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Seminars in Oncology Nursing, Vol 28, No 1 (February), 2012: pp 64-74
TRADITIONAL CHINESE
MEDICINE FOR
CANCER-RELATED SYMPTOMS
MARY ELIZABETH SMITH AND SUSAN BAUER-WU
OBJECTIVE: To familiarize oncology nurses about the theory and research
related to Traditional Chinese Medicine (TCM) for management of cancerrelated symptoms.
DATA SOURCES: Peer-reviewed journal articles, TCM texts, professional
experience.
CONCLUSION: The increasing integration of TCM into mainstream medicine
mandates that oncology professionals be familiar with the benefits as well as
risks. Clinical research on acupuncture in cancer care is growing and
demonstrates it is safe for cancer patients, although results on efficacy across
symptoms have been mixed.
IMPLICATIONS
FOR
NURSING PRACTICE: Informed oncology nurses can assist
patients by making appropriate referrals to licensed acupuncturists and
qualified TCM practitioners to help alleviate unpleasant symptoms
associated with cancer and conventional cancer treatment.
KEY WORDS: Acupuncture, Traditional Chinese Medicine, cancer, Qi
RADITIONAL Chinese Medicine (TCM)
is based on the understanding that the
body has an innate intelligence and
healing ability. It is a whole system of
medicine that integrates many therapies and is
applied by practitioners to prevent and treat
illness or disease. It uses acupuncture and herbal
T
medicine to help balance and regulate the flow of
‘‘Qi,’’ a person’s vital energy force, therefore
enhancing the body’s healing process.1 In this
medical system, illness is caused because of an
improper flow of this vital energy force.
With its 2,500 to 5,000 year tradition of use,
TCM is one of the oldest, continuously used
Mary Elizabeth Smith, RN, DOM: Director of Chinese
Medicine Services, UNM Center for Life, University of
New Mexico, Department of Internal Medicine, Albuquerque, NM. Susan Bauer-Wu, PhD, RN, FAAN: Associate Professor, Nell Hodgson Woodruff School of
Nursing, Emory University, Atlanta, GA.
Address correspondence to Mary Elizabeth Smith,
RN, DOM, UNM Center for Life, 4700 Jefferson NE, Suite
100, Albuquerque, NM 87109. e-mail: mesmith@salud.
unm.edu
Ó 2012 Elsevier Inc. All rights reserved.
0749-2081/2801-$36.00/0.
doi:10.1016/j.soncn.2011.11.007
TRADITIONAL CHINESE MEDICINE FOR CANCER-RELATED SYMPTOMS
systems of medicine known to mankind. In China,
it has been used as the primary health care system
for thousands of years and most recently has been
used in combination with Western medicine to
treat a variety of conditions. TCM consists of six
primary branches that offer a holistic approach
to lifestyle and health care: 1) acupuncture, 2)
herbal medicine, 3) massage (tuina), 4) exercise
(Tai Chi, taiji, Qigong), 5) dietary therapy, and 6)
lifestyle modifications.1 Growing evidence shows
that TCM can be used safely and as a helpful
adjunct to conventional care in the treatment of
cancer-related symptoms. This article will provide
an overview of the theory guiding TCM, describe
research of TCM for cancer-related symptoms
focusing on three branches of TCM (acupuncture,
Chinese herbal medicine, and exercise [Tai Chi]),
provide an example of a TCM practitioner’s case
example, and describe practical suggestions for
oncology nurses related to TCM practitioner qualifications, cost, and insurance coverage.
COMPARISON OF TCM AND CONVENTIONAL
MEDICINE
There are several factors that distinguish TCM
from conventional medicine. TCM focuses on
a global holistic view of a person. It encompasses
the physical, emotional, social, and spiritual
aspects that can influence health and illness. In
TCM, signs and symptoms are pieced together to
form a ‘‘pattern of disharmony’’ within the entire
human body. This process takes into consideration the whole pattern presented by the patient,
giving equal importance to the body, emotions,
mind, and spirit. Conventional medicine has the
ability to view and treat each system of the human
body with intense focus and accuracy. TCM
synthesizes a number of factors that lead to imbalance: internal factors such as stress, nutritional,
emotional, sexual, and lifestyle factors, as well as
external factors relating to the daily external environment including wind, dampness, heat, dryness,
and cold.1 If the person is able to maintain a state
of internal balance, they are less likely to contract
illness or pain from either internal or external
factors. TCM puts a premium on assisting the
body to achieve and maintain this balance. In
conventional medicine, illness, disease and symptoms are often treated pharmacologically or surgically. The combination of both approaches often
provides optimal results.
65
Treatment with TCM is not disease-oriented,
but strategy-oriented based on the underlying
cause. The cause is determined by accompanying
signs and symptoms, strength of the patient,
strength of any pathogenic influence, root and
secondary symptoms, location of pain (in terms
of body organs and channels affected) and
whether the symptom is acute or chronic.1
BASIC CONCEPTS OF TCM
Yin and Yang
The principle of yin and yang is one of the most
important concepts in TCM. Yin and yang express
polar complements that exist in relationship to
each other and represent essential parts of a whole.
Neither yin nor yang can exist without the other.
Each supports the other and depends on the other
for existence. Everything in the cosmos has both
yin and yang aspects in constant motion. The Taiji
symbol or the great polarity is balanced black and
white. The black represents yin and the white
represents yang. Yang always includes a seed of
yin and yin always includes a seed of yang.
In a pain-free healthy body, yin and yang are
balanced and in harmony. Because of the everchanging influence of internal and external
factors, the balance of yin and yang can shift.
The treatment goal is to restore the equilibrium
of yin and yang.
According to TCM, health results from maintaining balance within the interior of the body
and the external environment and lifestyle factors
such as diet, exercise, sexual activity, habits, accident, trauma, and epidemic. In this paradigm,
disease, including cancer, is caused by an imbalance between the body and the environment or
within the internal landscape of the body (which
can also be genetic). TCM puts more importance
on maintaining this balance so that the body can
naturally resist disease rather than killing microorganisms that can make us ill.
The basic causes of disease can be internal or
external. External factors include climatic conditions of wind, cold, heat, summer heat, dampness,
and dryness. Internal factors include the emotional
landscape within a person. TCM focuses on seven
primary emotions that affect us: fear (normal and
adaptive human emotion), anger, joy, worry,
sadness, grief, and fright. Disease caused by
emotions often becomes chronic, injuring the
organs, Qi, and blood.1
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M.E. SMITH AND S. BAUER-WU
Pain, for example, can be associated with the
internal organs. The yin organs are the solid
organs that include the heart, liver, spleen, lung,
kidney, and pericardium. Their main function is
the manufacturing and storing of the vital essence:
Qi, blood, and body fluid. The yang organs are the
hollow organs. They receive and digest food,
absorb nutrition, and dispose of waste. The yang
organs include the small intestine, gall bladder,
stomach, large intestine, urinary bladder, and an
extra organ system called the ‘‘triple burner.’’1
The yin organs and the yang organs work together
as a unit. They are considered functional
complexes rather than just anatomical structures.
These organs systems transform and cycle in five
phases known as Wu Xing.
Wu Xing: The Five Phases of Transformation
The five phases of transformation, Wu Xing,
describes a cycle by which transformation happens
in the human body. The five phases are: water,
wood, fire, earth, and metal.1 Each phase corresponds to particular structures and functions in
the body, as well as emotions, spiritual qualities,
tissues, and life stages. Each stage also has a particular connection with aspects of the external world
such as a season of the year, climate, directions,
color, and taste.
The Channels or Meridians
Channels or meridians carry blood and Qi
through the body via an invisible network that
links fundamental structures, functions, and
organs of the body. Channel theory states that
a disorder within a particular channel affects the
course of the channel and the organ system associated with it.1 A disharmony in the organ likewise
affects the associated channel. For example,
a disharmony in the urinary bladder may manifest
in symptoms along the urinary bladder channel,
such as pain in the back.
The channels are regarded as 3-dimensional
passageways through which the Qi and blood
flow at different levels of the body. The channels
are bilateral. There are 14 major channels, each
containing a number of independent points, 12
of which correspond to the major yin-yang organs
of the body. These channels have continuous, interlinking patterns of circulation. The two additional major channels, the Conception Vessel
(along the front midline of the body) and the Governing Channel (along the backside of the body)
are part of the system of eight extra channels.
The eight extra channels do not fit the pattern
of the major channels. Rather, they serve as reservoirs, filling and emptying in response to the
varying conditions of the major channels and exerting a regulating effect on them.
Qi and Blood
Qi is the essence of everything in the universe.
It is the vital energy force in the human body.
Without it, there would be no existence, no life.
According to TCM, all things that exist, living
and nonliving, have Qi.1 Qi is considered yang
(as compared with blood) and is associated with
function, activity, and movement. In this system,
blood is more than the red fluid that runs through
our veins. Its primary function is to circulate
through the blood vessels and channels to nourish,
maintain, and moisten the body, while promoting
the functional activities of the organ systems and
tissues.1
Qi and blood are one of the most primary yinyang polarities in the human body. Qi (yang) is
necessary to move the blood. According to TCM,
blood (yin) is made from the Qi of food. Blood
nourishes the organs that produce and regulate
Qi. Clinically, a deficiency of Qi often leads to
a deficiency of blood and vice versa. Disharmonies
of blood (such as in blood cancers) can lead to deficient blood and/or stagnant blood. Both Qi and
blood deficiency/stagnation can cause pain.1
Diagnosing imbalances. Chinese medical
patterns of cancer have three specific diagnostic
similarities for the majority of cancer patients.1
These patterns are noted in stages.
Stage 1 – A yin-yang imbalance develops in the
body and usually involves several organ
systems.
Stage 2 – As the imbalance worsens, Qi and
blood are depleted and begin to stagnate.
Stage 3 – The communication and cooperation
among the organs (as related in the fiveelement cycle) deteriorates, the immune
response becomes impeded, the endocrine
system malfunctions, and the adaptive qualities
of the body deteriorate.
Diagnosing the imbalance or pattern of disharmony is key to encouraging health and healing
as well as identifying the stage.
There are specific diagnostic tools used in
TCM.1 A diagnosis is made by observing, listening,
smelling, palpating, and asking the patient about
TRADITIONAL CHINESE MEDICINE FOR CANCER-RELATED SYMPTOMS
all symptoms including emotions, onset of symptoms, time of day or year that symptoms become
worse, and medical history. Specific questions
will provide information on: what improves or
worsens the pain, chills, fever, perspiration, eating
and drinking, appetite, taste, bowel movements,
urination, pain location and quality, sleep, sexual
function/desire, and menstruation. These questions assist in acquiring the whole picture of the
pattern of disharmony.
An additional palpation tool in TCM is pulse
diagnosis. A rapid pulse typically means heat,
slow pulse means cold, strong pulse means excess,
weak pulse means deficiency, and floating pulse
means external condition such as cold or flu.
Tongue diagnosis is a tool used by the practitioner to observe the shape, color, and condition
of the tongue body and coating. A healthy tongue
has no restrictions in movement, is light pink in
color, thin white coat, without being overly dry
or wet, and is not swollen or too thin. An
unhealthy tongue would be a deviation from the
healthy tongue. Some basic tongue diagnosis are
red tongue body ¼ heat; yellow tongue coating ¼
heat; pale tongue body ¼ cold and deficiency;
white tongue coating ¼ normal or cold; purplish
tongue body ¼ stagnation of Qi and/or blood;
and a thick or sticky tongue coating ¼ dampness,
phlegm, or food stagnation.1
Acupuncture
Acupuncture is a branch of TCM that modulates
neurological processes to bring about its effects.2,3
Acupuncture is a technique in which very tiny
needles of varying lengths are inserted through
the skin in specific locations called acupoints. To
restore balance and a healthy energy flow to the
body, needles are inserted into acupoints and left
in place for less than half an hour. The practitioner
may apply heat or a weak electrical current (electro-acupuncture) to enhance the effects of the
therapy. Auricular acupuncture is a method of
acupuncture that involves stimulating points on
the ear to obtain relieving benefits. Moxibustion
may also be used in conjunction with acupuncture. It uses the heat generated by burning herbal
preparations containing Artemisa vulgaris to
stimulate acupuncture points,1 and is helpful in
reducing side effects from chemotherapy.4 Additionally, acupressure may be used in place of
acupuncture, particularly because patients can
do it themselves. Acupressure works similarly to
acupuncture; however rather than needles,
67
finger-point pressure is placed on acupoints. In
general, acupuncture is well tolerated and significant adverse effects are rare.5-8 Research on the
use of acupuncture for management and prevention of cancer symptoms is increasing. To date,
studies have addressed the safety and effectiveness of acupuncture for cancer-related pain, hot
flashes, nausea and vomiting, xerostomia, lymphedema, as well as other symptoms. See Table 1.
Pain. A number of studies have evaluated the
effectiveness of acupuncture on cancer-related
pain.9-14 In a recent Cochrane Review paper on
this topic,11 three randomized controlled trials
(RCTs) were identified and included in the analysis. While all three studies revealed lower selfreported pain during and up to 2 months after
acupuncture treatments, the authors concluded
that there is insufficient evidence and results
need to be viewed with caution because of methodologic limitations. In one of the studies Alimi
et al10 conducted a randomized, blinded, controlled trial of auricular (ear) acupuncture in
cancer patients experiencing neuropathic pain
(N ¼ 90). Three groups were assessed, one treatment (acupuncture, n ¼ 29) and two control
(placebo auricular acupuncture, n ¼ 30 and
placebo auricular seeds, n ¼ 31), at baseline
(before the 1-month intervention period) and 30
and 60 days later. Using a visual analog score
(VAS), they noted that pain intensity significantly
decreased in the acupuncture group at day 30
(P ¼ .02) and day 60 (P <.001) compared with
both of the placebo groups. Similarly, positive
findings were also demonstrated in a small, uncontrolled pilot study with cancer patients experiencing pain caused by bone metastasis (N ¼ 5).14
Paley and Johnson14 found that a single acupuncture treatment reduced mean pain scores from 4.3
(on a numerical rating scale) before treatment to
0.8 immediately after, which increased to 3.2
at 48 hours after the acupuncture treatment.
In contrast, Deng et al9 failed to show any difference in reducing pain after cancer surgery
between a special acupuncture technique (delivered preoperatively with implanted needles that
were retained for 4weeks) and sham (placebo)
acupuncture in a well-designed study of cancer
patients undergoing thoracotomy (N ¼ 162). In
summary, several studies have been conducted
on acupuncture for cancer-related pain with
mixed results. Many of the studies are methodologically flawed. Research to date has used
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M.E. SMITH AND S. BAUER-WU
TABLE 1.
Summary of Research on Acupuncture for Different Cancer-Related Symptoms
Symptom
Substantiality of Evidence
Summary of Findings and Comments
Pain
Several studies including some with
high-quality designs
Nausea and vomiting
Several studies including some with
high-quality designs
Hot flashes
Xerostomia
Several studies with both breast
and prostate cancer patients.
More high-quality studies done
with breast cancer patients
A few studies including some RCT
Mixed. Some studies demonstrate
reduction in pain after acupuncture and
some do not. Different acupuncture
techniques used. Different types of
cancer pain evaluated
Mixed. Traditional acupuncture appears
to be helpful in alleviating acute
vomiting and acupressure helpful for
acute nausea. Acupuncture does not
seem to be any more effective than
sham in preventing or controlling
delayed nausea and vomiting
Generally positive in both breast and
prostate cancer patients
Lymphedema
Two small pilot studies
Other: General health-related
quality of life, anxiety, depressed
mood, sleep, and fatigue
Small and/or uncontrolled
different acupuncture techniques and included
patients with different types of cancer-related
pain. Therefore, it is difficult to draw conclusions
on the benefits of acupuncture for cancer patients
experiencing pain.
Nausea and vomiting. A fairly substantial
evidence base exists on the use of acupuncture
for chemotherapy-induced nausea and vomiting.
In a Cochrane Review report15 consisting of 11
studies compiled until 2006, differential effects
were found depending on the technique and the
specific symptom (ie, nausea vs. vomiting, acute
vs. delayed). In this meta-analysis including a total
of 1,247 cancer patients, they found electroacupuncture to be effective for reducing the incidence
of acute emesis, but not severity of acute emesis
or delayed nausea. They also found that acupressure reduced acute nausea, but not delayed
nausea or acute or delayed emesis. Furthermore,
they determined that noninvasive electrostimulation was not effective for either nausea or vomiting. Regarding the use of acupuncture for
radiation-induced nausea, Enblom et al16 conducted a large RCT of cancer patients receiving
Promising for electroacupuncture,
although studies have had small
sample sizes
Promising findings, although uncontrolled
studies with very small sample sizes
Promising findings for mood, arthralgias,
sleep, and neuropathy. Studies are
limited by methodologic flaws and small
sample sizes
abdominal/pelvic irradiation. Participants were
randomized to either acupuncture (n ¼ 109) or
sham (n ¼ 106), for which they received two to
three treatments each week during radiation
therapy. Acupuncture was found to be no more
effective than sham in reducing incidence of
radiation-induced nausea. In summary, acupuncture and acupressure are associated with diminished chemotherapy-induced acute vomiting and
acute nausea, respectively, across a number of
studies, but no effect was found on radiationinduced nausea in one well-designed study.
Hot flashes. Several studies have assessed the
effects of acupuncture in reducing cancer
treatment-related hot flashes in both women
with breast cancer and men with prostate cancer.
Walker et al17 conducted an impressive RCT,
comparing acupuncture with venlafaxine in
hormone receptor-positive breast cancer patients
(N ¼ 50, 25 per group). After 12 weeks of treatment, both groups had significant improvements
as measured by reduced hot flashes and depressive
symptoms and enhanced quality of life. Two weeks
after the treatments were completed, the
TRADITIONAL CHINESE MEDICINE FOR CANCER-RELATED SYMPTOMS
venlafaxine group had significant increase in hot
flashes, which was not observed in the acupuncture group. The medication was also associated
with 18 incidences of adverse effects, while none
for acupuncture. Frisk et al18 conducted a similarly
designed study with breast cancer survivors,
comparing acupuncture with HRT. Forty-five
women were randomized to either acupuncture
for 12 weeks or HRT for 24 months. (Note that
this study was conducted when HRT was an
acceptable treatment, which it is not now.) Both
groups demonstrated improvements with reduced
number of and distress from hot flashes and
increased number of hours slept and levels of
general well-being after the intervention periods,
although the acupuncture group did not demonstrate as large decrease in the number of hot
flashes as the comparison group.
In another RCT, Deng et al19 assessed hot flash
frequency in women with breast cancer experiencing three or more hot flashes per day (N ¼
72). They were randomly assigned to receive
either true or sham acupuncture, both delivered
twice weekly for 4 consecutive weeks; those assigned to the sham group were crossed over to
receive true acupuncture beginning at week 7.
Number of hot flashes was evaluated at baseline,
at 6 weeks, and after 6 months. At 6 weeks, both
groups had reduced frequency of hot flashes,
with the true acupuncture group decreasing from
8.7 (standard deviation [SD], 3.9) to 6.2 (SD,
4.2) and the sham group from 10.0 (SD, 6.1) to
7.6 (SD, 5.7), which was not statistically significant. After the sham acupuncture participants
were crossed over to true acupuncture, further
reductions were observed. Both groups demonstrated persistent reduction in the number of hot
flashes for up to 6 months after the completion
of true acupuncture treatment. Finally, in breast
cancer patients (N ¼ 50) experiencing hot flashes
while on treatment with tamoxifen, a single-arm,
pre-post study found a 49.8% decrease in the
mean frequency of hot flashes and improvements
in health-related quality-of-life symptoms from
baseline to end of eight acupuncture treatments.20
Regarding men with prostate cancer, a systematic review identified six studies evaluating
acupuncture for treatment of hot flashes.21 Of
these, five were observational and one was an
RCT. The uncontrolled studies identified consistent improvements in the number and severity of
hot flashes; however, all of these studies have
notable methodologic limitations. In the one
69
RCT, Frisk et al22 compared 12 weeks of electroacupuncture with traditional acupuncture (N ¼ 29)
and found statistically significant within-group
differences from baseline to end of treatment,
from a median of 7.6 to 4.1 in the electroacupuncture group (P ¼ .012) and 5.7 to 3.4 in the traditional acupuncture group (P ¼ .001). Distress
decreased in both groups. Both groups demonstrated lasting effects up to 9 months after completion of treatment and minimal side effects. In
summary, evidence to date demonstrates positive
effects of acupuncture in the treatment of hot
flashes in men with prostate cancer.
Xerostomia. Studies have investigated the
effectiveness of acupuncture in the alleviation of
dry mouth and dysfunction in head and neck
cancer patients treated with radiation therapy.
O’Sullivan and Higginson5 conducted a systematic review on this topic and identified three
RCTs, two comparing true acupuncture to sham
acupuncture and one compared with usual clinical
care. While all three of these trials demonstrated
benefits, authors of the systematic review noted
that evidence is too limited to draw conclusions.
Pfister et al23 conducted a RCT comparing
acupuncture (weekly for 4 weeks) to usual care
over the same period of time. Fifty-eight patients
with head and neck cancer (28 in acupuncture
group and 30 in control group) completed selfreport measures of xerostomia and a composite
measure of pain, function, and activities of daily
living (called the Constant-Murley score). They
found significant improvements in the acupuncture group compared with control for xerostomia
(P ¼ .02) and the composite score (P ¼ .008).
Another randomized, controlled study evaluated
the effects of preventive acupuncture during radiation therapy for patients with head and neck
cancer and found significant improvements in biological salivary flow (P <.001) and self-reported
and dry mouth (P <.05) in patients who received
acupuncture compared with controls.24 Additionally, one study tested ‘‘acupuncture-like transcutaneous electrical nerve stimulation’’ (ALTENS)
delivered daily throughout the course of radiotherapy. They measured saliva production and
subjective ratings of dry mouth in 56 head and
neck cancer patients (30 intervention, 26 usual
care control) and found no differences between
groups at 3 months after completion of treatment.
While the number and methods of studies are
limited, true acupuncture seems to be a promising
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M.E. SMITH AND S. BAUER-WU
treatment for radiation-induced xerostomia in
patients with head and neck cancer. The one
study of a noninvasive, ‘‘acupuncture-like’’ treatment suggests that is not a beneficial approach.
Lymphedema. Two small studies have been
identified on the use of acupuncture for management of lymphedema. Cassileth et al25 evaluated
the safety and feasibility of acupuncture in nine
women with chronic lymphedema after breast
cancer surgery. All participants received acupuncture twice weekly for 4 weeks. They found that
44% (4/9) of the women had >30% reduction in
size difference affected and unaffected arms at 4
weeks compared with baseline, and no serious
adverse effects. The other study, by de Valois
et al,26 used mixed methods to evaluate effectiveness of acupuncture (seven weekly individualized
treatments and six optional) in breast (n ¼ 37)
and head and neck cancer (n ¼ 8) patients. The
main study variable was an instrument called
‘‘Measure Yourself Medical Outcome Profile’’ (MYMOP), whereby participants identify and rate their
most troublesome symptoms. Significant improvements (P <.0001) in MYMOP were identified after
the acupuncture treatment periods in both breast
and head and neck cancer patients, and in function (SF-36) in breast cancer only at 4 weeks after,
not at 12 weeks. In summary, research on
acupuncture for lymphedema is extremely
limited. Two pilot studies had promising results
that warrant additional research in this area.
General symptoms and health-related quality
of life. Studies have addressed the effects of
acupuncture on other cancer-related symptoms,
such as mood, arthralgias, neuropathy, sleep, and
fatigue. Feng et al27 conducted an RCT of acupuncture (n ¼ 40) versus the antidepressant medication
fluoxetine (n ¼ 40) using validated instruments for
self-reported depressive symptoms and sleep.
They found that the acupuncture group had significantly lower depressed mood (P <.05) and better
sleep quality (P <.01) after treatment compared
with the group receiving the antidepressant medication. A well-designed (randomized and blinded)
study compared true acupuncture with sham
intervention for treatment of arthralgias for postmenopausal breast cancer patients receiving aromatase inhibitors.28 After 6 weeks of treatment
(twice each week), significant differences in joint
pain-related scores were observed across all
measures with greater improvements in the
acupuncture group compared with sham, such as
lower worst pain scores (P <.001), and lesser
pain severity (P ¼ .003) and pain-related interference (P ¼ .002). In a small, single-arm pilot study
with 18 patients with mixed cancer diagnoses,
acupuncture was associated with improvements
in peripheral neuropathy and self-reported sleep
and decreased analgesia use.29 In a small, uncontrolled pilot study, patients with advanced ovarian
and breast cancer had statistically and clinically
significant improvements in anxiety, fatigue,
pain, depression, and life satisfaction after 8 weeks
of acupuncture treatments (12 treatments given
over 8 weeks), which were sustained at 12 weeks.30
In summary, the small studies have explored
acupuncture for other cancer-related symptoms,
and have identified promising findings in selfreport measures.
Chinese Herbal Medicine
Chinese herbal medicine focuses on restoring
the balance of energy, body, and spirit to maintain health rather than treating the cancer itself.
Herbs are used to restore balance by changing
abnormal patterns and by nourishing the body.1
Herbal medicine treats the underlying disharmony as well as patterns and symptoms and is
often used along with conventional cancer treatments. There are a variety of methods of administering TCM herbal treatments, including oral
administration,
topical/external
application
(particularly for pain), intravenous infusion, and
inhalation.1,31 Because of the variety and combination of herbs used in Chinese herbal medicine,
and shared mechanisms with prescribed drugs,
there is a potential for negative interactions
such as increased toxicity or diminished treatment effects.32
Chinese herbal medicine for treatment of
cancer-related symptoms has been studied fairly
extensively, with most studies focusing on pain.
In a systematic review paper of 115 studies, 41
were RCTs that compared Chinese herbal medicine with conventional analgesics or placebo
controls.31 Conclusions drawn from this extensive
review indicate the following: Chinese herbs are
effective in treating cancer pain, similar to traditional analgesic medications; Chinese herbal medicine has lesser side effects than conventional pain
medicines; various methods (topical, oral, and
intravenous) are all acceptable modes of delivery
of Chinese herbs for treatment of cancer pain.
While there are many studies included in this
TRADITIONAL CHINESE MEDICINE FOR CANCER-RELATED SYMPTOMS
review, the authors note that quality of the studies
varied greatly, with some studies having methodologic limitations or lacking sufficient information
to adequately judge. Furthermore, in another
extensive review paper of preclinical and clinical
studies, Chinese herbs were found to be effective
in improving a number of side effects associated
with chemotherapy and radiation therapy,
including diarrhea, poor appetite, and radiationinduced pneumonitis.33 Finally, a large RCT of
2,466 cancer patients experiencing pain evaluated
three study groups: 1) traditional Taiwanese herbal
diet for pain (consisting of analgesic herbs [paeony
root and licorice root] plus vegetable soup); 2)
reference group (usual diet control); and 3)
comparison group without herbs (vegetable
soup). After 1 week on the respective diets, the
herbal diet intervention group had significantly
lower levels of pain compared with the two control
groups (P <.05).34 These data support the use of
Chinese herbal medicine for the management of
cancer symptoms, especially pain.
Tai Chi
Tai Chi Chuan (Tai Chi) is a Chinese system of
exercise characterized by a series of very slow and
deliberate balletic body movements that enhance
the flow of vital energy force.1 It was designed for
self-defense, exercise, and meditation and is
usually practiced in group settings.
Growing evidence across clinical conditions
demonstrates benefits of Tai Chi.35 However,
studies with cancer patients are limited. Mustian
et al36,37 conducted a RCT of breast cancer survivors who were randomized to either Tai Chi or
psychosocial support (control group); both study
arms had three 60-minute group sessions each
week for 12 consecutive weeks. The Tai Chi group
had improvements in self-esteem as well as healthrelated quality of life while the control group
declined.36 Physiological measures of functional
and aerobic capacities and muscular strength also
improved in the Tai Chi participants and declined
in the controls, while both groups had improved
flexibility.37 In a small, single-arm feasibility study
of a 6-month Tai Chi self-help education for gastric
cancer survivors (N ¼ 21), there were no measurable differences between pre- and postintervention scores of depression and quality of
life.38 Two systematic reviews on Tai Chi for cancer
patients39,40 found benefit of Tai Chi in controlling
psychological and physical symptoms. However,
meta-analysis of three RCTs of women with breast
71
cancer revealed no significant effects of Tai Chi
compared with controls.40 The authors conclude
that the evidence is not strong enough to draw
reasonable conclusions as to the effectiveness of
Tai Chi in cancer patients.39,40 While further
research is needed in this area, Tai Chi is gentle
and safe for most patients.38,39
A TCM PRACTITIONER’S PERSPECTIVE
The first author (MS) is a TCM practitioner in an
integrative medicine clinic associated with an
academic medical center. A typical treatment plan
for symptomatic cancer patients involves weekly
acupuncture treatment (which may include auricular, full body, and/or electro-acupuncture), nutritional advice, sleep schedule, and favorite activity
or exercise program. There is direct communication
with the oncology team via a computerized charting
system regarding the treatment plan, changes in
patient condition, laboratory and imaging study
findings, changes in medications and herbs/supplements. Many patients find this integrative, approach
satisfying and empowering during and after cancer
care.
An example of a recent case involves a 74-yearold married man presenting with a diagnosis of
stage 4 metastatic prostate cancer. He was
a researcher and exposed to long-term high levels
of radiation in his field of work. He is religious and
spiritual in his belief system. His chief complaint
was upper back pain, 8/10 on VAS, for 3 months.
Location of pain was the left paraspinous region
on the urinary bladder channel/meridian. He was
alternating extra strength acetaminophen and
ibuprofen for 3 months without relief. Rest
improved his pain and activity aggravated it.
Heat applied to the local area improved his pain
and cold worsened it. Because of his pain, he was
unable to participate in his favorite activity, which
is to sit and play cards with his friends in the
evenings. Other complaints included insomnia,
anxiety, hot flashes and night sweats, irritable
bowel, and loss of sexual function. He presented
with a list of supplements that he had selfprescribed. The patient was placed on Lupron
Depot IM monthly (hence his hot flashes and night
sweats as a side effect) by his oncologist, but no
other drugs nor chemotherapy agents were
prescribed. A oncology clinic note included
a detailed history with recent labs and imaging
studies.
72
M.E. SMITH AND S. BAUER-WU
The TCM assessment revealed a purple tongue
and excess pulse, suggesting a TCM diagnosis of
Qi and blood stagnation of the urinary channel
resulting in blood stasis at stage 3. The patient
was interested in adding any appropriate supplements to his list and inquired about dietary
advice. Recommendations were as follows:
gluten-free diet (because past history revealed
he had gluten sensitivity with irritable bowel
symptoms), at least 4 daily servings of steamed
organic yellow/green and organic cruciferous
vegetables (for beneficial antioxidants and flavonoids), vegetable or fruit smoothies, fishes high
in Omega 3 such as salmon two to three times
weekly, and daily green tea. Daily shitake and reishi mushroom extract for immune system
enhancement were also suggested. He was instructed on correct sleeping position and posture
to reduce pain and promote comfort. The patient
received 30 minutes of electro-acupuncture to
the upper back and spine in combination with
auricular acupuncture to assist in resolving blood
stasis. Upon return for a follow-up visit 6 days
later, the patient reported significant relief in
his upper back pain from the acupuncture treatment with a pain scale being 3/10 on VAS. He
received weekly treatment sessions for 1 month,
followed with bi-weekly sessions. All supplement/dietary recommendations and procedures
were dictated in the patient’s medical chart for
all providers over the patient’s care to review.
Within 3 weeks the patient was able to play cards
with his friends because of a reduction in pain and
from appropriate sleep and rest. He also had
a reduction in frequency and intensity of hot
flashes with night sweats by approximately 50%,
improving his insomnia. The patient continues
with bi-weekly TCM sessions with a pain score of
2 on a 10-point VAS. Because the patient did not
initially receive relief from the pain medications,
he elected to discontinue them. A large portion of
each treatment session included allowing him to
express his feelings and concerns and providing
a safe environment for him to cry. Listening,
consoling, and providing support have been beneficial in allowing him to grieve his own illness. He was
encouraged to attend support groups in the
community and was referred to a counselor and
an Integrative Medicine doctor for coordination
of integrative care early in the course of his
treatment.
As a TCM practitioner, the interpersonal
approach to patient care includes the following:
1. Being non judgmental, which includes understanding the healing process is not always
physical nor attached to a particular
outcome.
2. Being focused in the moment with the patient
and accepting the patient where they are in
all aspects of their life, which assists in developing a trusting relationship for healing.
3. Seeing the patient as a person with feelings,
which assists the TCM practitioner in treating
the person, not their disease or condition.
4. Empowering the patient to assist in emotional,
physical, and spiritual healing.
5. Listening and acting on the patient’s personal
goals (without personal bias) and providing
information in a timely manner without overwhelming the patient.
6. Allowing patients to grow in their own experience of health and healing while promoting
a connection to their own personal spiritual
source.
FINDING A QUALIFIED TCM PRACTITIONER
Now that acupuncture and TCM are rapidly
entering the mainstream of medicine in North
America, an increasing number of nurses, physicians, and lay people are interested in finding
a qualified practitioner to refer their patients.
The laws are different in every state, and some
states, like New Mexico and California, have very
stringent licensing standards for practice. Fortunately, there are certifying agencies that establish
standards that a practitioner must meet to be qualified. The most established is the National Certification Commission for Acupuncture and Oriental
Medicine (NCCAOM) in Washington, DC. The
NCCAOM website (www.nccaom.org) lists practitioners who are qualified to practice throughout
the country.8 After the completion of 3 to 4 years
of study in an accredited school of Oriental Medicine, a student can sit for the licensing boards.
Certification is used as the basis for licensure in
90% of the states that have set standards for practicing acupuncture.
INSURANCE COVERAGE AND COST
Medicare and Medicaid do not cover acupuncture and other Chinese medicine treatments;
however, these treatments are covered under
many supplemental health plans and employee
TRADITIONAL CHINESE MEDICINE FOR CANCER-RELATED SYMPTOMS
medical benefit plans. The patient is responsible
for contacting the health insurance provider to
find out if the practitioner and treatments are
covered. The patient can also check with their
employer, if receiving health benefits at work, to
see if TCM treatments are covered through their
health plan. If insurance does not cover a Chinese
medicine office visit, the out-of-pocket cost in
most parts of the country ranges from $100 to
$150 for the initial session and $65 to $85 for basic
follow-up acupuncture treatment.
RECOMMENDATIONS FOR ONCOLOGY NURSES
The most common risk associated with TCM
is related directly to herb-drug interactions.
Cancer patients often take a number of different
medications, antineoplastics, and other drugs to
manage symptoms, and typical Chinese herbal
medicine regimens often use a number of
combined herbs. Potential negative herb-drug
interactions include increased toxicity or diminished treatment effects.32 Caution must be taken
73
to minimize these risks through thorough assessment and ongoing communication between the
oncology and TCM teams.
While acupuncture is considered to be quite safe,
it is not without risks.6,7 The risk of significant
adverse events with acupuncture is very low, less
than 0.55 per 10,000 individuals.6-8 Mild side effects,
like needle sensation and bruising at the needle site,
can occur during acupuncture treatment and is
common even with the most experienced and qualified practitioner. Of note, acupuncture within the
radiation field should be avoided.6
Oncology nurses can guide cancer patients to
increase their physical activity through Tai Chi
by pursuing a community Tai Chi class or watching videotapes, if homebound.
Oncology nurses need to stay informed of the
growing body of evidence on TCM for cancer
patients and be aware of resources and qualified
TCM practitioners in their community. TCM offers
opportunities to help to alleviate unpleasant
symptoms associated with cancer and untoward
effects of conventional cancer treatment.
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