Chinese Herbal Medicine for Symptom Management in Cancer Palliative Care: Systematic Review And Meta-analysis

Developing implementation strategies for promoting integrative oncology outpatient service delivery and utilisation: a qualitative study in Hong Kong

Purpose

Current evidence supports the use of integrative oncology (IO) interventions in cancer supportive care. The demand for outpatient IO services in Hong Kong is expected to soar following the surge in cancer incidence due to population ageing. This study identified the factors influencing the delivery and utilisation of outpatient IO from local stakeholders' perspectives and developed corresponding implementation strategies.

Methods

This study involved two sequential stages. First, with individual semi-structured interviews guided by the Theoretical Domains Framework (TDF), we explored stakeholders' views on the barriers to and facilitators for implementing IO. Second, guided by a TDF-based qualitative data analysis of interview transcripts, we performed intervention mapping to develop Behaviour Change Wheel-based implementation strategies that may overcome the barriers and strengthen the facilitators.

Results

We interviewed 31 stakeholders, including traditional Chinese medicine (TCM) practitioners (n = 8), biomedically-trained doctors (n = 7), nurses (n = 6), administrators (n = 4), caregivers (n = 4), and pharmacists (n = 2). The key local factors influencing outpatient IO are (1) lacking nursing and administrative workforce supporting IO service delivery, (2) lacking awareness of IO services among healthcare professionals, administrators, patients, and caregivers, and (3) lacking knowledge among healthcare professionals of herb-drug interaction and herbal toxicities.

Conclusion

We recommended a multi-faceted implementation strategies package that included arranging funding to train, recruit, and retain nursing and administrative staff, devolving resources into promoting interprofessional collaborations and evidence on IO effectiveness and safety, integrating evidence on herb-drug interactions and herbal toxicities into automated electronic health record systems monitored by pharmacists with dual qualifications in TCM and conventional pharmacy.

Review Deciphering the Anticancer Efficacy of Resveratrol and their Associated Mechanisms in Human Carcinoma

The scientific world has recently shown wider attention to elucidating the anticancerous potential of numerous plant-based bioactive compounds. Many research studies have suggested that consuming foods high in polyphenols, which are present in large amounts in grains, legumes, vegetables, and fruits, may delay the onset of various illnesses, including cancer. Normal cells with genetic abnormalities begin the meticulously organized path leading to cancer, which causes the cells to constantly multiply, colonize, and metastasize to other organs like the liver, lungs, colon, and brain. Resveratrol is a naturally occurring stilbene and non-flavonoid polyphenol, a phytoestrogen with antioxidant, anti-inflammatory, cardioprotective, and anticancer properties. Resveratrol makes cancer cells more susceptible to common chemotherapeutic treatments by reversing multidrug resistance in cancer cells. This is especially true when combined with clinically used medications. Several new resveratrol analogs with enhanced anticancer effectiveness, absorption, and pharmacokinetic profile have been discovered. The present emphasis of this review is the modulation of intracellular molecular targets by resveratrol in vivo and in vitro in various malignancies. This review would help future researchers develop a potent lead candidate for efficiently managing human cancers.

Synergistic and Additive Effects of Herbal Medicines in Combination with Chemotherapeutics: A Scoping Review

BACKGROUND

Natural products are increasingly gaining interest as potential new drug candidates for cancer treatment. Herbal formula, which are combinations of several herbs, are primarily used in East Asia and have a long history of use that continues today. Recently, research exploring the combination of herbal formulas and chemotherapy for cancer treatment has been on the rise.

METHODS

This study reviewed research on the co-administration of herbal formulas and chemotherapy for cancer treatment. The databases PubMed, Embase, and Cochrane Library were used for article searches. The following keywords were employed: "Antineoplastic agents," "Chemotherapy," "Phytotherapy," "Herbal medicine," "Drug synergism," and "Synergistic effect." The selection process focused on studies that investigated the synergistic interaction between herbal formulas and chemotherapeutic agents.

RESULTS

Among the 30 studies included, 25 herbal formulas and 7 chemotherapies were used. The chemotherapy agents co-administered included cisplatin, 5-fluorouracil, docetaxel, doxorubicin, oxaliplatin, irinotecan, and gemcitabine. The types of cancer most frequently studied were lung, breast, and colon cancers. Most studies evaluating the anticancer efficacy of combined herbal formula and chemotherapy treatment were conducted in vitro or in vivo.

DISCUSSION

Most studies reported synergistic effects on cytotoxicity, apoptosis, and tumor growth inhibition. These effects were found to be associated with cell cycle arrest, anti-angiogenesis, and gene expression regulation. Further studies leading to clinical trials are required. Clinical experiences in East Asian countries could provide insights for future research.

Mapping the clinical practice of traditional, complementary and integrative medicine in oncology in Western countries: A multinational cross-sectional survey

BACKGROUND

Many cancer patients seek adjunctive therapies to biomedical cancer treatments at some point of their disease trajectory. While acupuncture is increasingly recommended by leading oncological associations, limited evidence exists concerning the evidence-informed practice and adherence to current guidelines of traditional complementary and integrative medicine (TCIM) practitioners treating cancer patients.

METHODS

An international online-survey assessed the demographical data, clinical practice, and sources of information used by TCIM practitioners in Austria, Germany, United States of America, Australia, and New Zealand.

RESULTS

In total, 404 respondents completed the survey, of which 254 (62.9%) treated cancer patients. Most practitioners were acupuncturists and herbalists (57.1%), had (16.8 ± 9.9) years of clinical experience and see a median of 2 (1, 4) cancer patients per week. Breast cancer (61.8%) is the most common cancer type seen in TCIM clinics. Adjunctive TCIM treatments are frequently concurrent with the patient's cancer specific treatment (39.9%), which is also reflected by the main goal of a TCIM treatment to alleviate side effects (52.4%). However, only 28.0% of the respondents are in contact with the treating oncologist. According to the respondents, pain is most effectively treated using acupuncture, while herbal medicine is best for cancer-related fatigue. TCIM practitioners mostly use certified courses (33.1%) or online databases (28.3%) but often believe that experts are more reliable to inform their practice (37.0%) than research publications (32.7%).

CONCLUSION

Acupuncturists and herbalists commonly treat cancer patients. Most practitioners use TCIM as an adjunct to biomedicine as supportive care and use it largely in accordance with current oncological guidelines.

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Huemer M, Graca S, Bitsche S, Hofmann G, Armour M, Pichler M. Mapping the clinical practice of traditional, complementary and integrative medicine in oncology in Western countries: A multinational cross-sectional survey. J Integr Med. 2024; 22(1): 64-71.

The effect of Andrographis paniculata water extract on palliative management of metastatic esophageal squamous cell carcinoma-A phase II clinical trial

Patients with metastatic esophageal squamous cell carcinoma (ESCC) have a grave prognosis with limited life expectancy. Here, a phase II clinical trial was conducted to investigate the effect of Andrographis paniculata (AP) on the palliative care of patients with metastatic ESCC. Patients with metastatic or locally advanced ESCC deemed unfit for surgery, and who have already completed palliative chemotherapy or chemoradiotherapy or are not fit for these treatments, were recruited. These patients were prescribed AP concentrated granules for 4 months. They also received clinical and quality of life assessments for clinical response, as well as positron emission tomography-computed tomography at 3 and 6 months after AP treatment for the assessment of tumor volume. Furthermore, the change in gut microbiota composition after AP treatment was studied. From the results, among the 30 recruited patients, 10 completed the entire course of AP treatment, while 20 received partial AP treatment. Patients who completed the AP treatment achieved significantly longer overall survival periods with the maintenance of the quality of life during the survival period when compared to those who could not complete AP treatment. The treatment effect of AP also contributed to the shift of the overall structure of gut microbiota for ESCC patients towards those of healthy individuals. The significance of this study is the establishment of AP as a safe and effective palliative treatment for patients with squamous cell carcinoma of the esophagus. To the best of our knowledge, this is the first clinical trial of AP water extract in esophageal cancer patients demonstrating its new medicinal use.

Traditional herbal medicine for anorexia in patients with cancer: a systematic review and meta-analysis of randomized controlled trials

Background: The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of traditional herbal medicine (THM) for improving anorexia in patients with cancer. Methods: We searched for randomized controlled trials (RCTs) that evaluated orally administered THM for cancer-related anorexia using 10 databases from the inception to 1 August 2021. The primary outcome was an improvement in anorexia, measured with the total effective rate (TER) or visual analog scale (VAS). The secondary outcomes were the changes in body weight, the Karnofsky performance scale, acylated ghrelin, and adverse events. We used the Cochrane risk of bias assessment tool and the Grading of Recommendations Assessment, Development, and Evaluation method to assess the quality of the studies and the quality of the evidence. Results: A total of 26 RCTs were included, of which 23 were subjected to quantitative analysis. THM showed a significant improvement in anorexia measured with the TER [risk ratio (RR) 1.12, 95% confidence intervals (CI) 1.04-1.20] than appetite stimulants with moderate quality evidence and in the Karnofsky performance scale (RR 1.38, 95% CI 1.12-1.70) with low quality evidence but not in body weight gain (RR 0.98, 95% CI 0.80-1.20). THM showed a significant improvement in anorexia measured with the TER (RR 1.74, 95% CI 1.23-2.48) compared with usual care with low-quality evidence but did not significantly improve the VAS score (mean difference 0.72, 95% CI 0.00-1.43) or the level of acylated ghrelin (mean difference 0.94, 95% CI 1.08-2.97). There were no serious adverse events. Conclusion: This review suggests that THM may be considered a safe alternative therapeutic option for improving anorexia in patients with cancer. Nonetheless, more rigorous RCTs are needed due to methodological limitations. Systematic Review Registration: https://www.crd.york.ac.uk/prospero, identifier CRD42021276508.

Bibliometric Analysis of Acupuncture Therapy for Cancer Pain Over the Past 10 Years

Purpose

Cancer pain is a common symptom of cancer patients and greatly affects quality of life. Acupuncture has certain curative effects on cancer pain. The aim of this study was to analyze and visualize the current status and research trend of acupuncture treatment for cancer pain over the last 10 years and provide directions for future development.

Methods

A search of the Web of Science Core Collection from 2012-01-01 to 2022-08-20 was performed to collect studies related to acupuncture therapy for cancer pain. CiteSpace was used to conduct bibliometric analysis and visualization from the perspective of the volume of annual publications, journals, nations, institutions, authors, keywords, and references.

Results

A total of 302 studies were included in the analysis. The number of publications increased steadily with some fluctuations over the past decade. Integrative Cancer Therapies was the journal with the most relevant publications, and the Journal of Clinical Oncology was the most frequently cited journal. China had the highest volume of publications, and the USA contributed most to international collaboration. The most prolific institution was Memorial Sloan Kettering Cancer Center. The most productive author was Mao JJ, and the most influential author was Lu WD. "Acupuncture" was the top keyword in frequency and centrality. The references with the highest frequency and centrality were published by HE, Y, and Ting Bao, respectively.

Conclusion

A stable development trend has formed in this field. The overall collaborative network needs to be strengthened. Breast cancer and multiple myeloma, electroacupuncture and bee venom acupuncture, postoperative pain, peripheral neuropathic pain syndrome, and aromatase inhibitors-associated arthralgia syndrome are research hotspots in this field. Randomized controlled trials (RCTs), evidence-based evaluations and mechanisms (cancer-induced bone pain) are research trends and frontiers.

The Use of San-Huang-Xie-Xin-Tang Reduces the Mortality Rate among Breast Cancer Patients

Globally, breast cancer is the most common cause of cancer deaths. In Taiwan, it is the most prevalent cancer among females. Since San-Huang-Xie-Xin-Tang (SHXXT) exerts not only an anti-inflammatory but an immunomodulatory effect, it may act as a potent anti-tumor agent. Herein, the study aimed to explore the influence of SHXXT and its constituents on the mortality rate among breast cancer patients in Taiwan regarding the component effect and the dose-relationship effect. By using the Taiwan National Health Insurance (NHI) Research Database (NHIRD), the study analyzed 5387 breast cancer patients taking Chinese herbal medicine (CHM) and 5387 breast cancer patients not using CHM. CHM means SHXXT and its constituents in the study. The Kaplan-Meier method was utilized to determine the mortality probabilities among patients. Whether the CHM influences the mortality rate among patients was estimated by Cox proportional hazard regression analysis. The use of CHM could lower the cancer mortality rate by 59% in breast cancer patients. The protective effect was parallel to the cumulative days of CHM use and the annual average CHM dose. In addition, the mortality rate was lower in patients who used SHXXT compared to those who only used one of its constituents. SHXXT and its constituents were all promising therapeutic weapons against breast cancer.

The influence of Chinese herbal medicines on cancer-related pressure ulcer wound, fatigue, constipation, and anorexia: A meta-analysis

We performed a meta-analysis to evaluate the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia. A systematic literature search up to March 2022 was done and 25 studies included 1777 subjects with cancer-related symptoms at the start of the study; 953 of them were provided with Chinese herbal medicines and 824 were control. They were reporting relationships about the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia using the dichotomous method with a random or fixed-effect model. Chinese herbal medicines had significantly higher effectiveness in treating pressure ulcer wound (OR, 5.94; 95% CI, 3.94-8.95, P < .001), fatigue (OR, 2.81; 95% CI, 1.78-4.41, P < .001), and effectiveness on treating constipation (OR, 2.59; 95% CI, 1.57-4.25, P < .001) compared to control in subjects with cancer-related symptoms. However, Chinese herbal medicines had no significant effect on treating anorexia (OR, 1.69; 95% CI, 0.61-4.66, P = .31) compared to control in subjects with cancer-related symptoms. Chinese herbal medicines had significantly higher effectiveness in treating pressure ulcer wound, treating pressure ulcer wound, fatigue, and constipation compared to control in subjects with cancer-related symptoms. However, Chinese herbal medicines had no significant effect on the effectiveness of treating anorexia compared to control in subjects with cancer-related symptoms. Further studies are required to validate these findings.

Recent Advances in Glycyrrhiza glabra (Licorice)-Containing Herbs Alleviating Radiotherapy- and Chemotherapy-Induced Adverse Reactions in Cancer Treatment

Cancers represent a significant cause of morbidity and mortality worldwide. They also impose a large economic burden on patients, their families, and health insurance systems. Notably, cancers and the adverse reactions to their therapeutic options, chemotherapy and radiotherapy, dramatically affect the quality of life of afflicted patients. Therefore, developing approaches to manage chemotherapy- and radiotherapy-induced adverse reactions gained greater attention in recent years. Glycyrrhiza glabra (licorice), a perennial plant that is one of the most frequently used herbs in traditional Chinese medicine, has been heavily investigated in relation to cancer therapy. Licorice/licorice-related regimes, used in combination with chemotherapy, may improve the adverse effects of chemotherapy. However, there is little awareness of licorice-containing herbs alleviating reactions to radiotherapy and chemotherapy, or to other induced adverse reactions in cancer treatment. We aimed to provide a descriptive review, and to emphasize the possibility that licorice-related medicines could be used as an adjuvant regimen with chemotherapy to improve quality of life (QoL) and to reduce side effects, thus, improving compliance with chemotherapy. The experimental method involved searching different databases, including PubMed, the Cochrane Library, and Wang Fang database, as of May 2022, to identify any relevant studies. Despite a lack of high-quality and large-scale randomized controlled trials, we still discovered the potential benefits of licorice-containing herbs from published clinical studies. These studies find that licorice-containing herbs, and their active ingredients, reduce the adverse reactions caused by chemotherapy and radiotherapy, and improve the QoL of patients. This comprehensive review will serve as a cornerstone to encourage more scientists to evaluate and develop effective Traditional Chinese medicine prescriptions to improve the side effects of chemotherapy and radiation therapy.

Alsahli M, S. M. Aljohani A, Alhumaydhi FA, Babiker AY, Khan AA, Rahmani AH. Potential Therapeutic Targets of Resveratrol, a Plant Polyphenol, and Its Role in the Therapy of Various Types of Cancer

Cancer is among the most prominent causes of mortality worldwide. Different cancer therapy modes employed, including chemotherapy and radiotherapy, have been reported to be significant in cancer management, but the side effects associated with these treatment strategies are still a health problem. Therefore, alternative anticancer drugs based on medicinal plants or their active compounds have been generating attention because of their less serious side effects. Medicinal plants are an excellent source of phytochemicals that have been recognized to have health-prompting effects through modulating cell signaling pathways. Resveratrol is a well-known polyphenolic molecule with antioxidant, anti-inflammatory, and health-prompting effects among which its anticancer role has been best defined. Additionally, this polyphenol has confirmed its role in cancer management because it activates tumor suppressor genes, suppresses cell proliferation, induces apoptosis, inhibits angiogenesis, and modulates several other cell signaling molecules. The anticancer potential of resveratrol is recognized in numerous in vivo and in vitro studies. Previous experimental data suggested that resveratrol may be valuable in cancer management or improve the efficacy of drugs when given with anticancer drugs. This review emphasizes the potential role of resveratrol as an anticancer drug by modulating numerous cells signaling pathways in different types of cancer.

Similarities and differences between China and Sweden regarding the core features of palliative care for people aged 60 or older: a systematic scoping review

Background

Despite the increasing longevity of the world’s population, with an unprecedented rise in the number of people who need palliative care (PC), there has been sparse research regarding palliative care for older people, especially when it comes to comparison of PC between healthcare systems and cultures. The aim of this systematic scoping review was to identify the characteristics of the body of literature and to examine the knowledge gaps concerning PC research for older people (> 60 years) in two healthcare systems and cultures, mainland China and Sweden.

Methods

The guidelines PRISMA (Preferred Reporting Items for Systematic Reviews), and PICOS (Patient/population, Intervention, Comparison/control, and Outcome) were used. Empirical studies on patients 60 years or older, next of kin or staff participating in a palliative care intervention or setting were included. They were conducted in mainland China or in Sweden during 2007–2019, were published in English and were extracted from seven databases: Embase, PubMed, Scopus, Cinahl, PsycInfo, Academic Search Complete and Cochrane Library. Two independent researchers conducted the selection of studies, data extraction and methodological evaluation. Any disagreements were resolved in consultation with a third researcher. The analysis was manifest directed content analysis based on PICOS domains.

Results

Of the 15 studies, four were from mainland China and 11 from Sweden. Both countries included older patients with cancer but also other end-stage diseases such as heart failure and dementia. The studies differed in design, method and the content of the interventions. The study in China based on traditional Chinese medicine concerns traditional Chinese folk music. The six qualitative studies from Sweden were evaluations of five interventions.

Conclusions

Despite the high age of the participating patients, there was no focus on an ageing perspective concerning palliative care. To adapt to the changes taking place in most societies, future research should have increased focus on older persons’ need for palliative care and should take account of issues concerning research ethics, ethnicity and culture.

Registered in Prospero

CRD42020078685, available from.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-00906-7.

A pilot randomized placebo-controlled study on modified MaZiRenWan: a formulated Chinese medicine to relieve constipation for palliative cancer patients

BACKGROUND

Constipation is a common problem among advanced cancer patients; however, many of them find limited effective from current therapies. Thus, we aimed to test the effect of a traditional Chinese herbal formula, modified MaZiRenWan (MZRW), by comparing with placebo among palliative cancer patients with constipation.

METHODS

This is a randomized, double-blind, placebo-controlled trial. Participants aged over 18 were recruited and randomized to MZRW or placebo group in addition to current prescriptions (including ongoing laxatives treatment) for two weeks. Exclusion criteria included cognitive impairment, presence of a colostomy or gastrointestinal obstruction and estimated life expectancy of less than one month. Individualized modification of MZRW was allowed according to the traditional Chinese medicine (TCM) pattern of patient. The primary outcome was the global assessment of improvement, which reflected whether the constipation had improved, remained the same or worsened.

RESULTS

Sixty patients, with mean age 75.2 years (range 47-95 years), were randomized to MZRW or placebo group. Among the MZRW group, 59.3% (16/27) had improvement in the global assessment score, as compared with 28.6% (8/28) of the placebo group (p-value = 0.022). Besides, the MZRW group had significant increase in stool frequency, and reduction in constipation severity and straining of defecation (p-value < 0.05). No serious adverse event was reported due to the research medication.

CONCLUSION

This pilot trial suggests modified MZRW is well-tolerated and effective for relief of constipation in patients with advance cancer. It could be considered as a potential treatment option for constipation in palliative care.

TRIAL REGISTRATION

The trial had been registered in ClinicalTrials.gov with identifier number NCT02795390 [ https://clinicaltrials.gov/ct2/show/NCT02795390 ] on June 10, 2016.

Effect of Foot Reflexology Protocol on Premenstrual Syndrome Symptoms in Nursing Students: a Pre-Post Pilot Study

Background:

Premenstrual syndrome is a highly prevalent cyclical disorder among women of childbearing age which interferes with daily activities, mood, and quality of life.

Purpose:

To evaluate the effects of a foot reflexology protocol on relieving premenstrual syndrome symptoms in nursing students.

Setting:

Nursing School, São Paulo University, Brazil.

Participants:

A convenience sample of 17 nursing students, diagnosed with moderate-to-severe premenstrual syndrome as assessed by the Premenstrual Symptoms Screening Tool (PSST).

Research design:

A pre–post pilot intervention study.

Intervention:

The intervention consisted of eight reflexology sessions lasting 30 minutes for eight weeks.

Main Outcome Measure:

Evaluation of the participants by the PSST applied at the beginning and at the end of the study.

Results:

The participants had an average age of 21.7 (±2.6) years, ranging from 19 to 28 years; all were single, and most were in the third year of the course (58.8%); 75.6% lived with their family; 82.4% do not use contraceptives; 64.7% reported regular menstrual flow with an average duration of 5.1 (±1.1) days, and an average menstrual cycle interval of 29.3 (±4.9) days. The intervention significantly reduced the premenstrual symptoms assessed by the PSST (p<.017) with a pre–post difference of 10.2 points in the overall score, and the items score decreased between 1.2 to 3.4 for difficulty concentrating, insomnia, hypersomnia, feeling overwhelmed, muscle/ joint pain, bloating, weight gain; and between 3.5 to 5.2 to anger/irritability, anxiety/ tension, tearful, depressed mood, decreased interest in daily activities, fatigue, overeating, and breast tenderness. There was a significant decrease regarding the functional impact of premenstrual symptoms domain in the overall score with a pre–post difference of 10.7, and between 1.7 and 3.0 for all of the items (p<.04), except for the item “your home responsibilities”.

Conclusion:

Foot reflexology has shown promising results in reducing premenstrual syndrome symptoms.

The positive role of traditional Chinese medicine as an adjunctive therapy for cancer

Traditional Chinese medicine (TCM), especially Chinese herbal medicines and acupuncture, has been traditionally used to treat patients with cancers in China and other East Asian countries. Numerous studies have indicated that TCM not only alleviates the symptoms (e.g., fatigue, chronic pain, anorexia/cachexia, and insomnia) of patients with cancer and improves their quality of life (QOL) but also diminishes adverse reactions and complications caused by chemotherapy, radiotherapy, or targeted-therapy. Therefore, Chinese herbal medicines and acupuncture and other alternative therapies need to be understood by TCM physicians and other health care providers. This review mainly summarizes the experimental results and conclusions from literature published since 2010, and a search of the literature as been performed in the PubMed, MEDLINE, Web of Science, Scopus, Springer, ScienceDirect, and China Hospital Knowledge Database (CHKD) databases. Some Chinese herbal medicines (e.g., Panax ginseng, Panax quinquefolius, Astragali radix, Bu-zhong-yi-qi-tang (TJ-41), Liu-jun-zi-tang (TJ-43), Shi-quan-da-bu-tang (TJ-48), and Ban-xia-xie-xin-tang (TJ-14)) and some acupuncture points (e.g., Zusanli (ST36), Zhongwan (CV12), Neiguan (PC6) and Baihui (GV20)) that are commonly used to treat cancer-related symptoms and/or to reduce the toxicity of chemotherapy, radiotherapy, or targeted-therapy are highlighted and summarized. Through a review of literature, we conclude that TCM can effectively alleviate adverse gastrointestinal reactions (including diarrhea, nausea, and vomiting) to these anti-cancer therapies, decrease the incidence of bone marrow suppression, alleviate cardiotoxicity, and protect against chemotherapy-induced peripheral neuropathy and radiation-induced pneumonitis. Moreover, TCM can alleviate epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI)-related acneiform eruptions, diarrhea, and other adverse reactions. The hope is that this review can contribute to an understanding of TCM as an adjuvant therapy for cancer and that it can provide useful information for the development of more effective anti-cancer therapies. However, more rigorously designed trials involving cancer treatment must be conducted in the future, including complete quality control and standardized models at the cellular, organic, animal and clinical levels, in order to study TCM in multiple forms and at multiple levels.

Synergistic effects of herbal medicines and anticancer drugs: A protocol for systematic review and meta-analysis

BACKGROUND

An increasing number of studies have been reporting combination therapy using herbal medicines and anticancer drugs, and the synergistic effects of this combination have gained much attention across the medical community. In this study, we will review and summarize all published studies that have investigated the synergistic interaction between herbal medicines and anticancer drugs.

METHODS

We will search the PubMed, Embase, and Cochrane Library databases. Studies investigated the synergistic interaction between herbal medicines and anticancer drugs will be included. The selection and extraction process will be performed by 2 independent reviewers, and we will perform qualitative synthesis.

DISCUSSION

The present study is being performed to investigate the herbal medicines and anticancer drugs that are used concomitantly, and to determine the combinations that are expected to show a synergistic effect. This knowledge will provide new insights into the possible role of herbal medicines in anticancer treatment.

REVIEW REGISTRATION

Trial registration: OSF Registration number: DOI 10.17605/OSF.IO/H5QS9.

Role of Complementary and Alternative Medicine in the Management of Cancer Cachexia

Cancer cachexia is an important concern in cancer patients in view of advanced stage at presentation. The treatment goal for cachexia is the reversal of the loss of body weight and muscle mass with a variety of pharmacological agents. Various treatment guidelines focus on patients with advanced cancer who are likely to suffer from refractory cachexia. There is a paucity of data on research directed to cancer cachexia on cancer patients. Complementary and alternative medicines (CAMs) are widely use at some or other point of time by the majority of cancer patients in spite of little or no evidence to support that. There are many CAM which have been tried in different set up for cancer cachexia. These medicines are well accepted in view of lesser side effects and easy to use. There is a need for more randomized controlled trials with larger sample size with longer follow-up to generate more evidence in support to the use of CAM in cancer and cancer cachexia.

Prioritizing Chinese medicine clinical research questions in cancer palliative care from patient and caregiver perspectives

BACKGROUND

Chinese medicine (CM) modalities, including acupuncture and Chinese herbal medicine (CHM), are popular palliative interventions among patients with cancer, but further clinical research is required to assess their effectiveness and safety.

OBJECTIVE

To prioritize top ten important CM clinical research questions from patients with cancer, cancer survivors and caregivers' perspectives via a face-to-face prioritization workshop in Hong Kong.

METHODS

A list of 25 CM clinical research questions for cancer palliative care, which were identified from existing systematic reviews (SRs) and overview of SRs, was presented to 17 participants (patients with cancer [n = 5], cancer survivors [n = 6] and caregivers [n = 6]). The participants were then invited to establish consensus on prioritizing top ten research questions.

RESULTS

Among the top ten priorities, five (50%) focused on acupuncture and related therapies, while five (50%) were on CHM. The three most important research priorities were (i) manual acupuncture plus opioids for relieving pain; (ii) CHM for improving quality of life among patients receiving chemotherapy; and (iii) concurrent use of CHM plus loperamide for reducing stomatitis.

CONCLUSION

The top ten participant-endorsed CM clinical research priorities for cancer palliative care can guide local researchers on future direction. They can also inform local research funders on patient-centred allocation of limited funding. Under limited research funding, the most important co-prioritized research question from professional and patient perspectives may be addressed first.

PATIENT OR PUBLIC CONTRIBUTION

Patients with cancer, cancer survivors and caregivers participated in conduct of the study to prioritize CM clinical research questions.

Professionals' experiences and attitudes toward use of Traditional Chinese Medicine in hospice palliative inpatient care units: A multicenter survey in Taiwan

BACKGROUND

Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care.

METHODS

This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson's Chi-square test and Fisher's exact test.

RESULTS

A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care.

CONCLUSIONS

Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.

Efficacy of Herbal Medicines Intervention for Colorectal Cancer Patients With Chemotherapy-Induced Gastrointestinal Toxicity - a Systematic Review and Meta-Analysis

Purpose: Chemotherapy-induced gastrointestinal (CIGI) toxicity affects the quality of life of patients with colorectal cancer (CRC) and the clinical application of treatment drugs. This review aims to evaluate the efficacy of traditional herbal medicines (HMs) in alleviating symptoms of CIGI toxicity (including nausea and vomiting, anorexia, diarrhea, constipation, oral mucositis, abdominal pain, and abdominal distension), and to explore further individual herb or herbal combinations in alleviating the CIGI toxicity.

Methods: Nine electronic databases were screened from 2010 to 2020. Twenty-two randomized controlled trials with a total of 1,995 patients evaluating the complementary efficacy of HMs with chemotherapy compared with chemotherapy-alone were included. Further, sensitivity analyses of orally administered multi-ingredient HM interventions were explored based on the composition of HM interventions.

Results: The meta-analysis showed that HM treatment combined with chemotherapy significantly alleviated the overall CIGI toxicity (RR = 0.78 [0.72, 0.84], p < 0.001, I² = 44%), nausea and vomiting (RR = 0.74 [0.66, 0.82], p < 0.001, I² = 35%), diarrhea (P = 0.02, RR = 0.64, 95% CI = 0.44–0.93, I² = 50%), oral mucositis (RR = 0.65 [0.48, 0.88], P = 0.005, I² = 24%), and abdominal distension (RR = 0.36 [0.18, 0.73], P = 0.004, I² = 0%). However, no statistically significant effects of HMs were shown in studies with a double-blind design for CIGI toxicity. Based on the ingredients of the HMs, further sensitivity analyses identified five herbs [Glycyrrhiza uralensis Fisch., Atractylodes macrocephala Koidz., Astragalus membranaceus (Fisch.) Bge., Codonopsis pilosula (Franch.) Nannf., and the pericarp of Citrus reticulata Blanco.] that were associated with significant reductions in CIGI toxicity.

Conclusion: A statistically significant effect of HMs combined with chemotherapy on alleviating the overall CIGI toxicity, nausea and vomiting, diarrhea, oral mucositis, or abdominal distension is only shown in studies without a double-blind design. Further well-designed, double-blinded, large-scaled randomized controlled trials (RCTs) are warranted to comprehensively evaluate the treatment efficacy. Further clinical research that includes the five herbs with chemotherapy for patients, the safety of the combinations of these herbs, and the potential synergistic effects of these combinations of herbs should be conducted.

Palliative Care in the Greater China Region: A Systematic Review of Needs, Models, and Outcomes

CONTEXT

There is rapidly increasing need for palliative care in Greater China because of rapidly aging populations.

OBJECTIVES

This study aimed to systematically review and appraise evidence for palliative care needs, models of care, interventions, and outcomes in Greater China.

METHODS

Four databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) were searched, with hand searching of local journals and databases. Narrative synthesis was applied to the qualitative and quantitative evidence.

RESULTS

Nineteen qualitative studies and 47 quantitative studies were retained. With respect to care needs, nine themes were synthesized: pain control, reduced aggressive end-of-life care, truth telling, physical, emotional, and spiritual supports, and achieving preferred place of care/death. Informal caregivers expressed their needs for education and burden reduction. Health care professionals called for training and national policy support. Twenty-four studies evaluated interventions, mostly among patients with advanced cancer. Positive effects were suggested for improvements in quality of life, pain, anxiety and depression, readmission rate, and costs. Models of care evaluated were mostly specialist palliative care delivered in various settings (hospitals, residential care, and home). Outcome measures used were grouped into six categories of construct: quality of life, pain, physical assessment, psychospiritual assessment, quality of care, and implementation assessment. Limited rigorous randomized controlled trials are available to document intervention outcomes, and some problems (such as high attrition rates) reduced the strength of the evidence.

CONCLUSION

Palliative care services within Greater China should pay more attention to management of nonmalignant disease and to integration into primary services. Policy support is key to establishing culturally appropriate person-centered services.

Effectiveness of Combined Treatment with Traditional Chinese Medicine and Western Medicine on the Prognosis of Patients with Breast Cancer

Objective: Traditional Chinese Medicine (TCM) can be used to balance the body's immunity and tumor development during different stages of cancer treatment. Recently, TCM has been an important part of the health care system for breast cancer in Taiwan. This study was conducted as a prospective observation of the prognosis of Western medicine and combined treatment of TCM and Western medicine. Methods: Between April 2014 and March 2015, eligible participants were treated with Western medicine (n = 16) or TCM plus Western medicine (n = 29). The TCM treatment for patients followed the principles of a breast cancer protocol that had been developed in the Integrative Cancer Center. The outcome measures included quality of life, frequency of symptom distress, and clinical safety, and were measured with the Functional Assessment of Cancer Therapy-General (FACT-G), the Common Terminology Criteria for Adverse Events (CTCAE) Scale, and laboratory examinations, respectively. Data on these measures were collected at baseline and at 3 months after treatment initiation. Survival was estimated by Kaplan-Meier curves. Results: The two treatment groups did not differ significantly at baseline in terms of demographic information, FACT-G score, or frequency of symptom distress, except for fatigue, sleep disturbance, and mucositis. Most laboratory examinations did not differ significantly between the two groups, but higher red blood cell counts and lower liver function were found with the combined treatment than with Western medicine alone (p < 0.05). The mean overall survival rates were 25.5 months for the combined group and 22.7 months for the Western medicine group (p = 0.037). Conclusion: The results of this study suggest that combining Western and TCM therapy may have a favorable effect on the prognosis of breast cancer patients. Chinese herbal medicine is worth studying in a future larger cohort with a control group. It also warrants verification as a preventive intervention.

The Benefit of Enhanced Daycare of Traditional Chinese Medicine for Cancer Treatment Related Adverse Events: A Retrospective Study of Medical Records

OBJECTIVE

Cancer patients undergo therapies that might lead to severe adverse events. The enhanced daycare of Traditional Chinese medicine (TCM) we describe was intended to help cancer patients suffering from severe adverse events to obtain relief. We used the Taiwan brief version of the Common Terminology Criteria for Adverse Events Version 4.0 (Taiwan brief version questionnaire of CTCAE) as a primary measurement to evaluate the efficacy of the enhanced day care of TCM. The secondary measurements were the Taiwanese version of the Brief Fatigue Inventory (BFI-T) questionnaire and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire, which were used to quantify fatigue and quality of life (QOL), respectively.

METHODS/DESIGN

This is a retrospective study of medical records. There were 401 patients treated with enhanced daycare of TCM from June 2017 to November 2019.

RESULTS

Among 22 common adverse symptoms in the Taiwan brief version questionnaire of CTCAE4.0, 14 symptoms achieved a significant improvement, and the change of the total scores was also statistically significant (P < .001). Cancer stages II to IV showed significant improvement on the CTCAE and BFI-T; stage I only showed improvement on the BFI-T. On the WHOQOL questionnaire, there was a statistically significant difference in self-evaluation of the quality of life (P = .001) and self-evaluation of the total health condition aspect (P < .001).

CONCLUSIONS

The enhanced TCM daycare program helped cancer patients decrease the severity of their adverse events and improve their fatigue and QOL. ClinicalTrials.gov identifier: NCT04606121.

Traditional Chinese Medicine in Cancer Care: An Overview of 5834 Randomized Controlled Trials Published in Chinese

BACKGROUND

Traditional Chinese medicine (TCM) is widely integrated into cancer care in China. An overview in 2011 identified 2384 randomized and non-randomized controlled trials (RCTs, non-RCTs) on TCM for cancer published in the Chinese literature. This article summarizes updated evidence of RCTs on TCM for cancer care.

METHODS

We searched 4 main Chinese databases: China National Knowledge Infrastructure, Chinese Scientific Journal Database, SinoMed, and Wanfang. RCTs on TCM used in cancer care were analyzed in this bibliometric study.

RESULTS

Of 5834 RCTs (477 157 cancer patients), only 62 RCTs were indexed in MEDLINE. The top 3 cancers treated were lung, stomach, and breast cancer. About 4752 RCTs (81.45%) tested TCM combined with conventional treatment, and 1082 RCTs (18.55%) used TCM alone for treating symptoms and side-effects. Herbal medicine was the most frequently used TCM modality (5087 RCTs; 87.20%). The most frequently reported outcome was symptom improvement (3712 RCTs; 63.63%) followed by quality of life (2725 RCTs; 46.71%), and biomarkers (2384 RCTs; 40.86%). The majority of RCTs (4051; 69.44%) concluded there were beneficial effects using either TCM alone or TCM plus conventional treatment compared with conventional treatment.

CONCLUSION

Substantial randomized trials demonstrated different types/stages of cancer were treated by various TCM modalities, alone or in combination with conventional medicine. Further evaluation on the effects and safety of TCM modalities focusing on outcomes such as quality of life is required.

Phase I study to evaluate the maximum tolerated dose of the combination of SH003 and docetaxel in patients with solid cancer: A study protocol

INTRODUCTION

Cancer is the second leading cause of death, and the burden of cancer continues to grow globally. Research on the efficacy of combined administration of herbal medicine and anticancer drugs is also increasing. SH003 is a new herbal medicine composed of Astragalus membranaceus, Angelica gigas, and Trichosanthes kirilowii. SH003 alone up to 4800 mg daily was found to be safe. Preclinical studies have shown SH003 to have a synergistic effect with coadministration of anticancer drugs. This study aimed to determine the maximum tolerated dose of SH003 combined with docetaxel in patients with lung or breast cancer.

METHODS

This is an open-label, dose-escalation study to evaluate the safety of SH003 combined with docetaxel. Patients with lung or breast cancer will be recruited. The participants will be divided into 3 groups based on SH003 daily dose (2400, 3600, and 4800 mg); the medication will be taken orally for 21 days. The traditional 3 + 3 design will be adopted for the dose escalation. Dose-limiting toxicities are defined as grade 3 or 4 adverse events according to the Common Terminology Criteria for Adverse Events. The highest dose at which no more than 1 of the 6 patients experience dose-limiting toxicity will be determined as the maximum tolerated dose of SH003 combined with docetaxel.

DISCUSSION

This study investigates the safety of SH003 when combined with docetaxel. The results of this study will provide a safe dose range for conducting therapeutic exploratory trials.

TRIAL REGISTRATIONS

ClinicalTrials.gov NCT04360317.

Effectiveness and safety of herbal medicine for cancer-related fatigue in lung cancer survivors: A systematic review and meta-analysis

Approximately half of lung cancer patients (LCP) receiving chemotherapy are experiencing cancer-related fatigue (CRF). In East Asia, herbal medicines (HMs) have been used as tonics due to their anti-fatigue effect. This systematic review evaluated the effectiveness and safety of HMs for CRF in LCP. We comprehensively searched 12 electronic medical databases to search randomized controlled trials (RCTs) and quasi-RCTs investigating HMs for CRF in LCP, published up to September 2019. The primary outcome was the fatigue severity. Secondary outcomes included patients' quality of life (QOL), activities of daily life (ADL), and incidence of adverse events. Cochrane's risk of bias tool assessed the methodological quality of included RCTs. The risk ratio or mean difference was estimated with 95% confidence intervals by performing a meta-analysis. Twelve RCTs with 861 participants were included. Compared to conventional medicine alone, HM combined with conventional medicine significantly improved fatigue level, QOL, and ADL. As monotherapy, HM significantly improved ADL compared with megestrol. No serious HM-related adverse events were reported. Limited evidence suggests that HM could be effective and safe for CRF in LCP. However, further high-quality RCTs are needed to confirm these findings owing to the small number and low methodological quality of the included studies.

Integrating Traditional and Complementary Medicine Recommendations into Clinical Practice Guidelines for People with Diabetes in Need of Palliative and End-of-Life Care: A Scoping Review

Objectives: This study was conducted before an evidence review on Traditional and Complementary Medicine (TCM) to update the clinical practice guidelines (CPGs): "Deciding palliative and end-of-life (P/EoL) care for people with diabetes." The aim was to frame the PICO (population/problems, interventions/comparisons, and outcomes), ascertain their importance, and identify other modifying factors for grading recommendations. Design: A systematic scoping review mapped information about diabetes P/EoL problems and outcomes, TCM use, provision, benefits and risks, and stakeholder preferences and values. Thirteen electronic databases were searched in 2017/18 until no new information was identified. Relevant data were extracted, rated for quality, directness, and relevance, and synthesized using triangulation methods. Excluded was diabetes prevention or treatment, as this is not an important P/EoL problem. Results: Of the 228 included articles, except for diabetes P/EoL problems, insufficient direct evidence led to data being extrapolated from either adults with diabetes or any P/EoL diagnosis. The findings affirmed that caring for people with diabetes in need of P/EoL care is complex due to multiple fluctuating needs that are influenced by the P/EoL trajectories (stable, unstable, deteriorating, terminal, or bereaved), multimorbidity, and difficult-to-manage chronic and acute problems. The only problem specific to diabetes P/EoL care, was unstable glycemia. Over 50 TCM interventions commonly used by patients and/or provided by services were identified, of which, many might simultaneously address multiple problems and 18 had been appraised in systematic reviews. Physical and psychologic symptom reliefs were most often evaluated; however, these were only one aspect of a "good death." Other important outcomes were the quality and location of care, personal agency, relationships, preparations for the dying process, spirituality, and affirmation of the whole person. Other important modifying factors included opportunity costs, affordability, availability, preferences, cultural appropriateness, and alignment with beliefs about the meaning of illness and death. Conclusions: There is a role for TCM in the multidisciplinary holistic P/EoL care of people with diabetes. Due to the paucity of evidence specific to this population, the generalizability of some of these results is broader and the updated CPG will also need to consider indirect evidence from other patient groups. Along with recommendations about indications for TCM use, the CGP should provide guidance on ceasing unnecessary interventions, reducing polypharmacy and managing unstable glycemia is required. Before ceasing a TCM, a broader risk-benefit analysis is recommended, as unlike many conventional therapies, there may be multiple benefits warranting its continuation.

An Overview of Systematic Reviews: Complementary Therapies for Cancer Patients

Introduction: This article critically examines the systematic reviews (SR) and meta-analysis (MA) of complementary therapies for cancer patients to appraise the evidence level, and offers suggestions for future research and practice. Methods: The Cochrane Library and MEDLINE were searched from their inception to January 2018, to identify SR and MA of complementary therapies available for cancer patients. Final selected SR and MA were methodologically evaluated for their quality by applying the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR2) instrument. Data extraction and risk of quality assessments were performed by 2 independent reviewers. Results: A total of 104 studies were included in the analysis. The majority of the individual clinical trials included in the SR and MA were performed in China (48%) and the United States (26.9%). Breast cancer was the most studied cancer type (25%), and acupuncture was the most studied intervention (21%). Side effects of cancer such as pain, depression, and fatigue were effectively managed with complementary therapies. The methodologically problematic items included not listing the excluded studies and lack of protocol or protocol registration. Conclusions: With increasing interest in research, complementary therapies appear to be beneficial in reducing side effects and raising the quality of life of cancer patients. Complementary therapies have generally been studied for all cancers, with acupuncture being the most researched, regardless of the cancer type. Since AMSTAR2 is a stricter assessment tool than before, future studies need to consider the risk of methodological bias with caution and discuss appropriate overall quality assessment tools.

Application of Neural Network and Cluster Analyses to Differentiate TCM Patterns in Patients With Breast Cancer

Background and Purpose

Pattern differentiation is a critical element of the prescription process for Traditional Chinese Medicine (TCM) practitioners. Application of advanced machine learning techniques will enhance the effectiveness of TCM in clinical practice. The aim of this study is to explore the relationships between clinical features and TCM patterns in breast cancer patients.

Methods

The dataset of breast cancer patients receiving TCM treatment was recruited from a single medical center. We utilized a neural network model to standardize terminologies and address TCM pattern differentiation in breast cancer cases. Cluster analysis was applied to classify the clinical features in the breast cancer patient dataset. To evaluate the performance of the proposed method, we further compared the TCM patterns to therapeutic principles of Chinese herbal medication in Taiwan.

Results

A total of 2,738 breast cancer cases were recruited and standardized. They were divided into 5 groups according to clinical features via cluster analysis. The pattern differentiation model revealed that liver-gallbladder dampness-heat was the primary TCM pattern identified in patients. The main therapeutic goals of the top 10 Chinese herbal medicines prescribed for breast cancer patients were to clear heat, drain dampness, and detoxify. These results demonstrated that the neural network successfully identified patterns from a dataset similar to the prescriptions of TCM clinical practitioners.

Conclusion

This is the first study using machine-learning methodology to standardize and analyze TCM electronic medical records. The patterns revealed by the analyses were highly correlated with the therapeutic principles of TCM practitioners. Machine learning technology could assist TCM practitioners to comprehensively differentiate patterns and identify effective Chinese herbal medicine treatments in clinical practice.

Development of Evidence-Based Chinese Medicine Clinical Service Recommendations for Cancer Palliative Care Using Delphi Approach Based on the Evidence to Decision Framework

Objectives: Existing evidence supports the use of certain Chinese medicine (CM) interventions for symptom management among palliative cancer patients. However, evidence-based service recommendations tailored to the local context are needed for CM planning and implementation. In response, we aimed to establish consensus on CM clinical service recommendations for cancer palliative care among Hong Kong experts. Methods: Seven CM interventions showing statistically significant favorable results in existing systematic reviews (SRs) and overviews of SRs were subjected to a GRADE-ADOLOPMENT-based 2-round Delphi survey. Twelve Hong Kong experts in cancer palliative care, including conventionally trained physicians, CM practitioners, and nurses (n = 4 from each category), were invited to participate. Use of the Evidence to Decision framework within the GRADE-ADOLOPMENT approach enabled experts to consider aspects of problem priority, benefits, harms, equity, acceptability, and feasibility when making CM recommendations in cancer palliative care. Results: Three evidence-based CM interventions reached positive consensus as service recommendations, namely: (1) acupuncture for reducing fatigue among palliative cancer patients; (2) acupressure for reducing fatigue among palliative cancer patients; and (3) moxibustion for reducing nausea and vomiting among patients receiving chemotherapy. Median rating of recommendation ranged from 2.5 to 3.0 (interquartile range = 0.00-1.00) on a 4-point Likert-type scale, and the percentage agreement ranged from 83.4% to 91.7%. Conclusions: The GRADE-ADOLOPMENT approach facilitates a consensus-based process of reaching 3 evidence-based CM recommendations for cancer palliative care. Future studies may develop tailored strategies to implement these recommendations in the Hong Kong health system.

Herbal medicine on cancer-related fatigue of lung cancer survivors: Protocol for a systematic review

BACKGROUND

Lung cancer is one of the most common cancers worldwide, and approximately half of the patients with lung cancer receiving chemotherapy suffer from cancer-related fatigue (CRF). Herbal medicines (HMs) have been used in Oriental countries for centuries as tonics. Various beneficial effects of HM on fatigue and cancer have been reported. However, the effectiveness and safety of HM for CRF in lung cancer patients have not been synthesized. The purpose of this systematic review is to evaluate the effectiveness and safety of HM for CRF in patients with lung cancer, regardless of their cancer type or stage.

METHODS AND ANALYSIS

A comprehensive search will be conducted in 12 electronic medical databases including 5 English-language databases (Medline via PubMed, EMBASE via Elsevier, the Cochrane Central Register of Controlled Trials [CENTRAL], the Allied and Complementary Medicine Database [AMED] via EBSCO, and the Cumulative Index to Nursing and Allied Health Literature [CINAHL] via EBSCO), 4 Korean-language databases (Oriental Medicine Advanced Searching Integrated System [OASIS], Koreanstudies Information Service System [KISS], Research Information Service System [RISS], and Korea Citation Index [KCI]), 2 Chinese-language databases (China National Knowledge Infrastructure [CNKI] and Wanfang Data), and 1 Japanese-language database (CiNii). Only randomized controlled trials (RCTs) and quasi-RCTs on HM for CRF will be allowed. The severity of fatigue assessed using a validated tool will be considered as theprimary outcome. The secondary outcomes will include the patients' quality of life, activities of daily life, incidence of adverse events, and total effective rate. Two independent researchers will perform the study selection, data extraction, and quality assessment. RevMan version 5.3 will be used for data synthesis. The methodological quality of the included RCTs will be assessed using the Cochrane Collaboration's risk of bias tool. In the meta-analysis, for dichotomous data and continuous data, risk ratio and mean difference, respectively, will be estimated with their 95% confidence intervals. According to the heterogeneity, either a fixed-effects or a random-effects model will be used.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data are not included. The findings of this systematic review will be disseminated through a peer-reviewed publication or conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019141660.

Prioritizing Chinese Medicine Clinical Research Questions in Cancer Palliative Care: International Delphi Survey

CONTEXT

Chinese medicine modalities, including acupuncture and Chinese herbal medicine (CHM), have been used as palliative interventions among cancer patients. More research should be conducted to confirm their effectiveness.

OBJECTIVES

The objective of this study was to prioritize Chinese medicine clinical research questions for cancer palliative care.

METHODS

Twelve international experts, including physicians, Chinese medicine practitioners, nurses, and clinical research methodologists (n = 3 from each category), from Asia, North America, Australia, and Europe participated in a two-round Delphi survey for prioritizing 29 research questions identified from existing systematic reviews. The experts were asked to 1) rate clinical importance of answering the questions on a nine-point Likert scale; 2) provide qualitative comments on their ratings; and 3) suggest outcome measurement approaches.

RESULTS

Eight research priorities reached positive consensus after the two-round Delphi survey. Six of the priorities focused on acupuncture and related therapies, of which median ratings on importance ranged from 7.0 to 8.0 (interquartile range: 1.00 to 2.50), and the percentage agreement ranged from 75.0% to 91.7%. The remaining two priorities related to CHM, with median ratings ranged from 7.0 to 8.0 (interquartile range: 1.00 to 1.50) and percentage agreement ranged from 75.0% to 83.3%. Neither positive nor negative consensus was established among the remaining 21 questions.

CONCLUSION

The findings will inform rational allocation of scarce research funding for evaluating the effectiveness of Chinese medicine for cancer palliative care, especially on acupuncture and related therapies. Further research on herb safety and herb-drug interaction should be performed before conducting international trials on CHM.

The Method of Activating Blood and Dredging Collaterals for Reducing Chemotherapy-Induced Peripheral Neuropathy: A Systematic Review and Meta-Analysis

Background

Chemotherapy-induced peripheral neuropathy (CIPN) remains as a big unsolved challenge for cancer patients and oncologists. However, there is no effective treatment to prevent and cure it. This systematic review and meta-analysis chiefly aimed to assess the effectiveness and safety on the method of activating blood and dredging collaterals in traditional Chinese medicine (TCM) for reducing CIPN.

Methods

Two authors comprehensively searched all the randomized controlled trials (RCTs) via PubMed, Cochrane, China National Knowledge Infrastructure (CNKI), and Wanfang Database of China Science Periodical Database (CSPD). The Review Manager (RevMan) 5.0 was used to conduct the meta-analysis.

Results

20 trials including 1481 participants were analyzed. 15 trials tested the incidence of all-grade CIPN which was significantly lower in intervention arm and 16 trails presented that the result of high-grade CIPN was the same. The total effective rate of the use of Chinese herbs was 77.19% versus 45.79% in the comparator group. Besides, the use of Chinese herbs statistically promoted the sensory nerve conduction velocity (SNCV) and the motor nerve conduction velocity (MNCV). Besides, the quality of life (QoL) in the intervention group was better than the comparator one. Herbs-related adverse events were skin allergy, skin chap, and scald, which could be managed well.

Conclusions

The work involving studies of the effectiveness and safety on TCM for reducing CIPN proves to be encouraging. Herbs with the function of activating blood and dredging collaterals were found to potentially promote the curative effects as well as making improvements of SNCV and MNCV. However, in the future, more double-blind, multicenter, large-scale RCTs and more comprehensive researches are still required.

Comparison of the efficacy and safety of phloroglucinol and magnesium sulfate in the treatment of threatened abortion: A meta-analysis of randomized controlled trials

BACKGROUND

To compare the clinical efficacy and safety of phloroglucinol (PHL) and magnesium sulfate (MS) in the treatment of threatened abortion through systematic review.

METHODS

Foreign databases, such as the Cochrane Library, PubMed and EMBASE, and Chinese databases, including the China Biology Medicine disc (SinoMed), China National Knowledge Infrastructure (CNKI), Chongqing VIP (VIP) and WanFang Data, were searched. Published randomized controlled trials (RCTs) documents obtained from these databases were included if they were associated with the research objective. The search timeframe was from the beginning of the establishment of each database to May 2018. Document selection, data abstraction and document quality evaluation were independently performed by 2 investigators. A combined analysis of the data was performed for those documents that fulfilled the study requirements; Rev Man 5.3 and Stata 12.0 software were used to compare and analyze the 2 drugs in terms of the total effective rate (TER), rate of adverse events, time required to relieve uterine contractions, onset time, time of complete relief of uterine contraction symptoms, medication duration and length of hospital stay.

RESULTS

A total of 21 RCT trials were included in the present research, according to the inclusion criteria. However, the quality of the included studies was low. The meta-analysis suggested that the TER and drug onset time of PHL were higher than those for MS, while the rate of adverse events, the time required to relieve uterine contractions, time to complete relief of uterine contraction symptoms, drug continuous treatment time and length of hospital stay were shorter than those for MS.

CONCLUSION

The clinical efficacy of PHL is better than that of MS, and PHL obviously results in fewer adverse reactions than MS. However, due to poor quality of evidence, high quality, multi-center RCTs with large samples are required for further verification.

Complementary Therapies as a Strategy to Reduce Stress and Stimulate the Immunity of Women With Breast Cancer

The stress associated with cancer development leads to disturbances in the hypothalamic-pituitary-adrenal axis and suppresses important facets of the immune response. The use of complementary therapies in the treatment of women with breast cancer has demonstrated therapeutic benefits that entail improvements in the patients’ quality of life. The objective of this article is to present evidence on the use of complementary therapies as a stress reduction strategy and on its stimulating effects on the immune system of women with breast cancer. This is a reflexive updating article that will support the health professionals’ understanding on the use of complementary therapies in breast cancer care. The use of complementary therapies in the treatment of women with breast cancer has significantly improved these subjects’ stress, depression, fatigue, anxiety, and consequently, their quality of life, as well as their immune response, which is mainly illustrated by the increased number and cytotoxic activity of natural killer cells. Clinicians, health professionals and patients need to be cautious about using complementary therapies and fully understand the real benefits and risks associated with each therapy. Little or no supporting evidence is available to clarify the effects on the immune system of women with breast cancer, and the consequent therapeutic benefits obtained through the use of these practices.

Association of use of Chinese herbal medicines and the risk of fracture in patients with osteoporosis: a population-based cohort study

After utilizing a large population-based claims database and the application of propensity score match approach to reduce the confounding effects, we found that the use of Chinese herbal medicines (CHMs) was related to the lower risk of sequent osteoporotic fracture by 27% among the individuals with osteoporosis. The predominant effect was observed in those receiving CHMs for more than two years.

INTRODUCTION

Osteoporosis (OS) is a highly disabling condition that can lead to fragility fracture, thus posing greater burdens of functional limitations for the affected individuals. It is unclear if the use of Chinese herbal medicines (CHMs) could reduce the risk of fracture due to OS. This study aimed to investigate the association of CHMs and the subsequent osteoporotic fracture risk among OS patients.

METHODS

This longitudinal cohort study used the Taiwanese National Health Insurance Research Database to identify 250,699 newly diagnosed OS patients aged 20 years or older between 1998 and 2010. We recruited 103,325 CHM users following the onset of OS (CHM users) and randomly selected 103,325 subjects without CHM usage as controls (non-CHM users) by propensity score matching according to the demographic characteristics and comorbidities at enrollment. All enrollees were followed until the end of 2012 to record the incidence of osteoporotic fracture. We applied the Cox proportional hazard regression model to compute the hazard ratio (HR) of the risk of osteoporotic fracture.

RESULTS

During the 15-year follow-up period, 7208 CHM users and 11,453 non-CHM users sustained osteoporotic fracture, with an incidence rate of 9.26 and 12.96, respectively, per 1000 person-years. We found that CHM users had a significantly reduced risk of osteoporotic fracture compared to non-CHM users (adjusted HR 0.73; 95% confidence interval [CI] = 0.70-0.75). Those treated with CHMs for longer than 730 days had a lower fracture risk by 54%. Some commonly used CHMs, such as Yan hu suo (Rhizoma Corydalis), Huang Qin (Scutellaria Baicale), Jie Geng (Platycodon grandifloras), Xiang Fu (Cyperus rotundus), Hai Piao Xiao (Cuttlebone Sepium), Jia-Wei-Xiao-Yao-San, Ge-Gen-Tang, Shao-Yao-Gan-Cao-Tang, and Du-Huo-Ji-Sheng-Tang, are related to the lower risk of fracture.

CONCLUSIONS

The use of CHMs was associated with lower risk of osteoporotic fracture for OS patients, suggesting that it could be integrated into conventional therapy to prevent subsequent bone fracture.

Complementary Therapies as a Strategy to Reduce Stress and Stimulate Immunity of Women With Breast Cancer

The stress associated with cancer development leads to disturbances in the hypothalamic-pituitary-adrenal axis and suppresses important facets of the immune response. The use of complementary therapies in the treatment of women with breast cancer has demonstrated therapeutic benefits that entail improvements in the patients’ quality of life. The objective of this article is to present evidence on the use of complementary therapies as a stress reduction strategy and on its stimulating effects on the immune system of women with breast cancer. This is a reflexive updating article that will support the health professionals’ understanding on the use of complementary therapies in breast cancer care. The use of complementary therapies in the treatment of women with breast cancer has significantly improved these subjects’ stress, depression, fatigue, anxiety, and, consequently, their quality of life, as well as their immune response, which is mainly illustrated by the increased number and cytotoxic activity of natural killer cells. Clinicians, health professionals, and patients need to be cautious about using complementary therapies and fully understand the real benefits and risks associated with each therapy. Little or no supporting evidence is available to clarify the effects on the immune system of women with breast cancer, and the consequent therapeutic benefits obtained through the use of these practices.

Yanghe Huayan decoction inhibits the capability of trans-endothelium and angiogenesis of HER2+ breast cancer via pAkt signaling

Background: Yanghe Huayan Decoction (YHD), a traditional Chinese medicine, is one of the most common complementary medicine currently used in the treatment of breast cancer (BC). It has been recently linked to suppress precancerous lesion and tumor development. The current study sought to explore the role of YHD on trans-endothelium and angiogenesis of BC. Methods: HER2+ BC cells were treated with YHD, Trastuzumab, or the combination in vitro and in vivo to compare the effects of them on trans-endothelium and angiogenesis features. The present study also investigated the potential molecular mechanism of YHD in inhibiting angiogenesis of BC. Results: YHD significantly suppressed the invasion and angiogenesis of BC cells via elevated pAkt signaling. Administration of YHD in vivo also strikingly repressed angiogenesis in tumor grafts. Conclusion: YHD could partially inhibit and reverse tumorigenesis of BC. It also could inhibit Akt activation and angiogenesis in vitro and in vivo Its effect was superior to trastuzumab. Thus it was suitable for prevention and treatment of BC.

Hong Kong Chinese Medicine Clinical Practice Guideline for Cancer Palliative Care: Pain, Constipation, and Insomnia

It is common for patients with cancers in Hong Kong seeking Chinese Medicine (CM) therapies as supportive care during cancer treatment and to manage treatment-related side effects. This article provides clinical practice guideline (CPG) on the use of CM for specific clinical indications caused by cancer and during cancer treatment, including pain, constipation, and insomnia, and aims to guide local licensed CM practitioners and provide beneficial reference for social medical decision makers and patients. In this manuscript, we summarize the clinical manifestation, CM pattern classification, and CM intervention including herbal treatment, acupuncture treatment, regulating, and nursing based on pattern differentiation.

The management strategies of cancer-associated anorexia: a critical appraisal of systematic reviews

BACKGROUND

Cancer-related anorexia remains one of the most prevalent and troublesome clinical problems experienced by patients with cancer during and after therapy. To ensure high-quality care, systematic reviews (SRs) are seen as the best guide. Considering the methodology quality of SRs varies, we undertook a comprehensive overview, and critical appraisal of pertinent SRs.

METHODS

Eight databases (between the inception of each database and September 1, 2017) were searched for SRs on the management of cancer-related anorexia. Two researchers evaluated the methodological quality of each SR by using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) checklist. Characteristics of the "high quality" SRs were abstracted, included information on relevant studies numbers, study design, population, intervention, control, outcome and result.

RESULTS

Eighteen SRs met the inclusion criteria. The R-AMSTAR scores of methodological quality ranged from 18 to 41 out of 44, with an average score of 30. Totally eight SRs scored ≥31 points, which showed high methodological quality, and would be used for data extraction to make summaries. Anamorelin had some positive effects to relieve cancer anorexia-cachexia syndrome (CACS) and improve the quality of life (QoL). Megestrol Acetate (MA) could improve appetite, and was associated with slight weight gain for CACS. Oral nutritional interventions were effective in increasing nutritional intake and improving some aspects of QoL in patients with cancer who were malnourished or at nutritional risk. The use of thalidomide, Eicosapentaenoic Acid, and minerals, vitamins, proteins, or other supplements for the treatment of cachexia in cancer were uncertain, and there was inadequate evidence to recommend it to clinical practices, the same situation in Chinese Herb Medicine and acupuncture (acupuncture and related therapies were effective in improving QoL) for treating anorexia in cancer patients, warranting further RCTs in these areas.

CONCLUSIONS

Anamorelin, MA, oral nutrition interventions, and acupuncture could be considered to be applied in patients with cancer-related anorexia. Future RCTs and SRs with high quality on the pharmaceutical or non-pharmaceutical interventions of anorexia in cancer patients are warranted.

Chinese Herbal Medicine, Jian Pi Li Gan Decoction, Improved Survival of Nonresectable Hepatocellular Cancer After Radiofrequency Ablation: A Retrospective Study

OBJECTIVE

To observe the effect of Jian Pi Li Gan Decoction (JPLGD) on long-term survival of nonresectable hepatocellular cancer (HCC) after radiofrequency ablation (RFA).

METHODS

Between January 2010 and February 2013, 95 patients with nonresectable HCC treated by RFA in our hospital were enrolled, of whom 47 patients received JPLGD accompanying RFA (JPLGD group), and 48 patients received RFA alone (control group). Medical records of these patients were retrospectively analyzed. Long-term survival, complication, and treatment event were compared.

RESULTS

Baseline characteristics did not differ between the 2 groups. No significant adverse effects or toxicities related to herbal medicine were found. The JPLGD group had significantly less liver failure (3/47 vs 10/48, P = .0405) and a higher treatment success rate than the control group (44/47 vs 37/48, P = .0230). The 3-year overall survival probability was significantly higher in the JPLGD group ( P = .0175).

CONCLUSION

JPLGD has the potential to effectively and safely improve long-term survival of nonresectable HCC by increasing treatment success of RFA.

Use of Complementary Traditional Chinese Medicines by Adult Cancer Patients in Taiwan: A Nationwide Population-Based Study

BACKGROUND

Many patients with cancer seek complementary and alternative medicine treatments. We investigated the use of traditional Chinese medicine (TCM) by adult cancer patients in Taiwan.

METHODS

We reviewed the Registry for Catastrophic Illness Patients Database of Taiwan, and included all adult patients diagnosed cancer, based on the International Classification of Diseases (ninth revision), from 2001 to 2009 and followed until 2011. This database allowed categorization of patients as TCM users (n = 74 620) or non-TCM users (n = 508 179). All demographic and clinical claims data were analyzed.

RESULTS

Compared with non-TCM users, TCM users were younger and more likely to be female, white-collar workers, and reside in highly urbanized areas. The average interval between cancer diagnosis and TCM consultation was 15.3 months. The most common cancer type was breast cancer in TCM users (19.4%), and intrahepatic bile duct cancer in non-TCM users (13.6%). The major condition for which TCM users visited clinics were endocrine, nutritional and metabolic diseases, and immunity disorders (23.2%). A total of 33.1% of TCM users visited TCM clinics more than 9 times per year and their time from diagnosis to first TCM consultation was 5.14 months. The most common TCM treatment was Chinese herbal medicine. The common diseases for which cancer patients sought TCM treatment were insomnia, malaise and fatigue, dizziness and headache, gastrointestinal disorders, myalgia and fasciitis, anxiety, and depression. Overall, TCM users had a lower adjusted hazard ratio (aHR) for mortality (aHR = 0.69, 95% CI = 0.68-0.70) after adjustment for age, sex, urbanization of residence, occupation, annual medical center visits, and annual non-medical center visits.

CONCLUSIONS

This study provides an overview of TCM usage among adult cancer patients in Taiwan. TCM use varied among patients with different types of cancer. Physicians caring for cancer patients should pay more attention to their patients' use of complementary TCM.

What has traditional Chinese medicine delivered for modern medicine?

The field of Traditional Chinese Medicine (TCM) represents a vast and largely untapped resource for modern medicine. Exemplified by the success of the antimalarial artemisinin, the recent years have seen a rapid increase in the understanding and application of TCM-derived herbs and formulations for evidence-based therapy. In this review, we summarise and discuss the developmental history, clinical background and molecular basis of an action for several representative TCM-derived medicines, including artemisinin, arsenic trioxide, berberine and Salvia miltiorrhiza or Danshen. Through this, we highlight important examples of how TCM-derived medicines have already contributed to modern medicine, and discuss potential avenues for further research.

A Systematic Review of Herbal Medicine for Chemotherapy Induced Peripheral Neuropathy

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a common adverse effect in cancer patients. The aim of this review was to assess the effectiveness of herbal medicine in preventing and treating CIPN.

METHODS

Randomised controlled trials were included in this review. Extracting and assessing the data independently, two authors searched 13 databases.

RESULTS

Twenty-eight trials involving 2174 patients met the inclusion criteria. Although there were some exceptions, the methodological quality was typically low. Seventeen trials reported the incidence rate of CIPN assessed by various tools and 14 showed a significant difference regarding the decrease of the incidence rate between the two groups. For clinical improvement, 12 trials reported it using various tools and 10 showed a significant difference between two groups. Two cases of adverse events occurred in one trial; the other nine trials reported no adverse events.

CONCLUSIONS

We found that herbal medicines in combination with and/or without other therapies potentially have preventive or therapeutic effects on CIPN. However, conclusions cannot be drawn because of the generally low quality of the methodology, the clinical heterogeneity, and the small sample size for each single herbal medicine. Trials that are more rigorous and report sufficient methodological data are needed.

Toward Evidence-Based Chinese Medicine: Status Quo, Opportunities and Challenges

How to test the treatments of Chinese medicine (CM) and make them more widely accepted by practitioners of Western medicine and the international healthcare community is a major concern for practitioners and researchers of CM. For centuries, various approaches have been used to identify and measure the efficacy and safety of CM. However, the high-quality evidence related to CM that produced in China is still rare. Over the recent years, evidence-based medicine (EBM) has been increasingly applied to CM, strengthening its theoretical basis. This paper reviews the past and present state of CM, analyzes the status quo, challenges and opportunities of basic research, clinical trials, systematic reviews, clinical practice guidelines and clinical pathways and evidence-based education developed or conducted in China, pointing out how EBM can help to make CM more widely used and recognized worldwide.