Homeopathy as Praxis: Integration of Homeopathy as Supportive Care into Daily Life in Early Breast Cancer Patients

Abstract

Introduction:

Homeopathy is one of most widely used non-conventional supportive care methods used by women with breast cancer. This article aims to describe the routines and practices related to homeopathy as supportive care used by women with non-metastatic breast cancer in France.

Methods:

This qualitative study used Grounded Theory. Participants were women with early breast cancer and healthcare professionals (General Practitioner homeopaths & oncologists). Inclusion depended on specific criteria and the aim of theoretical sampling until data saturation. Data were collected through individual semi-structured interviews and focus groups following evolving topic guides. Transcribed interviews underwent in-depth thematic analysis. Inclusion, interviewing, transcription and coding occurred iteratively. Data was reported according to COREQ guidelines.

Results:

The therapeutic agency of homeopathy was distributed to different actors and ritualized material activities highly involving the patient. The choice of remedy was mostly delegated by patients to General Practitioner homeopaths (GPH) during consultations. Individualization, that is to say adaptation to the patient, differed from other modes of access to homeopathy (self-medication and oncologists). Self-medication was mostly limited to known products in a limited time frame. However, we identified a supported self-medication using trusted homeopathic protocols. Following homeopathic prescriptions involves a high level of commitment on behalf of the patient and follows different rules for homeopathy intake. This knowledge was either acquired earlier for users or discovered along breast cancer treatment for non-users. Taking homeopathy involved small daily actions for intake of different products at different times of the day. New users used strategies to ease the integration of homeopathy into their daily life. The stance toward such rules differed among patients. Some followed rules to optimize their effects while others simplified the rules and took those rituals as part of homeopathy benefits.

Conclusion:

Homeopathy as supportive care in breast cancer is distributed toward different actors and ritualized activities. Homeopathy is a supported practice where GPH played a role in the prescription. Health Literacy in homeopathy played a role to ease its integration into daily life and identify the potential benefits. The high involvement of patients in their homeopathic treatment is a form of treatment reappropriation and empowerment.

Introduction

Breast cancer is one of the most frequent causes of death among women in France. ¹ The net survival rate for women diagnosed between 2005 and 2010 was 88% at 5 years post-diagnosis. ² This high survival rate is undoubtedly the result of the development of advanced oncological treatments, helped by supportive care techniques, some of which are part of alternative and complementary medicine (CAM). One-third of people with cancer in Europe use CAM ³ including over 20% of women with breast cancer.^{4 -6} Patients who use them seek a reduction in side effects from chemotherapy, increase their immune response, and improve their quality of life. ⁵

Homeopathy is one of the most widely used CAM in Europe ⁷ by patients with cancer,^{8 -12} and in particular those with breast cancer.^4,6 As shown by various randomized and observational studies, homeopathy may decrease the side effects of conventional oncological treatments,^{13 -18} become an alternative to supportive analgesics, ¹⁹ and improve the patients’ quality of life.^20,21 However, randomized studies do not demonstrate significant results in reducing chemotherapy-induced nausea ²² or menopause-related symptoms.^23,24

Despite the widespread use of homeopathy, few studies focused on users’ practices of homeopathy with breast cancer.^4,25 In France, homeopathy can be dispensed without a prescription and is no longer reimbursed as of January 2021, ²⁶ but can be reimbursed by mutual insurance companies. In France, homeopaths are physicians and homeopathy is taught at 2 universities or in healthcare professional teaching centers. However, since homeopathic literature is available to the public, anyone can learn about the fundamentals without formal training. This situation is one reason why the WHO has expressed concern about developing alternative care, including homeopathy, due to inadequate training. ²⁷ Investigating patient-reported practices and the perceptions of health professionals makes it possible to understand the contribution of homeopathy from a different angle beyond biomedicine. This article aims to describe the routines and practices related to homeopathy as supportive care in women with non-metastatic breast cancer in France.

Materials and Methods

Population and Setting

The study was presented to patients as a study about homeopathy as Supportive Care (SC) in women with non-metastatic breast cancer. Researchers aimed to include 3 populations: patients, oncologists, and homeopaths. Inclusion criteria for patients were: to be (1) female, (2) 18 years old or older, (3) French resident, (4) diagnosed with a non-metastatic breast cancer, (5) currently receiving conventional treatment or having completed conventional treatment, (6) and to have purchased at least one homeopathic medicinal product (HMP) in the last 12 months. Oncologists had to be (1) practicing in France and (2) having cared for at least 3 breast cancer patients within 12 months prior to the study. Homeopaths had to comply with the same criteria, received formal training in homeopathy, and (3) have at least 12 months of experience in SC. Since a theoretical sampling and a snowball effect were used, a gynecologist trained in homeopathy, a gynecologist-oncologist, and a nurse trained in oncology and homeopathy were also included. Prospective participants were contacted through hospitals’ websites, professional and patient-led organizations, pharmacies, and one oncological department. Participation was financially compensated.

Data Collection

Researchers used Grounded Theory ²⁸ as a research design and analysis, and 3 data collection methods: sociodemographic forms, individual semi-structured interviews, and focus groups. Before being interviewed, all participants had to complete a form with medical or professional information. This helped to personalize the interview and search for sampling diversity. Interview and focus groups’ guides were developed and tailored by researchers. Topics explored in individual interviews were: the knowledge and use of homeopathy, consultation for breast cancer, use and opinion about supportive care, and (for healthcare professionals) patients’ description. To delve into these topics, 2 non-mixed focus groups were set for patients and homeopaths, each with a distinct agenda. All interviews and focus groups were voice-recorded, then transcribed. Transcription occurred in 2 ways: concise, without exact wording and repetitions; and verbatim with behavioral and emotional annotations. A first concise transcription helped to enhance the interview guides with emerging themes and to aim toward data saturation. Data collection started in November 2021 and finished in July 2022.

Data Analysis

The analysis proceeded as the data was collected, concisely transcribed and by constant comparison. A second verbatim transcription permitted in-depth analysis. ²⁹ Transcriptions were coded using NVivo 1.6.1. Five interviews were independently coded by 2 researchers, who compared and discussed results, resolved differences until reaching intercoder-agreement. This method permitted to elaborate a common codebook which was subsequently used to code the proceeding interviews.

Ethics

The study was anonymous and researchers did not collect any identifying data. If incidentally collected during the interview, identifying data were deleted during transcription. Researchers obtained oral consent from each participant before inclusion, and at the start of each interview. Foch Hospital’s (Suresnes, France) ethical and regulatory board approved the study (IRB ref: 00012437; 10/27/21).

Results

Sociodemographic

The study included 50 participants (Table 1): 28 female breast cancer patients, 13 oncologists, 6 general practitioner-homeopaths, 2 gynecologists, and 1 nurse. Two sociodemographic forms were not fully completed.

Table 1.

Sociodemographic Characteristics.

	Patients	Oncologists*	Homeopaths	Other healthcare professionals
Total	28	13	6	3
Sex
Male	0	8	1	0
Female	28	5	5	3
Age
20-29 years old	0	0	1	1
30-39 years old	5	6	0	1
40-49 years old	5	4	0	0
50-59 years old	8	1	2	0
60-69 years old	5	1	3	1
70-79 years old	5	0	0	0
Country of birth
France	25	8	3	3
Another country	3	4	3	0
Region
Parisian region	11	11	1	1
Provinces	17	2	5	2
Decade of graduation in medicine/nursing
1980-1989	NA	1	3	1
1990-1999	NA	2	1	0
2000-2009	NA	2	1	0
2010-2019	NA	7	1	2

*

Missing data for one participant for age, country of birth and decade of graduation in medicine.

Nineteen patients were individually interviewed and 9 participated in the focus group. The majority were born in France and ages ranged from 32 to 76 years old (median: 52 years old), and 18 were university graduates. At inclusion, 19 were in the work force (8 worked or had worked in the healthcare sector). Seventeen were diagnosed with a non-metastatic breast cancer in 2021. Stages II (n = 11) and III (n = 12) were the most represented. No Stage IV patients were included. At inclusion, 16 were on endocrine therapy. All used HMP in the last 12 month, 18 were still using it at the time of the interview or focus group, 10 were not using it anymore.

Concerning medical oncologists, there were 8 males and 5 females. Eight were born in France, and ages ranged from 30 to 62 years old (median: 39 years old). They mostly worked in the Paris region (n = 11) and in public hospitals (n = 8). They practiced oncology between 3 and 27 years (median: 17 years) and had treated anywhere from 10 to 500 patients with breast cancer in the 12 months prior to the study (median: 150 patients). Two were trained in SC, but none in homeopathy. Seven were personally against homeopathy.

Five female and one male general practitioner-homeopaths were included. Half were born in France. Ages ranged from 29 to 68 years old (median: 58 years old) and practicing medicine from 3 to 42 years (median: 29.5 years). Two were also trained in SC. All but one worked outside of Paris, mostly in private practice (n = 4). Homeopaths saw anywhere from 2 to 800 patients with breast cancer in the 12 months prior to the study (median: 20 patients).

Theoretical sampling also included 2 gynecologists and 1 oncology-trained nurse. They were French-born women of various ages (29-65), seniority ranged from 5 to 36 years, and workplaces included private practices, private centers, and hospitals. Two practiced outside the Paris region. Two were trained in homeopathy. They saw anywhere from 150 to 400 patients with breast cancer in the 12 months prior to the study (median: 275 patients).

Analysis

From the transcribed data, we distinguished 3 main themes: (1) Cancer Conventional Care Path, (2) Homeopathy and Cancer, (3) Representations of Homeopathy and its Uses. The first theme is not our focus for this article. In (2) Homeopathy and Cancer, 9 subthemes emerged and this article will focus on 3 of them: (a) General Practitioner Homeopath (GPh) consultations (b) Prescriptions of HMP, and (c) Integration of homeopathy in daily routines (Figure 1). We will develop 2 subthemes of (3) Representations of Homeopathy and its Uses: (a) General Representations of Homeopathy, (b) Patients’ General Uses of HMPs.

Figure 1.

Thematic diagram from selected themes and subthemes.

Homeopathic Literacy and Intake Perceived Exigencies

Patients claimed different levels of homeopathic literacy, which we will refer to as knowledge of homeopathic uses in practice. Perceived recommendations of homeopathy intake were part of this shared literacy and played a role in the way patients integrate it into daily life.

Homeopathic literacy

Patients displayed different knowledge of and different relationships with homeopathy before their cancer. Some patients defined themselves as non-users of homeopathy before cancer, even if they already used it in limited ways:

“I discovered homeopathy with breast cancer, so I already used it, but you know for the little children’s hurts, Arnica, but that was all” (≈50 years).

Some patients displayed a wide homeopathic literacy:

“Now I know my stuff, I don’t need to refer to him [General Practitioner homeopath]” (≈75 years).

Long-term users, who started using homeopathy years ago either regularly or for specific purpose, were often introduced to homeopathy in social contexts: “I have always been immersed in homeopathy since I was a child” (≈30 years).

Intake perceived exigencies

Long-term users displayed knowledge of products they could use for known circumstances but this know-how was taken for granted. For example, recommendations to take remedies “separate from meals,” “separate” for each product and “to leave [granule] under your tongue” (≈65 years) were implicit knowledge shared among participants. Other exigencies of homeopathy were discovered:

“She [my pharmacist] told me that I shouldn’t take mint with it, even though nobody had told me that. So, I didn’t know that.” (≈40 years).

Other recommendations or perceived requirements were more commonly shared among patients:

“It’s something that has to be taken over time. It’s not something that can be done in one intake” (≈40 years).

The requirement of precision and regularity were presented as key factors in the outcome of these patients and attributed to the soft nature of homeopathy:

“it’s very soft and it’s true that it’s over time that you realize that you get the results, by being, how to say, it’s also due to the ripeness” (≈75 years).

Overall, perceived requirements were associated with the nature of homeopathy:

“when I was a teenager, I didn’t take any because I didn’t care at all. It made me angry, it’s complicated, it’s true that you have to get really involved because it’s small stuff. After when you know it, when you master it, it’s okay” (≈75 years).

Practical recommendations for the intake of homeopathy were related with its nature and involved a commitment to taking such remedies while integrating them in their daily routines. By following recommendations, patients took control of the expected benefit of homeopathy.

Access to Homeopathic Medicinal Products: Literacy and Trust

Breast cancer patients accessed HMPs, depending on their homeopathic literacy by (1) self-medication; with the support of a physician: (2) in rare cases with an oncologist, and (3) most frequently, with a General Practitioner homeopath (GPh).

Framed homeopathic self-medication

Self-medication as supportive care in breast cancer was not prevalent and took 2 forms: long-time users’ self-medication and “assisted” self-medication. An oncologist believed that self-medication was uncommon because: “When we talk specifically about homeopathy, it’s when they come with a [homeopathic] prescription” (Female oncologist, ≈40 years) meaning they had a homeopathic consultation.

The first kind of self-medication practice was mostly limited to known products in a limited time frame: during biopsy and surgery phases or while waiting for an appointment with a GPh. A patient spoke of a previous experience with homeopathy self-medication for a previous ingrown toenail surgery and tried the same product for her breast cancer surgery:

“I say to myself, well this I’ve already seen, I know this. And so, I took Arnica. And, when I typed mammography, homeopathy, and for the operation they told me the same thing: Arnica” (≈75 years)

Her existing knowledge of homeopathy, previous experience with surgery, and informal research encouraged her use of homeopathy before and after cancer surgery. This practice was not reported to her surgeon at the time of the surgery, but to her medical oncologist. Another patient had a similar approach for her anxiety. She discovered a HMP in a medical waiting room magazine and tried it:

“I asked the pharmacist, I read the instructions. It is marketed by a homeopathic specialist. Well, it works. And when I tested it, I saw that it suited me. So uh, that’s how I went about it and then a little bit on my own” (≈50 years).

Here the use of homeopathy relied on her assessment through trial and error, involving a commitment to her homeopathy practice acquiring knowledge on what works for her. The role of the pharmacist was limited to answering patients’ questions in this case. The process of self-seeking adaptations from HMPs was uncommon. In other cases, patients relied on trusted practitioners such as pharmacists or relatives to support their self-medication:

“I went to the pharmacy before the operation and I asked them for homeopathy which finally. . . things to relax me [. . .] It’s at the pharmacy next to my house that I go to get the homeopathy. So, I know I can talk to her about it, ask her what she thinks” (≈40 years).

This patient sought homeopathy by herself but received recommendations from a professional. A few patients tried to follow homeopathic protocols provided by trusted relatives:

“There is a protocol that my colleague gave me. It was established for her mother, who had gone through cancer. It was established by a nurse coordinator from a hospital.” (≈30 years).

Those patients had a self-medicated approach in the sense they did not seek professional homeopathic follow-up, but their choice of HMPs relied on people they trusted.

Oncologists delegation to homeopath and protocol prescriptions

Most oncologists did not propose or orient patients toward homeopathy. In some rare cases, oncologists either prescribed or referred to a homeopath. Those oncologists gave the first prescription of HMPs. As an oncologist explained:

“I have ready-made combinations of homeopathy that you can try. I suggest for the four symptoms for which we don’t have much in conventional medicine, notably asthenia and neuropathy, and hot flushes. [. . .] I just give a first prescription, then they go to a homeopath, then I stop there” (male oncologist, ≈55 years).

They mostly used pre-established protocols for specific and limited symptoms:

“As I don’t have a great knowledge of homeopathic molecules, I tell them to go and get advice from the pharmacists, [. . .] I don’t write homeopathic prescriptions.” (Male oncologist, ≈30 years).

General practitioner homeopaths’ prescriptions

Most patients preferred the support of a GPh before taking homeopathic medicine and had, at least, one appointment with them:

“I didn’t know homeopathy at all. So, I would not have risked taking a medicine, even if I know that there is no danger with homeopathy. But I would not have risked not having any benefit with” (≈60 years).

GPh homeopathic prescriptions are embedded in long consultations divided in different phases. After “the reason for consultation,” a long intake of history with items such as her “medical history,” “oncological history,” “the side effects she’s experiencing,” and “her lifestyle” (Female GPh, ≈65 years). A patient explains:

“she took the time, she took the time to discuss, to see my profile, all the little health concerns I had in my life” (≈75 years).

Another patient stressed that her homeopath was “interested in my life history and not just the symptoms I had at the time” (≈50 years). The consultation also includes a “homeopathic interrogation” enabling:

The remedy that best corresponds to her general state, and her, there you go, so as to prescribe a background treatment, and then, to adapt the homeopathic treatment to the circumstances (Female GPh, ≈60 years).

Like a few oncologists, GPhs also followed protocols: “The first prescription is probabilistic” (Male GPh, ≈65 years), that is to say based on expected side effects of the upcoming treatment. But homeopaths claimed the individualization of the prescription:

“Depending on what they tell us, their side effects, they also tell us something about themselves that helps us with the homeopathic treatment.” (Female GPh, ≈60 years).

However, homeopaths could adapt the protocols:

“Ideally, I see her after the first treatment. [. . .] During the second consultation, this protocol will be individualized according to the patient’s reaction” (Male GPh, ≈65 years)

Prescription Perceived Complexity: Stakes of Understanding

The perceived complexity of homeopathic prescriptions was a topic for new users. Identification and understanding the purpose of prescriptions helped identify its benefits and adherence.

Intake prescriptions perceived complexity

Patients mostly followed prescriptions from a GPh or a protocol in the context of their cancer. Homeopathy prescriptions mostly take the form of pills and sometimes liquid doses. The number of prescriptions varies depending on the phase of the conventional treatment. One patient explained her treatments during the radiotherapy phase:

“I had pills especially I think Radium Bromatum I had every day, I think at least 2 times a day certainly and after she had given me, I don’t know anymore, Apis Melifica also that I took then. On the other hand, the Influenzinum, the serum of Yersin it was one Sunday out of 2, one Sunday Influenzinum, the Sunday after Thymuline, the third Sunday Yersin’s serum and I started again, there you go.” (≈75 years).

Homeopathy involved a lot of daily actions at specific times with different products: selecting the right number of the right pills at the right moment and taking them according to expected recommendations. Prescriptions had the tendency to be more complex during chemotherapy and sometimes radiotherapy which included a large number of products with varying periodicity and posology. The perceived complexity was related to the homeopathic literacy of the patients and the place attributed to homeopathy for their supportive care: “I’m used to homeopathy, for me it was very easy” (≈75 years) (P14), while for others:

“It’s a bit restrictive, because it’s true that you have to think about it at the right time, in the evening, in the morning, at noon, and I’m not at all a fan of medication. I’m not really used to having to take so much medication every day.” (≈50 years).

Understanding prescriptions purposes

Some patients did not seek explanations from their GPh and just trusted them: “I was completely guided by the homeopathic doctor” (≈75 years) (P09). Understanding prescriptions played a key role in its adherence and perceived benefits. Often, patients did not remember the purpose of each remedy:

“There are a lot of things I don’t really know what they are [. . .] She gave me [. . .] two different types of pills, but now I don’t remember at all” (≈65 years).

Homeopathic remedies intended to alleviate visible side effects were more often identified by patients compared to those whose benefits were less known. The lack of understanding played a role in the perception of efficacy. Understanding a prescription and its purpose helped evaluate its benefits.

“[my GPh] must have told me I was prescribing this because it’s chemo. But I didn’t know what it was supposed to counteract or what it was supposed to improve. So that’s why I said that I didn’t know if it had worked” (≈40 years).

Variations in prescriptions’ explanations

To counter the difficulty of the plurality of prescribed products, some practitioners proposed:

“I’ll tell them: well, that’s to prevent anxiety, it’s for, uh, a kind of anticipatory fear. You see? I explain on the prescription why. Because otherwise they quickly forget.” (Female gynecologist, ≈65 years).

In this context, the homeopath’s explanation or lack of explanation played a role:

“She explained very well the principle, there I found that I had been well accompanied, uh on the treatment the protocol to. And it was better because it’s not obvious homeopathy to take when you don’t know.” (≈50 years).

A perceived difference remained the importance of the homeopathic prescription explanations:

“She [my oncologist] didn’t tell me what it was for. She said it was for the side effects of the hormone. But she didn’t tell me what it was for either” (≈70 years).

Habit Formation: Homeopathic Routines and Engagement

Patients highly observed their homeopathic prescriptions: it required strategy to integrate into their routine with some adaptations depending on their expectancies from homeopathy.

Integration of homeopathy in daily life

Homeopathy was mainly taken through a granule form at different times of the day. Patients deployed an array of strategies to integrate homeopathy in their daily routines. They placed HMPs in specific places:

“I had it in my kitchen and then I took my pills at breakfast and in the evening” (≈75 years).

Other patients used spreadsheets to follow the complex prescriptions:

“I had large sheets of paper like I put in every day of the week, that’s a lot of sheets and I printed them and it was fine” (≈65 years).

Patients took mnemonic routines, not to forget remedies:

“I was doing blue, white, red. Because in fact there was a blue tube, a white tube, and a red tube.” (≈60 years).

Those strategies helped the commitment and the integration of homeopathy into daily routines: “I thought it was complicated at first but in fact it was quite simple” (≈60 years). By all those daily actions, patients were actively involved in the process of their care.

Adapting homeopathic demanding nature

Patients adapted their use of homeopathy to their expectancies with an impact on how they integrated it into daily life. Some patients were in the process of benefits’ self-assessment by adapting and improving the way they took their remedies:

“I feel like I have fewer hot flashes. I still get them, especially at night. So, the other time I was thinking I should take it at night before going to bed. So maybe I’ll test it like that.” (≈50 years).

This patient did not limit herself to a prescribed protocol, but actively tried to improve it by some adaptations. The benefits of homeopathy relied on its effects. Other patients displayed another stance on their homeopathic use: “The important thing is the intention, the intention to heal” (≈55 years). This means that they observed their prescriptions but took liberties regarding taken-for-granted recommendations on the know-how to use them:

“I took them, but if it was after the meal or before it didn’t matter, that’s it I, as long as I took them on time that’s it.” (≈30 years).

Patients simplified the intake of homeopathy:

“Because the separate stuff and everything, to suck three or four little pellets and all that, it takes a hell of a long time. If you leave them under your tongue and everything, so between all of them and I mean it takes hours in fact. And as it has to be separate from meals and all that, so uh no what, I did a bit, I did it like that.” (≈65 years).

In the first case, patients are empowered through the search of their individualized remedy. In the second case, taking action, as empowerment is already a benefit.

Commitment and adherence to homeopathic prescriptions

Despite the relative constraints of using homeopathy, most patients were committed to their remedies:

“I immediately integrated it every morning, every evening, taking into account Sundays, Wednesdays and certain days of the month, etc. I was very, very serious, and then after I think that after two weeks, um I integrated it” (≈50 years).

Several highlighted their involvement in homeopathy: “I did everything I had to do” (≈75 years); “Until the end of my prescription, I took everything” (≈30 years). This commitment consisted of following the homeopath’s prescriptions. Stopping homeopathy as supportive care happened only at a juncture with a new phase of the conventional therapy: after chemotherapy or radiotherapy, when a new homeopathic prescription was expected.

Discussion

Previous studies have not addressed how homeopathy has been implemented into daily life but focused on the determinant of CAM use (including homeopathy,^4,30 motivations for CAM usage^31,32 or areas of use ¹⁸ ). Studies focused more on the knowledge of prescriptions ³³ but less on homeopathic know-how. The ritual dimensions have been stressed for CAM ³⁴ but few studies have focused on practical knowledge for integration into daily life.^35,36

The present study explored the agency of homeopathy experiences in non-metastatic breast cancer management. The therapeutic agency of homeopathy was distributed toward different actors ³⁷ and ritualized material activities highly involving the patient. The choice of homeopathy relied either on previous experiences (that of the patient or from relatives) of similar products in similar situations or trusting health professionals. Self-medication was mostly limited to known products in a limited time frame and rarely involved an adaptation and the research for a suitable remedy. The choice for the most appropriate remedy was mostly delegated to GPh during consultations. Oncologists or relatives sometimes offered pre-defined protocols. GPh referred to protocols as well but claimed individualization of the treatment.

Following homeopathic prescriptions involved following different recommendations for homeopathy consumption and a high commitment. This knowledge was either previously acquired by long-term users or discovered post breast cancer diagnosis. Taking homeopathy involved small daily actions to consume different products. New users used strategies to ease the integration of homeopathy into their daily life. The stance toward those rules varied among patients. Some followed recommendations to optimize their effects while others used those rituals for the homeopathic benefits, while self-adapting some recommendations. This involvement is a form of treatment reappropriation. ³⁴

Homeopathy as a Praxis

Our study stresses the perceived complexity of homeopathic prescriptions for new users. According to Bégot, ³⁴ most patients used homeopathy prior to their diagnosis. Complementary medicine was mostly either part of the family therapeutic arsenal or used in the case of chronic disease. ³⁴ In our study, some patients started using homeopathy once diagnosed with breast cancer. Patients were mainly informed of CAM by friends or family, and trusted providers such as pharmacists.^3,5,38,39

Homeopathy cannot be reduced to an additional product taken by patients. The complexity of prescriptions is transformed into a ritualization and integration into daily life.

Patients follow rules and protocols for product consumption that are acquired through personal experience. In either case, we stressed that homeopathy is associated with mundane knowledge and exigencies for homeopathy intake. We pointed out that some exigencies of homeopathy, precision and regularity are associated with its soft nature and individualization. Without detailing this aspect. Rughiniş et al ³⁵ stressed that patients followed different recommendations for the ingestion of homeopathy. Those include recommendations to take remedies independently from meals and not together, or to avoid herbs such as mint, in combination to homeopathy. Other required dimensions associated with homeopathy intake are precision and regularity. In this sense, patients are involved in the success of their treatment following perceived recommendations. Mokrane and Bujold suggests that beyond biomedical effects, drugs are also an object of meaning ⁴⁰ with its promises and representations. We argue that homeopathy takes its meaning through concrete, daily integration and praxis. ³⁶

Literacy, Involvement, and Adherence

The integration of medications in daily life is not specific to homeopathy. Our results reflect other studies where patients adopt specific spaces ⁴¹ to facilitate the adherence of remedies. Integration of homeopathy into daily life was quicker and easier for long-term users. Most patients took homeopathic prescriptions throughout the duration of their treatment. Some stopped homeopathy at a juncture of a cancer treatment phase (ex: after chemotherapy) but not during. Most were committed to taking remedies as recommended. One study stressed the greatest adherence to a homeopathic remedy was for patients attending a second visit. ⁴² Positive attitudes or beliefs in therapy along with appreciation of the CAM is associated with adherence. ⁴³ Some studies show a relationship between health literacy and medication adherence.^44,45 The required acquisition of knowledge to follow homeopathic prescriptions in this context could explain the observed medication adherence. We also pointed out the importance of GP homeopath explanations of prescription to help identify potential benefits. Patients’ understanding of prescriptions helped better identify the benefits of homeopathy.

The way patients integrate homeopathy into their daily life displays different stances and expectations toward it. The status of homeopathic recommendations is either a way to optimize its effects or a ritual that could be adapted where the intent of care has its benefits. Cancer treatments involve a reorganization of the patient’s daily life. Patients regain possession of their lives over the disease through their involvement in supportive care.

Self-Medication and Health Professional Support

Our results stress that most patients accessed homeopathy via a professional, mostly a GPh ⁴⁶ to receive overall care and to relieve anticancer-related side effects. ⁴⁶ A systematic review stresses that complementary medicine consultations are an empowering experience. ⁴⁷ The prescription of homeopathy by GPhs was embedded most of the time in lengthy, specific consultations. ⁴⁸

As one study points out, most oncologists do not mention the role of complementary medicine to their patients. ⁴⁹ Bagot et al stress that oncologists view the interests in homeopathy to manage specific side effects. ⁵⁰ Few oncologists proposed homeopathy to their patients and when doing so, it was in a limited way. They either oriented the patient toward GPhs or pharmacists. Those who prescribed used homeopathic protocol. While both oncologists and GPhs used protocols, GPhs claimed individualization as a distinctive feature.

Self-medication was mainly limited to long-term users for specific and known purposes. As Fainzang highlighted self-medication extends from benign situations to similar and familiar situations. ⁵¹ This could explain why, despite previous experience with cancer, patients used self-medication as supportive care for their cancer. We identified a form of self-medication where patients rely on homeopathic protocols provided by a trusted person, either a professional such as pharmacists, or relatives. In the latter case, the homeopathic protocol was usually experienced previously by relatives or friends. In a sense, this specific use of self-medication is close to oncologists’ homeopathic, where patients apply a protocol without seeking individualization. Self-medication was extended to known situations ⁵¹ by trusted relatives. This self-medication is not seen as a contestation of biomedical therapeutic choices. ³⁶ In this case, relatives or friends were not only a source of information for CAM^3,5,38,39 but also for prescriptions. This autonomy could be seen as a form of empowerment. ⁹

Limitations

This study has limitations in its sampling. Regarding patients’ inclusion criteria, the study could not cover all homeopathic uses. All patients used homeopathy as supportive care but other uses were not included. Patients were highly educated—as found in the literature, ³ and mostly French-born. There were a majority of women in the focus group with homeopaths because 2 men from the Paris region withdrew from the study. Internal validity of analysis was assumed by the plurality of coding researchers. We used grounded theory as our theoretical background, however episodic interviews ⁵² would have been an interesting alternative to elicit participant memories and recount their conception of homeopathy across a range of situations.

Conclusion

Homeopathy, as supportive care in breast cancer, is distributed toward different actors and ritualized material activities. Homeopathy is a supportive practice where GP homeopaths play a role in the prescription. Explanation of prescriptions is leverage for homeopathic adherence, helping patients to identify their potential benefits. Patients’ therapeutic education could be a way to improve perceived benefits from homeopathy. Homeopathy requires shared practical knowledge and can be seen as praxis. The high level of involvement on behalf of patients in respect to homeopathic treatment is a form of empowerment, regardless of their expectations, that could trigger perceived benefits.