Chinese Medicine and Supportive Cancer
Care: A Model for an Evidence-Based, Integrative Approach
Stephen M Sagar; Raimond
Wong Department of Medicine,
Evidence-Based Integ Med 1(1):11-25,
2004. © 2004 Open Mind Journals, Ltd.
Please note an early print version of Evidence-Based Integrative Medicine
appeared in 2003.
Abstract and Introduction
Abstract
Traditional
Chinese medicine (TCM) may be integrated with conventional Western medicine to
enhance the care of patients with cancer. Recent evidence confirms a scientific
basis for the use of acupuncture, herbs, diet and
energy therapies. We suggest a holistic care plan based on the concepts of
biological response modification, enhancement of psychoimmunological
function, better symptom control and improvement of psychospiritual
wellbeing. There is enough preliminary evidence to encourage good quality clinical
trials to evaluate the efficacy of integrating TCM into Western cancer care.
Introduction
Recent evidence
suggests that many traditional Chinese medical therapies can be effective for
the supportive care of cancer patients. This is a review of the published
literature (indexed in MEDLINE®) and our own practical experience.
It is not intended to be a systematic review, but does provide various levels
of evidence that support further research into a developing model of
integrative care. Most published studies are at evidence level III; in other
words, trials without randomisation, single-group
pre-post cohort, time series or matched case-controlled studies. Level I and II
evidence from well designed, randomised, controlled
trials of appropriate size is emphasised in the text
of this review. Because of the paucity of quality data from level I and II
evidence, meta-analysis of the data is currently not possible. Well designed, randomised, controlled trials are encouraged in view of the
promising initial observations.
Traditional Chinese medicine (TCM) may be practised
alongside conventional Western medicine to enhance patient care. The philosophy
of TCM proposes novel hypotheses that will support the development of a
science-based holistic medicine.
Cancer as a Systemic Disease
In Western
medicine, cancer is conventionally viewed from the somatic point of view as a
clone of cells that has outgrown its environmental constraints and control
mechanisms. These cells are abnormal and are considered to be foreign to the
body. The main philosophy of cancer treatment is direct annihilation of the
cancer cells using aggressive and destructive therapies. The importance of the
body-mind communication network in conventional cancer treatment is being emphasised through the innovative models and clinical
practices developed by Carl Simonton, Jeanne Achterberg,
David Spiegel, Alistair Cunningham and others. In particular, the science of psychoneuroimmunology has demonstrated a physiological
basis for cancer cell transformation through the effects of emotions on
cellular immunity and other mechanisms.
In TCM, the development of cancer is viewed as a part of the
presenting features of a syndrome representing an imbalance of the whole
body-mind network (Macek 1984). In other words,
cancer is a systemic disease from the start, and the terrain is considered to
be as important as the tumour itself (Schipper et al 1995). It is believed that if one can
strengthen and rebalance the body-mind network, the normal pattern will be restored,
and this will help to resolve the cancer.
Chinese Medicine and Supportive Cancer Care
The Body-Mind Network
TCM recognises that the human being functions as a body-mind network
(Ikemi and Ikemi 1986). The
philosophy of TCM analyses the process of body-mind communication, rather than
a 'snap shot' of structural, material entities such as molecules. If Western
medicine is viewed as the hardware of a computer, TCM could represent the
software. It recognises a correspondence between
patterns of information that are independent of the carrier of the information.
For example, the pattern of information may be similar regardless of whether it
is mediated by pulses of hormones and neuropeptides,
or the electrophysiological frequency pattern of the heart (Watkins 1995; Dardik 1996; Pennisi 1997; Pert
et al 1998; Song et al 1998). Acupuncture stimulation of specific points on the
body releases neuropeptides (such as somatostatin and vasoactive
intestinal peptide) within the central nervous system (Zhang et al 1997; Zhang
et al 1999). The body-mind information system may be partly regulated by the
relative contributions of the sympathetic and parasympathetic components of the
autonomic nervous system. This corresponds to the traditional Chinese concept
of a balance between yin and yang, which represents a pattern of information,
rather than concrete material entities. Analysis of the pulse, using the
classical Chinese technique, may indicate the relative imbalance. This has been
demonstrated indirectly by spectral analysis of the electrocardiogram, using
appropriate computer software. Acupuncture has been shown to rebalance the
relative contributions of the sympathetic and parasympathetic nervous systems (Haker et al 2000). The patterns of information transfer may
interact to entrain and reinforce information flow in a complex dynamic system
(Lee and Wei 1983; McCraty
et al 1995; Rubik 1995). The system is an autopoietic
process. In other words, it can recreate itself and evolve through learning, so
that the body can adapt to changing circumstances.
When the person
is healthy, communication between systems flows freely through a complex,
non-linear heterarchical and hierarchical process of
information transfer, via physiological interactions. Metaphorically, mind-body
communication is represented by an informatics system of energy-in-motion, in
other words, 'e-motion'. Cancer may be associated with a disturbance in
information flow, manifest by an over-plastic system that loses process
structure and becomes irreversibly chaotic (Coffey 1998; Cuzick
et al 1998). Experiments in rats show that chronic restraint stress promotes
lymphocyte apoptosis through modulating CD95 gene expression via a pathway that
involves opioid receptors (Yin et al 2000). In other
words, stress can influence both the function and structure of the nervous
system that, in turn, may modulate lymphocyte gene expression, thereby
influencing immunity and resistance to cancer (Yin et al 2000). Intervention
with a technique such as acupuncture may restore the imbalance in information
flow, for example through the autonomic nervous system by balancing the
sympathetic and parasympathetic components (Thomas et al 1992; Chao et al 1999). The same model may help us understand how
the compassionate intentionality of a healer can restore health through
entrainment and normalisation of the imbalanced
system (Watkins 1996). To understand these processes, we need to consider
systems outside our current reductionist
pharmacological model. These may include electromagnetic and non-local effects
between molecules and the analysis of information flow between cells by novel
mechanisms such as quantum mechanics (Jovanovic-Ignjatic
and Rakovic 1999). To understand the concurrent,
synergistic contributions of multiple systems, it is necessary to develop computerised algorithmic modelling,
such as power spectral analysis (Haker et al 2000),
neural networks (Riess and Abbas
2000) and fuzzy logic (Kosko and Isaka
1993).
The beauty of
this body-mind network model is that it can combine constitutional personality
factors (such as emotions and feelings) with bodily symptoms into a single
diagnostic and treatment paradigm. This is represented in TCM terms by patterns
of disharmonies in the main organ systems, as well as abnormalities of qi (energy flow), essence (energy reserves), blood, heat
and moisture. It is interesting that there is correspondence with the TCM model
of cancer predisposition being associated with rising qi
(sheng qi) or liver fire
(representing anger), and the scientific evidence that repressed anger both
suppresses the immune system and may increase the risk of breast cancer in the
so-called type C personality (Amkraut and Solomon
1972; Temoshok 1985; Temoshok
and Dreher 1992).
In TCM, herbs are
used in combinations that enhance their benefits while reducing their side
effects (
Most evidence suggests that acupuncture modulates neurotransmitters,
cytokines and neuropeptides through
electrophysiological changes in the nervous system (Bucinskaite
et al 1996; Dawidson et al 1997). Interaction with
the brain stem, hypothalamus, limbic system and autonomic nervous system occurs
through either stimulating or suppressing the activity of afferent peripheral
nerves (Kerr et al 1978; Kumar et al 1994; Alavi et
al 1997; Cho et al 1998; Wu et al 1999; Zonenshayn et al 2000). Acupuncture may also modify the
somatic electromagnetic field (Jessel-Kenyon et al
1992). It is a technique that allows us to modulate communication within the
body-mind network through concurrent changes in multiple signalling
pathways.
The roles of TCM in cancer supportive care are illustrated in
Figure 1. The goals of cancer treatment should be to increase patients'
survival, when possible, and to improve their quality of life. TCM is able to
support patients being treated with conventional Western medicine (surgery, radi biological response modification
potentiation of psychospiritual wellbeing.otherapy and chemotherapy) through four major
approaches:
- biological response modification
- increase in psychoneuroimmunological
function
- improvement of symptom control
- potentiation of psychospiritual
wellbeing.
Biological Response Modification
Adjunctive Cancer Treatment
Modification of Tumour Physiology
There is
increasing evidence that suggests TCM can favorably modify the tumor response
to conventional Western cancer treatment. There is a correspondence between the
TCM theory of cancer and recent medical research findings.
TCM herbs have
been extensively investigated in the laboratory and are known to have multiple
pharmacological effects (Wang et al 1992; Tode et al
1993; Lao et al 1994; Boik 1996; Boik
1997; Kang et al 2000). It is often important to specify the botanical parts
from which the herbal agent is prepared, since the active pharmacological
agents depend on their source. Radix (Rx) denotes the root, cortex (Cx) denotes the bark or rind and rhizome (Rh) denotes the rhizome. Rx ginseng has antitumour
activity, inhibits platelet aggregation and inhibits chemotherapy-induced immunosuppression. Glycyrrhizic
acid has antitumour activity, is anti-inflammatory
through increasing serum cortisol and also increases
natural killer (NK) cell activity against cancer cells. Rx astragali
membranaceus is a powerful stimulator of the immune
system, has antitumour activity and inhibits platelet
aggregation. Rx angelicae sinensis
stimulates the immune system, has antitumour
activity, inhibits platelet aggregation and inhibits vascular permeability. Rh atractylodis macrocephala has antitumour
activity and is an antithrombotic and fibrinolytic agent. Ginkgo biloba
has multiple effects including inhibition of platelet activation factor, stimulation
of the immune system, fibrinolysis and antithrombosis, scavenging of free radicals and dilation of
blood vessels to increase perfusion.
These herbs
contain a variety of chemicals that may act synergistically to inhibit tumour cell division, increase tumour
cell death (apoptosis), increase the proportion of immune cells within the tumour and increase blood flow through the tumour. This is associated with a change in the balance of
cytokines (communicating peptides released by the immune cells) that may
improve the therapeutic gain. This means that they reduce the proliferation of tumour cells and increase tumour
cell death, while minimising many side effects for
normal tissues. Examples of studies that illustrate these principles are
discussed.
In TCM, the
malignant tumour is viewed as being associated with
stagnation of qi (energy) and blood. Qi may be viewed as a model for intra- and inter-cellular
information and potential energy transfer. This would correlate with the known
abnormalities of signal transduction, cell contact and electrophysiology of
cancer cells (Coffey 1998; Cuzick et al 1998; Kang et
al 2000). It has been shown that there is increased fluid content and a
stagnant blood supply in malignant tumours (Baxter
and Jain 1989; Boucher and Jain 1992; Sagar et al
1993; Milosevic et al 1998). The microcirculation within a tumour
is very abnormal, and there are regions within the tumour
where the blood flow is sluggish. In TCM, stagnation of blood is classically
associated with tumours. The impaired blood
circulation leads to areas of poor oxygenation in the tumour.
Cancer cells that survive in a low oxygen tension environment are also found to
be more resistant to radiotherapy and some types of chemotherapy (Brizel et al 1997; Fyles et al
1998).
In TCM, destagnation or detoxification herbs are used to move the
blood and qi within the malignant tumour.
Interestingly, the use of anticoagulants, such as heparin and coumadin (warfarin), as an
adjunctive treatment to chemotherapy has been shown to prevent the development
of blood-borne metastases in animal laboratory studies and to improve the
survival of cancer patients in clinical studies (Lebeau
et al 1994; Hejna et al 1999).
The possible
usefulness of destagnation herbs was demonstrated in
a randomised, controlled clinical trial evaluating
the combined modality treatment of Chinese herbal destagnation
formula and radiotherapy in patients with nasopharyngeal carcinoma (Xu et al 1989). In this trial, 90 patients received
combined herbal and radiation treatment compared with 98 patients who were randomised to receive radiation treatment alone. The
ingredients of the herbal formula included Rx astragali
membranaceus, Rx paeoniae rubrae, Rx ligustici Chuan xiong, Rx angelicae sinensis, Semen persicae, Flos carthami tinctorii,
Rx et Caulis jixueteng, Rx puerariae, Pericarpium citri reticulatae and Rx codonopsitis pilosulae. The
combined treatment group showed a statistically significant increase in local tumour control and overall 5-year survival as compared with
the group treated with radiation alone (p < 0.05). The rate of local
recurrence in the intervention group was halved from 29% in those receiving
radiation alone to 14% in the group receiving destagnation
herbs as well. The 5-year disease-free survival was increased from 37% in the
control group to 53% in the group receiving destagnation
herbs. It is postulated that this herbal destagnation
formula may have improved tumour microcirculation and
increased tumour blood flow, leading to an
improvement in the oxygen tension inside the tumour.
The oxygen tension increases the radiosensitivity of
the tumour. In other words, the destagnation
formula has acted as a radiation sensitiser.
In animal
experiments, Ginkgo biloba has also been shown
to increase perfusion and radiosensitivity (Kleijnen and Knipschild 1992;
Sung et al 1996). Chinese herbs, such as Salvia miltiorrhiza,
which inhibit tumour oedema
caused by free radicals, may also increase tumour
perfusion, oxygenation and response to radiotherapy (Sagar
et al 1995; Peigen et al 1996). Other herbs may
directly sensitise neoplastic
cells to radiotherapy (Huali et al 1994). More
clinical trials need to be done to further evaluate this promising role of
herbs, and tumour blood flow needs to be monitored
using non-invasive techniques such as functional magnetic resonance imaging and
positron emission tomography (Sagar et al 1993).
Acupuncture. The interaction of acupuncture with appropriate
acupoints modulates blood flow (Thomas et al 1992;
Zhou et al 1995; Stener-Victorin et al 1996; Chao et al 1999). This may be through a local effect via
release of cytokines, or through neurological reflexes that adjust the balance
between the sympathetic and parasympathetic nervous systems. Its effect on tumour physiology and response to therapy remains to be
investigated. However, we do know that electric pulses to the tumour can increase the response to chemotherapy. A phase
II study of electro-chemotherapy using cisplatin in
patients with skin nodules from malignant melanoma demonstrated a significantly
increased control rate compared with cisplatin alone
(Sersa et al 2000). However, the effect of
acupuncture may be more diverse through the promotion of local cytokines at
physiological levels.
Enhancement of
Immunity
Herbs. Another strategy that TCM uses in cancer therapy is to strengthen
the whole body-mind system by enhancing and harmonising
the energy balance between all the organs. This may be viewed as correcting an
imbalance in the body-mind communication network and is reflected by an
enhancement in immunity. This is called Fu Zheng
treatment and is mediated by the specific group of TCM herbs called Fu Zheng herbs (Ning et al 1988;
Ling et al 1989; Chen 1990; Yu et al 1990; Hou et al
1991; Rao et al 1991; Li 1992; Yu et al 1993; Cao et al 1994; Cheng 1994; Horie
et al 1994; Lin et al 1995). There is some limited evidence that improvement of
the immunological function of cancer patients is associated with an improvement
in their survival. In
Fu Zheng herbs, including Rx ginseng, ganoderma, Rx astragali membranaceus, Rx angelicae sinensis, Cordyceps sinensis and Fructus
lycii, have been shown to enhance the body's defence mechanisms. Clinical studies, including two randomised trials, have found that the NK and OKT4
(immune-enhancing
lymphocyte) cell counts were increased with the use of Fu Zheng
herbs (Ning et al 1988; Ling et al 1989; Chen 1990;
Yu et al 1990; Hou et al 1991; Rao
et al 1991; Li 1992; Yu et al 1993; Cao et al 1994;
Cheng 1994; Horie et al 1994; Lin et al 1995). These immunocytes are known to attack cancer cells. In a study of
gastric cancer patients, increased survival was found in the combined treatment
group receiving both Fu Zheng herbs and chemotherapy
versus the group receiving chemotherapy alone. Many of these herbs are
associated with an increase in cytokines, such as interferon and interleukin (Kawakita et al 1990; Jin et al 1994; Feng
et al 1995). Chinese studies also suggest that healing of normal tissues may be
enhanced. Anti-inflammatory constituents may diminish radiation-induced ulcers
and chemotherapy-induced stomatitis (Zhu and Zhang
1993; Zhu 1994). However, these studies still need to be verified in the West,
using acceptable standards and quality assurance.
Acupuncture. Multiple animal and clinical studies have also
suggested that acupuncture has a positive immune-modulating effect in cancer
patients (Bianchi et al 1991; Yuan and Zhou 1993; Wu et al 1994; Yang et al
1994; Liu et al 1995; Wu 1995; Sato et al 1996; Wu B et al 1996; Petti et al 1998; Zhou JQ et al 1999). In these studies,
acupuncture has been shown to increase T-lymphocyte proliferation, increase NK
cell activities, activate the complement system and heat-stable mitogenic humoral factor, and
increase OKT4 cell counts. Inhibition of the growth of transplanted mammary
cancer has also been shown in mice with the use of acupuncture. The main acupoints that were used in these studies were those that
support blood formation and spleen function. These points include LI-4, LI-11,
St-36, Sp-6, Sp-10, P-6, UB-20, GB-39 and GV-14. An increased level of all
components (red blood cells, white blood cells and platelets) was found.
Hormonal Effects
Some Chinese
herbs inhibit hormone-responsive tumour cells.
PC-SPES is a combination of herbs with oestrogenic
activity associated with activity against prostate cancer (DiPaola
et al 1998). This study correlated laboratory activity with clinical response.
On the basis of these findings, a National Cancer Institute randomised,
controlled trial was initiated. Unfortunately, the clinical trial has been
temporarily halted when a batch of PC-SPES was contaminated with the hormone stilboestrol and other pharmacological substances. It is
not certain whether there was deliberate adulteration, accidental contamination
or a biochemical cross-reaction with natural constituents.
Acupuncture may
stimulate levels of steroids and other hormones, such as melatonin, somatostatin and vasoactive
intestinal peptide, which could potentially have antitumour
effects (Massion et al 1995; Zhang et al 1997; Zhang
et al 1999). Exposure of the popliteal fossa (over the bladder meridian) to bright light modulates
the circadian release of melatonin from the pineal gland (Campbell and Murphy
1998).
Cancer Prevention
TCM also emphasises appropriate nutrition according to specific
constitutional and disease patterns. Green tea (Camellia sinensis)
and Panax ginseng are two dietary
supplements that have been extensively investigated both in the laboratory and
in epidemiological studies. Both reduce the risk of cancer induction, and both
may prevent cancer recurrence (Yang and Wang 1993; Kaegi
1998; Yun and Choi 1998).
Green tea
contains isoflavones and a powerful antioxidant
called epigallocatechin (EGC) (McKenna et al 2000).
The latter may potentiate the destruction of cancer
cells through the process of apoptosis (natural programmed cell death) and by
inhibiting angiogenesis (new blood vessel formation that enhances tumour growth and metastasis) (Cao
and Cao 1999; Fujiki et al
1999). Panax ginseng may induce the
differentiation of neoplastic cells into normal
tissue (Lee et al 1996). Both EGC and ginseng appear to restore normal
intercellular communication through the gap junctions (Kang et al 2000), and
both dietary supplements seem to work through novel mechanisms of signalling and communication through the body-mind network.
The soy bean
contains genistein, which is an isoflavone
with multiple anticancer effects demonstrated in the laboratory (Boik 1996). These include the induction of tumour cell death through the process of apoptosis,
inhibition of cancer cell proliferation through decreasing the availability of
sex hormones, inhibition of angiogenesis, inhibition of tyrosine kinase (involved in intracellular signalling
from the membrane to the nucleus) and inhibition of platelet aggregation (Kim
et al 1998; Li, Bhuiyan and Sarkar
1999; Li, Upadhyay et al 1999). Some epidemiological
studies suggest that populations with a high soy or tofu content in their diet
may have a reduced risk of breast cancer (Wu AH et al 1996; Witte et al 1997;
Lu et al 2000), whereas other studies cannot confirm this link (Key et al
1999). The phytoestrogens contained within soy may
reduce the symptoms of hot flushes associated with chemotherapy-induced
menopause (Scambia et al 2000), although not all
studies support this (Quella et al 2000). The isoflavones and phytoestrogens in
soy also appear to reduce the incidence of prostate cancer, and may play a role
in prevention and as an adjunctive therapy to reduce the risk of recurrence
(Jacobsen et al 1998; Kamat and Lamm
1999; Moyad 1999; Stephens 1999; Adlercreutz
et al 2000). Cell culture and animal xenograft
studies show that treatment with soy is associated with inhibition of
prostate-specific antigen, activation of NF-kappa B (a nuclear transcription
factor), induction of apoptosis and inhibition of angiogenesis (Aronson et al
1999; Davis et al 1999; Zhou JR et al 1999; Davis et al 2000).
TCM herb combinations may reduce the risk of lung cancer in
ex-smokers. A National Cancer Institute-sponsored study through the British
Columbia Cancer Agency, led by Dr Stephen Lam, is recruiting 100 participants
aged 45-74 years, who are ex-smokers, to evaluate the efficacy of a herbal combination called Anti-Cancer Preventive Health
Agent (ACAPHA) (Lam S 2003, pers comm).
This contains Sophora tonkinensis,
Polygonum bistorta,
Prunella vulgaris,
Sonchus brachyotus,
Dictamnus dasycarpus
and Dioscorea bulbifera.
In Chinese studies, ACAPHA reduced the risk of oesophageal
cancer by 50% through reversing severe oesophageal dysplasia. In addition, a pilot study of 20 former heavy
smokers with bronchial dysplasia treated with ACAPHA
showed that after 6 months 50% had complete regression of dysplasia,
compared with only 13% in the placebo group.
Psychoneuroimmunology is a scientific
discipline that has produced evidence for a dynamic mutual interaction between
the mind, nervous system, endocrine system and immunity. The interaction of
emotions and immunocytes through molecules, such as neuropeptides, is now well recognised.
In fact, the immune system can be viewed as a complex evolutionary
communication system within the body-mind network (Page and Ben-Eliyahu 1997; Jessop 1998; Nutt
1998; Pert et al 1998; Rabin 1999). TCM recognises
this complex interaction between personality, mood states and susceptibility to
illness through malfunction of the body-mind network.
There is
accumulating evidence that psychological function is linked with outcomes in
cancer patients (Shekelle et al 1981; Levy and Wise
1987; Ramirez et al 1989; Orsi et al 1996; Andersen
et al 1998; Watson et al 1999). There is evidence to suggest a link between
mood disorders and function of the immune system. Indeed, the experience of
pain and suffering is intimately connected to immunity. A mood disorder such as
helplessness and hopelessness may lead to a depressed immune system. Treatment
of depression and feelings of hopelessness may not only increase quality of
life, but also increase survival (Spiegel et al 1989; Fawzy
et al 1995; Fawzy 1999). In a cancer practice, 50% of
patients suffer from clinically recognised
depression. In 15% of these patients, the degree of depression is severe.
Therefore treatment of depression is an important intervention in the
management of the body-mind network of cancer patients.
Conventionally, clinical depression is treated with oral
medication, such as amitriptyline or the newer
serotonin reuptake inhibitor drugs. Studies indicate that acupuncture treatment
may be an equally effective alternative treatment modality to drugs in patients
with mild depression. In one study, the profile of side effects associated with
acupuncture treatment was shown to be better than that with amitriptyline
(Han 1986). In a single-blind, placebo-controlled study of the antidepressant mianserin, supplementary acupuncture improved the course of
depression more than pharmacological treatment with the drug alone (Roschke et al 2000). Since pharmaceutical antidepressants
are not usually effective until 2 weeks after starting therapy, their
combination with acupuncture may enable more rapid results with fewer side
effects.
Symptom Control
Cancer patients
experience multiple symptoms related either to the cancer itself or to late
treatment side effects. Even if a patient's cancer were clinically 'cured', the
person may still be suffering from late treatment side effects. For example,
radiation may cause xerostomia, trismus
and skin ulceration. These side effects have an adverse effect on quality of
life and are often not effectively managed by conventional Western medicine.
Chinese medicine
plays a useful role in symptom supportive care for cancer patients. Symptoms
that can be effectively managed include general constitutional symptoms, such
as fatigue and depression, pain and specific symptoms such as gastrointestinal
side effects and myelosuppression.
Cancer patients
receiving chemotherapy usually develop myelosuppression
(with risk of infection and bleeding) and gastrointestinal side effects
(nausea, vomiting and diarrhoea). They easily become
fatigued and develop a reduced appetite. In TCM terms, the chemotherapeutic
agents are causing spleen and kidney deficiency, leading to a general decrease
in qi and blood. Radiotherapy and chemotherapy act as
'heat toxins' that damage the yin and qi. 'Heart
fire' is expressed as stomatitis; 'deficient spleen qi' is manifest as diarrhoea.
Chemotherapy drugs 'disturb spleen and stomach qi',
expressed physically as damage to the lining of the stomach and intestines (
Herbs. Spleen and stomach qi are supported by
appropriate formulas containing Rx ginseng, poria and
Rh atractylodis macrocephala (
At least five randomised, controlled trials have shown that Chinese
herbal treatment can decrease the degree of myelosuppression,
reduce gastrointestinal side effects and increase the patient's appetite (Ning et al 1988; Ling et al 1989; Chen 1990; Wang 1990; Yu
et al 1990; Hou et al 1991; Rao
et al 1991; Li 1992; Yu et al 1993; Cao et al 1994;
Cheng 1994; Horie et al 1994; Lin et al 1995).
Importantly, it can also increase the probability of patients completing the
scheduled chemotherapy. One randomised trial
recruited 669 patients with late-stage gastric cancer (Yu et al 1993). One
group of patients was treated with herbs that support the spleen and kidney
function (Jian Pi Yi Shen
prescription) twice daily for 4-6 weeks with concurrent chemotherapy, while
another group was treated with the same type of chemotherapy alone. The
combined treatment group showed significantly higher leucocyte
and platelet counts with fewer general and gastrointestinal side effects. The
percentage of patients completing the scheduled chemotherapy was 95% in the
combined treatment group versus 74% in the group receiving chemotherapy alone
(p < 0.01). Unfortunately, the quality and verification of the data from
these studies, which were reported from
In TCM, systemic
Chinese herbal treatments and topical herbal applications appear to be
effective in treating cancer-related pain. In one study, the effectiveness in
pain control was shown to be over 90% (Yang et al 1995).
Ginger root has
been shown in many clinical studies to have antiemetic
activity (Mowrey and Clayson
1982; Grontved and Hentzer
1986; Grontved et al 1988; Bone et al 1990;
Fischer-Rasmussen et al 1991). It appears to particularly help nausea that may
be intransigent to standard antiemetics. Ginger syrup
was shown to be effective in a randomised controlled
trial (Keating and Chez 2002). Caution should be used
with patients on anticoagulants and those with low platelet levels, since it
does have anticoagulant effects at higher doses.
Vitexina (Vigna radiata) is a
flavonoid herb with radio-protective effects that may
be useful for reducing some side effects of radiotherapy. It treats the heat or
yin-deficiency side effects of anticancer treatment, such as fatigue,
restlessness, insomnia and constipation. This empty heat syndrome is characterised through tongue diagnosis, which reveals a
red, denuded and cracked tongue. Since the tongue is the most densely innervated
organ in the body, it may reflect the imbalance between yin and yang, via the
autonomic nervous system, which in turn may influence blood flow and epithelial
cell turnover through the local release of neuropeptides
and cytokines. A randomised controlled trial of
breast cancer patients receiving radiotherapy showed that vitexina
prevented the empty heat syndrome, reduced weight loss and protected against a
reduction in peripheral lymphocytes and platelets (Tran 2002).
The role of
Chinese herbs, together with conventional Western pharmaceuticals, for symptom
control is currently unclear. Laboratory data suggest that they can be
effective modifiers of biochemical pathways, immunostimulants
and signal transduction modulators. Potential detrimental interactions and
idiosyncratic toxicity are possible. Future studies need to be done using more
rigorous methodology and quality assurance. The use of appropriate modelling and suitable evaluative methodologies should
enable the integration of Chinese herbology into an
emerging model of holistic Western medicine.
Acupuncture. Acupuncture treatment at acupoint
P-6 has been shown to increase the antiemetic effect
of drugs for perioperative and chemotherapy-induced
nausea and vomiting (Dundee et al 1986; Dundee et al 1989). Innovative randomised, single-blind, controlled trials have since
confirmed these results (Al-Sadi et al 1997; Schlager et al 1998; Lee and Done 1999) and led to the
National Institutes of Health (US) consensus statement that, 'acupuncture is a
proven effective treatment modality for nausea and vomiting' (NIH Consensus
Development Panel on Acupuncture 1998). Stimulation of P-6 may be done more
conveniently with a small transcutaneous electrical
nerve stimulation (TENS) device, such as the Reliefband™,
which is worn like a wrist watch. A three-arm randomised,
controlled trial of conventional modern antiemetics
(such as the serotonin 5-HT3 antagonists), versus
electro-acupuncture, versus the combination of antiemetic
drugs plus acupuncture clearly demonstrated that the combination arm was the
most effective for preventing nausea and vomiting (Shen
et al 2000).
Pain is a common
symptom of cancer. Causes of pain can be disease- or
treatment-related. Acupuncture has been shown to be effective in
managing pain and other symptoms in cancer patients (Thompson and Filshie 1998). In a retrospective study from the
Some patients may
not be able to access an acupuncturist because of geographic restrictions or
poor performance status. In addition, some patients may not tolerate needle
insertions. For these patients, a TENS has the advantage of easy administration
by patients or staff with minimal basic training. Recently, acupuncture-like
TENS (AL-TENS) devices have been developed to mimic the treatment of acupuncture
using low-frequency (eg 4 Hz), high-intensity
stimulation (Pomeranz and Niznik
1987). The goal is to recruit the high threshold type III afferent nerve fibres which are potent releasers of endorphins. Recent
meta-analyses (including a Cochrane Database systematic review) have shown that
AL-TENS is more effective than placebo, and improves function more than
standard TENS, when treating chronic pain (Patel et al 1989; Gadsby and Flowerdew 1997; Ernst
and White 1998; Ghoname et al 1999). AL-TENS devices are
very simple machines that patients can learn to operate in less than an hour's
training. An acupoint prescription may then be given
to the patient, who can administer the appropriate treatments with AL-TENS at
home. The Codetron™ is a sophisticated AL-TENS device
that has the advantage of reducing tolerance to its analgesic effect, by
electronically rotating through a series of random electrical stimulation
patterns and acupoint locations.
At the
Other symptoms
that may be helped by acupuncture include constipation, trismus
(post-radiotherapy contracture of the masseter
muscle) (Ernst and White 1999), breathlessness (Filshie
et al 1996), radiotherapy-associated proctitis (Zhang
1987), hiccups (Yan 1988), persistent yawning (Wong
and Sagar 2000) and dysphagia
secondary to an oesophageal neoplasm (Feng 1984). Suppression of anxiety by acupuncture may be
associated with an increase in the pain threshold (Widerstrom-Noga
et al 1998). Acupuncture may also play a role in the treatment of fatigue and
malignant cachexia through the modulation of
cytokines and hormones (Lissoni et al 1996; Campbell
and Murphy 1998; Glaus 1998; Stone et al 1998).
Patients who are
in remission from their cancer may still continue to experience late treatment
side effects with reduced quality of life. Radiation-induced xerostomia (dry mouth) is one of the distressing late side
effects seen in patients who received radiation treatment that involved the
parotid glands. The presence of this condition renders patients with loss of
taste and difficulty in speaking and swallowing. Recently, acupuncture
treatment has been found to increase blood flow to the parotid glands and may
stimulate tissue regeneration in parotid glands damaged by radiotherapy (Blom et al 1992; Talal et al
1992; Blom et al 1993). A randomised
controlled trial of 38 patients with radiation xerostomia
was reported from the Karolinska Institute in
At the Hamilton
Regional Cancer Centre (
Acupuncture can reduce the hot flushes associated with anticancer
hormone therapy. Three prospective, uncontrolled cohort studies have been done,
one in men castrated for prostate cancer, and two others in women taking tamoxifen for breast cancer. They all demonstrated a
reduction in vasomotor symptoms (Hammar et al 1999; Tukmachi 2000; Cumins and Brunt
2001).
Conclusions
There is emerging
scientific evidence that Chinese medicine can play an important role in the
supportive care of cancer patients. There is enough preliminary evidence to
encourage good quality clinical trials to evaluate the efficacy of integrating
Chinese medicine into Western cancer care (Fontanarosa
and Lundberg 1998; Sagar 1998; Sagar
1999; Tagliaferri et al 2001). Currently, the
evidence for the utility of TCM in cancer care is promising, but prospective randomised clinical trials for specific clinical scenarios
are necessary to obtain reliable and generalisable
data. Appropriate stratification and individualisation
according to TCM diagnostic criteria is possible within the context of a randomised, controlled trial (Bensoussan
et al 1998). We believe that an evidence-based approach can be integrated into
an individualised therapeutic plan and that there is
still a major role for individual belief systems and psychospiritual
experience. Assessment and measurement of coping strategies, maintenance of
function, quality of life and patient satisfaction is important. We are hopeful
that future integration of different models of health, such as TCM, may lead to
further improvement of cancer patients' survival and quality of life (Sagar 2001).
Acknowledgements
Christina
M Garchinski for organising
references.