Effects of symptoms and complementary and alternative medicine use on the yang deficiency pattern among breast cancer patients receiving chemotherapy

Complementary Therapies in Medicine (2015) 23, 233—241

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ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim

Effects of symptoms and complementary and alternative medicine use on the yang deficiency pattern among breast cancer patients receiving chemotherapy Sheng-Miauh Huang a, Li-Yin Chien b, Cheng-Jeng Tai c,d, Ping-Ho Chen e, Pei-Ju Lien f, Chen-Jei Tai e,g,∗ a

Department of Nursing, Mackay Medical College, New Taipei City, Taiwan Institute of Clinical and Community Health Nursing, National Yang-Ming University, Taipei, Taiwan c Division of Hematology and Oncology, Department of Internal Medicine, Taipei Medical University Hospital, Taiwan d Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan e Department of Traditional Chinese Medicine, Taipei Medical University Hospital, Taiwan f Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan g Department of OB/GYN, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan Available online 12 January 2015 b

KEYWORDS Meridian energy; Qi; Symptom; Complementary and alternative medicine; Breast cancer; Traditional Chinese medicine; Yang deficiency pattern

Summary Background: Based on traditional Chinese medicine (TCM) theory, yang deficiency pattern defined as an insufficiency of meridian energy (qi) is related to worsening disease symptoms. However, there is a lack of studies portraying the relationship among complementary and alternative medicine (CAM) use, symptoms, and meridian energy. Therefore, the primary purpose of this study was to describe the changes of CAM use, symptoms, and yang deficiency pattern among patients with breast cancer receiving chemotherapy. Additionally, the study explored factors predicting yang deficiency pattern. Method: A longitudinal study was performed with 153 women with breast cancer at four teaching hospitals in northern Taiwan from June 1, 2009 to July 31, 2013. Researchers collected data before treatment and the 1st and 3rd months after chemotherapy. Yang deficiency pattern was

∗

Corresponding author at: 252 Wu-Xing Street, Xin-Yi District, Taipei 110, Taiwan. Tel.: +886 2 2737 2181x3102; fax: +886 2 2704 5034. E-mail addresses: [email protected] (S.-M. Huang), [email protected] (L.-Y. Chien), [email protected] (C.-J. Tai), [email protected] (P.-H. Chen), [email protected] (P.-J. Lien), [email protected] (C.-J. Tai). http://dx.doi.org/10.1016/j.ctim.2015.01.004 0965-2299/© 2015 Elsevier Ltd. All rights reserved.

234

S.-M. Huang et al. examined using the Meridian Energy Analysis Device Me-Pro. Symptom severity and interference were assessed using the MD Anderson Symptom Inventory-Taiwan version. CAM use was evaluated using the US National Center for Complementary and Alternative Medicine (NCCAM) classification. Results: Meridian energy remained essentially the same over the 3-month period as the difference was not statistically significant. As time went by, patients developed worsening symptom severity and interference. More than 66% of the patients used CAM during chemotherapy. Older women had lower overall meridian energy. The more severe the symptoms were, the lower the overall meridian energy was. The patients who used tai chi or qi gong had higher overall meridian energy and those who used prayer or spirituality had lower overall meridian energy. Conclusion and implications: Symptom severity and interference among patients deteriorated during chemotherapy. Health providers should observe symptom changes and improve yang deficiency pattern. Whether or not use of CAM practices such as tai chi or qi gong improves the overall health of breast cancer patients on chemotherapy is worth further study. © 2015 Elsevier Ltd. All rights reserved.

Introduction Based on the theories of traditional Chinese medicine (TCM), qi runs throughout the body via meridian vessels. Qi running through these vessels is regarded as meridian energy.1—4 The health of an individual is viewed as a function of meridian energy.4—6 Chinese medicine practitioners view pattern/syndrome type as a collection of symptoms or a syndrome that serves as a guide for TCM treatment.7,8 Yang deficiency pattern reflects an insufficiency of meridian energy, which may be treated by TCM, acupuncture, or both to modulate meridian energy levels.9 Nonetheless, the relationship between symptoms and meridian energy remains unclear because of insufficient scientific studies. Of all cancers in Taiwan, breast carcinoma ranks first in incidence and fourth in mortality. Death due to breast carcinoma in 2001 and 2012 were 10.7 and 11.6 per 100,000 people in Taiwan. Although a trend toward increasing death rate is reported, the median age at death in Taiwan increased from 53 years per 100,000 in 2001 to 58 years per 100,000 in 2012.10 Western medicine studies showed that chemotherapy provided hope for extending disease-free survival,11,12 but patients receiving chemotherapy experience severe physical symptoms, including musculoskeletal pain, fatigue, and nausea.13—15 TCM studies indicated cancer patients taking chemotherapy had deteriorating deficiency and stasis patterns during their treatments,16,17 which implies that the cancer patients experienced severe symptoms and insufficiency of meridian energy. The US National Center for Complementary and Alternative Medicine (NCCAM) classifies complementary and alternative therapies into two major groups, natural products and mind and body practices.18 Cancer patients receiving conventional treatment used complementary and alternative medicine (CAM) frequently (prevalence, 25—83%).19,20 Past studies have shown that CAM alleviated chemotherapy symptoms.21,22 In Taiwan, the National Health Insurance system covers both modern medicine and TCM expenses in parallel. In TCM clinics, the use of qi and blood tonifying herbs is a commonly used prescription pattern to treat or control disease.23,24 TCM use in the continuing care phase among patients with cancer in Taiwan is higher than TCM use in matched, cancer-free counterparts. TCM use during cancer care has increased considerably over the

past several years.25 Some evidence shows that TCM doctors alleviated symptoms among patients by supplementing qi and activating blood circulation. Those studies focused only on exploring TCM treatment effects on symptoms, not on meridian energy.24,26 Very few, if any, prior studies described the changes of meridian energy during chemotherapy in cancer patients. Additionally, we found no studies linking symptoms, CAM use, and meridian energy directly. Thus, our study describes the changes of symptoms, CAM use, and meridian energy among patients with breast carcinoma receiving chemotherapy. Additionally, we investigated the effects of symptoms and CAM use on meridian energy after adjusting for potential confounders.

Materials and methods This was a longitudinal and observational study. We collected data before treatment, 1 month, and 3 months after chemotherapy using face-to-face interviews with structured questionnaires, medical chart reviews, and electrodermal measurements. The interviews were conducted either at the outpatient department or in the ward at the patients’ convenience. The study was approved by the human subject review committee at each of the hospitals.

Study participants We recruited women with breast cancer who were 18 years or older and who were about to start chemotherapy. All patients in the study received 3-week cyclic anthracyclinebased, taxane-based, or trastuzumab therapy for at least 3 months. The women joined the study during the period from June 2009 to July 2013 from two hospitals in Taipei City and two hospitals in Yilan county. Among the potential study candidates, 180 patients met the inclusion criteria during the study period. Of those patients, 22 patients refused to participate at the first contact. The remaining 158 patients completed the first interview. Another five patients stopped treatment (n = 1) or refused further participation (n = 4). As a result, 153 patients (84.0%) were enrolled. The

Meridian energy among breast cancer patients patients in the anthracycline-based group had not previously received any chemotherapy. All patients in the taxane-based group were previously treated with anthracycline-based chemotherapy. All patients in the trastuzumab group were also previously treated with anthracycline- and taxanebased chemotherapy. We assumed the effect size to be 0.25, and the correlation among repeated measures was 0.5. When the power was set to 0.8, the number of repeated measurements was 3, the number of groups was 3, and the needed total sample size was 108 participants.

Measurements The study variables included demographics (age, marriage, occupation, family income, and religion), clinical treatment characteristics, diagnostic characteristics (disease history, cancer stage, site of lesion, type of mastectomy, and therapy), CAM use, symptom severity and interference, and meridian energy. We obtained the demographics, clinical treatments, and diagnostic characteristics before the start of treatment. We collected CAM use, symptom severity, symptom interference, and meridian energy data before treatment and at 1 month and 3 months after treatment. We applied the NCCAM classification to collect data on the different types of CAM.18 Natural products mean herbs, vitamins and minerals, and probiotics. Mind and body practices include acupuncture, meditation, tai chi and qi gong, spinal manipulation, and others. Because the National Health Insurance system covers TCM expenses in Taiwan, people often visit TCM clinics.23—25 Thus, we inquired about the use of TCM. Since many people in Taiwan also seek help for healing from their religions, we also surveyed prayer and spirituality activities. The MD Anderson Symptom Inventory is a multi-symptom, patient-reported outcome measure for clinical and research use. The MD Anderson Symptom Inventory-Taiwanese version (MDASI-T) is a reliable, valid, and sensitive instrument for measuring cancer-related symptoms among Taiwanese cancer patients.27 We used the 19-item MDASI-T to measure the symptom severity (13 items) and interference (6 items) characteristics of patients. Each item was rated on an 11-point Likert scale, ranging from 0 to 10. A higher score indicated a higher symptom severity and symptom interference. Meridian energy was examined using the MEAD Me-Pro (Hanja International Co. Ltd., Taoyuan, Taiwan), which yielded electrodermal measurements of the 24 meridians (12 for the left side and 12 for the right side)28,29 and was similar to the machine used in previous studies.6,30 Before the meridian energy measurements, the patients removed their shoes, socks, metal objects, and cell phones; then, they rested for 10 min before the measurements started. The level of the meridian energy was determined using the MEAD values for each meridian point that lay along the 12 meridians. The meridian energy for each meridian ranged from 0 to 200 ␮A. The overall meridian energy was the average of the 24 meridian energy measurements. The meridian energy data were transferred directly from the measuring device to the computer database. A lower score indicated a lower level of meridian energy (deteriorated yang deficiency pattern). The validity from cancer patients showed the lower meridian energy was significantly

235 associated with deteriorated yang deficiency pattern in a national research.31 The yang deficiency pattern was assessed by using the Traditional Chinese Medical Constitutional Scale, with higher scores indicating more deficiency.32 The correlation coefficient between different times in the same subjects was high (r = 0.88), suggesting that the MEAD measurements were reliable.

Data analysis Statistical analyses were performed using the Predictive Analytics Suite workstation running version 18.0 software (PASW, IBM Corp., Somers, New York, USA). We examined individual variables using percentages, means, and standard deviations. Differences among the three measurement periods were examined using 2 statistics and ANOVA. Repeated-measures ANOVA was used to examine the changes of symptoms and the overall meridian energy at the three time points. Because we expected substantial individual differences in the data, we used the generalized linear mixed model (GLMM) to perform multivariate analysis and assess symptom severity, symptom interference, and CAM use on the overall meridian energy, having adjusted for potential confounders. In all analyses, p < 0.05 was considered statistically significant.

Results Characteristics of participants The mean age of the subjects was 53.9 years (SD = 11.0). More than half of the women were married (62.7%) and unemployed (51.6%). Most of the patients (70.4%) had sufficient family income. The percentages of patients at cancer stages I, II, III, and, IV were 18.3%, 40.5%, 30.1%, and 11.1%, respectively. Only 23 patients (15.0%) did not undergo mastectomy. The percentage of anthracyclinebased, taxane-based, and trastuzumab therapies were 51.6%, 28.8%, and 19.6% (Table 1).

CAM use More than 66% of the patients used CAM at least once before treatment. While 66.7% of patients had used CAM before treatment, 75.2% used 1 month after treatment, and 67.3% used CAM 3 month after treatment. Statistically, there was no difference between 66.7%, 75.2%, and 67.3% (p = 0.2). Among all CAM uses, natural products were the most popular form of CAM. Patients used natural products more often than other forms of CAM after beginning chemotherapy (47.1% before treatment vs. 63.4% 1 month after treatment vs. 51.0% 3 months after treatment, p = 0.01). Patients chose a variety of products such as multiple vitamins, fucoid complex, tian xian liquid, dietary supplements, Ganoderma lucidum, Antrodia cinnamomea, and others. More than one in three people accepted unmarked foods or products offered as gifts from families and friends. Only one in four patients ever used mind and body CAM practices. There were no statistically significant differences in mind and body practices among the three time points. Among

236 Table 1

S.-M. Huang et al. Characteristics of the study participants (n = 153).

Age (mean, SD) Marriage Single Married Widower or divorced Employment No Yes Family income Insufficiency Sufficiency Religion No Yes Diabetes No Yes Hypertension No Yes Cardiovascular disease No Yes Cancer stage I & II III & IV Breast lesion Left Right Bilateral Mastectomy No Partial Simple Initial chemotherapy No Yes Type of drugs Anthracycline based Taxane based Trastuzumab only

n

%

53.9

11.0

31 96 26

20.3 62.7 17.0

79 74

51.6 48.4

30 123

19.6 70.4

24 129

15.7 84.3

139 14

90.8 9.2

124 29

81.0 19.0

139 14

90.8 9.2

90 63

58.8 41.2

75 67 11

49.0 43.8 7.2

23 83 47

15.0 54.2 30.7

74 79

48.4 51.6

79 44 30

51.6 28.8 19.6

mind and body practices, more than 10% of patients used prayer or spirituality activities and spinal manipulation. Less than 5% of patients had ever used tai chi or qi gong during chemotherapy. A steady 18—20% of patients visited the TCM clinic during treatment (Table 2).

Symptom severity Fig. 1 displays symptom severity at pretreatment, 1 month, and 3 months after treatment. Repeated measures ANOVA showed that the symptom severity increased significantly over time among patients (mean MIDASI-T ± standard deviation (SD): 28.8 ± 17.4 for pretreatment, 34.4 ± 18.7 at 1 month after start of treatment, and 36.7 ± 23.4 at 3 months after the start of treatment; F = 12.9, p < 0.01). The post hoc

Figure 1 The change in the M.D. Anderson Symptom Inventory (Taiwanese).

comparison showed patients receiving therapy at 1 month or 3 months after treatment had higher mean symptoms severity scores than the patients at pretreatment (pretreatment vs. 1 month after treatment, p < 0.01; pretreatment vs. 3 months after treatment, p < 0.01). Of the 13 symptoms, the most common symptoms were fatigue, sleep disturbance, dry mouth, distress, and sadness after chemotherapy. The mean severity scores of 13 symptoms were less than 6 (Table 3).

Symptom interference Fig. 1 displays symptom interference at pretreatment, 1 month, and 3 months after breast cancer treatment. Repeated measures ANOVA showed that patients had rising mean symptom interference scores over time, and the differences were statistically significant (15.0 ± 12.9 at pretreatment, 17.1 ± 13.3 at 1 month after treatment, and 18.5 ± 15.2 at 3 months after treatment; F = 6.9, p < 0.01). The post hoc comparison showed patients receiving CAM therapy 1 month or 3 months after treatment had higher mean symptoms interference scores than the patients at pretreatment (pretreatment vs. 1 month after treatment, p < 0.05; pretreatment vs. 3 months after treatment, p < 0.01). The most common symptom interferences were mood and work among the six symptom interference categories. All mean scores of the six symptom interferences were less than 5 (Table 3).

Meridian energy Fig. 2 displays the overall meridian energy at pretreatment, 1 month, and 3 months after breast cancer treatment. Meridian energy remained essentially the same over the 3-month period as the difference was not statistically significant (28.6 ± 19.5 at pretreatment, 29.5 ± 23.0 at 1 month after treatment, and 26.1 ± 20.9 at 3 months after treatment; F = 1.9, p = 0.16). For specific meridian energies, repeated measures ANOVA showed that pericardium, spleen, and bladder meridian energies decreased significantly over the study period among the patients. Of the 12 meridians, the highest energy scores were for lungs and large intestine meridians. The kidney and gallbladder meridians had the lowest energy (Table 4).

Meridian energy among breast cancer patients Table 2

237

Use of CAM during chemotherapy (n = 153).

CAM usea No Yes Natural products No Yes Mind and body practices No Yes Prayer and spirituality No Yes Spinal manipulation No Yes Tai chi or qi gong No Yes Traditional Chinese medicine No Yes

Pretreatment

1 month posttreatment

3 months posttreatment

n

%

n

%

n

%

51 102

33.3 66.7

38 115

24.8 75.2

50 103

32.7 67.3

81 72

52.9 47.1

56 97

36.6 63.4

75 78

49.0 51.0

116 37

75.8 24.2

117 36

76.5 23.5

114 39

74.5 25.5

136 17

88.9 11.1

135 18

88.2 11.8

137 16

89.5 10.5

135 18

88.2 11.8

134 19

87.6 12.4

132 21

86.3 13.7

146 7

95.4 4.6

149 4

97.4 2.6

147 6

96.1 3.9

125 28

81.7 18.3

125 28

81.7 18.3

123 30

80.4 19.6

2

p

3.24

0.20

8.95

0.01

0.17

0.92

0.13

0.94

0.28

0.87

0.86

0.65

0.11

0.94

a Patients accepted natural products, mind and body practices, or TCM. 2 is respective statistical values from Chi-squared tests. The significance level was set to p < 0.05.

Table 3

Symptom severity and interference during chemotherapy (n = 153). Time Pretreatment

Severitya Pain Fatiguea Nauseaa Sleep disturbance Distress Shortness of breatha Difficulty rememberinga Poor appetitea Drowsinessa Dry moutha Sadness Vomiting Numbness Interferencea General activitya Mood Worka Relations with other peoplea Walkinga Enjoyment of lifea

1 month posttreatment

3 months posttreatment

Mean

SD

Mean

SD

Mean

SD

F

p

28.8 2.6 3.6 0.5 4.1 3.9 0.6 1.7 1.5 1.7 2.7 3.7 0.2 2.0 15.0 2.5 3.9 3.5 1.3 1.3 2.5

17.4 2.4 3.2 1.6 3.6 3.3 1.7 2.5 2.5 2.5 2.9 3.3 1.2 2.7 12.9 2.7 3.4 3.3 2.3 2.4 3.1

34.4 2.6 5.1 0.9 4.6 3.5 1.1 2.5 2.1 2.5 4.1 2.9 0.3 2.3 17.1 3.1 3.6 3.8 1.6 2.0 3.0

18.7 2.5 3.1 1.9 3.7 2.9 2.0 2.5 3.0 3.1 3.2 2.6 1.0 2.8 13.3 2.6 3.0 3.4 2.5 2.7 3.1

36.7 2.4 5.2 1.0 4.7 3.6 1.2 2.6 2.1 3.1 4.3 3.2 0.4 2.7 18.5 3.4 3.7 4.3 1.9 2.0 3.3

23.4 2.5 3.3 2.3 3.7 3.1 2.3 2.7 3.1 3.4 3.3 3.0 1.4 3.0 15.2 2.9 3.2 3.6 2.9 3.0 3.5

12.9 0.4 20.5 5.1 2.3 1.4 6.7 12.5 3.6 13.9 19.1 4.6 0.6 5.5 6.9 8.9 0.8 4.5 4.3 9.7 4.7

<0.01 0.68 <0.01 <0.01 0.10 0.24 <0.01 <0.01 0.03 <0.01 <0.01 <0.01 0.56 <0.01 <0.01 <0.01 0.45 0.02 0.01 <0.01 0.01

F value is from the repeated measure ANOVA test. a Pairwise comparisons showed the severity scores at pretreatment were lower than the scores at 1 month or 3 months after treatment. The significance level was set to p < 0.05.

238 Table 4

S.-M. Huang et al. Meridian energy during chemotherapy (n = 153). Time

Overall meridian energy Lung Pericardiuma Heart Small intestine Triple energizer Large intestine Spleena Liver Kidney Bladdera Gallbladder Stomach

Pretreatment

1 month posttreatment

3 months posttreatment

Mean

SD

Mean

SD

Mean

SD

F

p

28.6 35.1 33.9 27.7 31.1 30.7 33.0 30.4 26.1 21.2 26.1 19.9 28.0

19.5 26.6 24.8 20.8 25.2 25.9 26.3 22.7 21.6 18.9 20.3 19.2 21.2

29.5 35.6 32.6 28.1 33.5 36.0 37.2 28.5 27.1 21.8 23.4 20.5 29.4

23.0 30.4 28.0 24.8 31.9 33.2 31.8 22.7 23.0 20.2 20.1 19.4 24.5

26.1 32.1 28.3 24.7 28.6 31.4 33.3 24.2 24.0 19.0 21.6 18.9 26.7

20.9 27.6 25.4 22.4 26.5 26.5 26.8 21.6 21.6 18.4 20.1 18.2 22.6

1.9 1.2 3.5 1.6 2.1 2.4 1.7 6.1 1.4 1.5 3.6 20.6 0.9

0.16 0.29 0.03 0.20 0.13 0.09 0.18 <0.01 0.24 0.22 0.03 0.57 0.41

F value is from the repeated measure ANOVA test. a Pairwise comparisons showed the energy scores at pretreatment were higher than the scores at 1 month or 3 months after treatment. The significance level was set to p < 0.05.

Bivariate analysis showed that age, marriage status, diabetes, cancer stage, initial chemotherapy, type of mastectomy, and CAM use were significantly associated with meridian energy. Higher symptom severity and interference scores were associated with lower overall meridian energy (r = −0.19 to −0.20). We included and adjusted for those variables in the multivariate analysis. Because the GLMM results showed no significant differences in meridian energy among the different marriage categories, or with or without diabetes, or different cancer stages, or with or without initial chemotherapy, or different therapy groups, we excluded those variables. GLMM model 1 shows the relationship between symptom and meridian energy, having adjusted for the age. Bivariate analysis showed significant differences in meridian energy among patients with

Table 5

or without CAM use at different times (data not shown in the table). Thus, all types of CAM use were included in GLMM model 2, having adjusted for age and symptoms. Final model shows that older women have lower overall meridian energy (adjusted ˇ = −0.30; 95% CI, −0.53 to −0.07; GLMM model 3). Patients with higher symptom severity had worse overall meridian energy (adjusted ˇ = −0.21; 95% CI, −0.30 to −0.11). For CAM use, patients that practiced tai chi or qi gong had higher overall meridian energy compared to those that did not practice tai chi or qi gong (adjusted ˇ = 10.92; 95% CI, 0.90—20.93). Patients who prayed and did spiritual activities had lower overall meridian energy compared to those who did not pray or do any spirituality activities (adjusted ˇ = −11.03; 95% CI, −18.52 to −3.53). The intraclass correlation coefficient was 0.43 in model

The GLMM results on the meridian energy (n = 153). Model 1

Intercept Age MDASI—severity MDASI—interference Tai chi or qi gonga Prayer and spiritualitya TCMb therapya Natural productsa Spinal manipulationa a

Estimate

SE

t

51.38 −0.30 −0.17 −0.07

6.62 7.76 0.12 −2.54 0.07 −2.45 0.11 −0.68

Model 2 p

Estimate

SE

t

<0.01* 0.01* 0.02* 0.49

51.14 −0.28 −0.21

6.57 7.78 0.12 −2.44 0.05 −4.28

10.88 −10.40 3.25 −2.29 4.63

5.08 2.14 3.84 −2.71 2.60 1.25 1.94 −1.18 2.95 1.57

Model 3 p

Estimate

SE

t

p

<0.01* 0.02* <0.01*

51.81 −0.30 −0.21

6.41 8.08 0.12 −2.55 0.05 −4.28

<0.01* 0.01* <0.01*

0.03* 10.92 0.01* −11.03 0.21 0.24 0.12

5.09 2.14 3.80 −2.90

0.03* <0.01*

The references were without tai chi or qi gong, without meditation, without TCM therapy, without natural products, and without spinal manipulation. b Traditional Chinese medicine. GLMM: generalized linear mixed model, AR(1). * The significance level was set at p < 0.05.

Meridian energy among breast cancer patients

Figure 2 apy.

The change of meridian energy during chemother-

3. All GLMM models for meridian energy are presented in Table 5.

Discussion The result indicates that meridian energy was unchanged among breast cancer patients during the 3 months of chemotherapy. It implies yang deficiency pattern remained essentially the same over the 3-month period. According to TCM theory, the left and right meridians are symmetrical to the center of the body and influence each other through the interconnected meridian vessels.1,3 We found the pericardium, spleen, and bladder meridians had significantly lower meridian energy over time among the 12 meridians. Whether the effect of the three meridians on overall meridian energy would increase or not after CAM use is worth investigating. We also found an apparent individual difference in our study by observing the high intraclass correlation coefficient. We suggest future studies in which investigators increase the duration of follow-up or the sample size, or both, to show the anticipated changes of the 12 meridian energies. Over time, the patients had worsening symptom severity and interference scores. These results are consistent with those of previous studies.13—15 In our study, the symptom severity remained the key factor predicting deterioration of overall meridian energy. Developing a program to reduce symptom severity could result in higher overall meridian energy, which improves yang deficiency pattern. Additionally, symptoms such as fatigue, nausea, shortness of breath, difficulty remembering, drowsiness, dry mouth, and numbness were consistent with the changes of the pericardium, spleen, and bladder meridian energies. This indicates that specific symptoms are associated with specific energy meridians. We found overall meridian energy was unchanged while the symptoms were getting more severe. A search of inquiry is in need that floor effect of overall meridian energy may exist in patients with breast cancer. Further research is needed to examine the mechanism linking symptoms to decreases in specific meridian energy levels. We found that natural products were the most popular form of CAM used by breast cancer patients in Taiwan, which

239 is consistent with previous studies.18,33 Patients used natural products more often after starting chemotherapy than before treatment. Accessibility was the most important reason for such frequent use because of the many convenience stores selling natural CAM products. These natural products included multiple vitamins, fucoid complex, tian xian liquid, dietary supplements, Ganoderma lucidum, Antrodia cinnamomea, and others. Although there was no significant overall meridian energy difference between patients who used or did not use natural products, it was necessary to detect side effects and drug interactions. In order to reduce those risks, physicians should understand the characterization of popular natural CAM products in order to communicate with patients. The theoretical basis of tai chi and qi gong is to recuperate the qi within the body by controlling the flow and distribution of qi.34 Past research indicated tai chi and qi gong had positive effects on the cancer-specific quality of life, fatigue, immune function, and cortisol levels in cancer patients.22,35 Our study showed patients practicing tai chi or qi gong had significantly higher overall meridian energy compared with those who did not practice tai chi or qi gong. Thus, overall meridian energy is a good indicator to evaluate the health status and harmony of mind and body. A longitudinal and observational design study was carried out in this study. The percentage of use of tai chi or qi gong was less than 5%. It is hard to draw some reliable conclusion. An experimental design study will be suggested in the future. Spirituality is described as an awareness of something greater than an individual’s power. It is often expressed through religion or prayer, or both.36 Past study showed religion and spirituality played a central role in coping with cancer, hope, and meaning. It was also helpful for psychosocial health in breast cancer survivors.37 Interestingly, we found that patients who prayed or were spiritual had lower overall meridian energy compared to those who did not pray or participate in spirituality. Most of the patients who engaged in prayer or spiritual practices chose motionless activities and chanted mantras and recited sutras. Patients with lower overall meridian energy might have insufficient energy to visit a TCM doctor or to perform manipulative or body-based practices, or energy medicine. Thus, further research is needed to determine whether or not mind-body practices improve health. Our study showed that older patients had lower overall meridian energy than younger patients, which is consistent with a previous study and TCM theory.38 This could mean that the ability to preserve meridian energy deteriorates among older people. Previous studies pointed out that using TCM therapy is effective in alleviating hematotoxicity and symptom.13,39 Our study showed there were blurred significant differences in the meridian energy between patients using and not using TCM therapy. All of the TCM medications used by our patients were different multi-component drugs. Patients undergoing TCM treatment might stop taking TCM drugs because of poor appetite, nausea, and vomiting induced by chemotherapy. Acupuncture, (a TCM body therapy) was also stopped for prevention of wound infections. Thus, the effects of TCM treatment could be underestimated. We recommend further studies to prove whether or not using TCM improves health by improving overall meridian energy.

240

Conclusion The yang deficiency pattern remained essentially the same over the 3-month period among breast cancer patients receiving chemotherapy. Additionally, the symptom severity consistently deteriorated during chemotherapy. The symptom severity was a strong factor predicting the yang deficiency pattern. Observing changes in symptoms and meridian energy lends insight into patient response to chemotherapy, especially among older adults. Health care providers may prescribe treatments to alleviate symptoms and improve meridian energy. Whether or not CAM activities such as tai chi or qi gong would improve the overall health of women with breast cancer undergoing chemotherapy is worthy of further investigation.

Funding The authors received financial support for the research, authorship, and publication of this article from the Department on Chinese Medicine and Pharmacy, Ministry of Health and Welfare (CCMP98-RD-034, CCMP99-RD-106), and Mackay Medical College, Taiwan (1002A08).

Conflict of interest The authors declare no competing financial interests exist.

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