Introduction: 

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

*corresponding author

  • 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[1]. 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[2]. 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[3]. 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 [4]. 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%[5]. 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)[6]. 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[7]. 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[8].

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?

Reference

1.           Zu ZY, Jiang MD, Xu PP, Chen W, Ni QQ, Lu GM, Zhang LJ: Coronavirus Disease 2019 (COVID-19): A Perspective from China. Radiology 2020:200490.

2.           Yang G, Zhang H, Yang Y: Challenges and Countermeasures of Integrative Cancer Therapy in the Epidemic of COVID-19. Integr Cancer Ther 2020, 19:1534735420912811.

3.           Liang W, Guan W, Chen R, Wang W, Li J, Xu K, Li C, Ai Q, Lu W, Liang H et al: Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. The Lancet Oncology 2020.

4.           Chan KW, Wong VT, Tang SCW: COVID-19: An Update on the Epidemiological, Clinical, Preventive and Therapeutic Evidence and Guidelines of Integrative Chinese-Western Medicine for the Management of 2019 Novel Coronavirus Disease. Am J Chin Med 2020:1-26.

5.           Council IOotS: Press Conference on Traditional Chinese Medicine’s Important Role on Prevention and Treatment of COVID-19 andis effective drug In.: Information Office of the State Council; 2020.

6.           Medicine SAoTC: Diagnosis and Treatment Protocol for COVID-19 (Trial Version 7). In.; 2020.

7.           Luo H, Tang QL, Shang YX, Liang SB, Yang M, Robinson N, Liu JP: Can Chinese Medicine Be Used for Prevention of Corona Virus Disease 2019 (COVID-19)? A Review of Historical Classics, Research Evidence and Current Prevention Programs. Chinese journal of integrative medicine 2020.

8.           Z. H: Expert consensus on novel coronavirus pneumonia during the epidemic period in Hubei area: Integrated Traditional Chinese and Western medicine prevention and rehabilitation (First Edition). Herald of Medicine 2020:1-8.

9.           Wang T HL, Wang Y, et al.: Research progress of Chinese patent medicine in the treatment of viral pneumonia. Chinese Journal of traditional Chinese Medicine 2020:1-7.

10.         Li C ZX, Liu S, Shang H: Novel coronavirus pneumonia (COVID-19) evidence and research prospect of Xuebijing Injection. World science and technology modernization of traditional Chinese Medicine 2020:1-6.

11.         Bian Y MJ, Ren Y, et al.: Based on VEGFR and FGFR, to explore the intervention effect of traditional Chinese medicine on pulmonary fibrosis in the sequelae of covid-19. Chinese Journal of traditional Chinese Medicine 2020:1-8.