Towards integrated care of the breast cancer patient : perspectives on the challenges and opportunities of medical pluralism in a disparate society

“Medical Pluralism” refers to the co-existence of many different medical systems, practices and products within a healthcare landscape. Whilst in most countries, mainstream biomedical treatment protocols dominate, many practices exist which are not routinely incorporated into these treatment protocols. For the ease of academic discourse, this large array of practices and products are often referred to collectively as “Traditional, Complementary, and Alternative Medicine” or “TCAM”. Patients with cancer, and specifically women with breast cancer, are some of the highest utilisers of TCAM as they battle the disease and mainstream treatment side-effects. Concurrent use alongside conventional oncology treatments however can hold risks, yet many patients do not disclose TCAM use to oncologists, and many oncologists do not engage in TCAM discussions with patients. “Integrative Oncology” incorporates a variety of evidence-based practices from across the pluralistic landscape, neither rejecting mainstream treatments nor accepting alternatives uncritically, and could potentially offer clarity to patients and oncologists in navigating medical pluralism. Whilst many studies have investigated patient TCAM use elsewhere in the world, there is a dearth of data on the choices and experiences of cancer patients and oncologists navigating the local pluralistic landscape. This study sought to describe aspects of current practice and lived experience of eThekwini breast cancer patients and their oncologists with respect to TCAM use. In doing so, it also sought to throw light on the incorporation of holistic or integrative practices by way of ascertaining the status of formalised Integrative Oncology in eThekwini, as well as outlining some of the challenges and opportunities for its growth in the local setting. The study utilised a mixed-methods sequential explanatory design which consisted of patient and oncologist surveys, followed by patient and oncologist interviews. Participants (316 patients and 18 oncologists) were recruited from government (GOV) and private (PVT) facilities in eThekwini by snowball and convenience sampling. Patients reported incorporating a range of lifestyle modifications and interventions as a way to gain control, combat side-effects and support the body in healing. These included dietary approaches, supplements, cannabis, exercise, meditation, yoga, psychological counselling, support groups, relaxation techniques, and prayer. Apart from spiritual support practices, frequencies of inclusion were consistently and significantly lower in the government cohort. Thirteen percent of government patients and 53% of private patients also consulted with TCAM practitioners. This included massage therapists, African traditional healers, chiropractors, homeopaths, aromatherapists, and acupuncturists. Most patients are incorporating additional practices in a self-directed fashion with varying levels of disclosure and reports of very limited to no patient practitioner discussions on TCAM. Many patients expressed the need for more information and guidance. Oncologists were divided as to the role of various TCAM inclusions. In terms of lifestyle modifications, the majority (79%) supported the role of nutrition in oncogenesis and healing, and 58% reported having a nutritionist associated with the practice. Fifty-three percent believed supplements are an important consideration in cancer management, with 79% discouraging supplement use during active mainstream treatments. All oncologists supported the vital role of exercise and 95% report raising this with their patients. Regarding TCAM practitioners, oncologists described their knowledge as “very little” or “none” for all the fields included in the survey and remain divided on the role that these practitioners can play in oncology. Oncologist reservations were rooted in previous negative experiences where patients had incorporated TCAM practices (mainly African traditional medicine); in proponents of questionable practices with unfounded claims of cure; and in a perceived lack of evidence for TCAM inclusions. Formalised Integrative Oncology is currently not evident in oncology care in eThekwini. There are, however, oncologists who strive towards a holistic model of patient care and are open to other evidence-based inclusions and collaborations. With the disparate nature of medical provision in South Africa, the government sector holds more challenges for both oncologists and patients. As such, the private sector is more suited to the growth of Integrative Oncology. Medical pluralism brings many challenges and opportunities. Empowering patients through accessible evidence-based health literacy remains a priority for them to navigate the health landscape of South Africa safely and effectively, avoiding risk whilst optimising quality of life and clinical outcomes across the cancer continuum.