This is the second of a 3-part series of 'Questions and Answers' on Traditional Chinese Medicine (TCM) and Cancer written by Dr Linn Yeh Ching (Senior Consultant, SGH Department of Haematology).
You may acess 'Doc, can I take TCM for my cancer? (Part 1)' - HERE
3. Can TCM really improve my immune system?
Many herbs have been studied in the lab and found to have the property of increasing activity of lymphocytes, which are the cells that mediate immunity. Some examples are Astragalus membranaceus (黄芪), Ganoderma lucidum (灵芝) Panax ginseng (人参), Poria coco(茯苓), Atractylodes macrocephala (白术), Angelica sinensis (当归), Ligustrum lucidum (女贞子), Paeonia lactiflora (芍药), Rehmannia glutinosa (地黄), etc. Changes in lymphocyte numbers have also been measured in many clinical trials. For example, a double blind, randomized control study on TCM vs placebo in women receiving chemotherapy for ovarian cancer showed a less severe decrease in neutrophil and lymphocyte counts and cytokine production in the TCM group [9]. In a meta-analysis on TCM for side effect of chemotherapy in breast cancer patients, Chinese herbs in conjunction with chemotherapy may be beneficial in terms of improvement in marrow suppression and immune system compared to chemotherapy alone, and may improve overall state of quality of life. However, the authors commented that further trials are needed before the effects of TCM for people with breast cancer can be evaluated with any real confidence. There was no evidence of any harm caused by TCM [10].
We must be clear that lymphocyte counts and functions are at best laboratory parameters, what matters really is whether there is a significant reduction in the episodes of infection, or whether the immune-potentiation result in better prevention of tumour recurrence. The former is almost never studied or reported in TCM trials on cancer patients, while the latter is difficult to be differentiated from anti-tumour effect mediated through other mechanisms. Therefore, the actual clinical impact of having preservation of or improvement in lymphocyte count or cytokine level is difficult to assess, but may be of potential benefit.
4. How do herbs work in cancer?
Many herbs have been researched in the laboratory for their activity in cancer. Some examples are Astragalus membranaceus (黄芪), Panax ginseng (人参), Codonopsis Pilosula(党参), Poria cocos(茯苓), Scutellaria barbata (半枝莲), Hedyotis diffusa (白花蛇舌草) ,Mylabris (斑蝥), toad venom (蟾酥), garlic (大蒜), turmeric (姜黄), and the list goes on. Laboratory studies have demonstrated various mechanisms such as inhibition of cancer cell multiplication, arresting the cell cycle, induction of programmed cell death, regulation of adhesion and motility of cancer cells, suppression of new vessel formation, inhibition of the enzymes that maintain chromosome length, regulation of immune function, reversal of multiple drug resistance, enhancing the cytotoxicity of the chemotherapy regimen, etc. Again, laboratory evidence is important but whether they result in real clinical efficacy can only be tested in real clinical settings.
5. So, can TCM really help to increase my chance of cure?
Let’s look at some common cancers where there are studies of better quality to address this question. Such studies as a rule involve standard treatment with addition of the herbal product in the study group, without or with placebo in the comparison (control) group. When there are many studies done using the same herbs for the same condition, a meta-analysis combining all the comparable studies can be done.
Lung cancer
Astragalus membranaceus (黄芪) is a commonly used “Qi-tonifying”(补气) herb used for cancer patients. One meta-analysis analysed 34 randomized studies involving 2815 patients with non-small cell lung cancer (NSCLC) treated with cisplatin-containing chemotherapy without and with astragalus-containing TCM concoctions and found a reduced risk of death at 6 months, 1 year and 2 years, improvement in tumour response as well as improvement in performance status [11]. Another TCM formulation made into injectable is the Shenqi Fuzheng(参芪扶正) injection, concocted from Codonopsis pilosula (党参) and Astragalus membranaceus (黄芪). A meta-analysis of 29 studies showed that addition of Shenqi Fuzheng injection resulted in a higher tumour response rate and performance status, less suppression of blood counts and nausea / vomiting as compared to platinum-based chemotherapy alone [12]. Another TCM-derived treatment is Kanglaite (康莱特) injection, an injection made from extract of Semen coicis, the Coix Seed (薏苡仁), and is commonly used in conjunction with chemotherapy in China. A meta-analysis including 6 trials showed that compared to chemotherapy alone, addition of Kanglaite injection resulted in an improvement in response rate and quality of life, as well as reducing side effects of marrow suppression, nausea and vomiting [13].
Gastrointestinal cancer
Medicinal mushrooms have been used for cancers, with good evidence arising from several clinical trials from Japan in the 1970’s to 1990’s. These were studies on the effect of Coriolus versicolor (云芝) extract polysaccharide K (PSK) on advanced gastric cancer given post-operatively with chemotherapy, all showing improvement in survival as compared to placebo[14]. For example, in a study from Japan, 262 patients with gastric cancer after curative gastrectomy were randomly assigned to either standard adjuvant chemotherapy alone or with addition of PSK. They reported improvement in 5 year disease-free and overall survival without any additional toxic effect in the PSK group [15]. Another Japanese group studied 207 patients with stage II or III colorectal cancer given adjuvant chemotherapy, where addition of PSK compared to chemotherapy alone resulted in an improved 5 year survival and reduction of recurrence [16]. Such efficacy was reproducible in other well-conducted studies for colorectal cancer [17]. Similar benefit in long term survival was also reported for esophageal cancer after resection and radiotherapy [18], as well as for lung cancer [19].
The data on medicinal mushroom to date, mainly confined to PSK and less so, Polysaccharide-peptide (PSP), seems encouraging, considering the low risk vs benefit ratio. Other extract of medicinal mushroom eg Maitake D fraction, Active Hexose Correlated Compound, Lentinan are less well studied. Ganoderma lucidum (灵芝) has been studied in some trials in China for various malignancies.
Personalized TCM formulations have also been used for gastrointestinal cancers. A meta-analysis on chemotherapy without or with herbal medicine for advanced colorectal cancer showed that addition of personalized TCM improved tumour response and 1 year survival as well as performance status and reduced chemotherapy induced suppression of white cell, nausea and vomiting [20]. In this analysis, the most frequently used herbs were Astragalus membranaceus (黄芪), Panax ginseng (人参), Atractylodes macrocephala (白术), Poria cocos (茯苓), Coix lachryma-jobi (薏苡仁) and Sophora flavescens(苦参), corroborating with experimental findings of anti-tumour activities in each of these herbs. A Korean study done in patients with stage III gastric cancer who underwent post-operative chemotherapy given red ginseng compared to placebo capsules reported a significantly higher 5 year disease free and overall survival [21].
Other cancers
Another common cancer is nasopharyngeal carcinoma (NPC). A meta-analysis on NPC analysed 18 randomized controlled trials of conventional therapy, of which 14 used radiotherapy, 3 used chemotherapy and 1 used a combination of both, all of which had TCM concoction in addition as the corresponding study group. It showed a better survival at 1 and 3 years for the study groups. Tumour response and quality of life were superior in the study groups, where oral mucositis, nausea and vomiting were reduced [22].
It is conceivable that the benefit of TCM has been explored for its benefit for other types of cancer. The above are just some better examples and not meant to be exhaustive.
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