Reviewer's report 
 Trends in Complementary/Alternative Medicine Use by Breast Cancer Survivors: Comparing Survey Title: 
Data from 1998 and 2005 
 1  8 September 2006 Version: Date: 
 Paul P Shekelle Reviewer: 
Reviewer's report: 
This paper presents the results of a 2005 survey of breast cancer patients and compares it to a similar 
survey done in 1998. The survey concerns CAM use. The authors report that, comparing several hundred respondents in each year, CAM use has increased, and almost half of patients in 2005 used CAM for their breast cancer symptoms. Certain types of CAM (bodywork practitioners, herbal-type products) have seen 
the greatest increases. The authors conclude that CAM use is increasing, and that it can no longer be 
regarded as "alternative". 
This paper adds some interesting data to the knowledge about CAM use, specific to breast cancer patients. 
I think readers will benefit from a little bit of additional clarification. 
What was the definition of "CAM" that was used, both conceptually by the authors and operationally in 
terms of the survey? For the latter, it appears this was a tick box, and perhaps there was no formal 
definition of CAM in the survey. 
I think the authors want to qualify "breast cancer is the most common neoplasm..." I didn't think it was even 
the most common malignant neoplasm, which I thought was skin cancer, let alone the most common 
neoplasm of any type, which would include benign ones. Perhaps "most common non-skin cancer..."? 
In terms of the survey response rates, how does the denominator from 1998 drop from 557 to 539? I don't 
think readers will want to go to the Boon 2000 reference to figure this out, and Figure 1 is not informative on 
this. 
I don't think it very sporting to refer readers to an unpublished manuscript for more details of their 2005 
sample. I think the authors need to provide in this paper whatever details they think are necessary. 
I don't think the predictors analysis is very information, and would recommend deleting it either in its 
entirety, or retaining the text but deleting the table. If the authors decide to retain it, why not also run the same analysis on the 1998 data? 
The portion of the discussion on page 9 where the evidence supporting uses of certain herbs is discussed 
is out of place in this manuscript. This paper is not about evidence of efficacy, is it? I think this section, and 
the following section about the use of essiac, can be deleted. Stick to reporting and discussing the changes 
in use. 
The limitations of the sampling strategy and response rate are appropriately stated, but I would delete the 
sentence "there is no reason to believe that the women lost to the follow-up...were any different..." This kind 
of statement is really an attempt without data to mitigate a limitation in response rate, and is without 
justification. 
Lastly, I would question the conclusion that CAM use can no longer be considered "alternative". Without a 
definition of what the authors mean as "alternative", readers can't determine whether these data do or do 
not support this designation. For example, in the introduction the authors state that women cite numerous reasons for taking alternative treatments, including anxiety, depression, sleep disturbance, nausea, etc. All of these symptoms have approved pharmaceutical therapies. Without knowledge that the respondents in 
this survey were using the therapies listed in table 2 instead of approved pharmaceuticals, how can the 41% 
usage be considered "alternative"? Alternative to what? 
 Accept after minor essential revisions What next?: 
 An article whose findings are important to those with closely related research interests Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests' below.