Vol. - No.

- - 2016 Journal of Pain and Symptom Management 1

Original Article

Effects of Acupuncture, Tuina, Tai Chi, Qigong, and Traditional

Chinese Medicine Five-Element Music Therapy on Symptom
Management and Quality of Life for Cancer Patients: A Meta-Analysis
Wei-Wei Tao, MS, Hua Jiang, MS, Xiao-Mei Tao, PhD, Ping Jiang, MS, Li-Yan Sha, MS, and Xian-Ce Sun, MD
College of Nursing (W.-W.T., L.-Y.S.); Graduate School (P.J.), and College of Public Health (X.-C.S.), Dalian Medical University, Dalian;
School of Nursing (H.J.), Peking University, Beijing; and Beijing Shijitan Hospital (X.-M.T.), Beijing, Peoples Republic of China

Abstract
Context. Most cancer patients suffer from both the disease itself and symptoms induced by conventional treatment.
Available literature on the clinical effects on cancer patients of acupuncture, Tuina, Tai Chi, Qigong, and Traditional Chinese
Medicine Five-Element Music Therapy (TCM-FEMT) reports controversial results.
Objectives. The primary objective of this meta-analysis was to evaluate the effect of acupuncture, Tuina, Tai Chi, Qigong,
and TCM-FEMT on various symptoms and quality of life (QOL) in patients with cancer; risk of bias for the selected trials also
was assessed.
Methods. Studies were identified by searching electronic databases (MEDLINE via both PubMed and Ovid, Cochrane
Central, China National Knowledge Infrastructure, Chinese Scientific Journal Database, China Biology Medicine,
and Wanfang Database). All randomized controlled trials (RCTs) using acupuncture, Tuina, Tai Chi, Qigong, or
TCM-FEMT published before October 2, 2014, were selected, regardless of whether the article was published in Chinese
or English.
Results. We identified 67 RCTs (5465 patients) that met our inclusion criteria to perform this meta-analysis.
Analysis results showed that a significant combined effect was observed for QOL change in patients with terminal
cancer in favor of acupuncture and Tuina (Cohens d: 0.21e4.55, P < 0.05), whereas Tai Chi and Qigong had no
effect on QOL of breast cancer survivors (P > 0.05). The meta-analysis also demonstrated that acupuncture produced
small-to-large effects on adverse symptoms including pain, fatigue, sleep disturbance, and some gastrointestinal
discomfort; however, no significant effect was found on the frequency of hot flashes (Cohens d 0.02; 95%
CI 1.49 to 1.45; P 0.97; I2 36%) and mood distress (P > 0.05). Tuina relieved gastrointestinal discomfort.
TCM-FEMT lowered depression level. Tai Chi improved vital capacity of breast cancer patients. High risk of bias was
present in 74.63% of the selected RCTs. Major sources of risk of bias were lack of blinding, allocation concealment,
and incomplete outcome data.
Conclusion. Taken together, although there are some clear limitations regarding the body of research reviewed in this
study, a tentative conclusion can be reached that acupuncture, Tuina, Tai Chi, Qigong, or TCM-FEMT represent beneficial
adjunctive therapies. Future study reporting in this field should be improved regarding both method and content of
interventions and research methods. J Pain Symptom Manage 2016;-:-e-. 2016 American Academy of Hospice and Palliative
Medicine. Published by Elsevier Inc. All rights reserved.

Key Words
Acupuncture, massage, Tai Chi, Qigong, cancer, symptom management, meta-analysis

W.-W. T, H. J., X.-M. T., and L.-Y. S. contributed equally to
this work and should be regarded as co-first authors.
Address correspondence to: Wei-Wei Tao, MS, College of
Nursing, Dalian Medical University, 9 West Section,
Lvshun South Road, Dalian, Peoples Republic of China.
E-mail: taoweiwei2003@163.com; or Ping Jiang, E-mail:
dywx.2009@163.com
Accepted for publication: November 20, 2015.

2016 American Academy of Hospice and Palliative Medicine. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2015.11.027
2 Tao et al.
Introduction
Cancer is one of the most common causes of death
worldwide. It accounted for 7.6 million deaths
(around 13% of all deaths) in 2008, and deaths
from cancer internationally are projected to rise to
more than 11 million in 2030,1 according to the World
Health Organization (WHO). Conventional treatment
for cancer, such as surgery, chemotherapy, radio-
therapy, and endocrine therapy, aiming at curing the
disease or prolonging life produces considerable
beneficial medical outcomes. However, these treat-
ments cannot eradicate the diseases and are often
accompanied by adverse effects. It is acknowledged
that most cancer patients suffer from both the disease
itself and symptoms induced by conventional treat-
ment, such as fatigue, anxiety, depression, nausea,
and pain, and being at an increased risk of developing
secondary tumors.2e4 Numerous patients report
feeling abandoned and isolated after cessation of
active treatment,5 which could exacerbate symptoms
such as depression and anxiety. This may have an
impact on their quality of life (QOL), which has
been reported as being lower than other population
groups.6 Therefore, for cancer survivors, it is essential
to look at ways of improving QOL and long-term
health outcomes.
Nonpharmacologic interventions typically encom-
pass a broad range of psychosocial, behavioral, and
environmental strategies that may complement con-
ventional treatment to enhance QOL for cancer
patients.7 Traditional Chinese nonpharmacologic
interventions include a series of approaches such as
acupoint stimulation, Chinese massage (referred to
as Tuina), Tai Chi, Qigong, and Traditional Chinese
Medicine Five-Element Music Therapy (TCM-FEMT).
The use of these interventions for the management
of cancer can be traced back to the Shang Dynasty
of China 3500 years ago.8 Over the centuries, various
interventions such as acupuncture (involving the
placement of solid, sterile, stainless steel needles
into specific points on the body), moxibustion (stimu-
lating skin thermally by the burning of moxa, also at
precise locations or other specific areas),9 Chinese
massage (a wide range of technical manipulations con-
ducted by a practitioners finger, hand, elbow, knee, or
foot applied to muscle or soft tissue at specific body lo-
cations),10 and Qigong have been developed and used
in cancer treatment.11 Qigong, a general term for a
large range of traditional Chinese energy exercises
and therapies, is popularly practiced by a large num-
ber of people in Chinese communities. Basically, there
are two categories of Qigong: internal qigong vs.
external qigong. Internal qigong or qigong exercise
is self-directed and involves the use of movements,
meditation, and control of breathing patterns. The
Vol. - No. - - 2016
gentle movements and postures of the exercise are de-
signed to achieve a harmonious flow of energy (qi) in
the body so as to improve physical fitness and overall
well-being. External qigong is usually performed by a
trained practitioner using their hands to direct
emitted qi energy onto the patients body in the
diagnosis and treatment of various diseases.12 Tai
Chi includes relaxation, deep and regulated breathing
techniques, and slow movements, and it is an interven-
tion that shares many characteristics with Qigong.13
Music therapy has been defined as the clinical and
evidence-based use of music interventions to accom-
plish individualized goals within a therapeutic re-
lationship..14 In China, researchers usually apply
some traditional music based on the five elements of
TCM in their studies, which is called TCM-FEMT.15
In the last decade, the use of these interventions has
increased dramatically. According to the WHO,
acupuncture is used in at least 78 countries.16
Although multiple studies applying these interven-
tions in cancer patients have reported positive
outcomes,15,17e20 others have described mixed
evidence.19,21e25 Differences in study design, interven-
tions type, frequency and duration and the therapist
in these interventions may produce varying results.
Therefore, a systematic review with a meta-analysis of
the interventions is needed to more accurately gauge
efficacy for cancer patients and evaluate the quality
of such studies.
Although several systematic reviews with or without
meta-analysis have addressed this issue,9,12,26e33 they
often have covered only a small section of evidence,
restricting their scope to either a specific subpopula-
tion of patients with cancer or a specific type of inter-
vention, or both, thus making broader conclusions
difficult. Moreover, many reviews are outdated. Several
reviews also have reported the utilization of TCM
among cancer patients34e36; however, a large propor-
tion of the reviews discussed the use of herbal medi-
cine, which was not involved in the interventions.
This study aims at closing this gap and producing an
overall picture of contemporary research in this field
while exploring the hypothesis that acupuncture, Tui-
na, Tai Chi, Qigong, or TCM-FEMT may contribute to
the QOL of cancer patients.
Methods
Eligibility Criteria
Eligibility criteria are detailed following the
Participants, Interventions, Controls, Outcomes, and
Studies (PICOS) framework37:
Participants. Participants were adults aged 18 years or
older who had been formally diagnosed with cancer of
Vol. - No. - - 2016 Interventions for Symptom Management and QOL
any type (solid and hematologic), any tumor stage, any
kind of treatment mode, and any time since diagnosis.
Interventions. Approaches including acupoint stimu-
lation, Chinese massage (Tuina), Tai Chi, Qigong,
TCM-FEMT, alone or in combination, were reviewed.
Studies evaluating any types of herbal medicine, point
injection, Thai massage, Japanese massage, Swedish-
style massage, reflexology, aromatherapy massage,
and other music therapy were excluded.
Controls. No treatment (usual care) and active (atten-
tion placebo) control conditions were both consid-
ered. Nevertheless, studies without the use of a
control condition were excluded.
Outcomes. Primary outcomes were health-related
QOL at post-treatment. Among the studies reviewed,
overall QOL was measured by the Functional
Assessment of Cancer TherapyeBreast or Functional
Assessment of Cancer TherapyeGeneral (FACT-B or
FACT-G), Karnofsky Performance Status (KPS) score,
European Organization for Research and Treatment
of Cancer Quality of Life QuestionnaireeCore 30,
and the Medical Outcomes Study Short Forme36
(SF-36). Secondary outcomes included cancer-related
symptoms and therapy-related adverse events such as
pain, flushes, fatigue, sleep disturbance, hair loss,
negative mood, diarrhea, flatulence, nausea, and
vomiting.
Studies. Only randomized controlled trials (RCTs)
were considered. All the articles included in this
meta-analysis are listed in the References.
Information Sources
Studies were identified by 1) searching electronic
databases (MEDLINE via both PubMed and Ovid,
Cochrane Central, China National Knowledge Infra-
structure from 1911 to October 2014; Chinese Scienti-
fic Journal Database from 1989 to October 2014;
China Biology Medicine from 1978 to October 2014;
and Wanfang Database from 1994 to October 2014),
2) scanning reference lists of relevant review articles;
and 3) contacting study authors.
Data Collection
The search terms in the English and Chinese litera-
ture were (cancer OR tumor OR tumour OR neoplas*
OR oncolog*), AND (acupoint OR acupuncture OR
moxibustion OR TCM OR Chinese massage OR
Qigong OR Tai Chi OR TCM Five Element Music
Therapy), AND (quality of life OR pain OR nausea
OR hot flashes OR hot flushes OR fatigue OR xerosto-
mia OR ileus OR anxiety OR depression OR mood
3
disorder OR sleep disturbance OR insomnia OR dys-
pnea OR shortness of breath OR peripheral neuropa-
thy OR hiccups OR hiccoughs).
Data extracted from the studies included year of
publication, country of origin, number of participants
randomly assigned, mean age, sex, type of tumor,
treatment status, type of intervention, duration of
intervention, control condition, and outcomes
(including assessment instruments).
All articles were read by two independent reviewers
(W. -W. T. and X. -M. T.), and data from the articles
were validated and extracted and entered into Excel.
Discrepancies between reviewers were resolved by
discussion.
Assessment of Risk of Bias
The risk of bias was assessed using the Cochrane
Handbook for Systematic Reviews of Interventions
(RevMan version 5.1.0, The Cochrane Collaboration,
2011). Six components associated with the risk of
bias were assessed: generation of the allocation
sequence, allocation concealment, masking of
outcome assessors, selective outcome reporting,
incomplete follow-up, and other potential sources of
bias. Trials with a low risk for all six components
were defined as having an overall low risk of bias. Tri-
als in which one or more of the six bias components
were unclear or had high risk of bias were defined
to be at high risk of bias.38 Disagreements were
resolved by discussions among the two reviewers and,
if necessary, through discussion among the authors.
However, there were no disagreements among the
two reviewers.
Statistical Analysis
The descriptive data for all the included studies
were entered into Excel, and statistical analyses were
completed using Review Manager 5.0, supplied gratis
by the Cochrane organization (www.cochrane.org/
cochrane/hbook.htm) for meta-analyses. The effect
sizes were calculated as Cohens d standardized
mean effects of the interventions. Individual study ef-
fect sizes were synthesized to generate an overall effect
size using a random or fixed effects model according
to the heterogeneity level, weighted by the inverse of
variance. For continuous variables, mean difference
was calculated when outcomes were measured using
the same scale, and the standardized mean difference
was used when different scales were used in different
trials, with corresponding 95% CIs. If data for SDs
were missing, they were computed for the calculation
of statistical pooling of effect size by calculating the
trial data using standard error of the mean or 95%
CIs.38 For dichotomous variables, the odds ratios
were calculated when appropriate summary statistics
4 Tao et al.
were reported.39 An odds ratio of more than 1 indi-
cates an advantage for the interventions. We also
completed a sensitivity analysis to identify potential
outliers by removing each study one by one to
examine the individual influence of each study on
the overall effect size. Heterogeneity was assessed
using Cochranes Q and I2, which calculates the pro-
portion of variation attributed to heterogeneity. Statis-
tical heterogeneity of trial results was assessed by visual
inspection of forest plots, c2 tests, and the I2 statistic.40
A P-value greater than 0.10 for c2 tests and an I2 value
of less than 25% were interpreted as signifying a low
level of heterogeneity.40 Primary analyses were per-
formed with a fixed effects model; secondary confir-
matory analyses were performed with a random
effects model if there was significant heterogeneity.
An effect size of 0.8 was considered large, 0.5 was
considered medium, and 0.2 was considered small.41
A two-tailed P-value of less than 0.05 was considered
to be significant.
Results
Study Selection
The search of the English and Chinese literature
retrieved 11,166 citations, of which 10,540 records
were excluded on the basis of the abstract alone because
of nonrelevance or duplication. The full texts of the
remaining 626 articles were retrieved for more detailed
evaluation, and 489 articles were excluded 1) for
including herbs or other medicine (n 149), 2) inter-
ventions combined with other nontraditional methods
(n 79), 3) no RCT (n 151), 4) no relevant outcomes
(n 72), 5) insufficient information (n 26), and 6)
publication not available (n 12). An additional five
articles were incorporated, gleaned from reference
lists, for a total of 142 studies included in this review.
Of these, 67 trials (20 in English and 47 in Chinese)
covering 5465 patients provided enough data for
statistical pooling and were used for quantitative
meta-analysis (Fig. 1, Table 1).15,17,19e22,24,42e70,71e100
Study Characteristics
The systematic search covered the period from 1980
to 2013. More than 80% of the studies (51/67) were
conducted in China, and the others were from the
United States (11/67), Sweden (2/67), and Australia
(2/67). The trials comprise 5456 patients. Study par-
ticipants had a median intervention duration of
4.9 weeks (ranging from 24 hours to 24 weeks), with
four reports in Chinese not supplying the length of
intervention. Thirty-seven percent of the trials
reported mixed cancer, 27% included breast cancer
diagnoses, followed by colorectal cancer (9%) and
liver cancer (7%). Forty-five trials were of acupoint
Vol. - No. - - 2016
stimulation, nine of Tai Chi, seven of Chinese mas-
sage, three of TCM-FEMT, two of Qigong, and one
of acupuncture combined with TCM-FEMT.
One-third of the studies (22/67) used an active con-
trol condition, such as sham acupuncture (n 9), oral
or injectable drug (n 8), psychosocial therapy
(n 3), music exercise (n 1), or relaxation
(n 1; Table 1).
Among the 67 RCTs included in the meta-analysis,
the top three outcome measures reported were pain,
hiccups, and fatigue, with nine studies each. Evalua-
tion tools for overall QOL were varied, among which
KPS score was the most frequently reported (n 7),
followed by the FACT-G (n 4), European Organiza-
tion for Research and Treatment of Cancer Quality of
Life QuestionnaireeCore 30 (n 3), and SF-36
(n 2; Table 2).
Risk of Bias Analysis
Each trial was evaluated in terms of its risk of bias.
Most (50/67) had high risk of bias, 12 of 67 with mod-
erate, and five with low risk of bias. Major sources of
risk of bias were lack of blinding, allocation conceal-
ment, and incomplete outcome data. Of 67 trials,
only 11 studies (10 on acupoint stimulation and one
on Tai Chi) described the method of blinding and
methods of allocation concealment. Less than half of
the reports provided specified numbers and reasons
for dropouts by each subject group. No more than
52% provided information on the method of random-
ization used (Fig. 2).
Effects of the Interventions on Clinical Outcomes for
Cancer Survivors
Effects are described according to outcome mea-
sures: overall QOL (20/67 of the comparisons),
adverse symptoms including gastrointestinal distress
(21/67), pain (9/67), fatigue (9/67), depression (7/
67), anxiety (4/67), sleep disturbance (4/67), flushes
(3/67). Other clinical outcomes involved are vital ca-
pacity (3/67) and body mass index (BMI; 3/67). Seven-
teen studies evaluated two or more outcomes (Table 2).
General QOL. Eleven trials17,19,43,59,70,71,74,75,95e97
used generic scales (e.g., KPS, SF-36, World Health Or-
ganization Quality-of-Life Scale) to assess changes in
general QOL scores after acupuncture and Tai Chi.
Cancer-specific QOL was measured by the FACT-G,
FACT-B, or EORTC QLQ-30 in nine
studies.15,20e22,24,48,51,57,92 Fig. 3 shows that a significant
combined effect was observed for general QOL change
in patients with terminal cancer in favor of acupunc-
ture; Chinese massage improved cancer-specific
QOL, and Tai Chi and Qigong had no effect on QOL
of breast cancer survivors.
Vol. - No. - - 2016 Interventions for Symptom Management and QOL
Duplicates (n =6862)
Excluded(n =3678)
Clearly not relevant(n =3678)
Excluded(n =489)
Interventions including herbs or other
medicine (n =149)
Interventions combined with other
non-traditional methods (n =79)
Method (no RCT) (n =151)
No relevant outcomes (n =72)
Insufficient information (n =26)
Publication not available (n =12)
Excluded (n =75)
Not providing sufficient data for
further analysis (n =75)
Fig. 1. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram of study selection.
CNKI China National Knowledge Infrastructure; CBM China Biology Medicine; RCT randomized controlled trial.
Sensitivity analyses yielded one study75 with a great
impact on both effects and heterogeneity for overall
QOL evaluated by KPS. Meta-analyses excluding this
study showed smaller effect sizes and heterogeneity
(d 2.79; 95% CI 1.12 to 6.69; P 0.16;
I2 77%).
Adverse Symptoms. Nine studies50,64,67e69,80,81,84,85
including 710 patients evaluated the impact of inter-
ventions on pain (eight on acupuncture and one on
Chinese massage). A small but significant effect was
found in our meta-analysis for acupuncture
(d 0.30; 95% CI 0.56 to 0.03; P 0.03;
I2 59%; Fig. 4a).
Association of interventions and fatigue was evalu-
ated in nine trials24,42,43,52,71,72,79,80,82 involving 886
participants (seven on acupuncture, one on Tai Chi,
5
Medline-325; Cochrane Central-
457;Chinese Scientific Journal
Database-3237;WanFang-3947 ;CN
KI-1582; CBM-1618; Total
citations (n = 11,166)
Screening of titles and abstracts
(n =4304)
Assessment of full-text articles
(n =626)
Identified from searches of
reference lists (n=5)
Studies included in systematic
review (n = 142 )
Studies included in quantitative
meta-analysis (n =67 )
and one on Qigong). Significant large post-
treatment effects were observed for acupuncture
(Figs. 4b and 4c).
Acupuncture was found to relieve gastrointestinal
distress including diarrhea,45,54 nausea, and vomit-
ing.47,73 Acupuncture and Chinese massage also
relieved hiccups (eight studies on acupuncture, one
on Chinese massage),55,62,76e78,89,98e100 and short-
ened hours to first flatus (five on acupuncture, three
on Chinese massage)44,46,56,58,63,66,81,90 and hours to
first bowel movement (three on acupuncture, three
on Chinese massage)44,46,56,58,66,90 (Figs. 4de4j).
Four trials involving 646 patients evaluated interven-
tions on sleep level using the Pittsburgh Sleep Quality
Index (two on acupuncture, one on Chinese massage,
and one on Qigong).24,53,60,65 Our meta-analysis
showed a significant combined effect of acupuncture
 6
Table 1
Descriptive Summary of Studies Included in the Meta-Analysis
Length of
Cancer Study Sample Experimental Control Intervention Outcome Risk of
Author Year Type Country Size Intervention Intervention (Weeks) Measures Bias

Yu L 2012 Mixed China 146 Acupoint stimulation Usual care 3 Fatigue (PFS) High
Yang JL 2012 Mixed China 180 Acupoint stimulation Standard medical care 4 Fatigue (PFS) and QOL High
(KPS)
Yu HX 2012 Gastric China 68 Acupoint stimulation Standard medical care 1 Hours to first flatus/ High
bowel movement/
defecation
Cheng L 2009 Mixed China 90 Acupoint stimulation Standard medical care 1 Remission rate of High
diarrhea
Lai JH 2011 Cervical China 100 Chinese massage Standard medical care 1 Hours to first flatus/ High
bowel movement
Chen FR 2011 Mixed China 200 Acupoint stimulation Usual care 2 Nausea and vomit High
(QLQ-C30)
Yin ZL 2012 Nasopharyngeal China 43 Acupoint stimulation Standard medical care 2 QOL (QLQ-C30) High
Qiang WM 2011 Breast China 120 Tai Chi Music exercises 16 Vital capacity, BMI, High
QOL (FACT-B)
Chen LR 2009 Colorectal China 56 Chinese massage Standard medical care 2 Pain (VAS) High
Zhang YM 2012 Breast China 60 Chinese massage Standard medical care 3 Days QOL (QLSBC) High
Jiang MY 2013 Lung China 60 Tai Chi Standard medical care 4 Fatigue (BFI) and sleep High
quality

Tao et al.
Wang HL 2012 Mixed China 399 Chinese massage Standard medical care 2 Sleep (PSQI), anxiety High
(SAS), and
depression (SDS)
Chen CF 2012 Mixed China 36 Acupoint stimulation Standard medical care 2 Remission rate of High
diarrhea
Xue WX 2011 Liver China 42 Acupoint stimulation Intramuscular 2 Response rate of High
injections hiccups
Chen YL 2008 Colorectal China 37 Chinese massage Standard medical care Not reported Hours to first flatus/ High
bowel movement
Wan SY 2011 Mixed China 134 Acupoint stimulation Standard medical care 1 QOL (QLQ-C30) High
Wang HM 2008 Colorectal China 30 Acupoint stimulation Standard medical care 1 Hours to first flatus/ High
bowel movement/
defecation, pain
(Prince Henry
method)
Lu Y 2005 Mixed China 62 Acupoint stimulation Standard medical care 6e8 QOL (KPS) High
Zhang MF 2009 Mixed China 71 Acupoint stimulation Standard medical care 4 QOL (FACT-G), anxiety High
(SAS), sleep quality
(PSQI), and pain
(self-made scale)

Vol.
Pei Y 2010 Breast China 67 Acupoint stimulation Standard medical care 6 Anxiety (SAS) and High
depression (SDS,

-
HAMD)

No.
Wang XP 2006 Mixed China 66 Acupoint stimulation Intramuscular 1 Response rate of High
injections hiccups

- -
Li PX 2006 Mixed China 50 Acupoint stimulation Standard medical care 4 QOL (KPS), appetite, High
and body weight

2016
 Vol.
Li HY 2008 Esophageal China 45 Acupoint stimulation Standard medical care Until first flatus Hours to first flatus/ High
nasogastric tube

-
retention

No.
Liu H 2010 Liver China 102 Acupoint stimulation Standard medical care 2 Pain (VAS) High
Huang YN 2012 Mixed China 80 TCM-FEMT Standard medical care 12 Fatigue (PFS) and QOL High

- -
(QLQ-C30)
Xiang CY 2006 Mixed China 92 Acupuncture combined Standard medical care 4 Depression (SDS, Moderate

2016
with TCM-FEMT HAMD), QOL (KPS)
Feng Y 2011 Mixed China 80 Acupoint stimulation Standard medical care 4 Depression (SDS, High
HAMD), sleep quality
(PSQI)
Meng ZQ 2010 Colon China 75 Acupoint stimulation Standard medical care 6 Days or until QOL (QOLS), hours to High
the first bowel first flatus/bowel
movement, movement
whichever came
first.
Elizabeth N 2006 Breast Sweden 38 Acupoint stimulation Relaxation 12 Frequency of hot High
fiushes per 24 hours,

Interventions for Symptom Management and QOL

symptoms (KI, VAS),
psychological well-
being (SCL-90),
general mood (Mood
Scale)
Randolph HL 2006 Lung China Hong 27 Acupoint stimulation Sham acupuncture 1 Pain (VAS; The Moderate
Kong cumulative dose of
patient-controlled
analgesia morphine
used on
postoperative day 2)
Joseph AR 2005 Breast USA 96 Acupoint stimulation Sham or no 1 Nausea and emesis, High
acupuncture QOL (FACT-G)
Zhu YY 2013 Pancreatic China 68 Acupoint stimulation Standard medical care 1 Pain (NRS), depression High
(HAMD)
Zhao BM 2013 Liver China 60 Acupoint stimulation Standard medical care 4 QOL (KPS), effective High
rate of ascites
Li J 2013 Breast China 168 Acupoint stimulation Standard medical care 8 QOL (KPS), fatigue High
(BFI)
Guo LY 2014 Gynecologic China 120 Acupoint stimulation Standard medical care 3 Fatigue (BFI) High
Fu LP 2014 Esophageal China 128 Acupoint stimulation Standard medical care 12 QOL (QLQ-C30), High
curative effect
Chen YH 2013 Gastric China 60 Acupoint stimulation Standard medical care 2 QOL (SF-36), anxiety High
(SAS), and
depression (SDS)
Yan QM 2014 Mixed China 150 Acupoint stimulation Standard medical care 4 QOL(KPS), effective High
rate of ascites
Liu XM 2007 Mixed China 62 Acupoint stimulation Oral drug 3 Days Response rate of High
hiccups
Xie XP 2005 Mixed China 101 Acupoint stimulation Point injection Not reported Response rate of High
hiccups
Chen SY 2007 Mixed China 36 Acupoint stimulation Standard medical care 1 Response rate of High
hiccups
Chen HT 2006 Mixed China 60 Acupoint stimulation Intramuscular 10 Days Response rate of High
injections hiccups
(Continued)

7
 Table 1

8
Continued
Length of
Cancer Study Sample Experimental Control Intervention Outcome Risk of
Author Year Type Country Size Intervention Intervention (Weeks) Measures Bias

Luo M 2007 Liver China 48 Acupoint stimulation Intramuscular 3 Days Response rate of High
injections hiccups
Bao FF 2012 Mixed China 60 Acupoint stimulation Intramuscular 1 Response rate of High
injections hiccups
Gary D 2013 Mixed USA 74 Acupoint stimulation Sham acupuncture 6 Fatigue (BFI), Low
depression (HADS),
QOL (FACT-G)
Caroline S 2014 Breast Australia 30 Acupoint stimulation Sham acupuncture, 6 Well-being (W-BQ12), Moderate
wait list control fatigue (BFI)
Gary D 2013 Colon USA 90 Acupoint stimulation Sham acupuncture 3 Days Time that the patient Low
first tolerated solid
food/passed fiatus or
a bowel movement,
pain, and nausea
(VAS)
Simon SMN 2013 Colorectal China Hong 165 Acupoint stimulation Sham or no 4 Days Time of first passing Moderate
Kong acupuncture fiatus/tolerated a
solid diet/walk
independently, pain
(VAS)

Tao et al.
Michael FJ 2011 Breast USA 12 Acupoint stimulation Usual care 8 Fatigue (BFI) and QOL Moderate
(FACT-Cog)
Annelie L 2012 Breast Sweden 74 Acupoint stimulation Sham acupuncture 5 Severity of hot fiushes Low
and sweating per
24 hours
David G 2010 Mixed USA 58 Acupoint stimulation Usual care 4 Composite score of Moderate
pain, function, and
activities of daily
living (Constant-
Murley instrument)
Gary D 2008 Mixed USA 106 Acupoint stimulation Sham acupuncture 4 Pain (BPI/NRS/MQS) Low
Gary D 2007 Breast USA 72 Acupoint stimulation Sham acupuncture 5 Hot fiash frequency Low
Yang JX 2013 Breast China 30 TCM-FEMT Usual care 12 Depression (SDS) High
Lei YY 2014 Mixed China 98 TCM-FEMT Usual care Not reported Anxiety (SAS) and High
depression (SDS)
Li WJ 2014 Liver China 13 Chinese massage Intramuscular Not reported Response rate of High
injections hiccups
Xiao J 2014 Gynecologic China 151 Chinese massage Usual care 24 Hours Hours to first flatus/ High
bowel movement
Byeongsang O 2012 Mixed Australia 81 Qigong Usual care 10 QOL (FACT-G), High

Vol.
cognitive function
(EORTC-CF, FACT-

-
Cog)

No.
Zhen C 2013 Breast China 96 Qigong Wait list 5 Depression (CES-D), High
fatigue (BFI), sleep

- -
quality (PSQI), QOL
(FACT-G)

2016
Vol. - No. - - 2016 Interventions for Symptom Management and QOL 9

on alleviating sleep disturbance (d 1.66; 95%

Moderate

mass index; FACT-B Functional Assessment of Cancer TherapyeBreast; VAS visual analog scale; QLSBC quality of life of breast cancer; BFI Brief Fatigue Inventory; PSQI Pittsburgh Sleep Quality Index; SAS

Element Music Therapy; QOLS Quality of Life Status assessment tool; KI Kupperman Index; SCL-90 Symptom Checkliste90; NRS Numerical Rating Scale; SF-36 the MOS item Short Form health survey; FACT-
PFS Piper Fatigue Scale; QOL quality of life; KPS Karnofsky Performance Score; QLQ-C30 European Organization for Research and Treatment of Cancer Quality of life QuestionnaireeCore 30; BMI body

Self-rating Anxiety Scale; SDS Self-rating Depression Scale; FACT-G Functional Assessment of Cancer TherapyeGeneral; HAMD Hamilton scale for depression; TCM-FEMT Traditional Chinese Medicine Five-

Quality-of-Life Scale; FACIT-F Functional Assessment of Chronic Illness TherapyeFatigue survey; HADS hospital anxiety and depression scale; W-BQ12 The well-being questionnaire with 12 items;
Cog Functional Assessment of Cancer TherapydCognitive scale; MQS Medication Quantification Scale; CES-D Center for Epidemiologic Studies Depression Scale; WHOQOL World Health Organization
CI 2.69 to 0.63; P 0.002; I2 87%;
High

High
High

High

High
High
Figs. 4ke4l).
Our meta-analysis also revealed that interventions
significantly lowered emotional distress, including
total expiration time
Vital capacity, maximal
inspiratory capacity,

muscular strength,
depression (four on acupuncture, two on TCM-
mass index, QOL
QOL (WHOQOL),

Vital capacity, body

aerobic capacity,
function of side

Body mass index FEMT, one on Chinese massage)19,53,61,65,74,87,88 and

QOL (FACIT-F),

and flexibility
QOL (FACT-B)

upper limbs

anxiety (two on acupuncture, one on TCM-FEMT,

QOL (SF-36)
(FACT-B)

one on Chinese massage),26,53,61,88 and exert a large

effect (depression: d 7.43; 95% CI 12.96 to
1.91; P 0.008; I2 98%; anxiety: d 7.82;
95% CI 13.74 to 1.90; P 0.01; I2 97%).
Further meta-analysis showed that TCM-FEMT
relieved depression while acupuncture had no effect
on depression or anxiety (Figs. 4me4q).
4

10
24

16

12
12
12

In three studies67,83,86 involving 184 breast cancer

patients, the effect of acupuncture on hot flashes
was evaluated; however, no significant effect was found
in the meta-analysis (d 0.02; 95% CI 1.49 to
1.45; P 0.97; I2 36%; Fig. 4r).
Standard medical care

Psychosocial therapy
Psychosocial therapy
Psychosocial therapy

Other Clinical Outcomes. Three trials23,93,94 involving

249 patients assessed the effect of Tai Chi on the
Usual care

Usual care

Usual care

BMI of breast cancer patients and were included in

our meta-analysis, which demonstrate a small but
significant combined effect (d 0.28; 95% CI,
0.53 to 0.03; P 0.03; I2 0%). Another three
trials49,93,94 evaluated the effect of Tai Chi on vital
capacity; a significant effect was observed in the
meta-analysis (d 339.53; 95% CI 78.50 to
600.56; P 0.01; I2 88%; Fig. 5).
EORTC-CF European Organization for Research and Treatment of Cancer-Cognitive Function.
Tai Chi

Tai Chi
Tai Chi

Tai Chi

Tai Chi
Tai Chi
Tai Chi

Discussion
This is the largest meta-analysis to date on the ef-
120

22
120

110

19
21
21

fects of acupuncture, Tuina, Tai Chi, Qigong, or

TCM-FEMT on symptom management and QOL in
patients with cancer. In this report, we searched for
all the reports in which the interventions were used
in clinical cancer trials published before October 2,
China

China

China
USA

USA
USA
USA

2014, regardless of whether the article was published

in Chinese or English. This systematic review identi-
fied 66 published RCTs (covering 5465 patients)
reporting comparisons of treatment against either
standard medical care or active control. Although we
Breast
Breast

Breast

Breast
Breast
Breast

retrieved studies from many countries around the

Lung

world, more than half the studies were performed in

China. Whereas the studies covered various cancer
2014

2007
2010

2011

2012
2011
2008

sites and treatments, the evidence clearly clustered

in studies on breast cancer. According to our meta-
analyses, acupuncture produced small-to-large effects
Mustian KM

on adverse symptoms including pain, fatigue, sleep

Michelle CJ
Rausch SM
Wang YL

disturbance, and some gastrointestinal discomfort,

Lisa KS
Liu YC

He JH

but no significant effect was found on the frequency

of hot flashes and mood distress. Tuina relieved
10 Tao et al. Vol. - No. - - 2016

Table 2
Summary of Meta-Analysis Results
No. of No. of
Comparison Studies Subjects Statistical Method Effect Size

General QOL change

By KPS 7 762 4 Studies: MD (IV, random, 95% CI); 4.55 (0.75 to 8.34)
3 Studies: OR (M-H, fixed, 95% CI) 2.32 (1.26 to 4.27)
By generic QOL scales (e.g., SF-36, 4 222 SMD (IV, random, 95% CI) 3.49 (0.99 to 5.99)
WHOQOL)
Cancer-specific QOL change (e.g., FACT-G, 9 686 SMD (IV, random, 95% CI) 0.97 (0.18 to 1.76)
FACT-B, or EORTC QLQ-C30)
Symptoms improvement
Pain (by VAS or NRS) 9 710 SMD (IV, random, 95% CI) 0.35 (0.60 to 0.09)
Fatigue
Response rate by PFS 2 326 OR (M-H, fixed, 95% CI) 2.40 (1.40 to 4.13)
Means by BFI 7 560 MD (IV, random, 95% CI) 1.19 (2.19 to 0.18)
Gastrointestinal distress
By hours to first flatus 8 671 MD (IV, random, 95% CI) 11.52 (16.50 to 6.54)
By hours to first bowel movement 6 461 MD (IV, random, 95% CI) 8.22 (13.50 to 2.95)
Response rate of diarrhea 2 126 OR (M-H, fixed, 95% CI) 3.48 (1.06 to 11.47)
Nausea and vomit (by subscales of 2 328 MD (IV, fixed, 95% CI) 0.21 (0.30 to 0.11)
QLQ-C30)
Response rate of hiccups 9 488 OR (M-H, fixed, 95% CI) 5.57 (3.42 to 9.08)
Sleep disturbance (by PSQI) 4 646 MD (IV, random, 95% CI) 2.53 (4.17 to 0.89)
Depression (by SDS) 7 826 MD (IV, random, 95% CI) 7.4 3 (12.96 to 1.91)
Anxiety (by SAS) 4 624 MD (IV, random, 95% CI) 7.82 (13.74 to 1.90)
Hot flushes (by median number/24 hours) 3 184 MD (IV, random, 95% CI) 0.02 (1.49 to 1.45)
Other clinical outcomes
BMI 4 270 SMD (IV, random, 95% CI) 0.28 (2.08 to 0.61)
Vital capacity 3 350 MD (IV, random, 95% CI) 339.53 (78.5 to 600.56)
QOL quality of life; KPS Karnofsky Performance Score; OR odds ratio; MD mean difference; SF-36 the MOS item Short Form health survey;
WHOQOL World Health Organization Quality-of-Life Scale; SMD standardized mean difference; FACT-G Functional Assessment of Cancer Therapye
General; FACT-B Functional Assessment of Cancer TherapyeBreast; EORTC QLQ-C30 European Organization for Research and Treatment of Cancer Qual-
ity of Life QuestionnaireeCore 30; VAS visual analog scale; NRS Numerical Rating Scale; PFS Piper Fatigue Scale; BFI Brief Fatigue Inventory; QLQ-
C30 European Organization for Research and Treatment of Cancer Core Questionnaire; PSQI Pittsburgh Sleep Quality Index; SDS Self-rating Depression
Scale; SAS Self-rating Anxiety Scale; BMI body mass index; M-H Mantel Haenszel.
Twenty-three studies valued two or more outcomes.

gastrointestinal discomfort, TCM-FEMT lowered
depression level, and Tai Chi improved the vital capac-
ity of breast cancer patients.
In our meta-analysis, the effect size of acupuncture
on pain, fatigue, and hiccups are consistent with the
reports of previous meta-analyses.27,101 A somewhat
lower effect (d 0.76) on clinical efficacy measured
by KPS score was reported in an earlier meta-
analysis; however, this meta-analysis only included tri-
als on acupuncture in lung cancer.102 Larger effect
sizes for acupuncture on cancer-specific QOL and
fatigue were found in our results than that of other
meta-analyses in this field,9,29 but these two reviews
were based on only a few selected trials on acupunc-
ture and moxibustion and omitted other interventions
such as Chinese massage, Tai Chi, Qigong, and
TCM-FEMT. One exception is that the significant
effects of Tai Chi on BMI are different from
a published meta-analysis,32 which failed to include a
high-quality trial.94
Strikingly, our meta-analysis demonstrated that
acupoint stimulation and Chinese massage exert

Fig. 2. Risk-of-bias analysis.

Vol. - No. - - 2016 Interventions for Symptom Management and QOL 11

a Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Li J 2013 80 1.4 79 75 1 79 33.7% 5.00 [4.62, 5.38]
Li PX 2006 67.78 8.01 27 63.48 4.87 23 25.8% 4.30 [0.68, 7.92]
Xiang CY 2006 59.26 16.43 46 63.52 13.61 46 17.9% -4.26 [-10.43, 1.91]
Yan QM 2014 59.23 11.23 70 48.12 17.15 80 22.6% 11.11 [6.52, 15.70]

Total (95% CI) 222 228 100.0% 4.55 [0.75, 8.34]

Heterogeneity: Tau = 11.10; Chi = 15.62, df = 3 (P = 0.001); I = 81%
-20 -10 0 10 20
Test for overall effect: Z = 2.35 (P = 0.02)
Favors experimental Favors control

b Experimental Control Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Lu Y 2005 25 32 22 30 35.6% 1.30 [0.41, 4.16]
Yang JL 2012 54 60 42 60 30.1% 3.86 [1.41, 10.57]
Zhao BM 2013 21 30 16 30 34.4% 2.04 [0.71, 5.89]

Total (95% CI) 122 120 100.0% 2.32 [1.26, 4.27]

Total events 100 80
Heterogeneity: Chi = 1.99, df = 2 (P = 0.37); I = 0%
0.05 0.2 1 5 20
Test for overall effect: Z = 2.72 (P = 0.007)
Favors experimental Favors control

c Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Lisa KS 2012 104.94 6.6 9 108.96 6.06 10 29.4% -0.61 [-1.53, 0.32]
Mustian KM 2008 121.7 7 11 124.3 8 10 30.7% -0.33 [-1.20, 0.53]
Wang YL 2010 62.5 8.05 62 57.13 7.48 58 39.9% 0.69 [0.32, 1.05]

Total (95% CI) 82 78 100.0% -0.01 [-0.90, 0.89]

Heterogeneity: Tau = 0.49; Chi = 9.62, df = 2 (P = 0.008); I = 79%
-10 -5 0 5 10
Test for overall effect: Z = 0.02 (P = 0.99)
Favors experimental Favors control

d Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Byeongsang O 2012 8.41 1.32 23 -4.25 2.17 31 8.7% 6.71 [5.29, 8.13]
Gary D 2013 70.2 11.94 47 67.9 14.61 50 11.8% 0.17 [-0.23, 0.57]
Huang YN 2012 58.85 4.21 40 52.3 7.78 40 11.7% 1.04 [0.57, 1.51]
Joseph AR 2005 75.4 2.4 32 77.6 2.4 31 11.6% -0.91 [-1.43, -0.39]
Rausch SM 2007 2.15 5.99 13 0.75 4.72 4 9.8% 0.23 [-0.89, 1.35]
Wan SY 2011 54.53 6.68 70 43.17 5.35 64 11.8% 1.86 [1.45, 2.26]
Yin ZL 2012 86.15 6.34 22 84.85 6.11 21 11.4% 0.20 [-0.39, 0.80]
Zhang YM 2012 254.3 45.75 30 221.7 41.76 30 11.5% 0.73 [0.21, 1.26]
Zhen C 2013 82.1 15.4 49 82.8 15.9 46 11.8% -0.04 [-0.45, 0.36]

Total (95% CI) 326 317 100.0% 0.97 [0.18, 1.76]

Heterogeneity: Tau = 1.34; Chi = 159.80, df = 8 (P < 0.00001); I = 95%
-10 -5 0 5 10
Test for overall effect: Z = 2.40 (P = 0.02)
Favors experimental Favors control

e Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Gary D 2013 70.2 11.94 47 67.9 14.61 50 35.7% 0.17 [-0.23, 0.57]
Joseph AR 2005 75.4 2.4 32 77.6 2.4 31 33.1% -0.91 [-1.43, -0.39]
Yin ZL 2012 86.15 6.34 22 84.85 6.11 21 31.2% 0.20 [-0.39, 0.80]

Total (95% CI) 101 102 100.0% -0.17 [-0.88, 0.53]

Heterogeneity: Tau = 0.32; Chi = 11.91, df = 2 (P = 0.003); I = 83%
-10 -5 0 5 10
Test for overall effect: Z = 0.48 (P = 0.63)
Favors experimental Favors control

Fig. 3. Forest plots of effect sizes for interventions on QOL. a) Acupuncture on QOL of terminal cancer survivors by means of
KPS, b) acupuncture on QOL by remission rate of KPS, c) Tai Chi on QOL of breast cancer patients by generic QOL scales, d)
interventions on QOL by cancer-specific QOL scales, e) acupuncture on QOL by cancer-specific QOL scales, f) Chinese mas-
sage on QOL by cancer-specific QOL scales, and g) Qigong on QOL by cancer-specific QOL scales. QOL quality of life;
KPS Karnofsky Performance Score; M-H Mantel Haenszel.
12 Tao et al. Vol. - No. - - 2016

f Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Wan SY 2011 54.53 6.68 70 43.17 5.35 64 51.1% 1.86 [1.45, 2.26]
Zhang YM 2012 254.3 45.75 30 221.7 41.76 30 48.9% 0.73 [0.21, 1.26]

Total (95% CI) 100 94 100.0% 1.31 [0.21, 2.41]

Heterogeneity: Tau = 0.57; Chi = 10.99, df = 1 (P = 0.0009); I = 91%
-10 -5 0 5 10
Test for overall effect: Z = 2.33 (P = 0.02)
Favors experimental Favors control

g Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Byeongsang O 2012 8.41 1.32 23 -4.25 2.17 31 49.5% 6.71 [5.29, 8.13]
Zhen C 2013 82.1 15.4 49 82.8 15.9 46 50.5% -0.04 [-0.45, 0.36]

Total (95% CI) 72 77 100.0% 3.30 [-3.32, 9.92]

Heterogeneity: Tau = 22.55; Chi = 80.39, df = 1 (P < 0.00001); I = 99%
-50 -25 0 25 50
Test for overall effect: Z = 0.98 (P = 0.33)
Favors experimental Favors control

Fig. 3. (continued).

a significant effect on gastrointestinal discomfort
including easing diarrhea, hiccups, nausea and vomit-
ing, and shortening time to first flatus and first bowel
movement (Fig. 4).The reduction in the last two out-
comes mentioned previously is important for reducing
the risk of paralytic ileus by stimulating digestive pro-
pulsion, particularly after gastrointestinal surgery. We
also found that Chinese massage and TCM-FEMT
contribute to the combined effect on QOL in cancer
patients but were not involved in any published review.
Although the forest plots seem to provide consider-
able evidences for effects of acupuncture, Tuina, Tai
Chi, Qigong, and TCM-FEMT on cancer-related symp-
toms and QOL, some effect sizes are modest. The
study heterogeneity may be one of the most important
factor contributing to this limited effect. First, inter-
ventions differed among studies. Intervention dura-
tion ranged from 24 hours to half a year. Different
types and stages of disease were used among and
even within studies; the studies recruited more than
eight types of cancer patients including breast cancer,
lung cancer, gastric cancer, and so forth. As well, the
overall QOL of cancer patients was evaluated by
various tools, including the KPS, SF-36, FACT-B, and
other tools used no more than once. Furthermore,
peri-intervention or accompanying clinical treatment
varied among studies ranging from surgery, radio-
therapy, various regimens of chemotherapy, and
various combinations thereof. In addition, the num-
ber of subjects in some studies was generally too small;
the smallest sample size was only 13. This makes the
means and SDs of indicators vulnerable to individual
outliers and higher or lower effects prone to be de-
tected because of chance. Therefore, the reliability
of the evidence presented here is clearly limited.
Risk of bias was present in many RCTs. More than
80% of the studies were burdened with a high risk
of bias; only 17 (29.82%) have low or moderate risk
of bias. Only 16% provided information regarding
adequate concealment of the randomization sequence
and methods of blinding. Because of the nature of
acupuncture, Tuina, Tai Chi, Qigong, and TCM-
FEMT, it may be difficult to blind participants to inter-
vention delivery. Few trials attempted to blind the
outcome assessors to minimize potential methodolog-
ical bias. Therefore, bias may affect most of the RCTs.
Although lack of allocation concealment and blinding
may be associated with exaggerated effect estimates
for subjective outcomes, the degree of bias seems to
be rather limited.103 Incomplete follow-up data pose
another problem, although this may be caused by
the unfavorable prognoses inherent in many cancer
diagnoses. Selective outcome reporting was present
in one-third of the studies, sometimes precluding
the quantitative analysis of effectsda common prob-
lem in clinical trials.104 Because unreported outcomes
were often nonsignificant, this may have inflated the
computed effect sizes.105 Low compliance with proto-
cols and lack of motivation to continue participating
influence intervention impact and can be other poten-
tial sources of bias and also an indicator that the inter-
vention is inappropriate for the recruited subjects.
Many studies included only small samples, thus raising
the issue of insufficient power.106 However, small
studies often produced larger effects than large
studies did.
Limitations of our systematic review and any sys-
tematic review in general pertain to the potential
incompleteness of the evidence reviewed. Although
an attempt was made to retrieve both published and
unpublished research and to conduct a comprehen-
sive search, some studies may have been missed.
Moreover, some of the identified studies could not
be retrieved. One other problem is the fact that
Vol. - No. - - 2016 Interventions for Symptom Management and QOL 13

a Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
David G 2010 3.6 2.4 28 5.8 2.3 30 11.5% -0.92 [-1.47, -0.38]
Elizabeth N 2006 3.7 1.8 17 3.5 1.5 14 8.6% 0.12 [-0.59, 0.82]
Gary D 2008 2.53 1.86 62 2.96 2 57 15.8% -0.22 [-0.58, 0.14]
Gary D 2013 5 1.9 39 4.8 2.3 42 13.9% 0.09 [-0.34, 0.53]
Liu H 2010 3.18 1.65 51 4.01 1.94 51 14.9% -0.46 [-0.85, -0.06]
Randolph HL 2006 3 3.6 13 3 1.4 12 7.5% 0.00 [-0.78, 0.78]
Simon SMN 2013 2.1 1.2 55 3.4 2.2 55 15.1% -0.73 [-1.11, -0.34]
Zhu YY 2013 3.46 1.82 28 3.46 1.33 37 12.6% 0.00 [-0.49, 0.49]

Total (95% CI) 293 298 100.0% -0.30 [-0.56, -0.03]

Heterogeneity: Tau = 0.08; Chi = 16.98, df = 7 (P = 0.02); I = 59%
-2 -1 0 1 2
Test for overall effect: Z = 2.19 (P = 0.03)
Favors experimental Favors control

b
Experimental Control Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Yang JL 2012 26 60 18 60 59.5% 1.78 [0.84, 3.79]
Yu L 2012 27 73 11 73 40.5% 3.31 [1.49, 7.35]

Total (95% CI) 133 133 100.0% 2.40 [1.40, 4.13]

Total events 53 29
Heterogeneity: Chi = 1.22, df = 1 (P = 0.27); I = 18%
0.05 0.2 1 5 20
Test for overall effect: Z = 3.16 (P = 0.002)
Favors experimental Favors control

c Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Caroline S 2014 3.1 2.7 9 5 1.8 10 19.3% -0.80 [-1.74, 0.14]
Gary D 2013 4.8 1.88 47 5.1 2 50 21.5% -0.15 [-0.55, 0.25]
Guo LY 2014 3.42 0.7 40 5.99 0.5 40 20.0% -4.18 [-4.98, -3.39]
Li J 2013 4.12 1.05 79 5.75 2.1 79 21.6% -0.98 [-1.31, -0.65]
Michael FJ 2011 2.13 1.23 5 4.38 2.53 7 17.6% -0.99 [-2.23, 0.26]

Total (95% CI) 180 186 100.0% -1.41 [-2.58, -0.24]

Heterogeneity: Tau = 1.62; Chi = 78.81, df = 4 (P < 0.00001); I = 95%
-4 -2 0 2 4
Test for overall effect: Z = 2.36 (P = 0.02)
Favors experimental Favors control

d Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Li HY 2008 45.2 5.3 22 68.7 3.7 23 17.3% -5.07 [-6.31, -3.83]
Meng ZQ 2010 68.26 23.38 35 65.24 17.5 40 21.0% 0.15 [-0.31, 0.60]
Simon SMN 2013 48 21.6 55 55.2 26.4 55 21.2% -0.30 [-0.67, 0.08]
Wang HM 2008 48 25.44 15 79.2 48.48 15 19.9% -0.78 [-1.53, -0.04]
Yu HX 2012 37.5 11.2 34 58.3 11.7 34 20.6% -1.80 [-2.36, -1.23]

Total (95% CI) 161 167 100.0% -1.44 [-2.58, -0.29]

Heterogeneity: Tau = 1.57; Chi = 79.54, df = 4 (P < 0.00001); I = 95%
-10 -5 0 5 10
Test for overall effect: Z = 2.46 (P = 0.01)
Favors experimental Favors control

e
Experimental Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen YL 2008 25.26 18.36 24 30.38 16.54 16 32.4% -0.28 [-0.92, 0.35]
Lai JH 2011 45.26 2.12 50 53.21 3.65 50 33.3% -2.64 [-3.18, -2.10]
Xiao J 2014 18 3.43 79 26 4.29 72 34.3% -2.06 [-2.46, -1.66]

Total (95% CI) 153 138 100.0% -1.68 [-2.88, -0.47]

Heterogeneity: Tau = 1.06; Chi = 32.60, df = 2 (P < 0.00001); I = 94%
-10 -5 0 5 10
Test for overall effect: Z = 2.73 (P = 0.006)
Favors experimental Favors control

Fig. 4. Forest plots of effect sizes for interventions on adverse symptoms. a) Acupuncture on pain; b) acupuncture on remis-
sion rate of fatigue by Piper Fatigue Scale; c) acupuncture on fatigue by Brief Pain Inventory; d) acupuncture on hours to first
flatus; e) Chinese massage on hours to first flatus; f) acupuncture on hours to first bowel movement; g) Chinese massage on
hours to first bowel movement; h) acupuncture on remission rate of diarrhea; i) acupuncture on nausea and vomit; j)
acupuncture on hiccups; k) acupuncture, Chinese massage, and Qigong on sleep disturbance; l) acupuncture on sleep distur-
bance; m) acupuncture, Chinese massage, and TCM-FEMT on depression; n) acupuncture on depression; o) TCM-FEMT on
depression; p) acupuncture, Chinese massage, and TCM-FEMT on anxiety; q) acupuncture on anxiety; and r) acupuncture on
hot flushes. TCM-FEMT Traditional Chinese Medicine Five-Element Music Therapy; M-H Mantel Haenszel.
14 Tao et al. Vol. - No. - - 2016

f
Experimental Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Meng ZQ 2010 119.04 47.97 36 119.38 60.21 40 34.1% -0.01 [-0.46, 0.44]
Wang HM 2008 24 5.52 15 24 5.76 15 32.7% 0.00 [-0.72, 0.72]
Yu HX 2012 33.1 8.9 34 54.7 9.1 34 33.2% -2.37 [-3.00, -1.74]

Total (95% CI) 85 89 100.0% -0.79 [-2.31, 0.73]

Heterogeneity: Tau = 1.72; Chi = 39.89, df = 2 (P < 0.00001); I = 95%
-4 -2 0 2 4
Test for overall effect: Z = 1.02 (P = 0.31)
Favors experimental Favors control

g
Experimental Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Chen YL 2008 12.54 3.82 24 18.56 7.29 16 13.8% -1.08 [-1.76, -0.40]
Lai JH 2011 24.65 9.1 50 34.15 8.45 50 36.2% -1.07 [-1.49, -0.65]
Xiao J 2014 11 3.25 79 17 5.12 72 50.0% -1.41 [-1.76, -1.05]

Total (95% CI) 153 138 100.0% -1.24 [-1.49, -0.99]

Heterogeneity: Chi = 1.64, df = 2 (P = 0.44); I = 0%
-4 -2 0 2 4
Test for overall effect: Z = 9.62 (P < 0.00001)
Favors experimental Favors control

h
Experimental Control Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Chen CF 2012 17 18 16 18 27.6% 2.13 [0.18, 25.78]
Cheng L 2009 42 45 35 45 72.4% 4.00 [1.02, 15.68]

Total (95% CI) 63 63 100.0% 3.48 [1.06, 11.47]

Total events 59 51
Heterogeneity: Chi = 0.19, df = 1 (P = 0.66); I = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.05 (P = 0.04)
Favors experimental Favors control

i
Experimental Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Chen FR 2011 1.33 0.12 102 1.5 0.58 98 64.9% -0.17 [-0.29, -0.05]
Fu LP 2014 1.31 0.16 64 1.58 0.63 64 35.1% -0.27 [-0.43, -0.11]

Total (95% CI) 166 162 100.0% -0.21 [-0.30, -0.11]

Heterogeneity: Chi = 0.98, df = 1 (P = 0.32); I = 0%
-1 -0.5 0 0.5 1
Test for overall effect: Z = 4.26 (P < 0.0001)
Favors experimental Favors control

j
Experimental Control Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Bao FF 2012 30 32 18 28 8.8% 8.33 [1.64, 42.39]
Chen HT 2006 33 40 11 20 18.7% 3.86 [1.16, 12.81]
Chen SY 2007 21 24 10 12 12.2% 1.40 [0.20, 9.75]
Liu XM 2007 29 32 20 30 14.1% 4.83 [1.18, 19.80]
Luo M 2007 18 24 8 24 14.6% 6.00 [1.71, 21.04]
Wang XP 2006 31 35 14 31 12.4% 9.41 [2.67, 33.14]
Xie XP 2005 51 54 34 47 14.7% 6.50 [1.72, 24.53]
Xue WX 2011 21 22 13 20 4.5% 11.31 [1.24, 102.72]

Total (95% CI) 263 212 100.0% 5.81 [3.54, 9.56]

Total events 234 128
Heterogeneity: Chi = 3.71, df = 7 (P = 0.81); I = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 6.94 (P < 0.00001)
Favors experimental Favors control

Fig. 4. (continued).
Vol. - No. - - 2016 Interventions for Symptom Management and QOL 15

k
Experimental Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Feng Y 2011 7.92 1.22 40 11.44 1.89 40 27.1% -3.52 [-4.22, -2.82]
Wang HL 2012 7.4 2.2 201 10.03 3.91 198 27.3% -2.63 [-3.25, -2.01]
Zhang MF 2009 7.88 3.42 32 12.57 4.53 39 20.9% -4.69 [-6.54, -2.84]
Zhen C 2013 10.1 3.1 49 9.6 2.9 46 24.7% 0.50 [-0.71, 1.71]

Total (95% CI) 322 323 100.0% -2.53 [-4.17, -0.89]

Heterogeneity: Tau = 2.46; Chi = 36.82, df = 3 (P < 0.00001); I = 92%
-20 -10 0 10 20
Test for overall effect: Z = 3.02 (P = 0.003)
Favors experimental Favors control

l Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Feng Y 2011 7.92 1.22 40 11.44 1.89 40 49.3% -2.19 [-2.75, -1.63]
Zhang MF 2009 7.88 3.42 32 12.57 4.53 39 50.7% -1.14 [-1.65, -0.63]

Total (95% CI) 72 79 100.0% -1.66 [-2.69, -0.63]

Heterogeneity: Tau = 0.48; Chi = 7.46, df = 1 (P = 0.006); I = 87%
-4 -2 0 2 4
Test for overall effect: Z = 3.16 (P = 0.002)
Favors experimental Favors control

m Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen YH 2013 45.24 5.01 30 57.54 5.78 30 14.4% -12.30 [-15.04, -9.56]
Feng Y 2011 43.64 5.28 40 50.76 5.42 40 14.6% -7.12 [-9.46, -4.78]
Lei YY 2014 33.24 4.21 50 54.02 5.34 48 14.7% -20.78 [-22.69, -18.87]
Pei Y 2010 45.55 6.31 31 44.44 7.04 31 14.2% 1.11 [-2.22, 4.44]
Wang HL 2012 24.38 2.89 201 29.41 3.43 198 14.9% -5.03 [-5.65, -4.41]
Xiang CY 2006 40.76 14.26 46 39.41 11.6 46 13.1% 1.35 [-3.96, 6.66]
Yang JX 2013 51.87 5.67 15 60.07 4.17 15 14.1% -8.20 [-11.76, -4.64]

Total (95% CI) 413 408 100.0% -7.43 [-12.96, -1.91]

Heterogeneity: Tau = 53.08; Chi = 283.21, df = 6 (P < 0.00001); I = 98%
-20 -10 0 10 20
Test for overall effect: Z = 2.64 (P = 0.008)
Favors experimental Favors control

n
Experimental Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen YH 2013 45.24 5.01 30 57.54 5.78 30 24.0% -2.24 [-2.90, -1.59]
Feng Y 2011 43.64 5.28 40 50.76 5.42 40 25.2% -1.32 [-1.80, -0.83]
Pei Y 2010 37.32 5.01 31 39.11 5.77 31 25.1% -0.33 [-0.83, 0.17]
Xiang CY 2006 40.76 14.26 46 39.41 11.6 46 25.7% 0.10 [-0.31, 0.51]

Total (95% CI) 147 147 100.0% -0.93 [-1.89, 0.04]

Heterogeneity: Tau = 0.90; Chi = 44.53, df = 3 (P < 0.00001); I = 93%
-4 -2 0 2 4
Test for overall effect: Z = 1.88 (P = 0.06)
Favors experimental Favors control

o Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Lei YY 2014 33.24 4.21 50 54.02 5.34 48 50.3% -4.30 [-5.03, -3.57]
Yang JX 2013 51.87 5.67 15 60.07 4.17 15 49.7% -1.60 [-2.44, -0.77]

Total (95% CI) 65 63 100.0% -2.96 [-5.60, -0.32]

Heterogeneity: Tau = 3.47; Chi = 22.58, df = 1 (P < 0.00001); I = 96%
-20 -10 0 10 20
Test for overall effect: Z = 2.20 (P = 0.03)
Favors experimental Favors control

p
Experimental Control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen YH 2013 45.2 8.12 30 61.34 7.54 30 23.5% -16.14 [-20.11, -12.17]
Lei YY 2014 35.45 3.03 50 47.03 6.72 48 25.4% -11.58 [-13.66, -9.50]
Pei Y 2010 37.32 5.01 31 39.11 5.77 36 25.0% -1.79 [-4.37, 0.79]
Wang HL 2012 24.63 3.27 201 27.08 3.19 198 26.1% -2.45 [-3.08, -1.82]

Total (95% CI) 312 312 100.0% -7.82 [-13.74, -1.90]

Heterogeneity: Tau = 34.78; Chi = 109.28, df = 3 (P < 0.00001); I = 97%
-20 -10 0 10 20
Test for overall effect: Z = 2.59 (P = 0.010)
Favors experimental Favors control

Fig. 4. (continued).
16 Tao et al. Vol. - No. - - 2016

q Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Chen YH 2013 45.2 8.12 30 61.34 7.54 30 49.3% -2.03 [-2.66, -1.40]
Pei Y 2010 37.32 5.01 31 39.11 5.77 36 50.7% -0.33 [-0.81, 0.16]

Total (95% CI) 61 66 100.0% -1.17 [-2.84, 0.51]

Heterogeneity: Tau = 1.38; Chi = 17.73, df = 1 (P < 0.0001); I = 94%
-4 -2 0 2 4
Test for overall effect: Z = 1.37 (P = 0.17)
Favors experimental Favors control

r
Experimental Control Std. Mean Difference Std. Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Annelie L 2012 5.7 4.1 38 4.5 3.7 36 43.4% 0.30 [-0.15, 0.76]
Elizabeth N 2006 4.1 3.3 17 4.5 2.2 14 18.2% -0.14 [-0.84, 0.57]
Gary D 2007 6.2 4.2 39 7.6 5.7 28 38.4% -0.28 [-0.77, 0.20]

Total (95% CI) 94 78 100.0% -0.00 [-0.30, 0.30]

Heterogeneity: Chi = 3.12, df = 2 (P = 0.21); I = 36%
-4 -2 0 2 4
Test for overall effect: Z = 0.01 (P = 0.99)
Favors experimental Favors control

Fig. 4. (continued).

most of the included trials (51/67) were carried out
in Chinese regions that have been shown to pro-
duce almost no negative studies.107 Moreover, it
could be argued about the rationale for some
meta-analyses pooling data from too few trials.
The main reasons for conducting meta-analyses
are to increase power, improve precision, answer
questions not asked by individual studies, settle con-
troversies arising from conflicting results, and
generate new hypotheses; a meta-analysis can be
performed by combining two or more trials.108
However, the use of statistics does not guarantee
that the results are valid. In our case, for the evalu-
ation of acupunctures effect on diarrhea, the con-
clusions from the meta-analyses are from only two
RCTs with small sample sizes; therefore, the conclu-
sions must remain tentative.
Future RCTs of acupuncture, Tuina, Tai Chi,
Qigong, and TCM-FEMT for adverse symptoms
and QOL of cancer patients should adhere to
accepted standards of trial methodology. The
studies included in this review show a number of de-
fects that have been noted by other related reviews,
for example, the frequency and duration of treat-
ment, using validated primary outcome measures,
adequate statistical tests, and heterogeneous com-
parison groups. Furthermore, even though it is
difficult to blind subjects to some forms of interven-
tions, using assessor blinding is important for
reducing bias. We recommend that future publica-
tions give detailed information of randomization
methods including sequence generation and
randomization concealment and blinding informa-
tion, including whether blinding is used and who

a Experimental Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
He JH 2011 -0.7 3.6 51 -0.2 3.1 46 40.2% -0.15 [-0.55, 0.25]
Michelle CJ 2011 -0.42 0.75 9 0.29 0.61 10 6.8% -1.00 [-1.97, -0.03]
Mustian KM 2006 -1.2 5.06 11 1.4 5.76 10 8.4% -0.46 [-1.33, 0.41]
Qiang WM 2011 -0.82 2.27 56 -0.14 3.08 52 44.6% -0.25 [-0.63, 0.13]

Total (95% CI) 127 118 100.0% -0.28 [-0.53, -0.03]

Heterogeneity: Chi = 2.73, df = 3 (P = 0.44); I = 0%
-2 -1 0 1 2
Test for overall effect: Z = 2.15 (P = 0.03)
Favors experimental Favors control

b Experimental Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
He JH 2011 2,500.4 554.4 51 2,390.6 334.3 46 32.3% 109.80 [-70.43, 290.03]
Liu YC 2014 2,638.25 468.36 60 2,018.05 524.32 60 32.4% 620.20 [442.31, 798.09]
Qiang WM 2011 2,631.4 302.01 56 2,339.5 334.1 52 35.3% 291.90 [171.47, 412.33]

Total (95% CI) 167 158 100.0% 339.53 [78.50, 600.56]

Heterogeneity: Tau = 46477.19; Chi = 16.34, df = 2 (P = 0.0003); I = 88%
-500 -250 0 250 500
Test for overall effect: Z = 2.55 (P = 0.01)
Favors experimental Favors control

Fig. 5. Forest plots of effect sizes for Tai Chi on other clinical outcomes. (a) body mass index and (b) vital capacity.
Vol. - No. - - 2016 Interventions for Symptom Management and QOL
was blinded, if available. Detailed reporting accord-
ing to the requirements presented by the CON-
SORT (Consolidated Standards of Reporting
Trials) statement will make it easier to reach clear
conclusions regarding study quality.109
Although there are some clear limitations regarding
the body of research reviewed in this study, a tentative
conclusion can be reached that at least acupuncture
may alleviate some symptoms including pain, fatigue,
gastrointestinal distress, sleep disturbance but has no
effect on hot flashes. Tuina relieved gastrointestinal
discomfort. TCM-FEMT lowered depression level. Tai
Chi improved vital capacity of breast cancer patients.
Acupuncture and Tuina improved overall QOL,
whereas Tai Chi and Qigong exert no effect on QOL
of breast cancer survivors. Future study reporting
should be improved regarding both research methods
and content of interventions.
Disclosures and Acknowledgments
No funding was received for this study, and the
authors declare no conflicts of interest.
The authors thank the health informatics experts
for their assistance in developing the search strategy.
References
1. World Health Organization. Cancer. [2008-9-23] Avail-
able at: http://www.whoint/mediacentre/factsheets/fs297/
en/
2. Boon HS, Olatunde F, Zick SM. Trends in complemen-
tary/alternative medicine use by breast cancer survivors:
comparing survey data from 1998 and 2005. BMC Womens
Health 2007;7:4.
3. Sirois FM, Gick ML. An investigation of the health
beliefs and motivations of complementary medicine clients.
Soc Sci Med 2002;55:1025e1037.
4. Findley PA, Sambamoorthi U. Preventive health ser-
vices and lifestyle practices in cancer survivors: a population
health investigation. J Cancer Surviv 2009;3:43e58.
5. Smithson J, Paterson C, Britten N, et al. Cancer
patients experiences of using complementary therapies:
polarization and integration. J Health Serv Res Policy
2010;15:54e61.
6. Monti DA, Sufian M, Peterson C. Potential role of
mind-body therapies in cancer survivorship. Cancer 2008;
112:2607e2616.
7. Tong G, Geng Q, Cheng J, et al. Effects of psycho-
behavioral interventions on immune functioning in cancer
patients: a systematic review. J Cancer Res Clin Oncol
2014;140:15e33.
8. Zhou DH. Clinical oncology of Chinese medicine. Bei-
jing: Peoples Health Publishing House, 2003.
9. He XR, Wang Q, Li PP. Acupuncture and moxibustion
for cancer-related fatigue: a systematic review and meta-anal-
ysis. Asian Pac J Cancer Prev 2013;14:3067e3074.
17
10. Goats GC. Massagedthe scientific basis of an ancient
art: part 2. Physiological and therapeutic effects. Br J Sports
Med 1994;28:153e156.
11. Liu WS. Application of Chinese medicine in clinical
oncology. Beijing: Peoples Health Publishing House, 2005.
12. Chan CL, Wang CW, Ho RT, et al. A systematic review of
the effectiveness of qigong exercise in supportive cancer
care. Support Care Cancer 2012;20:1121e1133.
13. Lee MS, Choi TY, Ernst E. Tai chi for breast cancer
patients: a systematic review. Breast Cancer Res Treat 2010;
120:309e316.
14. American Music Therapy Association. Definitions and
quotes about music therapy. Available at: http://www.
musictherapy.org/about/quotes/. Accessed August 13,
2012.
15. Huang Y, Yang X, Yang Q. Effect of traditional Chinese
medicine five elements music on cancer-related fatigue of
chemotherapy patients. Chin J Mod Nurs 2012;18:
1412e1414.
16. World Health Organization. WHO traditional medicine
strategy 2002-2005. Geneva, Switzerland: World Health Orga-
nization, 2002.
17. Sprod LK, Janelsins MC, Palesh OG, et al. Health-
related quality of life and biomarkers in breast cancer survi-
vors participating in tai chi chuan. J Cancer Surviv 2012;6:
146e154.
18. Wan S, Huang J, Gao J. Influence of acupoint massage
on quality of life of tumor patients accepting chemotherapy.
Chin Nurs Res 2011;25:317e318.
19. Xiang C, Guo Q, Liao J. Effect of therapy of traditional
Chinese medicine five element music and electroacupunc-
ture on the depression levels of cancer patients. Chin
J Nurs 2006;41:969e972.
20. Oh B, Butow PN, Mullan BA, et al. Effect of medical
Qigong on cognitive function, quality of life, and a
biomarker of inflammation in cancer patients: a randomized
controlled trial. Support Care Cancer 2012;20:1235e1242.
21. Deng G, Chan Y, Sjoberg D, et al. Acupuncture for the
treatment of post-chemotherapy chronic fatigue: a random-
ized, blinded, sham-controlled trial. Support Care Cancer
2013;21:1735e1741.
22. Roscoe JA, Matteson SE, Morrow GR, et al. Acustimula-
tion wrist bands are not effective for the control of
chemotherapy-induced nausea in women with breast cancer.
J Pain Symptom Manage 2005;29:376e384.
23. Mustian KM, Katula JA, Zhao H. A pilot study to assess
the influence of tai chi chuan on functional capacity among
breast cancer survivors. J Support Oncol 2006;4:139e145.
24. Chen Z, Meng Z, Milbury K, et al. Qigong improves
quality of life in women undergoing radiotherapy for breast
cancer: results of a randomized controlled trial. Cancer
2013;119:1690e1698.
25. Yin ZL. Effect of TCM on quality of life in nasopharyn-
geal cancer patients after radiotherapy. Chin J Phys Med
Rehabil 2012;34:618e620.
26. Chen HY, Li SG, Cho WC, et al. The role of acupoint
stimulation as an adjunct therapy for lung cancer: a system-
atic review and meta-analysis. BMC Complement Altern Med
2013;13:362.
18 Tao et al.
27. Choi TY, Lee MS, Ernst E. Acupuncture for cancer
patients suffering from hiccups: a systematic review and
meta-analysis. Complement Ther Med 2012;20:447e455.
28. Garcia MK, McQuade J, Haddad R, et al. Systematic
review of acupuncture in cancer care: a synthesis of the
evidence. J Clin Oncol 2013;31:952e960.
29. Lee MS, Choi TY, Park JE, et al. Moxibustion for cancer
care: a systematic review and meta-analysis. BMC Cancer
2010;10:130.
30. Chao LF, Zhang AL, Liu HE, et al. The efficacy of acu-
point stimulation for the management of therapy-related
adverse events in patients with breast cancer: a systematic re-
view. Breast Cancer Res Treat 2009;118:255e267.
31. Lee MS, Chen KW, Sancier KM, et al. Qigong for can-
cer treatment: a systematic review of controlled clinical trials.
Acta Oncol 2007;46:717e722.
32. Yan JH, Pan L, Zhang XM, et al. Lack of efficacy of Tai
Chi in improving quality of life in breast cancer survivors: a
systematic review and meta-analysis. Asian Pac J Cancer Prev
2014;15:3715e3720.
33. Lee MS, Pittler MH, Ernst E. Is Tai Chi an effective
adjunct in cancer care? A systematic review of controlled
clinical trials. Support Care Cancer 2007;15:597e601.
34. Li X, Yang G, Li X, et al. Traditional Chinese medicine
in cancer care: a review of controlled clinical studies pub-
lished in Chinese. PLoS One 2013;8:e60338.
35. Liu J, Li X, Liu J, et al. Traditional Chinese medicine in
cancer care: a review of case reports published in Chinese
literature. Forschende Komplementarmedizin 2011;18:
257e263.
36. Yang G, Li X, Li X, et al. Traditional Chinese medicine
in cancer care: a review of case series published in the Chi-
nese literature. Evid Based Complement Alternat Med
2012;2012:751046.
37. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA
statement for reporting systematic reviews and meta-
analyses of studies that evaluate healthcare interventions:
explanation and elaboration. BMJ 2009;339:b2700.
38. Higgins JPT, Green S, eds. Cochrane handbook for sys-
tematic reviews of interventions version 5.1.0. The Cochrane
Collaboration, 2011. Available at: www.cochranehandbook.
org.
39. Tierney JF, Stewart LA, Ghersi D, et al. Practical
methods for incorporating summary time-to-event data
into meta-analysis. Trials 2007;8:16.
40. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring
inconsistency in meta-analyses. BMJ 2003;327:557e560.
41. Faul F, Erdfelder E, Lang AG, et al. G*Power 3: a flex-
ible statistical power analysis program for the social,
behavioral, and biomedical sciences. Behav Res Methods
2007;39:175e191.
42. Yu L. Effect of moxibustion on cancer related fatigue
Guide of China Medicine 2012;10:591e593.
43. Yang JL. Effects of moxibustion on cancer related
fatigue in elderly advanced cancer patients. Chin J Gerontol
2012;32:4408e4410.
44. Yu HX. Effects of moxibustion on gastrointestinal func-
tion after surgery in elderly gastric cancer patients. Zhejiang
J Tradit Chin Med 2012;47:284.
Vol. - No. - - 2016
45. Cheng L. Effect of moxibustion moxa at zusanli on
cancer-related diarrhea. J Nurs Sci 2009;24:43e44.
46. Lai JH. Chinese massage at Yongquan on gastrointes-
tinal function in cervical cancer patients. Today Nurse
2011;14:124e125.
47. Chen FR, Wang M, Xue J. Study on influence of ginger
separated moxibustion on quality of life of elderly patients
with advanced cancer. Chin Nurs Res 2011;18:2951e2952.
48. Yin ZL, Meng ZX, Lin SY, et al. The intervention effect
of chemotherapy in patients with gynecological tumor relax-
ation training method. Chin J Phys Med Rehabil 2012;34:
618e620.
49. Qiang WM, Dong FQ, Yan L, et al. Comparison of two
different exercise programs in breast cancer patients after
postoperative adjuvant chemotherapy. Chin J Nurs 2011;
46:537e540.
50. Chen LR, Hou XC. Effect of chiropractic and psycho-
logical intervention on patients with cancer pain and bad
mood. Hebei J Traditional Chin Med 2009;31:1897e1898.
51. Zhang YM. Effects of hand massage therapy on the
quality of life in breast cancer patients undergoing chemo-
therapy. Chin J Nurs 2012;47:247e250.
52. Jiang MY. Influence of shadowboxing on improving
cancer-related fatigue and sleeping quality of patients with
advanced lung cancer. Chin Nurs Res 2013;27:420e421.
53. Wang HL, Liu CC, Wen XX. The effect of a foot mas-
sage combined with psychological intervention to improve
the sleep quality of patients with cancer. Zhejiang Clin
Med J 2012;14:1309e1310.
54. Chen CF. Treatment of moxibustion effecting on
cancer-associated diarrhea in 18 cases. Chin J Integr Tradit
West Med Digest 2012;20:514e515.
55. Xue WX. Liver cancer after interventional chemo-
therapy intractable hiccups acupuncture curative effect
observation. Chin J Misdiagnostics 2011;11:3061.
56. Chen YL. Acupressure reduces abdominal distention
after laparoscopic resection in colorectal cancer patients.
Chin J Misdiagnosis 2008;8:7627e7628.
57. Wan SY, Huang JP, Gao J. Influence of acupoint mas-
sage plus induced imagining relaxation on quality of life
of tumor patients accepting chemotherapy. Chin Nurs Res
2011;25:317e318.
58. Wang HM, Fan ZM. The clinical study on gastrointes-
tinal function recovery after colorectal carcinoma resection
in fast track programme using acupuncture. Masters Thesis.
2011. Available at: http://d.g.wanfangdata.com.cn/Thesis_
Y1945947.aspx.
59. Lu Y, Zhang Y, Jing NC. Acupuncture improved quality
of life in cancer patients via clinical study. J Oncol Pract
2005;19:299e301.
60. Zhang MF, Ruan JW, Gu MF. Effects of acupuncture
combined with relaxation training on pain, anxiety and
sleep quality in patients with advanced cancer. Chin J Phys
Med Rehabil 2009;31:674e677.
61. Pei Y, Yang J, Zhang J. To observe the state of depres-
sion and anxiety in patients with acupuncture in the treat-
ment of breast cancer. Chin J Inf On Tradit Chin Med
2010;17:62.
Vol. - No. - - 2016 Interventions for Symptom Management and QOL
62. Wang XP, Ding Y. The effect of music therapy on qual-
ity of life in patients with chemotherapy for advanced cancer.
J Clin Med Pract 2006;10:16.
63. Li HY, Yang DN. Acupuncture recovered gastrointes-
tinal function after surgery for esophageal cancer. Jiangsu
J Tradit Chin Med 2008;40:83e84.
64. Liu H. The effect of acupuncture and moxibustion and
acupuncture point injection on treatment of pain of hepato-
cellular carcinoma. J Hebei Tradit Chin Med Pharmacol
2010;25:37e38.
65. Feng Y, Wang XY, Li SD, et al. Clinical research of
acupuncture on malignant tumor patients for improving
depression and sleep quality. J Tradit Chin Med 2011;31:
199e202.
66. Meng ZQ, Garcia MK, Chiang JS, et al. Electro-
acupuncture to prevent prolonged postoperative ileus: a ran-
domized clinical trial. World J Gastroenterol 2010;16:
104e111.
67. Nedstrand E, Wyon Y, Hammar M, et al. Psychological
well-being improves in women with breast cancer after treat-
ment with applied relaxation or electro-acupuncture for
vasomotor symptom. J Psychosom Obstet Gynaecol 2006;
27:193e199.
68. Wong RH, Lee TW, Sihoe AD, et al. Analgesic effect of
electroacupuncture in postthoracotomy pain: a prospective
randomized trial. Ann Thorac Surg 2006;81:2031e2036.
69. Zhu YY. Effect of acupuncture at specific points com-
bined with thumbtach needle on pain and depression in
pancreatic cancer patients. Chinese General Practice 2013;
16:1923e1925.
70. Zhao BM. Effect of acupuncture on ascites in liver can-
cer. Health Way 2013;12:411.
71. Li J. Clinical research on treating advanced breast can-
cer related fatigue by moxibustion. Clin J Chin Med 2013;5:
1e4.
72. Guo LY. Effect of acupuncture therapy on cancere
related fatigue of patients with gynecological malignant tu-
mor after chemotherapy. J Clin Acupuncture Moxibustion
2014;30:67e70.
73. Fu LP. Effect of moxibustion on quality of life in esoph-
ageal cancer patients. Shaanxi J Tradit Chin Med 2014;35:
77e79.
74. Chen YH. Effect of moxibustion on depression and
quality of life in patients with advanced gastric cancer.
J Nurs (China) 2013;20:63e65.
75. Yan QM. Effect of moxibustion on ascites in advanced
cancer patients. J Qilu Nurs 2014;20:123e124.
76. Chen HT. Clinical observation of acupuncture therapy
on hiccuping in liver cancer. J Clin Acupuncture Moxibus-
tion 2006;22:18e19.
77. Luo MS, Wu SB. Acupuncture for 70 cases of hiccup
after operation of primary liver cancer. World J Acupunc-
ture-Moxibustion 2007;17:52e54.
78. Bao FF. Effect of acupuncture on hiccups in cancer
patients after radio-chemotherapy. Zhejiang J Tradit Chin
Med 2012;47:117.
79. Smith C, Carmady B, Thornton C, et al. The effect of
acupuncture on post-cancer fatigue and well-being for
women recovering from breast cancer: a pilot randomised
controlled trial. Acupunct Med 2013;31:9e15.
19
80. Deng G, Wong WD, Guillem J, et al. A phase II, ran-
domized, controlled trial of acupuncture for reduction of
postcolectomy ileus. Ann Surg Oncol 2013;20:1164e1169.
81. Ng SS, Leung WW, Mak TW, et al. Electroacupuncture
reduces duration of postoperative ileus after laparoscopic
surgery for colorectal cancer. Gastroenterology 2013;144:
307e313.e1.
82. Johnston MF, Hays RD, Subramanian SK, et al. Patient
education integrated with acupuncture for relief of cancer-
related fatigue randomized controlled feasibility study.
BMC Complement Altern Med 2011;11:49.
83. Liljegren A, Gunnarsson P, Landgren BM, et al.
Reducing vasomotor symptoms with acupuncture in breast
cancer patients treated with adjuvant tamoxifen: a random-
ized controlled trial. Breast Cancer Res Treat 2012;135:
791e798.
84. Pfister DG, Cassileth BR, Deng GE, et al. Acupuncture
for pain and dysfunction after neck dissection: results of
a randomized controlled trial. J Clin Oncol 2010;28:
2565e2570.
85. Deng G, Rusch V, Vickers A, et al. Randomized
controlled trial of a special acupuncture technique for
pain after thoracotomy. J Thorac Cardiovasc Surg 2008;
136:1464e1469.
86. Deng G, Vickers A, Yeung S, et al. Randomized,
controlled trial of acupuncture for the treatment of hot
flashes in breast cancer patients. J Clin Oncol 2007;25:
5584e5590.
87. Yang JX. Effect of Chinese medicine five-tone therapy
intervention on the depression state of the chemotherapy
patients with breast cancer. Chin J Mod Nurs 2013;19:
4461e4463.
88. Lei YY. Effect of five elements music of traditional Chi-
nese medicine on the tumor patients under hyperthermia
nursing. J Nurses Train 2014;29:335e336.
89. Li WJ. Effect of Chinese massage on hiccups in patients
with liver cancer. Yunnan J Tradit Chin Med Materia Med
2014;35:102.
90. Xiao J. Effect of Chinese massage combined with point
pressure on ventosity in patients with gynecologic cancer.
Yiayao Qianyan 2014;16:332e333.
91. Liu YC. Effect of Tai Chi on respiratory function in pa-
tients with lung cancer. Chin J Trauma Disabil Med 2014;22:
211.
92. Rausch SM. Evaluating psychosocial effects of two inter-
vention, tai chi and spiritual growth groups, in women with
breast cancer. MS Thesis. Richmond, VA: College of Human-
ities and Sciences, Virginia Commonwealth University, 2007.
Available at: http://scholarscompass.vcu.edu/etd/819/.
93. He JH. Rehabilitation effect of systematic exercise in
adjuvant chemotherapy for breast cancer patients. Chin
J Rehabil 2011;26:204e206.
94. Janelsins MC, Davis PG, Wideman L, et al. Effects of Tai
Chi Chuan on insulin and cytokine levels in a randomized
controlled pilot study on breast cancer survivors. Clin Breast
Cancer 2011;11:161e170.
95. Mustian KM, Palesh OG, Flecksteiner SA. Tai Chi
Chuan for breast cancer survivors. Med Sport Sci 2008;52:
209e217.
20 Tao et al.
96. Wang YL, Sun XY, Wang YB. Different exercise on
breast cancer patients postoperative upper limb function
and the influence of the quality of life. Chin J Phys Med
Rehabil 2012;34:64e65.
97. Li PX. Effect of acupuncture on anorexia in advanced
gastric cancer patients. N J Tradit Chin Med 2006;38:67e68.
98. Liu XM, Huang ZF. Acupuncture treatment for intrac-
table hiccup in patients with cancer of 32 cases. Liaoning
J Tradit Chin Med 2007;34:214e215.
99. Xie XP. Observation of electroacupuncture and press-
ing auricular point with pill in treating patients with tumor
suffering from hiccup. Cancer Res Prev Treat 2005;32:
42e43.
100. Chen SY, Huang LQ. Effect of electroacupuncture
treatment on zusanli(st36) for intractable hiccups with ma-
lignant tumors of 24 cases. J Qilu Nurs 2007;13:43e44.
101. Lu L, Liao M, Zeng J, et al. Quality of reporting and its
correlates among randomized controlled trials on acupunc-
ture for cancer pain: application of the CONSORT 2010
statement and STRICTA. Expert Rev Anticancer Ther
2013;13:489e498.
102. Chan HY, Chui YY, Chan CW, et al. Exploring the influ-
ence of traditional Chinese medicine on self-care among
Chinese cancer patients. Eur J Oncol Nurs 2014;18:
445e451.
Vol. - No. - - 2016
103. Wood L, Egger M, Gluud LL, et al. Empirical evidence
of bias in treatment effect estimates in controlled trials with
different interventions and outcomes: meta-epidemiological
study. BMJ 2008;336:601e605.
104. Smyth RM, Kirkham JJ, Jacoby A, et al. Frequency and
reasons for outcome reporting bias in clinical trials: inter-
views with trialists. BMJ 2011;342:c7153.
105. Faller H, Schuler M, Richard M, et al. Effects of psycho-
oncologic interventions on emotional distress and quality of
life in adult patients with cancer: systematic review and meta-
analysis. J Clin Oncol 2013;31:782e793.
106. Moyer A, Sohl SJ, Knapp-Oliver SK, et al. Characteris-
tics and methodological quality of 25 years of research inves-
tigating psychosocial interventions for cancer patients.
Cancer Treat Rev 2009;35:475e484.
107. Vickers A, Goyal N, Harland R, et al. Do certain coun-
tries produce only positive results? A systematic review of
controlled trials. Control Clin Trials 1998;19:159e166.
108. Higgins JPT, Green S. Cochrane handbook for system-
atic reviews of interventions. West Sussex, UK: Wiley-Black-
well, 2008.
109. Schulz KF, Altman DG, Moher D, et al. CONSORT
2010 statement: updated guidelines for reporting parallel
group randomized trials. Ann Intern Med 2010;152:
726e732.