Qigong for cancer treatment: a systematic review of controlled clinical trials

Qigong for cancer treatment: A systematic review of controlledclinical trials MYEONG SOO LEE1, KEVIN W CHEN2, KENNETH M SANCIER3 & EDZARD ERNST1 1Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK, 2Center for IntegrativeMedicine, University of Maryland School of Medicine, Baltimore, USA, 3Qigong Institute, Menlo Park, USA AbstractQigong is a mind-body integrative exercise or intervention from traditional Chinese medicine used to prevent and cureailments, to improve health and energy levels through regular practice. The aim of this systematic review is to summarize andcritically evaluate the effectiveness of qigong used as a stand-alone or additional therapy in cancer care. We have searched theliterature using the following databases from their respective inceptions through November 2006: MEDLINE, AMED,British Nursing Index, CINAHL, EMBASE, PsycInfo, The Cochrane Library 2006, Issue 4, four Korean MedicalDatabases, Qigong and Energy Medicine Database from Qigong Institute and four Chinese Databases. Randomised andnon-randomised clinical trials including patients with cancer or past experience of cancer receiving single or combinedqigong interventions were included. All clinical endpoints were considered. The methodological quality of the trials wasassessed using the Jadad score. Nine studies met our inclusion criteria (four were randomised trials and five were non-randomised studies). Eight of these trials tested internal qigong and one trial did not reported details. The methodologicalquality of these studies varies greatly and was generally poor. All trials related to palliative/supportive cancer care and none toqigong as a curative treatment. Two trials suggested effectiveness in prolonging life of cancer patients and one failed to do so.
We conclude that the effectiveness of qigong in cancer care is not yet supported by the evidence from rigorous clinical trials.
Cancer is a leading cause of death globally [1]. The practiced daily to promote health maintenance and World Health Organization estimates that 84 million disease prevention. In external qigong a practitioner people will die in the next 10 years if action is not is involved in the treatment. Although neither qigong taken [1]. Most cancer patients experience multiple itself nor the mechanism of its effects is explicable symptoms related to either the cancer itself or late within the paradigm of medical science, there is treatment effects.[2] Cancer patients therefore often increased report of its effects on the human health.
turn towards complementary or alternative thera- Several reviews claim that qigong offers therapeutic Acta Oncol Downloaded from informahealthcare.com by 95.224.73.236 on 10/23/10 pies. The results of the 2002 National Health Inter- benefits for cancer patients [7 Á9]. However, these view Survey showed that rates of CAM used are reviews are non-systematic and therefore open to especially high among USA patients with serious bias. The aim of this systematic review is to illness such as cancer [3]. Several surveys reported a summarize and critically evaluate the clinical trial prevalence range of CAM in cancer from 53 to 88% evidence regarding the effectiveness of any type of [4 Á6] and showed that CAM is usually combined Qigong is a mind-body integrative exercise or intervention from traditional Chinese medicine used to prevent and cure ailments, to improve health and energy levels through regular practice [7].
Internal and external qigong can be distinguished.
Electronic databases were searched from their re- Internal qigong is self-directed and actively engages spective inceptions through November 2006 using people in their own health and well-being. It is best following databases: MEDLINE, AMED, British Correspondence: Myeong Soo Lee, Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter,EX2 4NT, UK. Tel: '44 1392 439035. Fax: '44 1392 424989. E-mail: myeong.lee@pms.ac.uk or drmslee@gmail.com (Received 11 January 2007; accepted 31 January 2007) ISSN 0284-186X print/ISSN 1651-226X online # 2007 Taylor & FrancisDOI: 10.1080/02841860701261584 Nursing Index, CINAHL, EMBASE, PsycInfo, The patients. Patients were divided non-randomly into Cochrane Library 2006, Issue 4, Korean Medical two parallel groups: qigong (2 hours daily for 3 Databases (Korean Studies Information, DBPIA, months) combined with drugs (n 097, types of drug Korea Institute of Science, Technology Information, were not specified) and drug therapy only (n 030).
Research Information Center for Health Database The outcome measures included physical strength, and Korean Medline), Qigong and Energy Medicine appetite, diarrhea, defecation, and body weight. At Database (Qigong Institute, Menlo Park, version the end of the period, 82% of patients from the 7.4) and Chinese Databases (China Academic experimental group had improved physical strength, Journal, Century Journal Project, China Doctor/ 63% improved appetite, and 33% were free of Master Dissertation Full text DB, China Proceed- diarrhea or irregular defecation. The corresponding ings Conference Full text DB). The search terms rates for the control group were 10%, 10%, and 6%.
used were: qigong or chi adj gong or chi adj kung or All these parameters yielded significant inter-group qi adj kung or jih adj gong or qi adj gong or Korean or Chinese letter for qigong and cancer. Several Zheng [19] tested the effects of qigong on survival experts were contacted and asked to contribute any rates of various late-stage cancer patients. One unpublished trials. In addition, the references of all hundred patients were compared with patients in located articles and our departmental files were the same hospital who had other therapies but no hand-searched for further relevant articles.
qigong. This study did not mention the type of Randomised clinical trials (RCTs) and non-ran- qigong (regimen) and neither were the interventions domised controlled clinical trials (CCTs) were administrated in the control group. The main out- included if they investigated patients with cancer come was survival rate and median survival time.
or past experience of cancer who received single or One and 5 year survival rates were 83% and 17% for combined qigong interventions as sole treatment or lung cancer patients (in the control group, they were as adjuvant to conventional treatments. Outcomes 7% in 5 years) and 83% and 23% for stomach cancer had to be compared to other interventions or no patients (controls: 12% in 5 years). The median treatment at all. No language restrictions were survival time favored the experimental group (20.7 All clinical endpoints were considered but the Wang and co-workers [17] conducted an RCT to main outcome measures were effectiveness of qigong evaluate the effect of qigong in late stage cancer for treating symptoms in cancer patients and cancer patients. Sixty one patients were divided randomly to survivors. Secondary outcome measures included receive chemotherapy only (n 029) or chemotherapy survival rate and quality of life. Trials were excluded plus qigong (n 032). The main outcome measures from this review if the outcomes were related only to were improvement in health and white blood cell immunological or other surrogate endpoints. All (WBC) count. The experimental group experienced articles were read by two independent reviewers improved health and a stable WBC counts, whereas and data from the articles were validated and 12 of 30 patients in the control group reported worse extracted according to pre-defined criteria listed in health with more symptoms related to cancer, and all Table I. The methodological quality of all studies controls showed a decline in WBC count.
Acta Oncol Downloaded from informahealthcare.com by 95.224.73.236 on 10/23/10 was independently assessed by the two reviewers Fu and Wang [12] conducted an RCT to evaluate using the Jadad score [10]. Taking into account that the short-term effects of a Chinese herbal mixture qigong practitioners cannot be blinded to the treat- versus qigong therapy plus the herbal mixture among ment, we used a modification of this scale. Dis- elderly patients with late-stage stomach cancer.
crepancies between reviewers were resolved by a Forty patients in whom the cancer was confirmed third independent reviewer. Statistically significant (x-ray, CT scan, biopsy, and/or ultra-sound) were results of each trial were documented (Table I).
recruited. Most of the patients (80%) were too oldor too ill to have surgery. The patients wererandomly assigned to the two treatment groups.
After 3 months of treatment the majority of the The searches identified 162 potentially relevant patients reported improvement and 22 Á23% had articles, of which nine met our inclusion criteria measurable tumor reduction. However, there was no (Figure 1). Eight of these trials tested internal qigong significant difference between the two treatment [11 Á18] and one trial did not report specifically on groups. Patients receiving qigong plus herbal group qigong form [19]. Four were RCTs and five others reported significantly less symptoms (p B0.05) and were CCTs. Key data are summarised in Table I.
more increase in the immune functioning (p B0.01).
Sun and Zhao [16] conducted a CCT to assess the Fu [11] carried out an RCT to assess the effec- effectiveness of qigong on symptoms of cancer tiveness of combined qigong with herbal treatment Table I. Summary of clinical studies of qigong for cancer treatment.
management of cancer has advantageof raising curative rate, extending thetumour-free of survival and betterquality of their survival.' be related to the psychological factors.' 2) P B0.01 at week 4 and 8 difficulty of daily activities and some of Acta Oncol Downloaded from informahealthcare.com by 95.224.73.236 on 10/23/10 quality of life was not significant either.' Potentially relevant articles identified and Trials included in the systematic review Figure 1. Flowchart of trial selection process. RCT: randomized clinical trial; CCT: controlled clinical trial.
for survival rate in 186 post-surgery patients of cardiac adenocarcinoma (155 men and 31 women; mean age 059.898.8 years). Patients were rando- mised to four groups: surgery only (control; n chemotherapy only (etoposide, doxorubicin and cisplatin: EAP, n 042), herbal therapy only (not specified, n 046), and qigong combined with herbal treatment (n 050). The main outcomes were survival rate and median survival period. The survival rate were 80.1%, 36.5%, and 20.8% for the control group at 1, 3, and 5 years respectively; 85.7%, 45.2%, and 25.1% for chemotherapy group; 84.5%, 43.5%, and 26.1% for herbal group; 86.0%, 64.0%, and 36.0% for qigong combined with herbal treatment. There were significant differences between the qigong combined with herbal treatment and the control group (p B0.01). The median survival period was 30 months for the control group, 36 and 36.5 months for chemotherapy and herbal groups, and 48 months Acta Oncol Downloaded from informahealthcare.com by 95.224.73.236 on 10/23/10 for qigong combined with herb group.
Wang and Ye [18] investigated the therapeutic effects of qigong on psychological symptoms during rehabilitation of cancer patients. They recruited 104 cancer patients from a qigong rehabilitation unit as the experimental group, and 107 cancer patients from a regular cancer clinic with similar demo- graphic distribution and types of cancer. They evaluated all patients with the Eysenck Personality Questionnaire, Zung's Self-evaluate Anxiety Scale and Depression Scale, before and 3 months after the treatment. Patients who chose going to qigong rehabilitation were more likely to be extrovert, and have lower anxiety and depression levels at baseline than controls. Compared to the controls more patients in the qigong group reported relief of Hong [13] evaluated the efficacy of qigong on there was no large-scale RCT study in the literature.
adverse events of chemotherapy in advanced sto- The methodological quality of the existing studies is mach cancer patients. Twenty four patients were often poor. Of course, it is a methodologically non-randomly divided into two groups receiving challenging to design rigorous trials of qigong.
qigong with chemotherapy (5-FU plus Sunpla or Uncontrolled studies are open to bias with high Epirubicin) or chemotherapy only. The main out- risk of false-positive results. In CCTs, the nature of come was the level of fatigue as measured by Piper the control intervention deserves consideration. A fatigue scale. The difficulty of daily activities was ''placebo'' for qigong does probably not exist. In the assessed according to the Physical functioning sub- present set of studies absence of adequate statistical, scale of Medical Outcome Study-36. The frequen- variability of therapeutic protocols and poor quality cies of nausea, vomiting for the last 12 hours were of reporting are frequent methodological problems.
evaluated with an index ranging from 0 (none) to 5 Among the nine studies we included, only four (for more than 7 times). Fatigue was lower in qigong were randomized [11,12,14,17]. The rest of the group compare to controls. There were also signifi- studies [13,15,16,18,19] were therefore open to cant differences between the two groups in the level selection bias and false positive findings. Four of difficulty for daily activities, nausea, vomiting and studies were proceeding papers without adequate reporting of essential details.[11,16,17,19] Two were Lam [14] investigated the effect of qigong com- unpublished thesis [13,14] and one was published in bined with transcatheter arterial chemoembilisation a book [12], which had not gone through formal (TOCE) on survival rate and quality of life in peer review. One RCT failed to show an effect of patients with hepatocellular carcinoma. Patients qigong on survival rate and quality of life in were randomised into two groups receiving qigong hepatocellular carcinoma patients when compared with TOCE [14]. This trial lacked detail in reporting exercise lasted 2 hours per session, and were of methodological features such as carcinoma sta- performed twice weekly for 6 weeks in class and ging and co-interventions. Another RCT suggested 3.5 Á5 hours daily for 24 weeks at home. The main some survival advantages in cardiac adenocarcinoma outcome measured were survival rates and quality of patients receiving qigong [11]. Its methodology was, life, measured with SF-36. The survival rate was however, not clearly described. The third RCT 52.6% for qigong group and 29.0% for controls. The showed significant symptom reductions and an median survival time was not provided for the increase in immune function [12]. It was published qigong group (overall survival rate was higher than in a book, which had not gone through the process of 50%) and 242 days for the control group. The formal peer review. The forth RCT reported that differences between the intervention and the control qigong had favorable effects on health status and group are not statistically significant for either WBC count [17]. Unfortunately, it was also pub- lished only as an abstract, lacking essential details.
Lee and co-workers [15] conducted a CCT to Assuming that qigong is potentially beneficial evaluate the effect of qigong on symptoms and option for cancer patients, possible mechanism psychological distress of 67 breast cancer patients may be of interest. These may include improvement Acta Oncol Downloaded from informahealthcare.com by 95.224.73.236 on 10/23/10 receiving chemotherapy. Patients were divided into of immune function, which may enhance the im- one group having qigong with chemotherapy and mune deficiency experienced by most of cancer one having chemotherapy only. Primary outcome patients [8]. Others have postulated that qigong measures were symptom distress (measured with McCorkle and Young's symptom distress scale) and changes in blood viscosity, elasticity as well as psychological distress (measured with symptom platelet function [8]. A third proposed mechanisms is an increment of pain threshold combined with a showed significant differences between the groups relaxation effects [8]. If these theories were con- for the symptoms distress after 21 days but not in 5, firmed, they might explain how qigong leads to 8, 15 days. No significant differences between the intervention and control groups were noted for Limitations of our systematic review and indeed systematic review in general, pertain to the potentialincompleteness of the evidence reviewed. We aimedto identify all RCTs and CCTs on the topic. The distorting effects on systematic reviews and meta- Perhaps the most important finding of this systema- analyses arising from publication bias and location tic review is that the value of qigong for cancer bias are well documented [20 Á23]. In this review patients has not been adequately investigated as there were no restrictions in terms of publication language and a large number of different databases [9] Sancier KM. Therapeutic benefits of qigong exercises in were searched. We are therefore confident that our combination with drugs. J Altern Complement Med 1999;5: search strategy has located all relevant data. How- [10] Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, ever, a degree of uncertainty remains. Further Gavaghan DJ, et al. Assessing the quality of reports of limitations of our systematic review are the often randomized clinical trials: Is blinding necessary? Control poor quality of the primary data and poor reporting of results were highly heterogeneous in virtually [11] Fu JZ, Fu SL, Qin JT. Effect of qigong and anticancer body- building herbs on the prognosis of postoperative patients every respect. To establish the role of qigong in the with cardiac adenocarcinoma. In: Third World Conference management of cancer patients, adequately designed on Medical Qigong; 1996. Beijing, China: 1996.
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