• What is alredy known on this topic: Eight studies have been conducted in Morocco regarding the use of CAM. However, none of these studies specifically focused on women with gynecological cancer.

  • What this study adds: It is the first study which is interested in the predictors of the use of phytotherapy as it is the first study that focuses on the predictors of the use of phytotherapy as CAM.

  • How this study might affect research, practice or policy: Gynecological cancers represent the majority of cancers treated in Morocco. The results will enable health professionals to tailor educational messages to women affected by these cancers.

Introduction

Breast cancer, cervical cancer, ovarian cancer and uterine cancer are among the ten most common malignancies worldwide. Between 1990 and 2019, incidence and case-fatality rates for these gynecological and breast cancers rose significantly. Projections for 2040 indicate an expected increase of 33.8% in breast cancer cases, 40.3% in cervical cancer cases, 36.6% in ovarian cancer cases and 30.3% in uterine cancer cases (Sung et al. 2021).

In 2018, statistical morbidity data from Morocco indicated that breast cancer had the highest incidence, with 10,136 new cases (19.2%). It was followed by lung cancer with 6,488 cases (12.3%) and prostate cancer with 3,990 cases (7.6%). Lung cancer emerged as the leading cause of cancer-related deaths, accounting for 3,518 fatalities (19.4%). Breast cancer followed with 3,518 deaths (10.7%), and cervical cancer accounted for 2,465 deaths (7.5%) (Alami Merrouni and Elachouri 2021).

Chemotherapy is the primary treatment for most of these cancers, despite its potential to cause adverse effects. These side effects can lead to prolonged hospitalization, increased medical costs, reduced quality of life, and may even affect disease outcomes (Wu et al. 2018). As a result, patients often explore alternative options, including complementary and alternative medicines (CAM) (Singh et al. 2024).

Herbal medicine is a widely used form of CAM. For instance, Black cohosh (Cimicifuga racemosa) has been shown to help women with breast cancer manage menopausal symptoms with minimal side effects (Klose 2024). In the USA, a 66% prevalence of herbal medicine use has been reported among gynecological oncology patients (von Gruenigen et al., 2001). Herbal remedies like turmeric, quercetin, and resveratrol have demonstrated efficacy against ovarian cancer (Rezaei-Tazangi et al. 2021). These herbs influence key biological processes such as apoptosis, invasion, migration, oxidative stress, and immune response. By modulating pathways like VEGF, PI3K-AKT, MAPK, and NF-κB, herbal medicines play a significant role in the prevention and treatment of gynecological disorders (He et al. 2024).

However, patients may experience a variety of adverse effects following the use of this therapy. These may result from pharmacodynamic or pharmacokinetic interactions with chemotherapy. Potential toxicities include anaphylaxis, liver toxicity, renal failure, cardiovascular toxicity, and carcinogenic effects, among others ( Träger 2017). In Morocco, several adverse effects have been reported in these patients, including gastrointestinal disorders, nephropathy and hepatotoxicity (Aboufaras et al. 2023).

In Morocco, research on the use of phytotherapy in women with gynecological and breast cancers (GCBC) is lacking. Only one Moroccan study has investigated the use of all CAM modalities in women with breast cancer, but it failed to identify all predictive factors, such as economic and psychocognitive influences. The sole independent factor identified was a high level of education (Rahou et al. 2017). Our study aims to assess the prevalence and factors associated with herbal medicine use among GCBC patients at the Beni Mellal Oncology Center.

Materials and methods

Survey and participants

A total of 317 women diagnosed with breast or gynecological cancer voluntarily participated in this study, which employed both descriptive and analytical methods. Participants were selected through non-probability sampling, with stratification based on cancer type. The sample size was calculated using the SurveyMonkey website, targeting a population of 1,124 individuals. The minimum required sample size was determined to be 287, according to the [SurveyMonkey sample size calculator](https://fr.surveymonkey.com/mp/sample-size-calculator/).

The study was approved by the Ethics Committee of the Faculty of Medicine in Oujda, under authorization number 29/2020. Data were collected through interviews using a questionnaire administered to patients at the Beni Mellal Oncology Center, including both day hospital patients and outpatients.

Variables and statistical analyses

The study variables were structured within a theoretical framework tailored to the use of complementary medicines in healthcare, drawing on Anderson’s socio-behavioral model (Fouladbakhsh and Stommel 2007). The use of herbal medicine within the past year served as the dependent variable. For psychological variables, a Moroccan version of a questionnaire assessing subjective and psychological aspects of complementary medicine was.

Sequential logistic regression, a technique for both bivariate and multivariate analysis, was used to identify factors influencing and predicting the use of medicinal plants. The analysis was conducted using the Statistical Package for the Social Sciences (SPSS v23) software.

Results

Characteristics of the sample

Breast cancer was the most prevalent malignancy among the women studied (n = 213; 67.2%), followed by cervical (n = 72; 22.7%), ovarian (n = 17; 5.4%), and endometrial cancer (n = 15; 4.7%). Among the patients, 24% presented with advanced-stage cancer, while the remaining 76% were in stages II and III. Post-surgery, 31.2% received adjuvant chemotherapy. The average age of the women was 50.63 years. The majority were non-employed (86.1%), illiterate (72.9%), and married (64.4%).

Prevalence and usage trends

The use of medicinal plants was prevalent in 40.7% of the patients (129/317), with the highest usage among women with breast cancer (42%), followed by those with cervical (38.9%), ovarian (35.3%), and endometrial cancer (33.3%) (Fig. 1). The patients utilized 48 plant species from 28 different botanical families, with Marrubium vulgare L. (50 users), Allium cepa L. (37 users), and Retama monosperma (L.) Boiss (36 users) being the most common. Table 1 details the plants used, along with the corresponding number of users and cancer types treated.

Fig. 1
figure 1

Use rates of phyotheraphy by kind of cancer

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Table 1 Medicinal plants used
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Nearly half of the users (45.7%) aimed for a curative treatment, while 31% sought to improve their quality of life. Among the non-users (n = 188), 29 expressed intentions to try this therapy in the future. A significant portion of users (42.26%) consistently used the therapy from diagnosis, while 34% tried it for a month. Only 12.4% informed their caregivers about their use. Positive outcomes were reported by 43% of users, while 14.72% experienced side effects, including digestive disturbances, hepatotoxicity, and hemorrhage.

Factors of herbal medicine use

The bivariate analysis revealed that women with gynecological or breast cancer who had used herbal medicine in the preceding year were significantly more likely to present with stage III or IV cancer (p < 0.05), have experienced illness for over a year (p < 0.000), and report a decline in health, with symptoms negatively impacting their quality of life (p < 0.01).

Psychologically, these individuals were more likely to perceive the impact of their condition as predominantly social and emotional (p < 0.000). They exhibited a positive attitude toward the outcomes of complementary and alternative medicine (CAM) therapies (p < 0.000), regarded their disease as more severe (p < 0.000), and were strongly influenced by the social norms of their social circle, including friends, family, and fellow patients (p < 0.000).

No correlation was observed between herbal medication use and caregiver social norms, reported socioeconomic barriers to CAM use, or beliefs about the efficacy of conventional cancer treatment.

Table 2 presents the results of the multivariate analysis. Sequential logistic regression identified variables that independently predict herbal medication use. CAM use was less common among patients diagnosed within the past year. The likelihood of using herbal medicine was doubled in individuals experiencing anorexia or discomfort. Patients who believed their illness would have social consequences were four times more likely to use herbal therapy. Those influenced by family and with a strong belief in the treatment’s benefits were more inclined to engage in CAM therapy.

Table 2 Predictors of traditional herbal medicine use:
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Discussion

We found that 40.7% of the women in the sample reported using herbal medicine in the past 12 months. Our findings are consistent with those from Germany, where 48% of women with gynecological or breast cancer (GCBC) use CAM, with herbal medicine, particularly mistletoe, accounting for 77% of this use (Fasching et al. 2007). A higher prevalence of 69% was reported in Germany. However, in this country, patients with gynecological cancer used herbal medicine less frequently than healthy individuals. Their primary motivation was to alleviate symptoms associated with cancer and its treatment (Theuser et al. 2021).

In contrast, this prevalence is significantly higher than the 31% reported in Moroccan studies for herbal medicine use among cancer patients of all types. Additionally, the plant species used differ from those commonly employed in Morocco, where Aristolochia longa L., Nigella sativa L., and Trigonella foenum-graecum L. are frequently utilized (Aboufaras et al. 2021).

The higher rate of phytotherapy usage compared to the national average may be explained by several factors. First, the participants in this study are women, whereas other research in Morocco has included both sexes and various cancer types. Additionally, the surveyed patients in the Beni Mellal-Khenifra region receive care in public oncology centers, as no private facilities are available in the area. This suggests that these patients may belong to lower or middle social classes. In contrast, other patients seek treatment at university hospital centers in Casablanca, Marrakech, and Rabat, or in private clinics across Morocco.

The high prevalence of herbal medicine use in female cancers may be attributed to the general widespread use of these therapies among women, as noted in various studies (Amrati et al. 2021). This trend aligns with findings from Western studies, where female gender consistently emerges as an independent factor for CAM use (Bone and Mills 2013; Dufter et al. 2021). Women, particularly those of Arab and Moroccan descent, often possess extensive knowledge of herbal medicine, making these therapies both accessible and cost-effective. Cultural beliefs further reinforce the perceived safety and efficacy of herbal medicines, with the perception that they lack chemical components and are safer than conventional drugs (Alqethami et al. 2017; Kim Sooi and Lean Keng 2013; Nega et al. 2019).

In our study, the users were women who had been living with cancer for over a year, experiencing pain or anorexia, perceiving a significant social impact of the disease, strongly believing in the benefits of CAM, and being highly influenced by the social norms of their friends, families, and other patients. In contrast, only one study in Morocco specifically focused on women with breast cancer and used logistic regression to identify predictors of T&CM use. This study identified higher education as an independent factor associated with T&CM use (Rahou et al. 2017).

This paradox may be explained by the fact that the research included all CAM methods, not just natural products like herbal therapy. For instance, among American women with gynecological cancer, the use of mind-body techniques within CAM was associated with a higher level of education (Wong et al. 2020). In Turkey, CAM use was prevalent in 68.3% of patients, with high satisfaction (5.80/7) and perceived effectiveness (5.71/7). CAM use also increased with advanced cancer stages and chronic conditions (Gul Pinar 2020).

The disparity between the profile observed in our study and the typical profile in Western countries can be attributed to differences in the nature and typology of CAM, particularly regarding quality and economics, between developing and Western countries. For instance, herbal treatment is considered modern in Western countries, whereas it is viewed as traditional in the Middle East and North Africa (MENA) region. Additionally, our study is the first of its kind to investigate the factors influencing herbal medicine use among women with GCBC.

The traditional and non-integrated use of herbal medicine in clinical practice poses significant risks for patients, as herbal medicine is a biologically active form of CAM. In a study conducted in the gynecology and obstetrics department in Munich, 18.1% of patients experienced interactions due to the combination of CAM with anticancer drugs metabolized by cytochrome P450 3A4 (Drozdoff et al. 2019). Another study in Israel explored herb-drug interactions in gynecological cancer patients, finding that certain herbs, such as ephedra, reduced the cytotoxicity of carboplatin on ovarian cancer cells. Conversely, mistletoe and ginger enhanced the sensitivity of cisplatin-resistant cells treated with carboplatin and paclitaxel (Ben-Arye et al. 2017).

On the other hand, these plants can improve the quality of life of patients and reduce symptoms of cancer or adverse drug reactions such as fatigue, pain and discomfort. Plants such as Prunus armeniaca L. and Curcuma longa L. have been found to be particularly effective and positively perceived by patients in Morocco (Aboufaras et al. 2023).

Strengths and weaknesses

In Morocco, eight studies have explored this topic, but none have specifically focused on CAM use among women with gynecological cancer. This study is the first of its kind in Morocco and also the first to investigate predictors of phytotherapy use. When interpreting the results, it is important to consider the non-random quota sampling procedure used in the study. Additionally, some patients did not understand Arabic, requiring a multilingual translator to provide a secondary translation into the Amazigh dialect.

Implications for practice and future research

Identifying predictors of phytotherapy use among gynecological cancer patients will enable health professionals to implement targeted therapeutic education. This can improve communication, care, and trust between patients and healthcare providers. Additionally, enhancing professionals’ skills in this area may help mitigate risks associated with potentially dangerous CAM. Notably, the Moroccan Ministry of Health, in collaboration with the World Health Organization (WHO), is working to establish therapeutic education programs for chronically ill patients for the first time in Morocco.

Conclusions

Our research indicates that women with gynecological and breast cancers (GCBC) frequently use herbal medicine as part of CAM. The user profile identified in our study diverges from previous descriptive studies conducted in Morocco, which did not account for psychological characteristics or employ multivariate analysis. Additionally, our findings contrast with those from Western countries due to differences in CAM modalities studied. To validate these results, further research is needed at both regional and national levels within the MENA region. Medical personnel should remain vigilant to prevent potential herb-drug interactions.