Advanced Stage Cancer Patients Experience in Seeking Treatment in Medan, Indonesia.

BACKGROUND: Proper treatment of cancer can make it easier for the healing process. Delay in patients seeking treatment is a problem that often occurs today. Handling of complementary and alternative therapies, which is not appropriate is one of the causes of delay in seeking treatment, which worsens the patient's condition. Patients usually come to health services already diagnosed with advanced cancer. AIM: The purpose of this study is to explore the experience of advanced cancer patients in seeking treatment.
METHODS: This study is qualitative research with descriptive phenomenology approach. Participants in this study were 15 advanced cancer patients who were treated in the chemotherapy room at Adam Malik General Hospital Medan and Murni Teguh Hospital using purposive sampling technique. Data collection was done with in-depth interviews. All interviews were first recorded and then transcribed. This study was analysed using the Colaizzi approach method.
RESULTS: The six main themes indicated that advanced-stage cancer patients for seeking treatment. Themes such as 1) choose the complementary and alternative treatment rather than medical treatment, 2) seek medical treatment as a final decision, 3) integrating complementary treatment as supportive therapy in addition to medical treatment, 4) external sources influence patient decisions, 5) reduce negative feelings by surrendering to God, and 6) lack of involvement of basic health services.
CONCLUSION: Advanced cancer patients have experience using complementary and alternative therapies, which are not appropriate before using a medical treatment on the grounds of distrust of medical treatment and advice from the environment around patients. The importance of nurses in providing appropriate education related to complementary and alternative treatment to cancer patients according to the stage of the disease.

Introduction

Cancer is a cause of morbidity and mortality throughout the world with an increase in incidence each year based on the results of Basic Health Research in 2013; cancer was found to be the third cause of death in Indonesia. Sumatera Utara Province is the province with the highest estimate of the absolute number of cancer events in all Sumatra regions, namely 13,391 people [1]. The proper cancer diagnosis is very important for effective treatment because each type of cancer requires a specific treatment regimen that includes one or more modalities such as surgery, radiotherapy, and chemotherapy so that health services must be integrated. The main goal of this therapy regimen is to choose the most effective treatment that will eliminate or slow down cancer growth while ensuring the highest level of physical and emotional well-being during and after treatment [2].

According to the Hospital Information System (SIRS) in Indonesia, the handling of cancer is facing various obstacles that cause almost 70% of sufferers to be found in an advanced stage [3]. Based on medical records from Adam Malik General Hospital in Medan, the number of patients who came to the hospital with advanced cancer was recorded as many as 120 people from July to December 2013, out of 120 people who were treated at an advanced stage there were 10 people who died. Meanwhile, according to the results of research conducted at Adam Malik General Hospital on April 2014, where it was found about 24 people from 30 breast cancer patients came to the hospital for the first time in an advanced stage [4].

Health-seeking behaviour is behaviour that is preceded by a decision-making process then regulated by the individual himself and family habits, norms that exist in society, and expectations and characteristics and availability of health services [5]. The behaviour of seeking treatment in cancer patients is how cancer patients seek treatment, both medical treatment and complementary and alternative treatments after the patient feels signs and symptoms.

The attitude and behaviour of cancer patients in choosing health assistance are strongly influenced by the socio-economic level and cultural background. Another thing that supports is fear of side effects in treatment, fear of surgery in cancer patients in general and medical expenses is the reason for the delay in cancer patients in seeking treatment [6]. In North Sumatra Province, the number of households using traditional health services is 26.3% using 38.8% ingredients, using 6.0% tools, without 79.5% tools and with 2.0% thoughts[1].

There are so many traditional or alternative medical practices not listed in Sumatera Utara, especially in Medan. The Sumatera Utara Provincial Health Office does not yet have exact data regarding the place of practice of traditional/alternative medicine. This shows the many developments in traditional and alternative medicine in remote areas of Sumatera Utara which are not recorded.

The delay seeking treatment will affect the condition and success rate of patients who seek treatment. Many patients, after undergoing traditional medicine or complementary and alternative medicine come to the hospital with increasingly worse conditions so that the prognosis of survival becomes worse. The poor prognosis of cancer will affect the quality of life of patients [7], financial conditions [8], the role and function of patients and families and even death.

Methods

This research is qualitative research with descriptive phenomenology approach. This research was conducted by taking preliminary data from the chemotherapy room at Adam Malik General Hospital and chemotherapy room at Murni Teguh Hospital, Medan. The research was conducted in July-November 2018.

Data collection was carried out by in-depth interviews. Participants were selected by purposive sampling with criteria: 1) willing to be participants, 2) stage IIIB, IIIC and stage IV cancer patients, 3) able to communicate verbally clearly, 4) ages 18 years and over, and 5) has undergone medical therapy and complementary and alternative therapies or traditional medicine. The number of participants was 15 people and had reached the data saturation of the 14 participants. Before conducting the research, the research protocol had passed the ethical test from the Research Ethics Committee of the Faculty of Nursing; the Universitas Sumatera Utara and every cancer patient who was a participant had agreed and signed informed consent.

The preliminary data in this study were taken in the chemotherapy room at Adam Malik General Hospital and Murni Teguh Hospital, Medan. Further, the researcher looks for participants according to the existing criteria.

After obtaining approval from the participants, the researchers conducted prolonged engagement 2 times at home before conducting in-depth interviews. In-depth interviews in this study were conducted 1-2 times with 30-55 minutes and using SONY ICD-PX470 voice recorders, field notes, and open interview guides as many as 8 questions. This interview guide has been tested for validity with 3 experts in the qualitative and cancer fields by obtaining the CVI value = 0.87.

The results of the interviews were made in the transcript and carried out data analysis with the Colaizzi approach. This research uses the help of QDA Miner Lite software. The researcher obtained permission from the Research Ethics Committee of the Faculty of Nursing, Universitas Sumatera Utara. This research was funded by the researchers themselves and did not impose any costs on the participants of this study.

Results

Patients Experience in Seeking Treatment

The results of this study illustrate several themes based on the experience of participants who experience advanced cancer in seeking treatment.

The thematic analysis process in this study found 6 themes, namely: 1) choose the complementary and alternative treatment rather than medical treatment, 2) seek medical treatment as a final decision, 3) integrating complementary treatment as supportive therapy in addition to medical treatment, 4) external sources influence patient decisions, 5) reduce negative feelings by surrendering to God, and 6) lack of involvement of basic health services.

Theme 1: Choose complementary and alternative treatment rather than medical treatment

Choose complementary and alternative reasons for wanting to get well. When patients diagnosed with cancer generally experience rejection, sadness, and disbelief in a medical diagnosis so that patients feel they want to get well soon. The patient’s desire to recover makes patients choose to use alternative therapies that are not rational and even mystical.

“… Yes, the term is if the harsh words of people say shamans like that. The problem is that people say that there is someone who has a disease like you are here, and he is cured. We want to get well, so I try it, but the doctor stays. Over time there is no change. I am lazy again; I have already used up a lot. The shaman asked for a goat, asked the chicken for the media … “(P7).

“… At that time, what did I do? Because I also want to get well, so I lose my mind. I was recommended by my sister. Flowers bathed me and the dukun knew that I had stage 3 cancer… “ (P13).

Roles and responsibilities in the family. The patient feels the signs and symptoms of cancer, but the patient does not care about it because there is no time to go to the hospital, afraid that no one will take care of other family members. If they are hospitalized, their role and function in the family cannot be done properly.

“… Then I left my little boy, right? … still, there was no school; no one was on guard. If you are admitted to the hospital, you will be treated later; it will not be treated for one day. Let’s say it’s just alternative treatment while on the go… “ (P10).

“… Besides that, my children will not take care of it later. If my husband is already there, he rarely goes home. My second child is what I think about. There is no one who will take care of him later if his brother is used to wandering around…. “ (P11).

Do not trust medical treatment. Some participants have undergone medical treatment by checking themselves into health services but the illness they suffer from cannot be diagnosed appropriately. This condition makes participants and families give up and choose alternative medicine in addition to medical treatment.

“… but how come huh? the initial harm was not detected by medical treatment. Do not know what the disease is. So, we are looking for another alternative … “ (P1).

“… I am afraid because people say they will be bald, this is black and black (pointing to the fingernails and toes). Make the family can’t. “I just drank the herbs,” he said. Ya… I obey him to drink herbal medicine…. “ (P3).

Financial reasons. The financial condition of cancer patients is very influential when patients seek treatment. Some patients with conditions that lower economic class and does not have health coverage prefer to use handling of complementary and alternative (CAM).

“… I thought yesterday; there would be a lot of costs if the conditions of the long distance to the hospital, in addition to eating it too…” (P11).

“… Just the doctor said it was mandatory to operate, and after all that time I didn’t have the cost. How do you want surgery, right? Yes, I also sold land, sold a house, but it was not enough for operating costs. Yesterday the sale of land was around 35 million for medical treatment … “ (P14).

Complementary and alternative forms and processing. The handling of complementary and alternative therapies used by participants in overcoming cancer is generally herbal therapy, listening to the Quran, kusuk or sequence. “… At this halfway house, you can often read the verses of the Koran by the guard in charge. Let our hearts cool. Sometimes there are watching lectures; sometimes there are direct recitations, just our little ones. Later we will also read Yasin or read together … “ (P11).

“… Boiled then drank the water. Hmhm … make 5 glasses of boiled water until the mixture becomes 3 cups of water. Just wait for cold to drink. Then that’s it, Sis, until 7 times changed place… “ (P15).

Choosing alternative/traditional treatments are not appropriate. Participants who carry out complementary and alternative therapies generally attend traditional types of treatment that do not have permission from the local public health officials. Participants said if they did not know whether the practice had permission or not.

“… Using the sign is the schedule; there is a schedule. I don’t know about the permit; the important thing is that in front of the house there is a signpost and the schedule is that Friday night he closes…. “ (P10).

“… I don’t know, sis. I don’t think there is one who will come to my house. I don’t know where the treatment is. My husband knows. But it seems like it doesn’t exist. Because the problem is that he’s not coming anymore, he’s surrendered, he can’t bite anymore… “ (P11).

Theme 2: seek medical treatment as a final decision

Stopping the use of CAM adverse. Complementary and alternative therapies can have a bad effect if the user is not done properly. Generally, the condition that occurs in participants is broken cancer, cancer cells are growing and severe, or do not give any effect at all. Therefore, patients decide to choose medical actions that after being carried out by participants are felt to be quite beneficial.

“… No Sis, I haven’t used it anymore, it’s an alternative method, there’s no effect. Just to medical, I have improved my condition… “ (P10).

“… Because I have given up, already tired. I was tired of alternative treatments; now I just go to medical treatment. Medically told what the treatment is like. Surrender me. Follow medical treatment only. …”

Strive for a series of medical treatments, both domestically and abroad. Participants took part in a series of medical treatments to treat cancer both in the form of initial examinations, seeking clarity of medical diagnosis, carrying out therapy and other supporting examinations in many referral hospitals. Surely the search for treatment was not limited to domestic hospitals only, 2 participants even sought treatment abroad, namely in Penang Malaysia.

“… In short, I went to Penang. in Penang I do it again, I bring all the results again, they feel less accurate. So, we carry on the same examination again from the beginning, blood test, CT Scan. X-ray… “ (P13).

“… the doctor asked me if I was a cancer patient? I justify it. “Yes, doc” I replied. I was dealt with first, put on oxygen, and the doctor said “Sis. instead, we don’t want to serve you, but you have to be referred to another hospital, “he said.” If we were forced to serve you, we would be disqualified with the health department because you are a cancer patient, so you should be treated at hospital class A not C class hospital, that’s how it is”. So, it was explained by the doctor that I must be treated at the HAM Hospital. Ha “to be able not to be treated here”. “Then I should be treated where is the doc?” I said. “At the HAM hospital. Hospital class A. ha. From there, continue to HAM until now. Hmm. Almost 3 years…. “ (P14).

Theme 3: Integrating complementary treatment as supportive therapy in addition to medical treatment

Overcoming the side effects of medical treatment. Patients use some complementary therapies such as the consumption of external drugs and nutritious foods such as juice, milk to deal with the side effects of medical treatment.

“… Just treat it using Pikangsuang (herbal ointment), ointment so that it doesn’t itch, hmm … we bought it ourselves without using a prescription — just own initiative…. “ (P1).

“… Yes, if this skin, I diligently use lotion. It’s already gotten before it was worse. If nausea vomiting, there is a medicine from the doctor, and I also drink milk E. If the hair, hmm… I just cover it, use this (pointing my head) … “ (P5).

Increase stamina and the immune system. Cancer patients usually consume herbal products that are sold freely to increase endurance and increase stamina.

“… The trick: beet fruit as an addition to blood and guava. So, it’s not bitter, add the red guava, it’s fragrant. That is pretty beet. In the beet fruit, there is this weight gain; I am the most victorious, here my friend is down on his Hb. All down…. “ (P9).

“… Actually, no. That’s all my family recommends mixed, medical as well, but for endurance, take this kind of vitamin right. The cancer is in the womb, so don’t clash with medical, don’t clash with chemical, there’s no effect it says it’s just been drunk. But sometimes I forget to drink it, that’s the HPAI … “ (P12).

Theme 4: external sources influence patient decisions

The decision to choose the kind of treatment in patients with advanced cancer can be affected by external sources. These external sources who played a major role in the right decision made by cancer patients because it affects the delay to be handled correctly.

Family and friends. Participants considered the family, especially husband/wife, children, siblings, parents, friends, and neighbours, to influence the accuracy of their seeking cancer treatment. The influence given is information and support in the form of financial support, assisting participants, and influencing participant decisions.

“… my brother. He was the one who helped with all the costs, the cost of my life and the children at the expense of medical treatment, he helped… “ (P7).

“… my child. That’s what gives enthusiasm too. Get well soon, huh, don’t get sick. If I pray, I pray for you, so that the mother will recover quickly. Yes, I will be excited to hear children like that, right, right, Sis, because of children…” (P10).

Cancer survivor. The experiences experienced by cancer survivors are told and become a source of motivation for other cancer survivors. Participants said the support provided by cancer survivors was more on moral support, sharing experiences in running appropriate treatments so that they could influence participants’ decisions, especially as cancer survivors, in seeking appropriate treatment.

“… Sis, spirit, Sis, if we are in surgery, it doesn’t hurt, I say that. This is mine (breast), it’s been operated on, it’s already over, but it’s just a spirit, don’t be afraid the operation won’t hurt. Later we will sleep, be sedated; then the doctor invites the story, I say that. After a long time, we sleep. Yes, why can’t I do anything, I want to be healthy, “he said. Look like me. Eee, we must be enthusiastic. The name wants to be healthy; I say to people who are barriers, the same people like us a lot… “ (P10).

“… Right now, there are many friends in the hospital who are passionate, mam. Every chemo, every radiotherapy, there is always a friend who encourages. We often exchange ideas, mam. Those who have been sick for a long time, I keep on encouraging them, I salute them. From there, I learned to be thankful even though this illness has a family that supports me, meets with friends in the hospital who support it too. Exchange our telephone number…. “ (P15).

Social media. The progress of science and technology also affects participants in seeking treatment. The existence of the internet and easy access to health sites, the use and dissemination of information through Whatsapp, Facebook and radio can help participants find knowledge about cancer and treat it.

“… There was one and a half months ago with WA. from WA; I tried, I drank, yes even though I once opened on Google, what is that …? the effect is soursop leaves he said. But I don’t know I just drink. I think now, my chemotherapy does and I also drink the cooking water… “ (P5).

“… I heard from the radio. I heard it when advertising on the radio, but it seems like my heart said, ah…, I want to drink this because I listen to it on the radio, not from people…. “ (P8).

Involvement of health workers. Generally, doctors and nurses forbid the use of alternative medicine other than juice because it does not have a good effect on the therapy that will be undertaken. Medical personnel, especially nurses, also explain the side effects of medical treatment and provide medical treatment options that patients can make.

“… The doctor said you used to take medication using an alternative, sir? Yaa… I said Doctors prohibit using alternative therapies, but if the juice is okay. The nurse said that beat fruit juice was good…. “ (P1).

However, there were participants who stated that there were health workers who suggested using alternative medicine before medical treatment.

“… Hmmm … today if you want to say that alternative medicine can be said to be inappropriate. But there are health workers who recommend using alternative medicine before doing surgery, Sis! They suggested that. Even though he works at a health centre but my friend is in Perwiritan…. “ (P14).

Treatment culture in the community. Culture includes the habits of treatment carried out for generations. Participants said that when the initial symptoms appeared and resolved the symptoms, the participants chose the treatment carried out from generation to generation by their families the existence of certain tribal habits is also an option to overcome the symptoms that arise from this cancer.

“… I just know myself, usually when boils, that is. So I thought maybe this is a boil too. Our parents used it when we were kids… “ (P2).

“… The herbs that come with that bike. I usually drink turmeric, mix kencur rice, mix betel leaves. If the Javanese believe betel leaves are many benefits, one of them is for vaginal discharge. Only I rarely drink it. Not often or every day, just once… “ (P9).

Theme 5: Reduce negative feelings by surrendering to God

Negative feelings that arise. The patient says in seeking treatment and carrying out this therapy, the feelings that arise are in the form of fatigue, sadness, boredom, despair, and feeling useless with the current situation. Some participants also said regret, shocked and resigned.

“… Regret, mam! Why not from the first … Just what is it.? at the beginning of my treatment he said it was just an irritation, but it didn’t heal. There are several my neighbours using a shaman, and using herbal medicine … His name is also the business he wants to recover; I try. I mean, while I have a way to do it, I go ahead. I drink too, mam even though it tastes bitter, yea! But yeah … finally like this … maybe it’s fate … “ (P11).

“… Yes, frankly, bro, actually, sometimes I’m tired of being tired, yes, where are humans, too, is tired of all this. Sometimes my heart is crying, there is still a cure here and there is no cure, but yes when it also looks at the face of the husband, it becomes sad, he is excited, too tired to bring me there to here but don’t give up, so get up again “ (P15).

Get closer to God.Participants said that with the current conditions, they were more willing to surrender to God.

“… Yes … I still try to get treatment, try my best. Whatever the outcome will be, in the future, even if it’s possible that my uterus will be removed later, I leave it to God, Sis. This is a trial. My family and I tried, then it was up to God… “ (P4).

Theme 6: Lack of involvement of basic health services

According to participant, Puskesmas only as a referral centre.Participants made visits to the healthcentre to take referrals for treatment to the hospital. Generally, cancer in participants is diagnosed not at the clinic but the clinic or already in the hospital.

“… No, hmm … there is no health centre staff (health centre) coming to my house giving counselling. We just ask for referrals yesterday…. “ (P9).

Rejection of cancer patients in the clinic.A large number of cancer patients makes the length of service provided, so the hospital recommends doing some basic actions in basic health services. But one participant received a rejection because there was no service for cancer, both drugs, and other facilities.

“… I will drop it again, right? Even though sitting all day was difficult, that chemo time. So, it’s said, if it’s just changing bandages, just at the health centre. So, it was 1 person who guarded the pharmacy at the health centre; he objected when I was treated at the health centre. I mean that cancer should be treated in a hospital, not here … “ (P14).

Discussion

In this study, the majority of patients were women (86.67%) and men (13.33%). Based on the results of the research conducted, it was found that men were more likely to be late in seeking a diagnosis of cancer symptoms and late in treating cancer compared to women. This is because men are more masculine, so they tend to be less likely to seek help and less exposed to the health system [9], [10]. While women more often utilise health services related to pregnancy and role [11].

In this study, most types of cancer found were breast cancer (40%), then cervical cancer (33.33%) and colon cancer (13.33%). Colon cancer in this study entirely occurs in men. This is related to the research conducted by Iyer et al., the type of cancer that often affects women, such as cervical cancer and breast cancer [11]. According to research conducted by the type of cancer that often experiences delays is a type of cancer experienced by men compared to the type of cancer associated with women. This relates to women, in general, tend to act as role models for other people living with cancer and are more often exposed to health services [10].

The study found that participants who were advanced cancer patients chose complementary treatment and alternative therapies rather than medical treatment. At the beginning of the signs and symptoms appear, some participants chose the medical treatment as an initial examination and then diagnosed with early-stage cancer, but participants were afraid of medical treatment both medical measures themselves and medical treatment side effects. Also, the detection of diseases experienced by participants in medical services made sense of disbelief in medical treatment appears, so participants switched to using an alternative, complementary therapies. Participants choose complementary and alternative treatments with reasons for wanting to recover. Participants choose traditional medical practices such as sensei, “smart people” or shamans. The practice of this sensei treatment generally uses herbal medicines from plants but costs a very expensive one without any guarantee of recovery.

On the other hand, participants also visit shamans or smart people for reasons of wanting to recover. This practice calls for participation in surrendering chickens, goats, and other animals under the pretext of being dowry or media transfer. Other participants were also asked to take a bath using the prayed flower water. This is certainly not rational but is still carried out by participants. In this study, it was found that participants used an unlicensed alternative treatment site. In the Regulation of the Minister of Health of the Republic of Indonesia No. 61 of 2016 on empirical traditional health services states that every community who has a job as a traditional healer must have a permit/registered traditional healer (SIPT / STPT) issued from the local health office. Also, the Minister of Health Regulation also requires that each traditional practice place make a sign for a healthy home according to the stipulated conditions. This is certainly contrary to the experience of cancer patients [12].

Delay in cancer patients seeking treatment due to the role and responsibility of patients in the family. The patient acts as a husband/wife with duties and responsibilities as the head of the family and takes care of other family members making the participants ignore the signs of symptoms that arise. This is different from research showing that cancer patients with married status are more quickly seeking treatment for cancer that is suffered compared to single or divorced [13], this is due to the support of other family members to treat cancer.

The financial condition of participants also influences the choice of using complementary and alternative therapies. Most of the participants have a family income less than 2 million per month, and some patients at the beginning of being diagnosed with cancer do not have health insurance or insurance, so they are looking for complementary and alternative treatments. Cancer patients did not consult medical staff due to financial reasons [14]. However, this finding contradicts the research, which states that as the socio-economic increase of cancer patients increases, it allows patients to seek treatment that tends to decline rapidly [13].

Complementary therapy used by participants is generally herbal therapy, spiritual therapy in the form of listening to mural Al-Quran, and body-based manipulative methods such as sequences or ribs. Listening to the Koran, reading and memorising it can increase life expectancy in patients with palliative radiotherapy who have cancer [15].

Herbal therapies used generally come from parts of plants and grains which are processed by boiling namely, leaves of the “Dewa”, leaves of bin along, betel leaves, soursop leaves, Dayak onions, garlic, nutmeg and aloe vera, colour leaves. Also, oil and “rice parem” grated are one of the treatments performed by patients. Karo oil is generally used by participants as one of the local wisdom that is only found in the North Sumatra region. The rice parem is also used by cancer patients as one of the treatments to reduce the effects of heat on the patient’s stomach after chemotherapy. This param is made from rice and special spices which are processed in such a way that it causes a cold effect.

In this study, participants chose the medical treatment as the final choice in overcoming cancer. Erku stated that most cancer patients do not experience the side effects of using complementary and alternative therapies, and will continue to use them during cancer treatment. This occurs because the forms of complementary and alternative therapies used by patients in the study are generally based on clear evidence [16]. Research conducted by Temuci and Ortabag found that compared to the quality of life of cancer patients using CAM, there were no differences in physical activity, psychological and daily life [17]. All cancer patients in this study said that the handling of CAM used in general did not directly affect the cure of cancer suffered. The condition of the disease is even worse. Therefore, participants chose to stop using inappropriate CAM handling such as going to a dukun, a smart person or using a sensei.

This situation made participants decide to return to medical treatment. When the participants came to medical treatment again, the cancer was at an advanced stage. This finding is in line with the results of a study by Kim et al., stated that several factors related to cancer patients stop complementary and alternative therapies because of the side effects of therapy and the ineffectiveness of complementary and alternative therapies in overcoming cancer [18].

Some cancer patients generally choose complementary therapies, and these alternatives are due to disbelief in medical treatment. Patients claim to have carried out the treatment in more than three hospitals but to diagnose cancer has not been detected or do not believe in the diagnosis of cancer that has been determined. Also, other patients said that treatment at the hospital was not satisfactory due to improper handling of health workers in overcoming signs of symptoms that arise; even two participants chose to seek treatment abroad. Cancer patients seeking treatment tend to choose more than 6 health facilities because of feelings of disbelief, dissatisfaction with diagnoses of disease and others [19].

To overcome the side effects of medical therapy, patients usually use complementary therapies that support main therapies such as the use of milk, vitamins, and supplements from certain herbal products, as well as a source of vitamins from fruits and vegetables. In a study conducted by Thomas et al., stated that this complementary treatment was likely to succeed in one patient but was not effective in other patients. But complementary medicine is supportive therapy for existing conventional medicine. Also, the challenge for integrative treatment in oncology patients is efficacy and safety, prioritising based on the results of research, education, communication and appropriate arrangements [.

Most cancer patients use complementary therapies to increase endurance [. The use of herbal products that already have permission from the Food Drug Supervisory Agency (BPOM) so that their use is safe, but for the right dose of use for cancer itself is not clear. The use of these herbal products is limited to increasing stamina, reducing nausea and other side effects of medical therapy and not intended to cure cancer. The fruits that are often consumed are beet fruit, dragon fruit, guava fruit, papaya which is believed to have high anti-oxidants. But the use of herbs, both fruit and vegetables, vitamins and other foods must be considered because not all herbs match certain people.

According to research conducted by Johnson, Park, Gross, and Yu, explained that integrative medicine is not the same as an alternative treatment because it is integrated and complementary can be combined with conventional/medical treatment while alternative treatment is a substitute for medical treatment. The results of this study found that cancer patients who chose alternative medicine as the main treatment without being helped with medical treatment had a greater risk of death [21]. Evidence-based integrative therapy is recommended in breast cancer patients but requires further research for good results [22].

Therefore, the participants in this study generally prefer to combine complementary treatments that are in line with the medical treatment they carry out, namely radiotherapy, chemotherapy, and hormone therapy. Five participants admitted that they still had not consulted the use of complementary treatment to health workers or doctors. Participants argued that complementary treatments that they use, such as milk and juice products do not need to be consulted. In seeking treatment and treatment of cancer, it is quite long and is influenced by external sources. External sources obtained by participants came from family and friends, cancer survivors, social media, health workers and culture in the community. Research conducted by Muhamad, Afshari, & Kazilan that cancer survivors need the support of their family members for information about survival strategies related to emotions, lifestyle, and food to help patients in making decisions [23]. Therefore, the family plays an important role in influencing the patient to choose the right treatment.

The involvement of cancer survivor associations can help cancer survivors obtain appropriate treatment. Unfortunately, some participants said that there was an official association of cancer patients in the city of Medan, North Sumatra, who could provide guidance and counselling as well as a gathering place for cancer survivors.

The development of information technology now influences the selection of appropriate cancer treatment. This development certainly must be followed by the intelligence of social media users/communities to select and filter the correct information by looking at trusted sources and confirming to existing health practitioners. Also, there is a need for national policies to provide information, both social and public media, which are needed to meet different patient information needs. Health care providers must recognise that cancer patients will continue to need information at all stages, including those related to complementary therapies and appropriate alternatives [24].

According to Tariman and Szubski, there is a need for a good evolution of the relationship between patient doctors and nurses in making patient decisions to choose the right treatment. Nurses must have full awareness of their professional role to involve themselves in patient decisions, resolve obstacles faced by patients and use evidence-based interventions to reduce uncertainty in decision-making in patients choosing treatment [25].

All participants said there was involvement of health workers, especially nurses and doctors while seeking treatment. Generally, health workers do not recommend the use of complementary treatments and alternatives as patient choices except milk and fruit juice. But besides that, nurses still found that suggested the use of alternative therapies that were not appropriate to replace medical therapy recommended by doctors. This is certainly not appropriate and fatal.

The obstacles and obstacles that cancer patients undergo in seeking and undergoing treatment vary greatly from financial constraints, weak body conditions, transportation, and others. This certainly can affect the psychology of cancer patients in seeking treatment such as the emergence of feeling tired, tired, hopeless and even resigned. These feelings emerge as negative feelings that can affect a patient’s motivation to recover. According to the Irish Cancer Society (2012), cancer can affect emotional patients such as shock and disbelief, loss of self-control, sadness, resentment, anger, isolation and even cause anxiety and depression.

This spiritual support can be through prayer or guidance from Pastors, Rabbis, Imam, priests or religious leaders. This is supported by research carried out by Ahmadi, Darabzadeh, Nasiri, and Askari found that spirituality and religiosity are positively related to the well-being of cancer patients in seeking treatment [26].

In terms of religiosity, 12 participants were Muslim, and 3 participants were Protestant. One of the participants lives in a halfway house sheltered by a religious zakat body in the city of Medan, claiming that he has received psychological and spiritual support since living in that place. At this halfway house, patients are listened to the Quranic mural every day, get religious lectures every week, and get Ruqiah services every month. Also, participants are advised to always recite the dhikr and muhasabah themselves if the psychological condition is not stable. Protestant participants say they always say a prayer if the psychological condition is unstable. One in 3 patients said that they rarely attend church services due to the condition of the disease, but the participants claimed to do still the prayer led by one family member. Praying is a way that can be done individually, a spiritual feeling between individuals and God, providing peace for cancer patients [27].

Besides that, all participants admitted that when feelings of sadness and fatigue they would always try to remember God by praying, reciting, praying or praying according to religion and belief, and seeking support from people who knew more about religion.

In this study, there was a lack of the involvement of the health centre as basic health services, which played an important role in early detection of cancer. Participants generally said that they had never received counselling and pre-cancer examinations at the local health centre. Participants were not exposed to the dissemination of health centre officials regarding pre-cancer examinations such as IVA and SADANIS at the Puskesmas. Fourteen participants came to the health centre only when making referrals to the hospital. Of the 11 participants with breast and cervical cancer, 10 said they did not get the initial examination at the basic health centre after signs and symptoms.

Whereas in the Regulation of the Minister of Health of the Republic of Indonesia Number 29 of 2017 concerning changes to Minister of Health Regulation No. 34 of 2015 concerning the prevention of breast cancer and cervical cancer there is a role of health centre in the effort of early detection of breast and cervical cancer by involving trained midwives and trained doctors before refer patients to advanced health services or hospitals. Early detection services for cervical cancer and breast cancer can be done in primary care or health centres [28]. Whereas, in the follow-up, the patients referred to the health centre have not yet developed a clear path. The lack of clarity in the flow of handling follow-up of cancer patients makes health workers as implementers at the health centre level unable to implement this action, so the role of the health centre in preventing cancer is felt to be less than optimal [29].

The existence of gaps in the field with regulations issued by the Ministry of Health makes the explanation that the basic health centre is less optimal in tackling this cancer. This also relates to the quality of human resources, namely, health workers. Health workers in each service should have a special ability to detect this cancer from signs or symptoms that appear as early as possible. The reality is not in line with Minister of Health Regulation Number 29 of 2017 that the unavailability of health workers is trained midwives who have an early role who can refer to trained doctors at the Puskesmas level, and if they cannot be handled, they can be referred to further services [30]. Also, other health workers who diagnose the existence of cancer are less skilled so that patients can go to various health services both at home and abroad to seek treatment.

In conclusion, advanced cancer patients have experience using complementary therapies and inappropriate alternatives before using a medical treatment on the grounds of distrust of medical treatment and advice from the environment around patients. This study could be implicated in the field of nursing education as a reference for implementing education for patients in choosing the appropriate treatment. Cancer patients should be more concerned about the use of complementary and medical treatment appropriate to seek information to health care. For policy-makers should be able to perform any action against healthy institutions by applicable regulations. This study has limitations that the interview method cannot represent the type of cancer that has limitations in communication. This research can be further developed into more specific types of cancer or one type of complementary or alternative treatment.

Table 1

Demographic Data of Participants (n = 15)

Characteristics	f	%
Gender
Male	2	13:33
Female	13	86.67
Age
17- 25 years	1	6.67
36- 45 years	5	33.33
46- 55 years	6	40.00
56-65 years	2	13:33
65 - to the top	1	6.67
Ethnic
Banjarnesse	1	6.67
Bataknese	4	26.67
Chinesse	1	6.67
Javanese	7	46.67
Niasnesse	1	6.67
Tapanulinesse	1	6.67
Cancer types
Ca. Cervix	5	33.33
Ca. Colon	2	13:33
Ca. Mammary	6	40.00
Ca. Ovary	1	6.67
Melanoma	1	6.67
Duration of illness
< 1 year	2	13:33
1-2 years	6	40.00
2-3 years	3	20.00
4 years and above	4	26.67
Stage of cancer
IIIB	6	40.00
IIIC	4	26.67
IV	5	33.33
Occupational
< 2.9 million rupiah	11	20.00
> 2.9 million rupiah	4	40.00

Table 2

Themes Extracted from an In-Depth Data Interview

Themes	Sub-themes
Choose complementary and alternative treatment rather than medical treatment.	Choose complementary and alternative reasons for wanting to get well
	Roles and responsibilities in the family
	Do not trust medical treatment.
	Financial reasons.
	Complementary and alternative forms and processing.
	Choosing alternative/traditional treatments are not appropriate.
Seek medical treatment as a final decision.	I am stopping the use of CAM adverse.
	Strive for a series of medical treatments, both domestically and abroad.
Integrating complementary treatment as supportive therapy in addition to medical treatment..	Overcoming the side effects of medical treatment
	Increase stamina and the immune system
External sources influence patient decisions.	Family and friends.
	Cancer survivor
	Social Media
	Involvement of health workers.
	Treatment culture in the community.
Reduce negative feelings by surrendering to God	Negative feelings that arise.
	Get Closer to God
Lack of involvement of basic health services	Health centre only as a referral centre.
	Rejection of cancer patients in the clinic.