traditional chinese medicine for cancer-related symptoms

64 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

Mary Elizab

Medicine Ser

New Mexico,

querque, NM

ciate Profess

Nursing, Em

OBJECTIVE: To familiarize oncology nurses about the theory and research

related to Traditional Chinese Medicine (TCM) for management of cancer-

related 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

TRADITIONAL Chinese Medicine (TCM)is based on the understanding that thebody has an innate intelligence andhealing ability. It is a whole system of

medicine that integrates many therapies and isapplied by practitioners to prevent and treatillness or disease. It uses acupuncture and herbal

eth Smith, RN, DOM: Director of Chinese

vices, UNM Center for Life, University of

Department of Internal Medicine, Albu-

. Susan Bauer-Wu, PhD, RN, FAAN: Asso-

or, Nell Hodgson Woodruff School of

ory University, Atlanta, GA.

medicine to help balance and regulate the flow of‘‘Qi,’’ a person’s vital energy force, thereforeenhancing the body’s healing process.1 In thismedical system, illness is caused because of animproper 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

Address correspondence to Mary Elizabeth Smith,

RN, DOM, UNMCenter for Life, 4700 Jefferson NE, Suite

100, Albuquerque, NM 87109. e-mail: mesmith@salud.

unm.edu

� 2012 Elsevier Inc. All rights reserved.

0749-2081/2801-$36.00/0.

doi:10.1016/j.soncn.2011.11.007

Delta:1_given name

Delta:1_surname

Delta:1_given name

Delta:1_surname

mailto:[email protected]

mailto:[email protected]

http://dx.doi.org/10.1016/j.soncn.2011.11.007

http://dx.doi.org/10.1016/j.soncn.2011.11.007

TRADITIONAL CHINESE MEDICINE FOR CANCER-RELATED SYMPTOMS 65

systems of medicine known to mankind. In China,it has been used as the primary health care systemfor thousands of years and most recently has beenused in combination with Western medicine totreat a variety of conditions. TCM consists of sixprimary branches that offer a holistic approachto 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 showsthat TCM can be used safely and as a helpfuladjunct to conventional care in the treatment ofcancer-related symptoms. This article will providean overview of the theory guiding TCM, describeresearch of TCM for cancer-related symptomsfocusing on three branches of TCM (acupuncture,Chinese herbal medicine, and exercise [Tai Chi]),provide an example of a TCM practitioner’s caseexample, and describe practical suggestions foroncology nurses related to TCM practitioner qual-ifications, cost, and insurance coverage.

COMPARISON OF TCM AND CONVENTIONAL

MEDICINE

There are several factors that distinguish TCMfrom conventional medicine. TCM focuses ona global holistic view of a person. It encompassesthe physical, emotional, social, and spiritualaspects that can influence health and illness. InTCM, signs and symptoms are pieced together toform a ‘‘pattern of disharmony’’ within the entirehuman body. This process takes into consider-ation the whole pattern presented by the patient,giving equal importance to the body, emotions,mind, and spirit. Conventional medicine has theability to view and treat each system of the humanbody with intense focus and accuracy. TCMsynthesizes a number of factors that lead to imbal-ance: internal factors such as stress, nutritional,emotional, sexual, and lifestyle factors, as well asexternal factors relating to the daily external envi-ronment including wind, dampness, heat, dryness,and cold.1 If the person is able to maintain a stateof internal balance, they are less likely to contractillness or pain from either internal or externalfactors. TCM puts a premium on assisting thebody to achieve and maintain this balance. Inconventional medicine, illness, disease and symp-toms are often treated pharmacologically or surgi-cally. The combination of both approaches oftenprovides optimal results.

Treatment with TCM is not disease-oriented,but strategy-oriented based on the underlyingcause. The cause is determined by accompanyingsigns and symptoms, strength of the patient,strength of any pathogenic influence, root andsecondary symptoms, location of pain (in termsof body organs and channels affected) andwhether the symptom is acute or chronic.1

BASIC CONCEPTS OF TCM

Yin and YangThe principle of yin and yang is one of the most

important concepts in TCM. Yin and yang expresspolar complements that exist in relationship toeach 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 otherfor existence. Everything in the cosmos has bothyin and yang aspects in constant motion. The Taijisymbol or the great polarity is balanced black andwhite. The black represents yin and the whiterepresents yang. Yang always includes a seed ofyin 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 ever-changing influence of internal and externalfactors, the balance of yin and yang can shift.The treatment goal is to restore the equilibriumof yin and yang.According to TCM, health results from main-

taining balance within the interior of the bodyand the external environment and lifestyle factorssuch as diet, exercise, sexual activity, habits, acci-dent, trauma, and epidemic. In this paradigm,disease, including cancer, is caused by an imbal-ance between the body and the environment orwithin the internal landscape of the body (whichcan also be genetic). TCM puts more importanceon maintaining this balance so that the body cannaturally resist disease rather than killing micro-organisms that can make us ill.The basic causes of disease can be internal or

external. External factors include climatic condi-tions of wind, cold, heat, summer heat, dampness,and dryness. Internal factors include the emotionallandscape within a person. TCM focuses on sevenprimary emotions that affect us: fear (normal andadaptive human emotion), anger, joy, worry,sadness, grief, and fright. Disease caused byemotions often becomes chronic, injuring theorgans, Qi, and blood.1

66 M.E. SMITH AND S. BAUER-WU

Pain, for example, can be associated with theinternal organs. The yin organs are the solidorgans that include the heart, liver, spleen, lung,kidney, and pericardium. Their main function isthe manufacturing and storing of the vital essence:Qi, blood, and body fluid. The yang organs are thehollow organs. They receive and digest food,absorb nutrition, and dispose of waste. The yangorgans include the small intestine, gall bladder,stomach, large intestine, urinary bladder, and anextra organ system called the ‘‘triple burner.’’1

The yin organs and the yang organs work togetheras a unit. They are considered functionalcomplexes rather than just anatomical structures.These organs systems transform and cycle in fivephases known as Wu Xing.

Wu Xing: The Five Phases of TransformationThe five phases of transformation, Wu Xing,

describes a cycle bywhich transformation happensin the human body. The five phases are: water,wood, fire, earth, and metal.1 Each phase corre-sponds to particular structures and functions inthe body, as well as emotions, spiritual qualities,tissues, and life stages. Each stage also has a partic-ular connection with aspects of the external worldsuch as a season of the year, climate, directions,color, and taste.

The Channels or MeridiansChannels or meridians carry blood and Qi

through the body via an invisible network thatlinks fundamental structures, functions, andorgans of the body. Channel theory states thata disorder within a particular channel affects thecourse of the channel and the organ system asso-ciated with it.1 A disharmony in the organ likewiseaffects the associated channel. For example,a disharmony in the urinary bladder may manifestin symptoms along the urinary bladder channel,such as pain in the back.

The channels are regarded as 3-dimensionalpassageways through which the Qi and bloodflow at different levels of the body. The channelsare bilateral. There are 14 major channels, eachcontaining a number of independent points, 12of which correspond to the major yin-yang organsof the body. These channels have continuous, in-terlinking patterns of circulation. The two addi-tional major channels, the Conception Vessel(along the front midline of the body) and the Gov-erning Channel (along the backside of the body)are part of the system of eight extra channels.

The eight extra channels do not fit the patternof the major channels. Rather, they serve as reser-voirs, filling and emptying in response to thevarying conditions of the major channels and ex-erting a regulating effect on them.

Qi and BloodQi 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, livingand nonliving, have Qi.1 Qi is considered yang(as compared with blood) and is associated withfunction, activity, and movement. In this system,blood is more than the red fluid that runs throughour veins. Its primary function is to circulatethrough the blood vessels and channels to nourish,maintain, and moisten the body, while promotingthe functional activities of the organ systems andtissues.1

Qi and blood are one of the most primary yin-yang polarities in the human body. Qi (yang) isnecessary to move the blood. According to TCM,blood (yin) is made from the Qi of food. Bloodnourishes the organs that produce and regulateQi. Clinically, a deficiency of Qi often leads toa deficiency of blood and vice versa. Disharmoniesof blood (such as in blood cancers) can lead to defi-cient blood and/or stagnant blood. Both Qi andblood deficiency/stagnation can cause pain.1

Diagnosing imbalances. Chinese medicalpatterns of cancer have three specific diagnosticsimilarities for the majority of cancer patients.1

These patterns are noted in stages.

� Stage 1 – A yin-yang imbalance develops in thebody and usually involves several organsystems.

� Stage 2 – As the imbalance worsens, Qi andblood are depleted and begin to stagnate.

� Stage 3 – The communication and cooperationamong the organs (as related in the five-element cycle) deteriorates, the immuneresponse becomes impeded, the endocrinesystemmalfunctions, and the adaptive qualitiesof the body deteriorate.

Diagnosing the imbalance or pattern of dishar-mony is key to encouraging health and healingas 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


all symptoms including emotions, onset of symp-toms, time of day or year that symptoms becomeworse, and medical history. Specific questionswill provide information on: what improves orworsens the pain, chills, fever, perspiration, eatingand drinking, appetite, taste, bowel movements,urination, pain location and quality, sleep, sexualfunction/desire, and menstruation. These ques-tions assist in acquiring the whole picture of thepattern of disharmony.

An additional palpation tool in TCM is pulsediagnosis. A rapid pulse typically means heat,slow pulse means cold, strong pulse means excess,weak pulse means deficiency, and floating pulsemeans external condition such as cold or flu.

Tongue diagnosis is a tool used by the practi-tioner to observe the shape, color, and conditionof the tongue body and coating. A healthy tonguehas no restrictions in movement, is light pink incolor, thin white coat, without being overly dryor wet, and is not swollen or too thin. Anunhealthy tongue would be a deviation from thehealthy tongue. Some basic tongue diagnosis arered tongue body ¼ heat; yellow tongue coating ¼heat; pale tongue body ¼ cold and deficiency;white tongue coating ¼ normal or cold; purplishtongue body ¼ stagnation of Qi and/or blood;and a thick or sticky tongue coating ¼ dampness,phlegm, or food stagnation.1

AcupunctureAcupuncture is a branch of TCM that modulates

neurological processes to bring about its effects.2,3

Acupuncture is a technique in which very tinyneedles of varying lengths are inserted throughthe skin in specific locations called acupoints. Torestore balance and a healthy energy flow to thebody, needles are inserted into acupoints and leftin place for less than half an hour. The practitionermay apply heat or a weak electrical current (elec-tro-acupuncture) to enhance the effects of thetherapy. Auricular acupuncture is a method ofacupuncture that involves stimulating points onthe ear to obtain relieving benefits. Moxibustionmay also be used in conjunction with acupunc-ture. It uses the heat generated by burning herbalpreparations containing Artemisa vulgaris tostimulate acupuncture points,1 and is helpful inreducing side effects from chemotherapy.4 Addi-tionally, acupressure may be used in place ofacupuncture, particularly because patients cando it themselves. Acupressure works similarly toacupuncture; however rather than needles,

finger-point pressure is placed on acupoints. Ingeneral, acupuncture is well tolerated and signifi-cant adverse effects are rare.5-8 Research on theuse of acupuncture for management and preven-tion of cancer symptoms is increasing. To date,studies have addressed the safety and effective-ness of acupuncture for cancer-related pain, hotflashes, nausea and vomiting, xerostomia, lym-phedema, as well as other symptoms. See Table 1.

Pain. A number of studies have evaluated theeffectiveness of acupuncture on cancer-relatedpain.9-14 In a recent Cochrane Review paper onthis topic,11 three randomized controlled trials(RCTs) were identified and included in the anal-ysis. While all three studies revealed lower self-reported pain during and up to 2 months afteracupuncture treatments, the authors concludedthat there is insufficient evidence and resultsneed to be viewed with caution because of meth-odologic limitations. In one of the studies Alimiet al10 conducted a randomized, blinded, con-trolled trial of auricular (ear) acupuncture incancer patients experiencing neuropathic pain(N ¼ 90). Three groups were assessed, one treat-ment (acupuncture, n ¼ 29) and two control(placebo auricular acupuncture, n ¼ 30 andplacebo auricular seeds, n ¼ 31), at baseline(before the 1-month intervention period) and 30and 60 days later. Using a visual analog score(VAS), they noted that pain intensity significantlydecreased in the acupuncture group at day 30(P ¼ .02) and day 60 (P <.001) compared withboth of the placebo groups. Similarly, positivefindings were also demonstrated in a small, uncon-trolled pilot study with cancer patients experi-encing pain caused by bone metastasis (N ¼ 5).14

Paley and Johnson14 found that a single acupunc-ture treatment reduced mean pain scores from 4.3(on a numerical rating scale) before treatment to0.8 immediately after, which increased to 3.2at 48 hours after the acupuncture treatment.In contrast, Deng et al9 failed to show any differ-ence in reducing pain after cancer surgerybetween a special acupuncture technique (deliv-ered preoperatively with implanted needles thatwere retained for 4weeks) and sham (placebo)acupuncture in a well-designed study of cancerpatients undergoing thoracotomy (N ¼ 162). Insummary, several studies have been conductedon acupuncture for cancer-related pain withmixed results. Many of the studies are methodo-logically flawed. Research to date has used

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

Mixed. Some studies demonstrate

reduction in pain after acupuncture and

some do not. Different acupuncture

techniques used. Different types of

cancer pain evaluated

Nausea and vomiting Several studies including some with

high-quality designs

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

Hot flashes Several studies with both breast

and prostate cancer patients.

More high-quality studies done

with breast cancer patients

Generally positive in both breast and

prostate cancer patients

Xerostomia A few studies including some RCT Promising for electroacupuncture,

although studies have had small

sample sizes

Lymphedema Two small pilot studies Promising findings, although uncontrolled

studies with very small sample sizes

Other: General health-related

quality of life, anxiety, depressed

mood, sleep, and fatigue

Small and/or uncontrolled Promising findings for mood, arthralgias,

sleep, and neuropathy. Studies are

limited bymethodologic flaws and small

sample sizes


different acupuncture techniques and includedpatients with different types of cancer-relatedpain. Therefore, it is difficult to draw conclusionson the benefits of acupuncture for cancer patientsexperiencing pain.

Nausea and vomiting. A fairly substantialevidence base exists on the use of acupuncturefor chemotherapy-induced nausea and vomiting.In a Cochrane Review report15 consisting of 11studies compiled until 2006, differential effectswere found depending on the technique and thespecific symptom (ie, nausea vs. vomiting, acutevs. delayed). In this meta-analysis including a totalof 1,247 cancer patients, they found electroacu-puncture to be effective for reducing the incidenceof acute emesis, but not severity of acute emesisor delayed nausea. They also found that acupres-sure reduced acute nausea, but not delayednausea or acute or delayed emesis. Furthermore,they determined that noninvasive electrostimula-tion was not effective for either nausea or vomit-ing. Regarding the use of acupuncture forradiation-induced nausea, Enblom et al16 con-ducted a large RCT of cancer patients receiving

abdominal/pelvic irradiation. Participants wererandomized to either acupuncture (n ¼ 109) orsham (n ¼ 106), for which they received two tothree treatments each week during radiationtherapy. Acupuncture was found to be no moreeffective than sham in reducing incidence ofradiation-induced nausea. In summary, acupunc-ture and acupressure are associated with dimin-ished chemotherapy-induced acute vomiting andacute nausea, respectively, across a number ofstudies, but no effect was found on radiation-induced nausea in one well-designed study.

Hot flashes. Several studies have assessed theeffects of acupuncture in reducing cancertreatment-related hot flashes in both womenwith breast cancer and men with prostate cancer.Walker et al17 conducted an impressive RCT,comparing acupuncture with venlafaxine inhormone receptor-positive breast cancer patients(N ¼ 50, 25 per group). After 12 weeks of treat-ment, both groups had significant improvementsas measured by reduced hot flashes and depressivesymptoms and enhanced quality of life. Two weeksafter the treatments were completed, the


venlafaxine group had significant increase in hotflashes, which was not observed in the acupunc-ture group. The medication was also associatedwith 18 incidences of adverse effects, while nonefor acupuncture. Frisk et al18 conducted a similarlydesigned study with breast cancer survivors,comparing acupuncture with HRT. Forty-fivewomen were randomized to either acupuncturefor 12 weeks or HRT for 24 months. (Note thatthis study was conducted when HRT was anacceptable treatment, which it is not now.) Bothgroups demonstrated improvements with reducednumber of and distress from hot flashes andincreased number of hours slept and levels ofgeneral well-being after the intervention periods,although the acupuncture group did not demon-strate as large decrease in the number of hotflashes as the comparison group.

In another RCT, Deng et al19 assessed hot flashfrequency in women with breast cancer experi-encing three or more hot flashes per day (N ¼72). They were randomly assigned to receiveeither true or sham acupuncture, both deliveredtwice weekly for 4 consecutive weeks; those as-signed to the sham group were crossed over toreceive true acupuncture beginning at week 7.Number of hot flashes was evaluated at baseline,at 6 weeks, and after 6 months. At 6 weeks, bothgroups had reduced frequency of hot flashes,with the true acupuncture group decreasing from8.7 (standard deviation [SD], 3.9) to 6.2 (SD,4.2) and the sham group from 10.0 (SD, 6.1) to7.6 (SD, 5.7), which was not statistically signifi-cant. After the sham acupuncture participantswere crossed over to true acupuncture, furtherreductions were observed. Both groups demon-strated persistent reduction in the number of hotflashes for up to 6 months after the completionof true acupuncture treatment. Finally, in breastcancer patients (N ¼ 50) experiencing hot flasheswhile on treatment with tamoxifen, a single-arm,pre-post study found a 49.8% decrease in themean frequency of hot flashes and improvementsin health-related quality-of-life symptoms frombaseline to end of eight acupuncture treatments.20

Regarding men with prostate cancer, a system-atic review identified six studies evaluatingacupuncture for treatment of hot flashes.21 Ofthese, five were observational and one was anRCT. The uncontrolled studies identified consis-tent improvements in the number and severity ofhot flashes; however, all of these studies havenotable methodologic limitations. In the one

RCT, Frisk et al22 compared 12 weeks of electroa-cupuncture with traditional acupuncture (N ¼ 29)and found statistically significant within-groupdifferences from baseline to end of treatment,from a median of 7.6 to 4.1 in the electroacupunc-ture group (P ¼ .012) and 5.7 to 3.4 in the tradi-tional acupuncture group (P ¼ .001). Distressdecreased in both groups. Both groups demon-strated lasting effects up to 9 months after comple-tion of treatment and minimal side effects. Insummary, evidence to date demonstrates positiveeffects of acupuncture in the treatment of hotflashes in men with prostate cancer.

Xerostomia. Studies have investigated theeffectiveness of acupuncture in the alleviation ofdry mouth and dysfunction in head and neckcancer patients treated with radiation therapy.O’Sullivan and Higginson5 conducted a system-

atic review on this topic and identified threeRCTs, two comparing true acupuncture to shamacupuncture and one compared with usual clinicalcare. While all three of these trials demonstratedbenefits, authors of the systematic review notedthat evidence is too limited to draw conclusions.Pfister et al23 conducted a RCT comparingacupuncture (weekly for 4 weeks) to usual careover the same period of time. Fifty-eight patientswith head and neck cancer (28 in acupuncturegroup and 30 in control group) completed self-report measures of xerostomia and a compositemeasure of pain, function, and activities of dailyliving (called the Constant-Murley score). Theyfound significant improvements in the acupunc-ture group compared with control for xerostomia(P ¼ .02) and the composite score (P ¼ .008).Another randomized, controlled study evaluatedthe effects of preventive acupuncture during radi-ation therapy for patients with head and neckcancer and found significant improvements in bio-logical salivary flow (P <.001) and self-reportedand dry mouth (P <.05) in patients who receivedacupuncture compared with controls.24 Addition-ally, one study tested ‘‘acupuncture-like transcu-taneous electrical nerve stimulation’’ (ALTENS)delivered daily throughout the course of radio-therapy. They measured saliva production andsubjective ratings of dry mouth in 56 head andneck cancer patients (30 intervention, 26 usualcare control) and found no differences betweengroups at 3 months after completion of treatment.While the number and methods of studies arelimited, true acupuncture seems to be a promising


treatment for radiation-induced xerostomia inpatients with head and neck cancer. The onestudy of a noninvasive, ‘‘acupuncture-like’’ treat-ment suggests that is not a beneficial approach.

Lymphedema. Two small studies have beenidentified on the use of acupuncture for manage-ment of lymphedema. Cassileth et al25 evaluatedthe safety and feasibility of acupuncture in ninewomen with chronic lymphedema after breastcancer surgery. All participants received acupunc-ture twice weekly for 4 weeks. They found that44% (4/9) of the women had >30% reduction insize difference affected and unaffected arms at 4weeks compared with baseline, and no seriousadverse effects. The other study, by de Valoiset al,26 used mixed methods to evaluate effective-ness of acupuncture (seven weekly individualizedtreatments and six optional) in breast (n ¼ 37)and head and neck cancer (n ¼ 8) patients. Themain study variable was an instrument called‘‘Measure Yourself Medical Outcome Profile’’ (MY-MOP), whereby participants identify and rate theirmost troublesome symptoms. Significant improve-ments (P <.0001) in MYMOP were identified afterthe acupuncture treatment periods in both breastand head and neck cancer patients, and in func-tion (SF-36) in breast cancer only at 4 weeks after,not at 12 weeks. In summary, research onacupuncture for lymphedema is extremelylimited. Two pilot studies had promising resultsthat warrant additional research in this area.

General symptoms and health-related qualityof life. Studies have addressed the effects ofacupuncture on other cancer-related symptoms,such as mood, arthralgias, neuropathy, sleep, andfatigue. Feng et al27 conducted an RCT of acupunc-ture (n¼ 40) versus the antidepressantmedicationfluoxetine (n¼ 40) using validated instruments forself-reported depressive symptoms and sleep.They found that the acupuncture group had signif-icantly lower depressed mood (P <.05) and bettersleep quality (P <.01) after treatment comparedwith the group receiving the antidepressant medi-cation. A well-designed (randomized and blinded)study compared true acupuncture with shamintervention for treatment of arthralgias for post-menopausal breast cancer patients receiving aro-matase inhibitors.28 After 6 weeks of treatment(twice each week), significant differences in jointpain-related scores were observed across allmeasures with greater improvements in the

acupuncture group compared with sham, such aslower worst pain scores (P <.001), and lesserpain severity (P ¼ .003) and pain-related interfer-ence (P ¼ .002). In a small, single-arm pilot studywith 18 patients with mixed cancer diagnoses,acupuncture was associated with improvementsin peripheral neuropathy and self-reported sleepand decreased analgesia use.29 In a small, uncon-trolled pilot study, patients with advanced ovarianand breast cancer had statistically and clinicallysignificant improvements in anxiety, fatigue,pain, depression, and life satisfaction after 8 weeksof acupuncture treatments (12 treatments givenover 8 weeks), which were sustained at 12 weeks.30

In summary, the small studies have exploredacupuncture for other cancer-related symptoms,and have identified promising findings in self-report measures.

Chinese Herbal MedicineChinese herbal medicine focuses on restoring

the balance of energy, body, and spirit to main-tain health rather than treating the cancer itself.Herbs are used to restore balance by changingabnormal patterns and by nourishing the body.1

Herbal medicine treats the underlying dishar-mony as well as patterns and symptoms and isoften used along with conventional cancer treat-ments. There are a variety of methods of admin-istering TCM herbal treatments, including oraladministration, topical/external application(particularly for pain), intravenous infusion, andinhalation.1,31 Because of the variety and combi-nation of herbs used in Chinese herbal medicine,and shared mechanisms with prescribed drugs,there is a potential for negative interactionssuch as increased toxicity or diminished treat-ment effects.32

Chinese herbal medicine for treatment ofcancer-related symptoms has been studied fairlyextensively, with most studies focusing on pain.In a systematic review paper of 115 studies, 41were RCTs that compared Chinese herbal medi-cine with conventional analgesics or placebocontrols.31 Conclusions drawn from this extensivereview indicate the following: Chinese herbs areeffective in treating cancer pain, similar to tradi-tional analgesicmedications; Chinese herbalmedi-cine has lesser side effects than conventional painmedicines; various methods (topical, oral, andintravenous) are all acceptable modes of deliveryof Chinese herbs for treatment of cancer pain.While there are many studies included in this


review, the authors note that quality of the studiesvaried greatly, with some studies having methodo-logic limitations or lacking sufficient informationto adequately judge. Furthermore, in anotherextensive review paper of preclinical and clinicalstudies, Chinese herbs were found to be effectivein improving a number of side effects associatedwith chemotherapy and radiation therapy,including diarrhea, poor appetite, and radiation-induced pneumonitis.33 Finally, a large RCT of2,466 cancer patients experiencing pain evaluatedthree study groups: 1) traditional Taiwanese herbaldiet for pain (consisting of analgesic herbs [paeonyroot and licorice root] plus vegetable soup); 2)reference group (usual diet control); and 3)comparison group without herbs (vegetablesoup). After 1 week on the respective diets, theherbal diet intervention group had significantlylower levels of pain compared with the two controlgroups (P <.05).34 These data support the use ofChinese herbal medicine for the management ofcancer symptoms, especially pain.

Tai ChiTai Chi Chuan (Tai Chi) is a Chinese system of

exercise characterized by a series of very slow anddeliberate balletic body movements that enhancethe flow of vital energy force.1 It was designed forself-defense, exercise, and meditation and isusually practiced in group settings.

Growing evidence across clinical conditionsdemonstrates benefits of Tai Chi.35 However,studies with cancer patients are limited. Mustianet al36,37 conducted a RCT of breast cancer survi-vors who were randomized to either Tai Chi orpsychosocial support (control group); both studyarms had three 60-minute group sessions eachweek for 12 consecutive weeks. The Tai Chi grouphad improvements in self-esteem as well as health-related quality of life while the control groupdeclined.36 Physiological measures of functionaland aerobic capacities and muscular strength alsoimproved in the Tai Chi participants and declinedin the controls, while both groups had improvedflexibility.37 In a small, single-arm feasibility studyof a 6-month Tai Chi self-help education for gastriccancer survivors (N ¼ 21), there were no measur-able differences between pre- and post-intervention scores of depression and quality oflife.38 Two systematic reviews onTaiChi for cancerpatients39,40 found benefit of Tai Chi in controllingpsychological and physical symptoms. However,meta-analysis of three RCTs of women with breast

cancer revealed no significant effects of Tai Chicompared with controls.40 The authors concludethat the evidence is not strong enough to drawreasonable conclusions as to the effectiveness ofTai Chi in cancer patients.39,40 While furtherresearch is needed in this area, Tai Chi is gentleand safe for most patients.38,39

A TCM PRACTITIONER’S PERSPECTIVE

The first author (MS) is a TCM practitioner in anintegrative medicine clinic associated with anacademic medical center. A typical treatment planfor symptomatic cancer patients involves weeklyacupuncture treatment (which may include auric-ular, full body, and/or electro-acupuncture), nutri-tional advice, sleep schedule, and favorite activityor exerciseprogram.There isdirect communicationwith the oncology teamvia a computerized chartingsystem regarding the treatment plan, changes inpatient condition, laboratory and imaging studyfindings, changes in medications and herbs/supple-ments.Manypatients find this integrative, approachsatisfying and empowering during and after cancercare.An example of a recent case involves a 74-year-

old married man presenting with a diagnosis ofstage 4 metastatic prostate cancer. He wasa researcher and exposed to long-term high levelsof radiation in his field of work. He is religious andspiritual in his belief system. His chief complaintwas upper back pain, 8/10 on VAS, for 3 months.Location of pain was the left paraspinous regionon the urinary bladder channel/meridian. He wasalternating extra strength acetaminophen andibuprofen for 3 months without relief. Restimproved his pain and activity aggravated it.Heat applied to the local area improved his painand cold worsened it. Because of his pain, he wasunable to participate in his favorite activity, whichis to sit and play cards with his friends in theevenings. Other complaints included insomnia,anxiety, hot flashes and night sweats, irritablebowel, and loss of sexual function. He presentedwith a list of supplements that he had self-prescribed. The patient was placed on LupronDepot IM monthly (hence his hot flashes and nightsweats as a side effect) by his oncologist, but noother drugs nor chemotherapy agents wereprescribed. A oncology clinic note includeda detailed history with recent labs and imagingstudies.


The TCM assessment revealed a purple tongueand excess pulse, suggesting a TCM diagnosis ofQi and blood stagnation of the urinary channelresulting in blood stasis at stage 3. The patientwas interested in adding any appropriate supple-ments to his list and inquired about dietaryadvice. Recommendations were as follows:gluten-free diet (because past history revealedhe had gluten sensitivity with irritable bowelsymptoms), at least 4 daily servings of steamedorganic yellow/green and organic cruciferousvegetables (for beneficial antioxidants and flavo-noids), vegetable or fruit smoothies, fishes highin Omega 3 such as salmon two to three timesweekly, and daily green tea. Daily shitake and re-ishi mushroom extract for immune systemenhancement were also suggested. He was in-structed on correct sleeping position and postureto reduce pain and promote comfort. The patientreceived 30 minutes of electro-acupuncture tothe upper back and spine in combination withauricular acupuncture to assist in resolving bloodstasis. Upon return for a follow-up visit 6 dayslater, the patient reported significant relief inhis upper back pain from the acupuncture treat-ment with a pain scale being 3/10 on VAS. Hereceived weekly treatment sessions for 1 month,followed with bi-weekly sessions. All supple-ment/dietary recommendations and procedureswere dictated in the patient’s medical chart forall providers over the patient’s care to review.

Within 3 weeks the patient was able to play cardswith his friends because of a reduction in pain andfrom appropriate sleep and rest. He also hada reduction in frequency and intensity of hotflashes with night sweats by approximately 50%,improving his insomnia. The patient continueswith bi-weekly TCM sessions with a pain score of2 on a 10-point VAS. Because the patient did notinitially receive relief from the pain medications,he elected to discontinue them. A large portion ofeach treatment session included allowing him toexpress his feelings and concerns and providinga safe environment for him to cry. Listening,consoling, and providing support have been benefi-cial in allowing him to grieve his own illness. Hewasencouraged to attend support groups in thecommunity and was referred to a counselor andan Integrative Medicine doctor for coordinationof integrative care early in the course of histreatment.

As a TCM practitioner, the interpersonalapproach to patient care includes the following:

1. Being non judgmental, which includes un-derstanding the healing process is not alwaysphysical nor attached to a particularoutcome.

2. Being focused in the moment with the patientand accepting the patient where they are inall aspects of their life, which assists in devel-oping a trusting relationship for healing.

3. Seeing the patient as a person with feelings,which assists the TCM practitioner in treatingthe 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 personalgoals (without personal bias) and providinginformation in a timely manner without over-whelming the patient.

6. Allowing patients to grow in their own experi-ence of health and healing while promotinga connection to their own personal spiritualsource.

FINDING A QUALIFIED TCM PRACTITIONER

Now that acupuncture and TCM are rapidlyentering the mainstream of medicine in NorthAmerica, an increasing number of nurses, physi-cians, and lay people are interested in findinga qualified practitioner to refer their patients.The laws are different in every state, and somestates, like New Mexico and California, have verystringent licensing standards for practice. Fortu-nately, there are certifying agencies that establishstandards that a practitioner must meet to be qual-ified. The most established is the National Certifi-cation Commission for Acupuncture and OrientalMedicine (NCCAOM) in Washington, DC. TheNCCAOM website (www.nccaom.org) lists practi-tioners who are qualified to practice throughoutthe country.8 After the completion of 3 to 4 yearsof study in an accredited school of Oriental Medi-cine, a student can sit for the licensing boards.Certification is used as the basis for licensure in90% of the states that have set standards for prac-ticing acupuncture.

INSURANCE COVERAGE AND COST

Medicare and Medicaid do not cover acupunc-ture and other Chinese medicine treatments;however, these treatments are covered undermany supplemental health plans and employee

http://www.nccaom.org


medical benefit plans. The patient is responsiblefor contacting the health insurance provider tofind out if the practitioner and treatments arecovered. The patient can also check with theiremployer, if receiving health benefits at work, tosee if TCM treatments are covered through theirhealth plan. If insurance does not cover a Chinesemedicine office visit, the out-of-pocket cost inmost parts of the country ranges from $100 to$150 for the initial session and $65 to $85 for basicfollow-up acupuncture treatment.

RECOMMENDATIONS FOR ONCOLOGY NURSES

The most common risk associated with TCMis related directly to herb-drug interactions.Cancer patients often take a number of differentmedications, antineoplastics, and other drugs tomanage symptoms, and typical Chinese herbalmedicine regimens often use a number ofcombined herbs. Potential negative herb-druginteractions include increased toxicity or dimin-ished treatment effects.32 Caution must be taken

to minimize these risks through thorough assess-ment and ongoing communication between theoncology and TCM teams.While acupuncture is considered to be quite safe,

it is not without risks.6,7 The risk of significantadverse events with acupuncture is very low, lessthan0.55per10,000 individuals.6-8Mild side effects,like needle sensation and bruising at the needle site,can occur during acupuncture treatment and iscommon even with the most experienced and qual-ified practitioner. Of note, acupuncture within theradiation field should be avoided.6

Oncology nurses can guide cancer patients toincrease their physical activity through Tai Chiby pursuing a community Tai Chi class or watch-ing videotapes, if homebound.Oncology nurses need to stay informed of the

growing body of evidence on TCM for cancerpatients and be aware of resources and qualifiedTCM practitioners in their community. TCM offersopportunities to help to alleviate unpleasantsymptoms associated with cancer and untowardeffects of conventional cancer treatment.

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