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. Author manuscript; available in PMC: 2015 Dec 10.
Published in final edited form as: J Support Oncol. 2009 Nov-Dec;7(6):W23–W31.

Quality of Life and Patterns of Use of Complementary and Alternative Medicines Among Glioma Patients

Ketty Mobed 1, Raymond Liu 1, Susan Stewart 1, Margaret Wrensch 1, Lucie McCoy 1, Terri Rice 1, Michael Prados 1, Susan Chang 1
PMCID: PMC4675625  NIHMSID: NIHMS740130  PMID: 26692824

Abstract

Many people with cancer consider using complementary and alternative medicine (CAM). To describe the quality of life (QOL) and use of CAM therapies among adult patients with glioma, we assessed 718 patients from the Neuro-oncology Clinic at the University of California, San Francisco, between 2002 and 2006. They completed an interview on CAM use and the Functional Assessment of Cancer Treatment–Brain (FACT–Br) QOL questionnaire. Tumor grade was significantly associated with functional, brain function-related, and overall QOL. Age, gender, education, income, and marital status also were associated with various aspects of QOL. Of the 718 participants, 33% used at least one form of CAM, and 42% reported using prayer. Women and those with higher educational levels and incomes were more likely to use CAM than other patients. Tumor grade was only associated with the use of mind-body types of CAM (odds ratio [OR] = 1.87; 95% CI: 1.00–3.49; P < 0.05 for high- versus low-grade tumors). Although overall QOL was not associated with CAM use, lower emotional QOL was associated with any CAM use, and higher functional QOL scores were associated with body-based CAM use (OR = 0.97; 95% CI: 0.93–1.00; P < 0.05 and OR = 1.04; 95% CI: 1.01–1.07; P = 0.03, respectively). Although interventional randomized trials would be needed to assess more accurately the influence of CAM on QOL among patients with glioma, this study provides important baseline information on patient preferences and QOL.

The National Center for Complementary and Alternative Medicine (NCCAM) defines complementary and alternative medicine (CAM) as a “group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.”1 However, many of these therapies, such as herbal medicines, acupuncture, or faith healing, have been in use in different cultures throughout recorded history. Use and trends in CAM therapies over the past 20 years in the general US population2-6 have been reported. CAM use among population subgroups, including older adults,7 adolescents,8 women,9 and members of ethnic minorities,10 has increasingly been documented. Persons with diabetes,11 chronic back pain,12 cardiovascular conditions,13,14 hypertension,15 HIV/AIDS,16,17 arthritis,18 and mental illnesses19 have also been surveyed about their CAM use.

Cancer patients have been reported to use CAM to treat either their cancer directly in addition to conventional treatments (chemotherapy, radiation therapy, or surgery) to lessen the physical and emotional pain and distress and/or to improve their overall quality of life (QOL).20-29 For example, Mao et al,23 using the 2002 National Health Interview Survey data, compared the prevalence of CAM use and prayer between cancer survivors and persons with no previous cancer diagnosis. They concluded that a person with a previous cancer diagnosis was more likely to use CAM and to pray than any other medical population group.

Patients with primary brain tumors, especially those diagnosed with high-grade gliomas, are often faced with a highly disabling and rapidly fatal illness. The impact of glioma morbidity on patients’ functional QOL has been reported,30-35 but the relationship, if any, between QOL and interest in and use of CAM has not been well established for glioma patients. To our knowledge, only three studies have examined the use of CAM therapies and their association with QOL in glioma patients.36-38 According to these studies, similar to the general US population, between 24% and 34% of patients with glioma or other primary brain tumors have used CAM. In one study, patients with primary brain tumors who used CAM were significantly younger, less likely to be employed, and had higher incomes than those who did not use CAM.36 In another study, glioma patients who used CAM were significantly more likely to be female, have a college education, and have smaller tumors.37 In a third study,38 only higher Karnofsky Performance Status (KPS) distinguished glioma patients who used CAM from those who did not.

The purpose of this article is to assess differences in QOL and QOL subscales and to describe the patterns of use and interest in CAM therapies and prayer among adult glioma patients.

Materials and Methods

The University of California San Francisco (UCSF) Committee for Human Research and individual hospital institutional review boards approved the methods of this study as related to human subjects research.

Subject eligibility and enrollment

Adult men and women newly diagnosed with histologically confirmed glioma and seen at least once at the UCSF Neuro-oncology Clinic between 2002 and 2006 were eligible to participate in this study. After clinic physicians introduced the study to patients, a study interviewer obtained written consent from willing participants.

Study instruments and data collection

Study data were collected using three separate forms. First, study interviewers conducted a brief survey of participants (either in person or by phone) that included questions on demographic and other background information. Participants were asked the following questions: “At the time of diagnosis or after diagnosis, how interested were you in the following complementary treatment?” (The response options ranged from 0 = not interested at all, 1 = interested a little bit, 2 = interested somewhat, 3 = interested quite a bit, 4 = interested very much, to 5 = already have participated). The 10-item list that followed included nutrition/diet consultation, exercise classes, massage, meditation groups/classes, imagery group/classes, yoga, qigong, acupuncture, herbs/Chinese medicine, and prayer. Respondents also were able to list up to three other alternative treatments in which they had been interested or participated. The items and survey format were adapted from questionnaires implemented in previous breast and prostate cancer studies.25,26

Second, patients completed the validated self-administered 46-item Functional Assessment of Cancer Therapy–Brain (FACT–Br)39,40 (version 3) questionnaire, recording information on a Likert-type scale (ranging from 0 = not at all to 4 = very much) about their QOL in five identified subscales39 (physical, social, emotional, functional, and brain function-related QOL).

Third, medical data such as KPS score and histologic type of the brain tumor were abstracted from the patient’s medical record. All data were double-checked and corrected for logical errors and missing values before double-key entry.

Statistical analysis

Of the 10-item list of CAM therapies, nine items were classified into four categories according to the NCCAM recommendations. Nutrition/diet consultation and herbs/Chinese medicine were grouped into the biologic category; exercise classes and massage, into the body-based category; meditation, imagery, and yoga groups/classes, into the mind-body category; and qigong and acupuncture, into the energy-based category. Prayer was analyzed separately and was not included in combined CAM categories or scores. Mean interest summary scores were computed for the four CAM categories and all CAM categories combined by adding up individual scores within specific CAM categories and all CAM categories combined. Individuals with any missing CAM values were excluded in the specific category and in the overall CAM interest score computation. The summary mean interest score computation excludes the scores for those patients who already had participated (score = 5).

The FACT–Br questionnaire was recoded according to the Functional Assessment of Chronic Illness Therapy (FACIT) guidelines (http://www.facit.org), reversing the scoring of negatively worded items. Missing values within subscales were replaced by average values of the subscale, as long as >50% of the questions in the subscale were answered. Scores within each of the five QOL categories were summed up and averaged, and new summary measures were generated for each. Additionally, following FACIT guidelines, an overall QOL summary score (including all subscale scores except the brain function score) was generated.41

Other variables included in the analyses were based on those previously found to be associated with CAM use, such as gender, age, race/ethnicity, marital status, years of education, income and factors previously shown to be related to QOL (including glioma histology and days elapsed between diagnosis date and interview date). Because of the relatively few non-white patients in the study, the race/ethnicity variable was dichotomized as “white” and “nonwhite.” Age (at the time of the interview) was classified as younger than 50 years and 50 years and older; education was dichotomized as up to 12 years of education and 13 years or more; annual household income was classified as less than $50,000 and $50,000 or more; marital status was aggregated into either married/living with a partner, or single/separated/divorced/widowed. Tumor grade was based on histology, with glioblastomas and all anaplastic types of gliomas being classified as high grade, and all other glioma types considered low grade. The time lag between diagnosis and interview was dichotomized at the median (ie, less than 107 days and 107 days or longer).

Basic statistics such as mean, median, standard error and range for continuous variables and percentages for categorical variables were generated. Chi-square tests and two-sample t-tests were used to compare differences of QOL and use of and interest in the various CAM therapies and prayer between high- and low-grade and male and female glioma patients. Differences in QOL, glioma grade, and other previously described variables were also compared between CAM and prayer users and nonusers, using the chi-square and two-sample t-tests. All tests were two tailed and P values less than 0.05 were considered significant. Results that are listed as statistically significant at the P < 0.05 level may show an upper or lower confidence interval (CI) of 1.0 due to rounding. Stata was the statistical software used for data analyses.42 We also conducted multiple logistic regression to estimate odds of using CAM (or prayer) associated with QOL, gender, ethnicity, age, years of education, income, marital status, glioma grade (high or low), and days elapsed between diagnosis and interview.

Results

Of 928 eligible patients, 718 patients (77%) participated in this study. The demographic, clinical, and quality of life characteristics of the participants and non-participants are described in Table 1. The median time elapsed between first diagnosis and the completion of the FACT–Br survey was 106 days, ranging between 6 to 1,232 days.

Table 1.

Demographic, Clinical and Quality of Life Characteristics of 718 Glioma Patient participants and 210 non-participants

Participants (n=718) Non-participants (n=210)
Percent Percent
Gender Male 58.9 57.1
Female 41.1 42.9
Race/Ethnicity White 84.5 71.9
Black 2.4 1.4
Asian 6.4 8.6
Latino 5.2 3.3
Other 1.5 14.7
Marital Status Single 14.4 NA
Married 73.8
Divorced, Separated, Widowed 11.8
Annual Income, $ <10K 4.9 NA
10-30K 12.3
30-50K 16.9
50-70K 11.5
70-100K 18.8
>100K 35.7
Glioma gradea High-Grade
Glioblastoma (Grade IV) 54.9 64.3
Anaplastic (Grade III) 15.3 11.4
Low-Grade
Grade II 21.3 11.4
Other 8.5 12.9
Karnofsky Performance Status 100 10.2 NA
90 50.1
80 27.3
70 8.4
60 2.8
50 1.2
missing n=157
Mean ± SE Median Range Mean ± SE Median Range
Age 48.6 ± 0.51 49 20-84 52.3 ± 0.96 53.5 20-77
Education Years 15.6 ± 0.12 16 2-31 NA
Days between diagnosis date and Interview 158.5 ± 6.39 106 0-1232 NA
Quality of Lifeb
Overall 77.4 ± 0.57 78.8 24-108 NA
Physical 20.9 ± 0.20 22 2-28
Social 22.7 ± 0.16 23.3 4-31
Emotional 17.4 ± 0.17 18 1-24
Functional 16.4 ± 0.24 16 0-28
Brain function 51.6 ± 0.49 53 13-76
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KPS=Karnofsky Performance Score; SE=Standard Error

a

Glioma grade classification: High-grade: grade IV=glioblastoma multiformae (n=394); grade III=anaplastic astrocytoma (n=74), anaplastic oligodendroglioma (n=25), anaplastic oligoastrocytoma (n=11); Low-grade: grade II=astrocytoma (n=75), oligodendroglioma (n=53), oligoastrocytoma (n=25); Other: anaplastic ependymoma (n=2), ependymoma (n=10), juvenile pilocytic astrocytoma (n=8), medulloblastoma (n=6), astrocytoma-not ; otherwise specified (n=3), others (n=32)

b

Quality of life based on the FACT-Br survey

Demographic and clinical characteristics

The majority of enrolled clinic patients were male, white, and married; had a post-high school education; and had an annual income of $50,000 or higher (Table 1). The median age at glioma diagnosis was 49 years, ranging between 20 to 84 years, and the median KPS was 90. Glioblastoma was the most common diagnosis.

QOL characteristics

Aggregated overall QOL and QOL subscale distribution characteristics were assessed. Being male, younger than 50 years, having a post-high school education, or reporting an annual income of more than $50,000 was significantly associated with a higher overall QOL (Table 2). A diagnosis of high-grade glioma was associated with a notably lower functional (P = 0.001) and brain function-related QOL (P = 0.003), whereas being married was inversely associated with emotional QOL (P < 0.05) but highly positively associated with social QOL (P = 0.0001). When we stratified the emotional QOL scores by gender and marital status, we found that the association between marital status and emotional QOL was only significant in men (P < 0.05). Furthermore, the only question within the emotional well-being subscale that was significantly different between married and single men was the question that asked whether the patient was worried that the condition was going to get worse (P = 0.02).

Table 2.

Associations of QOL and Component Scoresa with Demographic and Clinical Patient Characteristics (n = 718)

CHARACTERISTIC OVERALL QUALITY OF LIFEb PHYSICALc SOCIALd EMOTIONALe FUNCTIONALf BRAIN FUNCTIONg
MEAN SE MEAN SE MEAN SE MEAN SE MEAN SE MEAN SE
Gender Male 78.4 0.73 21.3 0.26 23.0 0.20 17.7 0.22 16.5 0.32 51.7 0.64
Female 75.9 0.90* 20.3 0.32* 22.4 0.28 17.0 0.28 16.3 0.36 51.5 0.76
Race White 77.3 0.61 21.0 0.22 22.7 0.18 17.3 0.18 16.3 0.26 51.8 0.52
Non-white 78.1 1.61 20.5 0.54 22.9 0.41 18.0 0.52 16.7 0.63 50.6 1.41
Age, yr <50 78.6 0.80 21.2 0.28 22.5 0.23 17.6 0.23 17.3 0.32 54.3 0.66
50+ 76.2 0.81* 20.6 0.29 23.0 0.22 17.1 0.26 15.4 0.34** 48.8 0.70**
Education, yr <13 74.4 1.49 19.9 0.55 22.8 0.39 17.0 0.47 14.8 0.55 47.2 1.20
13+ 78.2 0.61* 21.2 0.22* 22.7 0.18 17.5 0.19 16.8 0.26** 52.8 0.53**
Annual income, $ <50K 75.0 1.08 20.1 0.38 22.0 0.31 17.3 0.32 15.6 0.43 49.6 0.89
50K+ 78.7 0.66** 21.4 0.24** 23.1 0.19** 17.5 0.21 16.8 0.29* 52.8 0.59**
Marital status Married 77.5 0.65 20.8 0.24 23.1 0.18 17.2 0.20 16.4 0.28 51.3 0.57
Single 77.0 1.18 21.2 0.38 21.6 0.36** 18.0 0.34* 16.2 0.46 52.5 0.97
Glioma gradeh,i High-gradeh 76.7 0.65 20.7 0.23 22.9 0.19 17.2 0.21 15.9 0.28 50.7 0.57
Low-gradei 79.1 1.12* 21.5 0.39 22.3 0.32 17.8 0.32 17.5 0.44** 53.8 0.93**
Days between diagnosis and interview <107 77.5 0.71 20.9 0.28 23.1 0.21 17.5 0.23 16.0 0.31 52.0 0.65
107+ 77.3 0.89 20.9 0.29 22.4 0.25* 17.3 0.27 16.7 0.36 51.2 0.73
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QOL = quality of life; SE = standard error

a

QOL is based on the Functional Assessment of Cancer Therapy–Brain. Scores are based on 5-point scale:0 = not at all, 1 = a little bit, 2 = somewhat, 3 = quite a bit, 4 = very much.

b

Overall QOL summary score is based on the summation of the physical, social, emotional, and functional QOL scores.

c

Physical QOL is based on 7 questions.

d

Social QOL is based on 7 questions.

e

Emotional QOL is based on 6 questions.

f

Functional QOL is based on 7 questions.

g

Brain function QOL is based on 19 questions.

h

High-grade gliomas include glioblastoma multiforme, anaplastic astrocytoma, anaplastic oligodendroglioma, anaplastic oligoastrocytoma.

i

Low-grade gliomas include astrocytoma, oligodendroglioma, oligoastrocytoma, and other gliomas (anaplastic ependymoma, ependymoma, juvenile pilocytic astrocytoma, medulloblastoma, astrocytoma not otherwise specified and other).

*

P < 0.05 is based on the 2-sample t-test (numbers with p<0.05 are also bolded).

**

P < 0.005 is based on the 2-sample t-test.

Patterns of usage and interest in CAM and prayer

Among all patients, 33% participated in at least one type of CAM, 42% prayed, and 58% used either CAM or prayer (Table 3). Among CAM users, 49% participated in more than one CAM therapy. Body-based therapies were most commonly used, followed by biologic and mind-body therapies, respectively. Specifically, nutrition/diet, exercise, and massage were the preferred CAM modalities (Table 3). About 33% of patients also indicated that they used at least one other CAM such as naturopathic medicine.

Table 3.

Patterns of CAM and Prayer Use Among Low- and High-Grade Glioma Patients and by Gender and of Interest by Gender

CAM AND PRAYER USE CAM AND PRAYER INTERESTa
ALL LOW-GRADE HIGH-GRADE MALE FEMALE ALL MALE FEMALE
CAM CATEGORY AND MODALITY % % % % % Mean (SE) Mean (SE) Mean (SE)
Biological 17.6 15.4 18.5 14.4 22.0* 0.84 (0.05) 0.75 (0.06) 0.99 (0.08)*
 Nutrition and diet 13.4 10.3 14.7 11.6 15.9 1.20 (0.06) 1.03 (0.08) 1.45 (0.10)**
 Herbs 8.1 7.5 8.3 7.1 9.5 0.58 (0.05) 0.53 (0.06) 0.64 (0.07)
Body-based 20.1 18.7 20.6 16.8 24.8* 0.92 (0.05) 0.74 (0.06) 1.20 (0.09)**
 Exercise 13.6 13.1 13.9 12.5 15.3 0.99 (0.06) 0.82 (0.07) 1.24 (0.09)**
 Massage 10.3 8.4 11.1 7.1 15.0** 0.90 (0.06) 0.68 (0.06) 1.25 (0.10)**
Mind-body 10.2 7.5 11.3 7.8 13.6* 0.53 (0.04) 0.45 (0.05) 0.65 (0.06)*
 Meditation 4.6 2.4 5.6 4.0 5.4 0.62 (0.05) 0.50 (0.06) 0.81 (0.08)**
 Imagery 4.5 2.8 5.2 3.8 5.4 0.51 (0.04) 0.46 (0.05) 0.58 (0.07)
 Yoga 5.3 5.6 5.2 3.1 8.5** 0.56 (0.04) 0.44 (0.05) 0.74 (0.08)**
Energy-based 5.7 3.7 6.6 5.2 6.4 0.33 (0.03) 0.28 (0.04) 0.42 (0.05)*
 Qigong 2.0 2.4 1.8 1.9 2.0 0.22 (0.03) 0.21 (0.04) 0.24 (0.05)
 Acupuncture 4.9 2.8 5.8 4.5 5.4 0.49 (0.04) 0.41 (0.05) 0.61 (0.07)*
Any CAM use 33.4 30.4 34.7 28.8 40.0** 0.57 (0.04) 0.48 (0.04) 0.73 (0.06)**
Prayer 42.1 38.8 43.5 40.2 44.8 0.96 (0.07) 0.85 (0.09) 1.14 (0.12)*
Use of other type of treatments
 1 Type 23.0 22.5 23.0 20.8 25.9 NA NA NA
 2 Types 7.1
 3 Types 3.1
Number of CAM modalities used
 1 51.3 60.3 48.0 51.2 51.3 NA NA NA
 2-3 35.3 31.8 36.6 36.4 34.2 NA NA NA
 4+ 13.4 7.9 15.4 12.4 14.5 NA NA NA
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a

Interest scores were based on an ordinal scale from 0 (no interest) to 4 (strong interest) and were averaged over each CAM category. CAM = complementary and alternative medicine; SE = standard error; NA = not applicable

*

P < 0.05 (numbers with p<0.05 are also bolded)

**

P < 0.005 (CAM and prayer use P values are based on the chi-square distribution, and interest score P values are based on the 2-sample t-test).

Characteristics of users of CAM and prayer

Table 3 shows no notable differences in the use of any type of CAM or prayer between low- and high-grade glioma patients but substantial gender differences in both interest and use of CAM. A significantly larger proportion of women than men participated in biological (P = 0.01), body-based (P = 0.01), and mind-body (P = 0.01) types of CAM. Mean interest in CAM showed similar results, with women having significantly more interest than men in using CAM and prayer.

Table 4 compares CAM and prayer users and nonusers for demographic and clinical characteristics and QOL measures. CAM users were more likely to be female (P = 0.002), have a post-high school education (P = 0.01), have an annual income level of $50,000 or more (P = 0.03), and have more days between diagnosis and interview (P = 0.02). No notable differences in QOL and its components were observed between those who did and did not use CAM. Prayer was used more frequently by married patients (P = 0.003), those with an education level 12 years or lower (P = 0.001), and patients with a shorter time between diagnosis and interview (P = 0.004). As with CAM use, there were no notable associations of prayer with overall QOL or its subscales.

Table 4.

Comparisons of Characteristics of Glioma Patients Who Reported CAM Use or Prayer and Those Who Did Not

CAM PRAYER
CHARACTERISTIC CAM USER (N = 240) NONUSER (N = 478) PRAYER (N = 302) NO PRAYER (N = 416)
% % % %
Male 50.8 63.0** 56.3 60.8
White 87.5 83.1 83.4 85.3
Age: <50 years 55.8 49.0 50.7 51.7
Education years: < 13 years 13.9 21.5* 24.6 14.8**
Annual income: < $50,000 28.6 36.9* 33.8 34.3
Marital status: married 73.2 74.1 79.5 69.6**
Glioma: high-grade 72.9 68.8 72.5 68.5
Days between diagnosis and interview: < 107 days 43.8 53.1* 56.3 45.4**
Quality of Life Mean (SE) Mean (SE) Mean (SE) Mean (SE)
 Overall 77.3 (1.00) 77.5 (0.69) 77.4 (0.87) 77.4 (0.75)
 Physical 20.8 (0.34) 21.0 (0.25) 20.7 (0.32) 21.1 (0.26)
 Social 22.6 (0.27) 22.8 (0.20) 22.9 (0.24) 22.6 (0.22)
 Emotional 16.9 (0.31) 17.6 (0.21) 17.5 (0.26) 17.3 (0.24)
 Functional 16.9 (0.42) 16.1 (0.28) 16.4 (0.37) 16.4 (0.31)
 Brain function 52.1 (0.85) 51.4 (0.60) 51.2 (0.75) 51.9 (0.65)
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CAM = complementary and alternative medicine; SE = standard error

*

P < 0.05 (numbers with p<0.05 are also bolded)

**

P < 0.005 from chi-square test

In multiple logistic regression analyses of any CAM or prayer use or use of subtypes of CAM with QOL and other characteristics (age, gender, ethnicity, education, income, marital status, tumor grade, and days elapsed between diagnosis and interview), emotional QOL was inversely associated with any use of CAM (odds ratio, 0.97; 95% CI: 0.93–1.0; P < 0.05), and functional QOL was directly associated with using body-based CAM (odds ratio, 1.04; CI: 1.01–1.07; P = 0.03). None of the other measures of QOL were associated with CAM or prayer use or any of the subtypes of CAM. Furthermore, after multivariate adjustment, gender continued to be associated with CAM use but not with prayer; in particular, women were more likely than men to report use of any CAM, biological, body-based, and mind-body therapies (results not shown). Additionally, patients with high-grade tumors were more likely than patients with low-grade tumors to report use of mind-body therapies after multivariate adjustment (odds ratio = 1.87; 95% CI: 1.0–3.49; P < 0.05).

Discussion

To our knowledge, this is the first article to comprehensively examine patterns of use and interest in CAM therapies and prayer in relationship to QOL and other characteristics among glioma patients. The large patient sample size is a notable strength of this study. We were limited, however, in our ability to compare our results with previous reports on QOL of glioma patients because the previous study had a smaller sample size,34 focused only on one aspect of QOL,32 used different measurement tools,35,43 and used patient populations that were either narrower (such as recurrent high-grade gliomas32,44) or broader (such as both benign and malignant brain tumors).34,36,40,45 Only the Weitzner et al study of 101 patients with primary brain tumors presented results in a way that was comparable to those in our study.40

Compared with our study, Weitzner et al reported higher physical and functional QOL scores (22.3 and 19.9, respectively) but lower social and emotional QOL scores (21.7 and 16.0, respectively) in their sample of patients. One possible explanation is that their study included far fewer patients diagnosed with glioblastoma (27%) than our study. Glioblastoma is the most disabling of primary brain cancer types. Their study also included patients with meningioma (13%), a generally less disabling type of primary brain tumor that was not included in our study.

Previous research on QOL measures in a general US population sample (n = 1,075) and a mixed cancer population sample (n = 2,236) using the FACT survey instrument found results that were similar to ours.39-41 The mean overall QOL score for the two general population groups (80.1 and 80.9) did not differ meaningfully from that of our adult patients with glioma (77.4). As for QOL subscale scores, social QOL was lower (19.1) and emotional QOL was higher (19.9) in the general population sample than in our patient sample (22.7 and 17.4, respectively), whereas functional QOL was higher in both normative samples (18.5 and 18.9) than in our sample (16.4). Given the physical impact of high-grade glioma on a patient, an even greater difference in the QOL of glioma patients with the general population was expected.

As with other studies, our data show some differences in QOL between patients with high- and low-grade glioma.34,44,46,47 Our data further highlight that although patients with low-grade glioma experienced significantly less functional and brain function-related burden than patients with high-grade tumors, the two groups reported similar emotional, social, and physical well-being. Given the poorer prognosis and lower functional and brain-function QOL of patients with high-grade glioma, one might hypothesize that they would be more likely to use CAM and prayer than patients with low-grade glioma.23 In general, however, we did not find this to be the case, with the exception that after multivariate adjustment, patients with high-grade tumors were more likely than those with low-grade tumors to report use of mind-based therapies.

Our finding that men reported higher overall and subscale QOL scores than women is similar to previous research reported from a study of the general US adult population but contrary to a study among mixed cancer patients.48 On the other hand, we found that CAM was consistently used more by women, a finding that concurs with a study of the general population3,6 as well as a study of a large sample of national cancer survivors23 and one of the three glioma CAM/QOL studies.37 As suggested in the literature, the reason for the greater use of CAM by women may be that women may have a more positive attitude toward CAM therapies and may be more willing to try them out.49 In addition, some of the listed CAM modalities significantly used more by female patients with glioma, such as yoga and massage, also have been reported to be generally used more frequently by women in the general US adult population.5 Further studies into the reasons why CAM and specific CAM therapies are used more often by women than men are needed.

We found that married men were more likely than single men to report poorer emotional well-being. Specifically, married men were more likely to report they were worried that their condition was going to become worse. In a study of patients with brain tumors, Kaplan and Miner found elevated depressive symptoms in those who were married.50 In contrast, other studies have concluded that married cancer patients have better mental QOL and report fewer symptoms of depression than unmarried patients.51,52 Although the reason for our finding is unclear, it is possible that married men may be more concerned about their condition worsening because of the additional burden it might place on their spouses.53 Additionally, Kaplan and Miner suggested that depressive symptoms in married patients may be related to the spouses becoming overprotective as well as to other marital or financial problems.50

Our study found modest associations between QOL and CAM use. People with lower emotional QOL scores were significantly more likely to report CAM use than those with higher emotional QOL scores. Similar results have been discussed in other studies examining CAM use among cancer patients.54-58 One potential reason for this finding is the possibility that some patients with poorer emotional well-being may try CAM to better cope with the disease and to bring more control to their lives.55,59 Another possible explanation is that some patients may be concerned that lower emotional well-being may lead to a poorer disease outcome and so may try CAM to improve their well-being and prognosis.60 We also found that those with higher functional QOL scores were significantly more likely to report body-based CAM use than those with lower functional scores. Although a poorer functional QOL may give some people more reason to try alternative treatments, those with a better functional QOL might also be more able to try more alternative options when faced with a potentially life-threatening illness.

Three other previous studies reported on the association between QOL and use of CAM in glioma patients. One found significant poorer physical, functional and brain function-related QOL in CAM users.36 This study included more people with low-grade gliomas than did our study and also included those with meningiomas, which were not included in our study. Another study of patients with high-grade glioma, which used a different survey tool for measuring QOL, reported that overall QOL was not significantly different in CAM users than in those who did not use CAM.37 A third study noted that CAM users had a higher KPS and better physical QOL than those who did not use CAM.38

Our study has several limitations. The underlying study was based at a single neuro-oncology clinic, so results may not apply to all patients; for example, patients attending this clinic tended to be younger than other glioma cases in the San Francisco area. Furthermore, because the study used a cross-sectional observational rather than an interventional randomized study design, we could not assess whether the use of CAM or prayer influenced QOL. Also, the FACT–Br survey is generally administered at several different points in time to record an individual’s well-being before, during, and after conventional or alternative treatments. This study, however, limited by its scope, obtained data only at one point in time for each patient. Furthermore, the CAM therapy questions were not specific enough to elicit when after glioma diagnosis CAM therapy was initiated. It is possible that some individuals may have been praying or practicing some type of CAM therapy, such as yoga, as part of their usual life-style or for other health reasons. Therefore, we could not assess whether the use of CAM or prayer influenced QOL.

Conclusion

CAM use and prayer were common among our large sample of adult patients with glioma. Although patients with low-grade and high-grade tumors had expected differences in reported QOL, they reported similar use of any CAM type and prayer. However, multivariate analyses showed that patients with high-grade glioma were more likely than those with low-grade glioma to have reported use of mind-body therapies. Women were more likely than men to use CAM, a difference that should be studied further. Those with higher education and income levels were more likely to report using CAM, whereas married patients and those with lower education levels were more likely to report using prayer. Overall QOL measures were not associated with CAM use or prayer, but lower emotional QOL scores were associated with a significantly higher use of any CAM, and higher functional scores were associated with significantly higher body-based CAM use. These results may be helpful to clinicians and researchers in designing other studies of QOL and complementary therapies for glioma patients.

Acknowledgments

This work was supported by the National Institutes of Health grants R01CA52689 and P50CA097257 and by gifts from the Robert J. and Helen H. Glaser Family Foundation and the Elvera Olsen Fund and the National Brain Tumor Foundation.

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