Integrative Oncology News
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Reflections on COVID-19 Rotation, by Ting Bao, MD, DABMA
Dear SIO Friends:
As I write to you, I am happy to report I have just completed a seven-day rotation at the COVID-19 inpatient service at my hospital in New York City! Overall, it was a positive experience, despite the occasional sad and scary moments. I left the service feeling uplifted and fulfilled. I am glad to have been on the front line of the war against this life-changing virus, making my contribution.
The most important lesson I have learned through this unique experience is things are not as bad as I thought they would be. I started the service with eleven patients; all were COVID-19 positive with cancer. Most of them had received chemotherapy within the previous two weeks, and some had low white cell counts and other co-morbidities. I thought most of them might deteriorate rapidly, and found with amazement that nine patients remained stable and got better over the next seven days. Among them, seven went home and two remained in the hospital with minimal COVID-19 symptoms, but waiting for placement. Two elderly end stage cancer patients ultimately passed away peacefully, with their family members able to visit the bedside one by one. I am glad our hospital was able to make the exception for our dying COVID-19 positive patients by allowing their family members to pay tribute as the end approached. As such, it makes this process much more humane and tolerable.
We admitted eight new patients over the week. Six were quite stable on the floor and would be going home soon. One patient quickly went to the ICU the same day of admission, but miraculously did not require intubation, improved significantly over two days, came back to the regular floor, and was discharged home three days later. Another patient with metastatic cancer, who had received chemotherapy about ten days prior, came in with COVID-19-induced respiratory failure. Initially he was classified “Do Not Resuscitate/Do Not Intubate” after extensive discussion with the family about his poor prognosis and essentially zero chance of coming off the ventilator. The family members then reversed his code status back to full code (requiring chest compression and intubation) when he was actively dying.
The whole process was very painful for everyone, especially the family members. My observation is that COVID-19 significantly shortened the time remaining for some of our end stage cancer patients, and often the family members were not ready for the inevitable end, not having had time to fully process their impending loss. We must be supportive in these cases, and should call in psychosocial support for the family when available.
Even though my service is over, there are a few moments that keep resurfacing in my mind.
Heartwarming moment: One of the infectious disease (ID) attendings not only saw patients and gave advice on COVID-19 management, but also helped us with code status discussion (Discussing Resuscitation Preferences), which is completely above and beyond her duty. One of our patients was not a native English speaker, but this ID attending happened to speak the patient’s language. She helped us clarify the patient’s code status while spending lots of time in the room with the patient, not worrying about her own risk of being infected at all. When I thanked her for doing this, she responded, “No problem. He reminded me of my dad.”
Nerve wracking moment: On my second day in the COVID-19 service, during our afternoon call, the resident told me the new intern was sent home early because of shortness of breath. The intern had just come off the ICU rotation in a busy COVID-19 hospital two days before. While listening, my mind was racing, recalling every moment I was standing close to her, touching her phone while talking to our patients. Over the next few hours while her COVID-19 test was pending, I tried to recall what I did after my close contact with her over the previous two days, almost reliving every moment, preparing for the worst, and considering what to do if she tested positive. Finally, her COVID-19 test result was negative. I was so relieved.
Heartbreaking moment: “Why don’t you monitor his heart rate? His oxygen level?” the patient’s daughter came out of the room, asking us with teary eyes.
My reply: “Because he is actively dying. He has too many underlying conditions and now severe respiratory distress.”
“But he is a fighter. It just takes a few days, then he will get better. He will overcome this.”
Again: “He is actively dying. We are trying to make him comfortable. Look, he is very comfortable.”
“He will get better, he will get better.” She started crying, I got teary too, for her, and for the helpless situation.
Before I knew it, the rotation was over and I am back to normal life. No more wearing scrubs, rushing to the hospital; no more wearing double-layered face masks that would leave a mark on my nose and face; no more FaceTiming with the patient right outside the room; no more going back and forth to the laundry room four times per day; no more wondering every time anyone around me sneezed, coughed, or complained of sore throat, D'id I catch it? Did I spread it to my family?' I am glad I worked on the front line and helped some COVID-19 patients. I am no longer living in fear that most of my cancer patients will die if they catch COVID-19, as I have seen that truly, most of them got better with time and treatment. I will continue to be cautious, though, as some of them could get very sick and die quickly.
The best moments usually came at 7pm everyday, when my daughter would join her friends on our building’s terrace, cheering for the health care providers. She would always add a sentence at the end, “I am cheering for my mom! She took care of COVID-19 patients!”
Stay safe and well. Let us stay connected during this isolating pandemic.
Ting Bao, MD, DABMA, MS
Traditional Chinese Medicine (TCM) and Integrative Oncology Practice in China During the COVID-19 Outbreak
Given the rapidly progressing global COVID-19 crisis, SIO leadership has decided to launch a COVID-19 column to specifically address our members’ needs. Our first interview is with Yufei Yang, MD, who is the director of integrative oncology at Beijing Xiyuan Hospital. We would like to learn from our Chinese colleagues’ recent advances in combating COVID-19. This is in keeping with SIO’s practice of facilitating opportunities to share our members’ experiences and perspectives. The following column represents Dr. Yang and her team’s views only.
Traditional Chinese Medicine (TCM) and Integrative Oncology Practice in China During the COVID-19 Outbreak
Yufei Yang MD*, Yun Xu MD, Lingyun Sun MD
Authors’ affiliation: Clinical Cancer Center, Xiyuan Hospital of China Academy of Chinese Medical Sciences
- How are Chinese healthcare practitioners providing integrative oncology care while limiting risk of transmission?
COVID-19 has a higher rate of transmission compared to other infectious diseases such as SARS or MERS. Because cancer patients often have suppressed immune systems, they may have higher risks of being infected. As such, it is imperative that cancer patients protect themselves by practicing social distancing. However, patients still need treatments for both cancer control and symptom management during this time. In China, about 80% of cancer patients receive Traditional Chinese Medicine (TCM) treatments, including herbal medicine, patent Chinese medicine, and acupuncture. To address these needs, we have certain procedures that provide TCM services to cancer patients while limiting the risk of transmission during the COVID-19 outbreak.
During COVID-19 outbreak, most TCM hospitals and their oncology departments outside Hubei province continuously accepted patients. At that time, admission was limited to local patients only. To be treated, patients first needed to undergo COVID-19 screening, which included history taking and relevant symptom screening. The patients who needed hospitalization underwent chest CT scans as well. Meanwhile, it was critical that every corner of the hospital be sterilized. Both doctors and patients wore masks and recorded their body temperature at least twice daily. For TCM services, even though we could not offer acupuncture or massage treatment that requires direct patient contact, we recommended TCM herbal medicine and patent Chinese medicine (patent Chinese medicine is commercialized TCM products of certain dosage approved by the National Medical Products Administration).
In China, many cancer patients receive TCM treatments in big cities such as Beijing, Shanghai and Guangzhou. Since the COVID-19 outbreak, many patients could not visit their doctors because of transportation and hospitalization restrictions. For these patients, online remote TCM consultations, services and educational programs were used. To the best of our knowledge, there are more than ten online apps that offer such services in China. Patients could also contact their TCM doctors through hospitals’ official websites. To help more cancer patients get through this crisis, some TCM doctors waived fees for online consultations. In Xiyuan Hospital of China Academy of Chinese Medical Sciences, staff helped patients by home delivering prescribed TCM herbs and other medicine.
- What have been the challenges and facilitators of integrative oncology care during the COVID-19 pandemic?
As mentioned above, transportation limitations and other restrictive policies presented the biggest challenge for us to provide TCM services to cancer patients, both outpatients and inpatients, during the COVID-19 outbreak. Nonetheless, there were still opportunities for TCM and other integrative oncology interventions such as mind-body therapies like Taichi/Qigong, to play an even more important role in helping cancer patients weather this outbreak. Patients whose cancer treatments were delayed or changed because of the COVID-19 outbreak had greater need for TCM interventions to control cancer-related or treatment-induced symptoms. Some TCM herbs or patent Chinese medicines with anti-tumor effects could be used for advanced cancer patients who needed timely chemo or radiotherapy to reduce their cancer burden. This echoed some western medicine oncologists’ recommendations in China on the management of cancer treatments during this period. This was also met with a high receptivity of cancer patients in China towards using TCM to protect themselves from COVID-19.
Since TCM plays an important role in the treatment of COVID-19, more Chinese cancer patients were confident and willing to utilize TCM for their treatments. TCM methods such as Taichi/Qigong could be practiced inside the home and were welcomed by many cancer patients to help strengthen their essential Qi, or vital life energy. From one of our ongoing multi-center clinical trials in China, we found that stage II/III colon cancer patients from TCM hospitals or integrative oncology departments were less likely to have adjuvant chemotherapy delays related to COVID-19.
3. What practices have been found helpful in supporting cancer patients affected by COVID-19 in China?
A national study of 1,590 COVID-19 patients in China showed a higher incidence of COVID-19 infections among cancer patients (1%), compared to the general population (0.29%). If they were infected by the virus, cancer patients usually had worse medical conditions and worse adverse events (death or ventilator requirement) than those without. This emphasized the importance of self-protection for cancer patients during COVID-19 outbreak. Staying at home is a relatively safer and better choice for them.
However, it is a dilemma that cancer treatments are usually time dependent, and just waiting at home could make many cancer patients feel anxious and helpless. As mentioned above, our multi-center RCT showed that over 50% of stage II/III colon cancer patients experienced delayed or changed treatment regimens, mainly due to hospitalization policies and transportation restrictions during this period. The real number of cancer patients who have been affected by the epidemic may exceed current estimations. For cancer patients who were waiting for scheduled surgery and adjuvant chemotherapy, as well as for cancer survivors, our recommendation was to hold off treatment for now and stay at home to reduce the risk of becoming infected. Emotional support from their families and caregivers, as well as online patient education and remote consultation were very important in reducing cancer patients’ concerns and worries. For patients with advanced diseases who need timely chemo or radiotherapy, we suggested they receive treatments locally instead of traveling to the larger cities, and that their disease progression be evaluated as scheduled locally. For patients needing palliative and supportive care, we suggested that healthcare providers offer them psychological support and emergency room referrals if needed.
4. What integrative medicine practices are being used in China to address the effects of COVID-19?
First of all, integrative medicine practices and TCM play a role in disease prevention, especially in vulnerable populations. From the perspective of TCM theory, the principle of ‘preventive treatment of diseases’ takes priority. Since the outbreak of COVID-19, TCM experts have collected and analyzed data on TCM characteristics of COVID-19 patients in WuHan. According to this data and experience, TCM experts in China quickly reached a consensus that the disease was highly correlated with TCM syndrome and the pathogenic factor of dampness. Thus, during COVID-outbreak, prevention methods such as herbal teas were widely used around China to prevent the infection by strengthening the body’s essential Qi of the Lung and Spleen, as well as eliminating pathogenic factors such as dampness, wind, cold or heat. However, such preventative methods need to be adjusted based on season, location and climate. In addition, mind-body therapies such as yoga and Taichi/Qigong are also useful as practical disease preventions, especially for those who stay at home.
TCM played a very important role in the treatment of COVID-19 patients in China during this pandemic . Since January 2020, over 4,900 TCM doctors or nurses have rushed to support the Hubei province, taking charge of several hospitals, wards and temporary mobile hospitals in WuHan. According to data released from the Information Office of the State Council press conference on March 23rd 2020, 91.5% of all COVID-19 patients in China have utilized TCM herbal medicine or patent Chinese medicine for treatment of mild disease, assistance in the treatment of severe cases, and the rehabilitation of the patients who have recovered. The overall effectiveness rate of TCM treatments for COVID-19 was 90%. None of the patients with mild diseases in temporary mobile hospitals developed severe disease after TCM intervention. For severe cases, the concurrent use of TCM reduced the use of hormone and antibiotic drugs as well as the death rate of the disease. Recently, Diagnosis and Treatment Protocol for COVID-19 (Trial Version 7) has been published in both Chinese and English. It introduced TCM regimens for different types and phases of the disease and highlighted three patent Chinese medicines ‘Jinhua-Qinggan Granule’ (金花清感颗粒), ‘Lianhua-Qingwen Capsule’ (连花清瘟胶囊), ‘Xuebijing injection’（血必净注射液）, and three prescriptions ‘Qingfei-Paidu Formula’（清肺排毒方), ‘Xuangfei-Baidu Formula’(宣肺败毒方),‘Huashi-Baidu Formula’(化湿败毒方). There are several ongoing registered randomized clinical trials on these TCM herbal medicine decoctions’ efficacy in treating COVID-19 and related symptoms in China. Acupuncture, Taichhi/Qigong (such as Baduanjin), and even dancing were also used by infected patient populations to relieve symptoms such as anxiety and dyspnea, and to promote quality of life during hospitalization.
5. Is there any data yet on the use of TCM to prevent COVID-19 infection (or reduce its severity) in cancer survivors?
So far, to the best of our knowledge, there is no existing evidence on TCM’s ability to prevent COVID-19 infection in cancer patients. However, in our clinical practices, we have been providing TCM preventative herbal medicine for cancer patients since they are immune-suppressed and vulnerable to infection. The herbal medicine is manufactured into granules, which are easily administered. Many cancer patients have reported that the medicine is useful in relieving symptoms of the common cold and fever. Experts from Hubei province published a consensus on prevention of COVID-19 for cancer patients by utilizing integrative Chinese medicine and western medicine, including daily prevention methods, TCM herbs and other TCM intervention such as moxibustion, massage, and auricular acupressure.
6. Are there specific TCM botanical combinations or practices that can address the buildup of pulmonary fibrosis due to COVID-19 infection in any patient population?
7. What advice would you have for providers in countries now facing an increase in cases, based on your experience in China?
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