|Year : 2023 | Volume
| Issue : 1 | Page : 8-14
Nursing perspective of expert consensus for diagnosis and treatment of gastric cancer with integrated traditional Chinese and Western medicine
Shuhong Liu1, Ling Tang2, Yanan Zhao1, Jingjing Huo1, Yan Zhao1, Kang Yan1, Baoya Zhao1
1 Department of Oncology, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China
2 Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China
|Date of Submission||02-Dec-2022|
|Date of Decision||26-Dec-2022|
|Date of Acceptance||27-Dec-2022|
|Date of Web Publication||23-Mar-2023|
Prof. Ling Tang
Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Zone 1, Fangzhuang Fangxing Garden, Fengtai, Beijing 100078
Source of Support: None, Conflict of Interest: None
Gastric cancer is a common and highly malignant tumor of the digestive system, which seriously threatens human health. The benefit of surgical treatment is limited. The effect of radiotherapy and chemotherapy is not significant, and the toxic and side effects are large. Although the diagnosis and treatment modes of molecular targeting and multidisciplinary cooperation have also been further developed and applied, a relatively unified comprehensive treatment standard scheme has not been formed. Traditional Chinese medicine (TCM), as complementary and alternative medicine, has unique advantages in the development of diagnosis and treatment of diseases in China. Therefore, the Chinese Association of Integrative Medicine formed “Expert Consensus for Diagnosis and Treatment of Gastric Cancer with Integrated Traditional Chinese and Western Medicine” on the basis of clinical practice and experience. In this article, the consensus is interpreted from the perspective of nursing, focusing on the pathogenesis, high-risk factors, characteristic therapies of TCM, and nursing of integrated traditional Chinese and Western medicine for gastric cancer, to provide a reference for front-line medical personnel in the roots in the future nursing care of gastric cancer.
Keywords: Consensus interpretation, gastric cancer, integrated traditional Chinese and western medicine nursing, integrative nursing, traditional Chinese medicine
|How to cite this article:|
Liu S, Tang L, Zhao Y, Huo J, Zhao Y, Yan K, Zhao B. Nursing perspective of expert consensus for diagnosis and treatment of gastric cancer with integrated traditional Chinese and Western medicine. J Integr Nurs 2023;5:8-14
|How to cite this URL:|
Liu S, Tang L, Zhao Y, Huo J, Zhao Y, Yan K, Zhao B. Nursing perspective of expert consensus for diagnosis and treatment of gastric cancer with integrated traditional Chinese and Western medicine. J Integr Nurs [serial online] 2023 [cited 2023 May 27];5:8-14. Available from: https://www.journalin.org/text.asp?2023/5/1/8/372411
| Introduction|| |
Gastric cancer is a primary malignant tumor of gastric mucosal epithelium, accounting for about 6% of global cancers, and it is the fourth largest cancer-related death cause, 48.6% of which occurred in China. The incidence rate of gastric cancer ranks second in China following lung cancer. The overall 5-year survival rate is only 35.1%. Although new drugs, technologies, and therapies are constantly emerging, we still face a considerable number of patients with gastric cancer whose clinical efficacy is not ideal. Because it is common and difficult to cure, with high incidence, it seriously threatens human health and life. The survival time of patients with late recurrence and metastasis and advanced gastric cancer is short and the quality of life is difficult to improve. A large number of clinical studies show that traditional Chinese medicine (TCM) drugs can alleviate the complications of gastric cancer and prevent tumor recurrence and metastasis after gastric cancer surgery.,,, Therefore, the Chinese Association of Integrative Medicine issued the “Expert Consensus for Diagnosis and Treatment of gastric Cancer with Integrated Traditional Chinese and Western Medicine” (hereinafter referred to as “Consensus”) in August 2021. This consensus focuses on the terms and definitions, etiology and pathogenesis, key points of diagnosis, and treatment and clinical pathway of integrated traditional Chinese and Western medicine in gastric cancer. The Consensus emphasizes to make full use of the complementary role of Chinese and Western medicine to improve the prevention and treatment level of gastric cancer in China.
Terms and definitions
Gastric cancer is a primary malignant tumor of gastric mucosal epithelium, which can occur in any part of the stomach, including gastric antrum, gastric horn, gastric body, and cardia. Early gastric cancer often has no specific symptoms. With the progression of the disease, symptoms similar to gastritis and ulcer disease appear, mainly including epigastric fullness and anorexia. In addition to the above symptoms, gastric cancer at the progressive stage is often manifested as epigastric mass, stomach pain, nausea and vomiting, and hematemesis, melena, etc. Advanced gastric cancer is manifested as severe weight loss, anemia, edema, fever, jaundice and cachexia, swelling of supraclavicular lymph nodes, abdominal mass, and gastrointestinal obstruction.
Although there is no name of “gastric cancer” in ancient Chinese medicine literature, according to the clinical manifestations and the records of ancient medical books, gastric cancer can be categorized as diseases of “epigastric pain,” “choking diaphragm,” “nausea,” “accumulation,” “Fuliang” in TCM.
Etiology and pathogenesis of gastric cancer
Understanding of pathogenic factors of gastric cancer from the perspective of Western Medicine
The Consensus points out that the incidence of gastric cancer is closely related to the environment, diet, infection, genetics, and precancerous changes. Among them, dietary factor accounts for most of the proportion in daily life. Moldy food, pickled vegetables, pickled smoked food, and excessive intake of salt can increase the risk of gastric cancer. A recent meta-analysis pointed out that moderate drinking and heavy drinking will increase the risk of gastric cancer. Even if the alcohol consumption is decreased, drinking will still increase the risk of gastric cancer. In addition to being related to Helicobacter pylori (HP) virus, gastric cancer is also related to Epstein–Barr virus. Besides the above factors, the previous study has shown that the occurrence of gastric cancer is also related to economic development, and race, age, gender, and behavior of human. Therefore, prevention from etiology is the key to reducing the incidence of gastric cancer.
Understanding of the pathogenesis of gastric cancer from the perspective of traditional Chinese Medicine
TCM believes that the pathogenic factors of gastric cancer are improper diet, internal emotional injury, invasion of exogenous pathogenic factors, and deficiency of healthy Qi. Deficiency of healthy Qi and weakness of the spleen and stomach are the root causes of gastric cancer, while Qi stagnation, blood stasis, phlegm coagulation, and toxin accumulation are the main pathological causes of gastric cancer. Professor Juxiang Wang believes that the pathogenesis of gastric cancer lies in Yang deficiency and Qi stagnation, with deficiency-cold in spleen and stomach as root cause, stagnation of Qi as a superficial cause, and phlegm dampness and blood stasis as the pathological products which are also the pathological factors to contribute to the development of the disease. In recent years, TCM-relevant research also believes that “cancer toxin” is a specific pathogenic factor leading to human cancerization, and is core causative factor induced by multiple internal and external factors on the basis of viscera, Qi, and blood disorders. It is hidden deep, wandering inside the body, easy to recur after treatment, and hard to be eradicated. Therefore, the key to the treatment of this disease is to strengthen healthy Qi and eliminate pathogenic factors.
Diagnosis, classification, and treatment of gastric cancer
Diagnosis, classification, and treatment based on Western medicine
The Consensus points out that the diagnosis of gastric cancer includes qualitative diagnosis, localization diagnosis, and staging diagnosis, and histopathology is the basis of definite diagnosis and treatment for gastric cancer. Thoracic, abdominal, and pelvic computed tomography (CT) is the basic means of clinical staging before treatment. Magnetic resonance image, laparoscopic exploration, and positron emission tomography-CT can be used as an auxiliary examination methods when liver metastasis, peritoneal metastasis, and systemic metastasis are suspected. Pay attention to clinical staging before surgery and histopathological diagnosis after surgery. Postoperative histopathological diagnosis is important basis of clarifying the histological type of gastric cancer, comprehensively evaluating the disease progression, judging the disease prognosis, and formulating a targeted individualized treatment plan.
According to pathological classification, gastric cancer can be classified into adenocarcinoma, undifferentiated cancer, mucinous cancer, and special type cancer. According to Lauren's classification, it is classified into intestinal type, diffuse type, and mixed type. According to the Borrmann classification, there are Borrmann I (tuberous mushroom umbrella type), Borrmann II (local ulcer type), Borrmann III (infiltration ulcer type), and Borrmann IV (diffuse infiltration type). According to molecular classification, it is classified into chromosomal instability, microsatellite instability, gene stability, and EB virus positive. The Consensus points out that according to the pathological type and clinical stage of the tumor, combined with symptom characteristics and functional status of patients, a multidisciplinary diagnosis and treatment model is adopted, and surgical, chemotherapy, radiotherapy, biological targeting, and other treatment methods are applied in a planned and reasonable manner to achieve a radical cure or maximum control of the tumor.
Diagnosis, classification, and treatment based on traditional Chinese medicine
The pathological changes of gastric cancer can be divided into three phases. The mild condition in the initial stage is mainly due to emotional discomfort, improper diet, and damage to the spleen and stomach; the condition in the middle stage is due to the stagnation of liver Qi caused by spleen and stomach Qi stagnation in the early stage, which further leads to the disorder of Qi mechanism, blood stagnation into blood stasis and accumulation day-by-day; the condition at an advanced stage is manifested as “deficient root and excessive superficial” due to further stagnation of Qi and blood stasis. The Consensus points out that the disease location elements of gastric cancer include the stomach, liver, spleen, and kidney; the syndrome elements include Qi deficiency, blood deficiency, Yin deficiency, Yang deficiency, Qi stagnation, blood stasis, phlegm dampness, and heat toxicity. The disease characteristics of patients with gastric cancer are mainly intermingled deficiency and excess, so it is necessary to clarify the clinical syndrome differentiation before TCM treatment. The literature reports that according to the frequency of classification, gastric cancer can be divided into spleen deficiency type, internal obstruction of blood stasis and toxin, disharmony between liver and stomach, deficiency of both Qi and blood, stomach heat damaging Yin, and phlegm-dampness stagnation. The modern medicine research has found that patients with different syndrome types differ in immune cells measured by flow cytometry. The cellular immune function of patients with deficiency syndrome is significantly lower than that of patients with excess syndrome. Therefore, it is advisable to adopt the method of strengthening the body, protecting the body, and enhancing the anti-cancer ability. Tumors are difficult to treat and cure, and there are many clinical difficulties. The auxiliary coordination of TCM in different treatment methods of Western medicine at different stages of tumors can give full play to the characteristics and advantages of TCM in treatment effects,, for example, cooperation of TCM with surgical intervention to reduce recurrence and metastasis; TCM combined with radiotherapy and/or chemotherapy to reduce adverse reactions of anti-tumor treatment; promotion of rehabilitation of gastric cancer. TCM therapies, such as acupuncture, moxibustion, and external treatment, can alleviate the complications of advanced gastric cancer such as cancer-related fatigue, cancer pain, cancer fever, and incomplete obstruction of the digestive tract. In brief, TCM is mainly used to assist the modern medical treatment of gastric cancer and is also used for the treatment of middle-and advanced-stage patients who can't tolerate the anti-tumor treatment of Western medicine, to improve symptoms, reduce pain and prolong survival.
Integrated traditional Chinese and western medicine nursing
A large number of studies have found that Helicobacter pylori infection is closely related to the occurrence of gastric cancer, and sharing chopsticks, towels, and tooth brushing cups unsanitary feeding, smoking, and high-salt diet are the reasons for the high rate of HP infection.,,, Therefore, it is necessary to correct those bad living habits and prevent diseases before they occur. As the first article of Synopsis of the Golden Chamber mentioned, “a good doctor should prevent a disease before its onset,” which emphasizes the importance of disease prevention. The prevention for the precancerous stage of gastric cancer mainly includes quitting smoking and alcohol, developing good eating habits, keeping a happy mood, and keeping exercising.
The Consensus puts forward that TCM dietary therapy is beneficial to the nutritional adjustment in different stages of gastric cancer. Based on the theory of TCM syndrome differentiation and treatment, and the principles of “treating the weak body form with something warm with the effect of invigorating Qi, and supplementing the insufficient essence (nutrient substance) with something rich or strong in flavour” recorded in Huangdi's Canon of Internal Medicine, postoperative patients with gastric cancer with shortness of breath, emaciation, loss of appetite should be given something sweet and warm in property with effect of invigorating Qi; gastric cancer patients with damage of Yin fluid after radiotherapy should be given something sour and sweet in taste with effect of transforming into Yin. Food varieties can be scientifically selected according to the patient's appetite and constitution, so as to ensure the balanced intake of nutrition. Food should be cooked until soft, and easy to digest. The recommended diets are as follows according to different syndromes: (1) Gastric cancer patients with spleen and stomach deficiency-cold syndrome should avoid eating uncooked and cold food and eat warm and digestible food, such as stewed pork with pepper. The pork lean is braised with fresh pepper, tangerine peel, and dried ginger. It has the effects of warming the spleen and stomach for dispersing cold, removing dampness, and relieving pain; (2) For gastric cancer patients with Qi and blood deficiency syndrome, the uncooked, cold, irritating, and spicy food should be avoided. The recommended diet is eel soup with Huangqi (Radix Astragali seu Hedysari) and Danggui (Radix Angelicae Sinensis), in which the combined use of Huangqi (Radix Astragali seu Hedysari) and Danggui (Radix Angelicae Sinensis) can invigorate Qi and blood, and strengthen spleen and stomach while the eel can tonify the five Zang-organs. The soup has the effect of curing asthenia and emaciation.(3) For patients with stomach Yin deficiency syndrome, avoid spicy and hot food. Tremella, black fungus, fresh fruit, etc. are recommended. Preserved kiwi fruit is recommended to be taken with warm boiled water. The preserved kiwi fruit, made with honey, has the effects of strengthening the stomach, promoting diuresis, clearing heat, quenching thirst, eliminating Yin deficiency and dryness-heat, and (honey in which) regulating the spleen and stomach. (4) Patients with disharmony of the liver and stomach should avoid eating greasy and spicy food. The patients can eat an appropriate amount of carrots, tangerine peel, etc. In addition, coix seed porridge with Chaihu (Radix Bupleuri) is recommended. The porridge, which is made of Chaihu (Radix Bupleuri), Baishao (Radix Paeoniae Alba), Baizhu (Rhizoma Atractylodis Macrocephalae), pawpaw, and coix seed, has effects of soothing the liver, regulating Qi and harmonizing the stomach.,,
Long-term depression and anxiety will disturb the normal endocrine metabolism of patients, resulting in the decline of patients' body immunity, which may induce cancer in long run. Therefore, it is necessary to maintain an optimistic and positive attitude every day and have a good mood to prevent cancer. The Consensus points out that excessive emotional changes are closely related to the occurrence, development, treatment, and prognosis of gastric cancer. Hence, it is very vital to take corresponding measures to relieve mental pressure and psychological distress. Huangdi's Canon of Internal Medicine puts forward the method of mental counseling through reasoning, analyzing, enlightening and comforting to make patients understand the condition, establish confidence, and eliminate their anxiety, depression, and tension, which is practical for patients with gastric cancer. Taking active and effective measures such as enlightenment, “method of overcoming emotion with emotion” and “method of removing essence and changing gas” can eliminate the impact of patients' negative emotions on treatment and rehabilitation and establish firm confidence to overcome diseases and reduce the resistance during the clinical nursing intervention, so as to restore patients' self-care ability and quality of life.,,,
The Consensus suggests that appropriate exercise is beneficial to the rehabilitation of gastric cancer. Exercise can improve the quality of life and physiological function, relieve psychological pressure, and cancer-related fatigue. The basic principle of exercise therapy in TCM is “alternating work with rest” and “static and dynamic combination.” Moderate exercise can dredge meridians, and regulate Qi, blood, five Zang-organs, and six Fu-organs. TCM exercise methods such as Tai Chi, Baduanjin, Wuqinxi, and Qigong, which belong to moderate aerobic exercises, are suitable for the rehabilitation of patients with gastric cancer. Xiu confirmed that practicing Baduanjin can significantly reduce the degree of cancer-related fatigue in cancer patients receiving chemotherapy and improve their quality of life. Zhao et al. pointed out that appropriate exercise, such as Qigong, is of great benefit to cancer patients as it can effectively reduce the incidence of cancer, improve the quality of life and psychological function of cancer patients as well as promote patients' rehabilitation.
Appropriate traditional Chinese medicine technology
The Consensus points out that the deficiency of healthy Qi and the weakness of the spleen and stomach are the fundamental internal causes of gastric cancer, and Qi stagnation, blood stasis, phlegm coagulation, and toxin knot are the main pathological factors for the pathogenesis of gastric cancer, which are mutually causal. Gastric cancer has the pathogenesis characteristics of “disease onset due to deficiency, deficiency due to disease, and intermingled deficiency and excess.” The common clinical complications of advanced gastric cancer include cancer-related fatigue, cancer pain, cancer fever, incomplete obstruction of the digestive tract (choking, nausea, and vomiting); loss of appetite, nausea and vomiting, general discomfort caused by radiotherapy, etc. The Consensus recommends: Acupuncture, moxibustion, and hot compress ointment for relieving pain; acupuncture for relieving nausea and hiccup; external application of TCM in combination with moxibustion to stop vomiting and diarrhea, etc. The synergistic treatment using appropriate TCM technologies plays an important role in preventing the recurrence and metastasis of gastric cancer after operation, reducing the toxic and side effects caused by radiotherapy and chemotherapy, and reducing the complications of advanced gastric cancer.
Acupoint application is mainly used for cancer-related fatigue, cancer pain, cancer fever, incomplete obstruction of the digestive tract, etc. The drugs are absorbed through the skin and act on acupoints, meridians and Qi, blood and viscera of the whole body, so as to alleviate the symptoms. Ma et al. used Xingjian decoction combined with acupoint application to treat cancer-related fatigue of patients with advanced gastric cancer, with the remarkable curative effect obtained. The specific operation of acupoint application is as follows: Zhongwan, Neiguan, Zusanli, and Shenmen acupoints are selected and are applied externally with Chinese medicinal drugs after the skin around the acupoints are disinfected, 6 h each time, once a day, for a total of 21 days. Yuan et al. used auricular point sticking combined with acupoint application to effectively improve postoperative pain, and promote the recovery of gastrointestinal function of patients with gastric cancer. The specific method is to keep the patient lying on his back and bending his knees and applying patches on selected acupoints Zusanli, Neiguan, and Sanyinjiao. The skins around the acupoints should be cleaned before application. The application sites are observed every 2 h after application, and the patches are removed after 24-h application. Zhang used stasis-removing and heat-purging prescription and acupoint application to treat early intestinal obstruction after gastrointestinal surgery, which can effectively accelerate the recovery of the disease.
Moxibustion is mainly applicable to gastrointestinal dysfunction caused by gastric cancer surgery, adverse reactions caused by radiotherapy and chemotherapy, abdominal pain, cancer pain, etc. The Consensus recommends mild moxibustion for relieving cancer pain, 20 min each time, once a day, and the recommended acupoints are Zhongwan, Xiawan, Weishu, Pishu, Guanyuan, Shenque, Zusanli, and Sanyinjiao. Kang et al. conducted a study of 54 patients with pancreatic and gastric cancer treated with moxibustion at Zusanli, Sanyinjiao, and Neiguan Points, and found that moxibustion could promote the recovery of gastrointestinal function of patients after endoscopic radical gastrectomy, and shorten their hospital stay. Another study showed that moxibustion on both sides of Zusanli acupoints was effective in promoting intestinal peristalsis, strengthening the contraction of smooth muscle, and accelerating the recovery of gastrointestinal function after operation. In a study conducted by Yang et al., gastric cancer patients with low immune function after FOLFOX chemotherapy were treated with Zusanli moxibustion. The results showed that moxibustion therapy could improve the immune function by increasing peripheral blood leukocyte count, the content of CD3+, CD4+, and CD8+ of T lymphocyte subsets, and the ratio of CD3+, CD4+, and CD8+. The main operation method is to fully expose the bilateral Zusanli acupoints, and place a thin ginger slice with a diameter of 3 cm covering the acupoint. After that, the mild moxibustion is performed with lighted moxa stick. The lighted moxa stick should be 3 cm away from patients' skin. It is appropriate for patients to feel local warmth without burning pain. The moxibustion is performed once daily, lasting 20 min for each Zusanli acupoint until the local skin presents redness. After moxibustion, each acupoint is gently massaged 3–5 min. In a study conducted by Wang et al., 40 gastric cancer patients of spleen and kidney Yang deficiency syndrome with ascites were treated with Distension-Eliminating Duiresis-Promoting Powder for external application of the abdomen with navel as the center in combination with moxibustion at Shenque, Guanyuan, yinlingquan (bilateral) and Zhongwan points once a day for 5 consecutive days. And the results showed that the total effective rate was 86.8%; the abdominal circumference was lower than that before treatment; the KPS score was higher than that before; the concentration of interleukin-2 and natural killer cells in ascites and the levels of CD4+ and CD8+ also increased; the therapy could help patients to improve their quality of life and prolong their survival time.
Traditional Chinese medicine ointment and massage
TCM ointment and massage therapy are also one of the traditional external treatment techniques, which refer to applying special ointment applied to appropriate acupoints of the patient's body on which point-pressing manipulation and kneading manipulation are performed for making the tense tendons and vessels soften and relax and making blocked tendons and vessels unblock through the penetration of different drugs. TCM ointment and massage therapy are applicable for cancer pain; gastrointestinal symptoms such as gastroparesis, incomplete intestinal obstruction, nausea and vomiting, abdominal distension, constipation, and ascites; pulmonary symptoms such as cough, expectoration, asthma, suffocation; and bone marrow suppression. The therapy can effectively solve the current clinical problems and better serve patients by improving patients' quality of life.
A meta-analysis shows that auricular plaster applied to patients with gastric cancer can shorten the time of first anal exhaust, the first defecation, intestinal tone recovery, postoperative eating, and of the disappearance of abdominal distension after operation, indicating it plays a certain role in helping the rapid recovery of postoperative patients with gastric cancer. Hence, the treatment can be promoted in clinical application. Ji et al. applied auricular plaster combined with fentanyl transdermal plaster to effectively alleviate patients' pain of gastric cancer receiving palliative treatment. Liu et al. confirmed that Ginseng Yangrong Decoction combined with acupoint application and auricular plaster can improve the sleep quality of patients with gastric cancer undergoing chemotherapy.
| Conclusion|| |
With the establishment of the modern medical model, nursing intervention plays a more and more important role in clinical work. In particular, integrated traditional Chinese and Western nursing takes complementary advantages of TCM nursing and western medicine nursing to meet the multi-angle and multi-faceted nursing needs of patients with gastric cancer. The Consensus systematically elaborates on the idea of syndrome differentiation and treatment of gastric cancer, and summarizes the integrated traditional Chinese and western medicine nursing of gastric cancer, including aspects of life care, dietary care, emotional care, exercises, and appropriate TCM nursing techniques (e.g., acupoint application, moxibustion, auricular plaster, and TCM ointment massage), which provides a reliable basis for nursing of gastric cancer patients and is instructive to improve the quality of life of patients. The nursing techniques in the consensus are simple, safe, and easy to use. The education information about those nursing technology application help patients and their families continue its use at home, and enhances the continuous effect of integrated traditional Chinese and Western medicine nursing.
Inspired by the Consensus, we should not only improve the ability of nursing staff to perform TCM nursing based on syndrome differentiation but also constantly explore and innovate the nursing technologies with TCM characteristics in the future. We should run TCM nursing technologies through the prevention, treatment, rehabilitation of gastric cancer, and form a management feature of gastric cancer that is characterized by the whole process of connecting wards, clinics to homes, so as to promote the all-round three-dimensional nursing of gastric cancer patients, and to promote the in-depth development of integrated traditional Chinese and western medicine nursing for gastric cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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