This study of 245 patients and 72 physicians at a Chinese cancer hospital is the first to systematically assess and compare Chinese physician and patient attitudes towards TCM. The importance of these results is threefold: first, to reflect a unique medical system and demonstrate the effect of culture, history, and politics on utilization of and attitudes towards CAM; second, to elucidate what and why particular TCM therapies are being utilized which could inform clinical care and research in the West; third, to increase cultural competence of western practitioners caring for Chinese immigrants who commonly use TCM.
The use of TCM by Chinese cancer patients is exceptionally high, and physicians are generally well informed and supportive of their patients' TCM use. The 83.5% rate of TCM use by patients in our study is similar to that found in the few prior studies of Chinese cancer populations [9
] and significantly higher than CAM usage reported in most western countries [2
]. This is not surprising given that TCM is intricately intertwined with the history, culture, and politics of China. Additionally, TCM is institutionalized in China and actively promoted by the Chinese government as an area of research, a point of pride, and even as a commodity for export.
As in other populations, Chinese users of CAM tended to be more educated and in higher income brackets [2
]. Given that these therapies are “traditional medicine” in China, relatively inexpensive, and often covered by health insurance, it was somewhat surprising that the demographics would be parallel to those in western countries.
In this study, the therapies most commonly used were various forms of Chinese herbal medicines, tonics and food therapies. This is similar to many other countries where biologically based therapies are the most commonly used CAM [20
]. However, this is in stark contrast to the focus of research into TCM in the West where acupuncture is the dominant TCM therapy.
Surprisingly, cancer patients in China very rarely use acupuncture, and the few who do use it do so for health problems other than cancer. The majority of physicians surveyed believe that acupuncture is useful for symptom relief and improving QOL, but rarely recommended acupuncture to their patients. Numerous studies have shown acupuncture to be a useful adjunct to relieving cancer and treatment-related symptoms [23
]. Most of this research has been performed in the West, while most research on TCM cancer care in China is focused on herbals. At FUSCC, there are 14 herbalists but only two acupuncturists. Many physicians had concerns about the safety of acupuncture. Based on informal follow-up questioning, it seems this concern stems from a belief that acupuncture may seed metastases. There has only been one case report in the literature of a speculated case of acupuncture spreading cutaneous metastases when an acupuncture needle was directly inserted into a malignant lymph node, but, again, even this case was speculative [56
]. It is contraindicated to insert acupuncture needles into a tumor due to this concern for seeding potential and it is similarly contraindicated to puncture infected skin. Overall, however, acupuncture is a safe, minimally invasive procedure with very few side effects and few absolute contraindications [57
Many physicians also expressed concern that Qi Gong may interfere with conventional treatment and felt that Qi Gong was the least acceptable for patients to use while on treatment compared to all TCM therapies. This was surprising given that Qi Gong is purely a movement-based mind-body practice that falls in the CAM category of an “energy” manipulation and has none of the potential interactions with chemotherapy of herbal treatments and is not an invasive procedure such as acupuncture. At the same time, the majority of physicians also indicated they thought Qi Gong would help improve QOL and they did not indicate any safety concerns. Although we did not probe as to the specific reasoning behind the concerns, physicians could be concerned that the time involved with Qi Gong practice could detract from getting conventional treatment or that patients forego conventional treatment in favor of Qi Gong. During the time of this survey, our group was also conducting a study of Qi Gong and quality of life in breast cancer patients undergoing radiotherapy which encouraged daily practice. This may have impacted physician attitudes towards Qi Gong. Additionally, since the Falun Gong controversy of the 1990s, there has been lingering skepticism towards Qi Gong of which Falun Gong is an outgrowth decried as a cult by the Chinese government [63
In contrast to many other populations, most Chinese patients discuss use of TCM with their oncologists and find their physicians to be generally supportive. In fact, over 90% of physicians reported having prescribed TCM to their patients and many physicians use TCM themselves. This is likely a reflection of the fact that almost all western trained physicians in China have had some TCM training [4
The majority of Chinese physicians believe that TCM therapies have utility in cancer care. Unlike their western colleagues, many Chinese oncologists believe these complementary therapies useful not only for symptom control but also for treating cancer (particularly CHM). However, many physicians also report concern about the lack of evidence supporting CHM. Not only is this concern discrepant with their reported personal beliefs in the utility of CHM but also at odds with the vast amount of positive studies published in Chinese medical journals. This incongruity may be a reflection of the knowledge that the quality of the RCTs on TCM published in Chinese medical journals, while improving, remains quite poor [64
]. There also seems to be an a priori
belief that TCM is useful and beneficial given the historical experience, and the role of scientific research is to prove to the world the value of this cultural legacy while at the same time using scientific principles to systematize and modernize TCM. Indeed, this view is reflected in Communist party slogans to “inherit and carry forward the treasure-house of TCM [5
As to why Chinese patients use TCM, many patients report using for symptom control or as an “immune booster,” but the most common reported reason for many of the biologics was to treat or cure cancer or to prolong life. In clinical practice, purified or semipurified herbal extracts made into injections or infusions are often used as chemotherapeutics, and research into these extracts is appropriately focused on botanical as novel drug. However, herbal decoctions, the true “traditional” Chinese medicine and the form most often used, are complex whole herb extractions with basic formulas made up of 4–10 individual herbs with additional herbs added or subtracted based on patient symptomatology. Patients visit an herbalist bimonthly for years for prescriptions for individualized formulas of herbs which they then decoct at home. Based on the large amount of write-in answers, the full perceived utility of these decoctions may not have been well captured in our survey which was adapted from US-based surveys of CAM use. Many write-in answers reflected TCM-specific concepts such as to tonify Qi, yin, or blood or the restoration of balance. In speaking to physicians, these functions of Chinese herbal medicine are thought to be important to both consolidate the effects of western treatments as well as to help the body recover from these treatments. These functions are reflected in the oft-heard sayings, “Chinese medicine treats the root, while western medicine treats the manifestations” or “Chinese medicine treats chronic; western medicine treats acute” [5
]. This possibility of Chinese medicine as a “consolidative” or maintenance therapy is an intriguing area for future research given that it would minimize potential for herb-drug interactions as patients would be “off-treatment” and is a therapy phase currently lacking in the western treatment of many cancers.
Several limitations of this study must be acknowledged. The findings may not be broadly representative of cancer patients in China as it was conducted at one tertiary cancer center in a large relatively affluent urban center, although most patients came from outside of Shanghai and the low income and education levels of the sample are reflective of the population as a whole. The physicians in this survey tended to be young with less than 10 years experience and as demographics were not collected on nonresponders it is unknown if this could represent respondent bias. However, the physician response rate was very high at 80%. The surveys were developed based on prior surveys conducted in the US and may therefore not have reflected Chinese values. We attempted to minimize this cultural bias through the engagement of Chinese colleagues in adapting the instruments and then piloting and refining the instruments. The categorization of the biologics was developed in collaboration with Chinese colleagues but is not standardized and patients may have interpreted these categories differently.
This first systematic assessment of Chinese physician and patient attitudes towards TCM in cancer care demonstrated high use and acceptance and general concordance between patients and physicians. The response rates for both patients and physicians were unusually high, suggesting the findings are representative of the population being assessed. The high rate of use of TCM is a reflection of a uniquely integrated medical system with a long history; however, the findings have relevance to practitioners in the West, particularly to clinicians caring for Chinese immigrants, TCM practitioners, and CAM researchers.
Ideally, more preclinical and clinical research should be focused on the form of TCM most commonly used by the Chinese in cancer care, Chinese herbal decoctions. However, there are significant barriers to this type of research given that decoctions involve whole herbs with many active and inactive ingredients and impurities greatly impacting quality control [65
] and formulations are individualized and change over time in response to patients' changing clinical patterns. Areas for future qualitative research include patient satisfaction and quality of life and more in-depth questions regarding duration and patterns of use, further questioning of physicians on the discordance between their beliefs in utility and personal use and their concerns regarding lack of evidence, and better understanding the concerns with acupuncture and Qi Gong in cancer care. Education on the true risks and benefits of different TCM therapies may result in improved symptom control for this population of patients.