientific evaluation. In conventional Western medicine, cancer is considered a process in which malignant cells outgrow environmental constraints and control mechanisms. The main strategy of conventional therapy (e.g. surgery, chemotherapy, radiotherapy) is direct annihilation of the cancer cells using aggressive treatment (Macek 1984; Wong et al. 2001). Within TCM philosophy, cancer results from a disturbance of smooth flow of qi (vital energy) and/or yin yang balance (the balance that maintains health), and manifests as a group of syndromes in which there is a disharmony in the body mind environment network. TCM cancer therapy focuses on mobilizing and activating body s natural resources to redress the balance. The enhancement of inner defences and restoration of normal patterns is thought to help defeat the cancer and promote healing. In China, many health caregivers and patients, aware of the limitations of conventional cancer therapy, are integrating TCM as complementary therapy. However, there is very limited high-quality scientific evidence on its effectiveness, nor is there formal documentation of personal experience regarding TCM cancer therapy. To determine whether TCM is a valuable addition to conventional therapy, we initiated a collaborative programme involving Chinese and Western clinicians and researchers to investigate this area. As the first step, we conducted a qualitative study in China to explore the perspectives and experiences of Chinese cancer patients and TCM professionals regarding TCM cancer therapies. Qualitative research methods are appropriate to investigate new fields and generate useful information for further development of quantitative studies (Denzin & Lincoln 2003). Focus groups are acknowledged as reliable means of eliciting people s thoughts about their therapies and obtaining a rich source of data on complex topics (Stewart & Shamdasani 1990; Krueger 2000). It can be especially useful for research on TCM, which encompasses a holistic style of treatment. Moreover, the interaction of participants within focus groups can enhance the depth of the information obtained as group members validate opinions, thereby allowing for a deeper discussion (Carey 1993). This approach can enhance understanding of the pattern and context of TCM use for cancer in China. Such information is useful for planning research projects and disseminating knowledge about TCM cancer care in Western countries. METHODS Design, settings and participants A qualitative focus group study was carried out in November A total of 28 persons participated in two patients groups and one TCM professional group. We used purposeful sampling (Morse 1991; Tuckett 2004) to find information-rich respondents whom the institutional representative or the attending physician thought might provide us with important insights. We conducted the first patient focus group at Beijing Cancer Hospital, which is a large-scale public cancer hospital and a teaching hospital affiliated with the School of Oncology, Peking University. This group involved eight cancer patients and five family members. All patients came from the Department of TCM. This hospital provides mainstream, conventional Western therapies such as surgery, chemotherapy and radiotherapy; however, patients may also have access to TCM treatments if they wish. Family members who accompanied patients spontaneously volunteered to participate in the meeting. We included them because they could give us insight concerning the patient s decision to use TCM. Family members might also be clearer than the patient himself regarding treatment schedule and regimens. The second patient focus group, involving six cancer patients and three family members, was conducted at Bai Cao TCM Cancer Clinic, which is a small-scale private family-run clinic where TCM practitioners use ancestral herbal treatment strategies and formulae for cancer care. Patients who receive treatments here have to seek conventional Western treatment and follow-up in larger hospitals. This type of TCM clinic is widespread in China. The majority of the cancer patients who attend the clinic have secondary/relapsed, refractory or end-stage cancer, or they are patients who are not able to use conventional therapies, those who choose TCM alone, and/or those in the recovery stage after conventional therapies. The third focus group involved TCM professionals from Beijing Cancer Hospital and Bai Cao Cancer Clinic: four TCM physicians, one qigong master and one TCM student. Recruitment, interview procedure and data collection The study protocol was approved by the research committee in Beijing Cancer Hospital and by institutional authorities in Bai Cao TCM clinic (the chief physician and chief administrator). Two TCM physicians involved in the professional group organized the patients group meeting and also attended those meetings. Patients were invited by Blackwell Publishing Ltd, European Journal of Cancer Care, 15,

3 Traditional Chinese medicine in cancer care Table 1. Interview guide For patient and family members group Why and when did you seek TCM? What did you expect of TCM? What type of TCM therapy did you seek and receive? What are strengthens and weaknesses (what do you like and dislike) regarding TCM therapy? What was the cost of using TCM? How important is TCM to you? Are there any barriers or facilitators for you to seek/receive TCM therapy? Would you recommend TCM therapy to other cancer patients? What do you see as being the future of TCM? For TCM professional group What is the place of TCM in cancer care (complementary, alternative) in China? Under what situations will patients seek TCM therapy? What type of TCM therapies you propose? The frequency of their use? Potential benefits and risks to patients, or advantage and disadvantage of using TCM? Are there any barriers or facilitators to the use of TCM therapy? What do you see being the trend of use, and barriers to its development? Potential collaboration on clinical research? TCM, traditional Chinese medicine. their physicians to participate. We provided the physicians who are responsible for the recruitment with written information about the study, including a list of the interview questions (Table 1) and the informed consent form. Because of the qualitative nature of the study and the absence of intervention and follow-up, written consent was not required by the participating institutions. Oral informed consent was obtained from all participants before the group meeting. At the beginning of the group discussion, the investigators explained clearly the study objective and the questions to be discussed. All participants were offered opportunities to withdraw from the discussion at any time. The semi-structured in-depth interviews were conducted within 1 week of each other, each lasting h. The list of open-ended questions (Table 1) was presented to the participants. The discussion, however, was not restricted to these questions and participants were asked to talk freely about their experiences and perspectives on TCM. All focus group discussions were facilitated and tape-recorded by the main author (W. Xu). Detailed field notes were also taken to record contexts of the discussions and to describe the clinical settings where TCM is administered. A senior research investigator from McGill University (J.P. Collet) was present at focus groups as an observer. To ensure confidentiality, all documents were stored in such a way that the participant s personal information was anonymous and the data were only available to the research team. Data analysis The taped records were transcribed and translated into English by the main author. Textual transcripts and field notes underwent inductive thematic analysis, along with some predetermined coding based on the interview questions (Murphy et al. 1998; Ryan & Bernard 2003). Using this method, new categories were allowed to emerge from the data rather than being strictly imposed on them. The data from all three focus groups were used to generate themes. First, the textual data were open-coded line by line according to the nature of the information. We quoted key words used by participants and tried to resist interpretation. Then, by grouping similar codes together and giving them a label, thematic categories were established. The open-coding and categorization was undertaken iteratively and independently by two researchers (W. Xu & A.D. Towers), which is known as double coding, to enhance the validity of the findings (Fielding 2001). The researchers then met to compare codes and categories, and searched for links and common themes across categories. The major themes were determined based on consensus among all the authors through ongoing meetings. RESULTS Participants The characteristics of patient participants are listed in Table 2. For all patients, the diagnosis, treatment and follow-up had been conducted according to Western procedures and technologies. Participants had seven cancer types in various stages (four patients having metastatic disease), with cancer histories ranging between 5 months to 21 years. Ages ranged from 47 to 83 years at the time of the interview. The youngest age at diagnosis was 41 years. Two had severe comorbidities (heart disease and diabetes). In the TCM professionals focus group, the TCM physicians from Beijing Cancer Hospital had received standard university training in both Western medicine and TCM. The TCM physicians from Bai Cao TCM cancer clinic had received formal TCM university training. Interestingly, the chief TCM physician and the qigong master from Bai Cao clinic were themselves cancer survivors and had received both conventional and TCM therapies for breast cancer and malignant rhinopharyngocoele respectively. Main themes Patients and TCM professionals expressed similar views regarding the use and perceived advantages of TCM in cancer care. Four main themes emerged Blackwell Publishing Ltd, European Journal of Cancer Care, 15,

4 XU et al. Table 2. The characteristics of patient participants (n = 16*) Number of Characteristics participants Gender Female 6 Male 10 Age at time of interview (year) >70 4 Current or previous occupation Mining worker 1 Farmer 1 Teacher 3 University professor 2 Technologist 2 Government officer 4 Housewife 1 TCM professionals 2 Cancer site Gastric cancer 2 Lung cancer 5 Breast cancer 4 Bladder cancer 1 Malignant melanosacoma 1 Non-Hodgkin s lymphoma 1 Malignant rhinopharyngocoele 2 Disease stage when using TCM First-time diagnosis 13 Recurrence 2 Metastases 4 In remission 9 Disease history (year) < >20 3 Undergoing active or palliative conventional treatment (surgery, chemotherapy, radiotherapy etc.) when using TCM Yes 11 No 5 TCM treatment Herbal treatment Tailored formula only 8 Standard formula only 1 Both 6 Neither 1 Qigong therapy 16 *Two traditional Chinese medicine (TCM) professionals who are also cancer patients were included. Some patient used TCM continuously across different disease stages. Using TCM is a popular and cultural process of self-help Participants indicated that almost all cancer patients around them had used TCM, mostly as a complement to conventional therapy. We found that the decision to use TCM was an ongoing process with a cultural grounding. Fear of chemotherapy damaging the vital essence The most common reason for using TCM was to avoid or reduce the adverse effects of conventional therapy. For instance, one patient abandoned chemotherapy and turned to TCM because he suffered high fever and felt extremely weak during the chemotherapy; he said, I d rather die than continue the chemo. Participants unanimously perceived that these harmful effects were because the chemo drugs damage the vital essence the root of a person, so that you lose the basic energy to fight the disease. On the other hand, TCM was believed to be able to nourish the healthy qi (vital energy) and restore the normal pattern of health, which is crucial in defeating the disease. A patient stated: One of my classmates had lung cancer. He could walk and talk for more than one hour before the chemo, but his condition was worsened so much that I couldn t recognize him after two cycles. His whole body was destroyed by the chemo instead of by the cancer. If he could have received TCM at the same time, his disease would not have developed so fast. (Group 2, patient F) Because of this strong belief, a number of patients planned to use TCM even before they started chemotherapy. The importance of individualized prescriptions Participants strongly believed that individualized assessment and tailored TCM prescription was crucial to obtain optimal and safe treatment results. They believed that the proper combination and dose adjustment of herbs could maximize beneficial effects, neutralize potential toxicity and minimize adverse effects. This is in contrast to conventional approaches using standard products and dosages for all patients. Part of the trust in TCM is related to its respect for individual situations and wishes. I felt that the individualized prescription was better than Western treatments and standard TCM products. It can be adjusted from time to time according to my condition. (Meeting 1, patient C) I agree. The individualized prescription takes into account different patients and different syndrome categories. It is very important because the formulae maybe useful for other patients but not suitable for me. (Meeting 1, patient B) A process of self-help Patients usually obtained information about TCM cancer therapy through self-help, using information from various sources. Families, friends, other patients and support groups were instrumental in this process Blackwell Publishing Ltd, European Journal of Cancer Care, 15,

5 Traditional Chinese medicine in cancer care I got to know TCM cancer therapy from other patients in a cancer recovery club. Almost all patients in this club have used TCM herbal treatment and they told me the effect was very good... (Group 1, patient A) Often, previous positive experience with TCM use resulted in a strong belief, which made people decide to use it for cancer without further investigation. My families all trust TCM treatment. Thirty years ago, one of my kids got pneumonia and it was cured with TCM herbs. (Group 1, patient D) Notably missing from this decision-making process is the involvement of conventional health caregivers who received Western-style medical training. Very few patients reported a supportive attitude from their conventional caregivers regarding the use of TCM. Most of the advice came from TCM practitioners and patients did not inform conventional caregivers regarding their decision. [The effect of herbs was very good]... but I didn t tell my physician that I was receiving TCM herbal treatment since he doesn t believe in it. (Group 1, patient F) Many [conventional] doctors don t believe that TCM treatments have an effect on cancer, and thus would not suggest it to patients. Patients themselves make their own decision to use either TCM or conventional therapy, or both. (Professional meeting, Dr Y) Perceived advantages of TCM cancer therapy Perceived positive effects Patients in our sample unanimously felt that their overall quality of life and ability to function were significantly improved with TCM therapy. A relatively quick effect on symptom control was highlighted: 3 days to 1 week for controlling anorexia, weight loss, nausea, vomiting, diarrhoea, constipation, insomnia and low blood cell counts; 1 3 months for improving fatigue, weakness, stress and general well-being. Patients also mentioned that herbal treatments eliminated other symptoms, such as cough, haemoptysis, haematuria, alopecia, skin ulcer etc. One key informant, a TCM physician and breast cancer survivor, presented her experience on symptom control: I prescribed myself herbs. I used herbal dressings to treat my skin ulcer and herbal decoctions for hair loss, which were induced by radiotherapy. After chemo, my platelet count was very low and my general condition was bad. Western medicine had no good solutions for me. After taking herbal decoctions, the platelet count increased quickly and remained stable thereafter. I also used herbal inhalations to control the vomiting, and decoctions to prevent liver toxicity related to long-term use of chemo drugs. One of the reasons and expectations in using TCM is the hope for cure, reducing tumour size, and/or preventing metastasis. Several patients believed that their primary tumour or metastatic lesion was cured by TCM. However, this perspective was questioned by other participants. I think conventional therapy is necessary for most cancer patients to reduce and eliminate tumour. TCM is a very good supplement to consolidate and potentiate the treatment effect and to reduce the adverse effects of chemotherapy. But in most situations, I don t think TCM alone can cure the cancer. (Meeting 2, patient D) A participating physician suggested that we should be very cautious regarding patients claim that TCM alone cured their cancer. She said that many patients actually use other treatments concurrently, and they usually do not have the capacity to determine which ones contributed to the cure of their disease. Safe treatment One of the most important reasons for patients to use TCM cancer therapy was safety. Overwhelmingly, all participants agreed that TCM does not cause any adverse effects.... The most important thing for me is that TCM is not harmful. Instead, they can reduce the toxicity and damaging effects of chemo. (Group 1, patient E) Participants believed that an individualized prescription and proper combination was crucial not only to maximize treatment effect but also to ensure a safe herbal treatment. If used correctly, the adverse effects of TCM herbs were minor. So it is very important to identify the syndrome individually and make the combination correctly. (Professional meeting, Dr X) Relatively low cost Participants felt that another big advantage of TCM was the low cost compared to conventional Western medicine. This made at least one patient, who was not covered by the government socialized medicine plan, choose TCM over conventional therapy. Nevertheless, patients indicated that some reputable standard herbal products were more expensive than others. Long-term effect in recovery TCM was mostly used in a long-term fashion throughout the cancer trajectory, to aid recovery in a seamless way and to prevent recurrence. Our 2006 Blackwell Publishing Ltd, European Journal of Cancer Care, 15,

6 XU et al. participants saw TCM as healing-orientated, focusing on activating the natural reserves and re-building the resistance of body, so the effect is long-term rather than transient. Several participants also claimed that TCM is important for recovery since it can enhance the immune system. Benefits of group intervention Patients felt stressed, depressed and isolated when hospitalized. They believed that these emotional stressors are harmful to the health and impede healing. The group practice of qigong provided a good opportunity and an open environment where patients could exchange information, share experiences and encourage each other. Participants felt that qigong was a good form of exercise that was especially helpful to build up energy, resistance and confidence for fighting the cancer. Which TCM? All patients had used traditional Chinese herbal medicine. The most common administration route was oral; other routes included intravenous infusion, muscle injection, spray and external use (e.g. herbal dressings for skin ulcers). Almost all patients had participated in Guo-Lin qigong sessions. This is a type of qigong especially developed for cancer, whose proponents publicly claim that it can be useful to treat cancer. No patients had used acupuncture, stating that this technique should be used with caution because it might stimulate tumour spread or progression. Research on TCM Participants perceived that research was instrumental to promote TCM recognition and its dissemination to Western countries. TCM professionals admitted that the most important barrier for the dissemination of TCM was the absence of clinical research evidence. Therefore, they showed a great interest in evaluating the effectiveness and safety of TCM for cancer. At the same time, they stated that they need support and training in clinical research methodology. They believed that collaboration between Western investigators and Chinese TCM clinicians would help fulfil this need. Both patients and TCM practitioners hoped that Western patients could have access to the TCM benefits that they experienced. DISCUSSION We found that the cancer patients in this study decided to use TCM as part of a self-help process that has a deep cultural grounding, related to the traditional Chinese philosophy of life. Participants perceived TCM to be an effective and harmless therapy. They highly valued the fact that TCM is tailored to patients, and believed that it was the basis of an optimal and safe treatment. Participants also highlighted the long-term positive effects, the benefits of group interventions, and the low cost as important features of TCM in cancer care. Subjects believed that future clinical research is crucial for the recognition and dissemination of TCM in Western countries. One limitation of this qualitative study is that the results were based on a sample of patients who were selected by their TCM physicians. Patients who were success stories, who had good relationships with their doctors and who were in better health were more likely to attend the focus groups. Therefore, it is not surprising that there was a strong support for TCM along with descriptions of positive experiences. However, we believe that the perspectives emerged from these discussions were quite representative of the general opinion of TCM in China. The main reason for this is that these perspectives (hence the use of TCM) are strongly related to a Chinese philosophy of life that is deeply engrained and rooted within the entire Chinese population. This cultural factor is a very important source of expectations and beliefs in TCM benefit, and hence positive experiences with TCM. Strong beliefs and expectations of a therapy are certainly important components that lead to positive experiences in treatment effect. However, we cannot differentiate between socio-cultural factors and biological effects in a qualitative study or a simple observational study. As the use of TCM in Western countries is not related to such socio-cultural contexts, the effects observed in these countries may be different from those reported in China. For these Chinese patients, the belief in TCM philosophy and paradigm was sufficient for them to decide on its use. The TCM professionals provided case material and clinical observations as proof of their claims and this evidence was well accepted by patients. Such anecdotal evidence, however, is certainly not sufficient to convince Western authorities and patients to use TCM. Therefore, positive results from strict clinical trials would be necessary to convince Western health professionals to adopt TCM in their practice. This study was the first step in developing a collaborative programme between Canada and China to formally evaluate the effectiveness and safety of TCM in cancer care. This study was conducted in China because we wanted to explore the long-standing traditional use of these treatments. The results will contribute to the Blackwell Publishing Ltd, European Journal of Cancer Care, 15,

7 Traditional Chinese medicine in cancer care knowledge base regarding current models of TCM cancer care in China, as well as providing useful information to help develop future clinical trials in Western countries. There have been a few randomized controlled trials (RCTs) conducted in China that aimed to evaluate the efficacy of TCM therapies (Wong et al. 2001). However, new studies, with more stringent methodology, are required. A pilot RCT, supported by the Canadian Institutes of Health Research, is being conducted in Canada to assess the feasibility of conducting full-scale RCTs. In that study we will assess personal beliefs and expectations regarding TCM prior to administering the interventions. We will then determine the association between these socio-cultural factors and the efficacy of TCM. The qualitative study reported in this paper underscores the paramount importance of comparing medical practices in different countries, in order to identify the role of cultural beliefs in the effectiveness of interventions. ACKNOWLEDGEMENTS The authors are grateful to all participants and participating hospitals and clinics. In addition, special thanks go to Dr Daning Zhang for help with the structured interviews in Bai Cao TCM Cancer Clinic, and special thanks go to Dr Jingyu Wang for help with communication and organization of the study. REFERENCES Boon H., Brown J.B., Gavin A., Kennard M.A. & Stewart M. (1999) Breast cancer survivors perceptions of complementary/alternative medicine (CAM): making the decision to use or not to use. Qualitative Health Research 9, Carey M.A. (1993) The group effect in focus groups: planning, implementing and interpreting focus group research. In: Critical Issues in Qualitative Research Methods (ed. Morse, J.M.), pp Sage Publications, Thousand Oaks, CA, USA. Denzin N.K. & Lincoln Y.S. (2003) Introduction: the discipline and practice of qualitative research. In: Collecting and Interpreting Qualitative Materials, 2nd edn (eds Denzin, N.K. & Lincoln, Y.S.), pp Sage Publications, Thousand Oaks, CA, UK. Ernst E. & Cassileth B.R. (1998) The prevalence of complementary/alternative medicine in cancer: a systematic review. Cancer 83, Fielding J. (2001) Coding and managing data. In: Researching Social Life, 2nd edn (ed. Gilbert, N.), pp Sage Publications, Thousand Oaks, CA, UK. Krueger R.A. (2000) Overview of focus group. In: Focus Groups: a Practical Guide for Applied Research, 3rd edn (eds Krueger, R.A. & Casey, M.A.), pp Sage Publications, Thousand Oaks, CA, UK. Macek C. (1984) East meets West to balance immunologic yin and yang. JAMA 251, Morse J.M. (1991) Strategies for sampling. In: Qualitative Nursing Research: A Contemporary Dialogue (ed. Morse, J.M.), pp Sage Publications, Newbury Park, CA, UK. Murphy E., Dingwall R., Greatbatch D., Parker S. & Watson P. (1998) Qualitative research methods in health technology assessment: a review of the literature. Health Technology Assessment 2, iii ix, Richardson M.A., Sanders T., Palmer J.L., Greisinger A. & Singletary S.E. (2000) Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology. Journal of Clinical Oncology 18, Ryan G.W. & Bernard R. (2003) Data management and analysis methods. In: Collecting and Interpreting Qualitative Materials, 2nd edn (eds Denzin, N.K. & Lincoln, Y.S.), pp Sage Publications, Thousand Oaks, CA, USA. Stewart D.W. & Shamdasani P.N. (1990) Introduction. In: Focus Groups: Theory and Practice (Stewart, D.W. & Shamdasani, P.M.), pp Sage Publications, Newbury Park, CA, USA. Tuckett A.G. (2004) Qualitative research sampling: the very real complexities. Nurse Researchers 12, Wong R., Sagar C.M. & Sagar S.M. (2001) Integration of Chinese Medicine into supportive cancer care: a modern role for an ancient tradition. Cancer Treatment Review 27, Blackwell Publishing Ltd, European Journal of Cancer Care, 15,