World Federation of Chinese Medicine Societies Consensus on integrated traditional and western medicine prevention and rehabilitation of malignant tumor during the Corona Virus epidemics
Specialty Committee of Classical TCM Formula for Cancer Treatment and Research of World Federation of Chinese Medicine Societies Expert Consensus on integrated traditional and western medicine prevention and rehabilitation of malignant tumor during the epidemics of Corona Virus Disease 2019 (First edition)
Corona Virus Disease 2019(referred to as COVID-19) has caused a global outbreak and become a major public health issue. On January 20, 2020, the announcement of National Health Commission (No. 1 of 2020) included COVID-19 as a category B infectious disease in Law of the people's Republic of China on prevention and control of Infectious Diseases, and took preventing and controlling measures like those of category A infectious diseases[1]. Tumor patients are more susceptible to infection because of their poor nutritional state and systemic immunosuppressive state caused by antitumor treatments, such as radiotherapy, chemotherapy and surgery. Cancer patients had an estimated 2-fold increased risk of COVID-19 than the general population according to the Report of the WHO-China Joint Mission on COVID-19[2]; The incidence rate of COVID-19 in cancer patients in Wuhan is 0.79%, while the general population is 0.37% in the same period[3]. And the COVID-19 cancer patients were with higher risk to become severe condition and worse prognosis, especially in those patients who received chemotherapy or surgery recently, than those without cancer [4]. In addition, the inconvenience for patients going out to see doctors also leads to the delay of diagnosis and treatment. As a result, under the current severe situation, scientific and effective management measures and reasonable responsive strategies are urgently needed to minimize the impact of the epidemic on tumor patients. Especially recently, the outbreak continues to spread in many countries around the world. World Health Organization (WHO) believes the COVID-19 epidemic has the characteristics of a pandemic, calling on all countries to take urgent and active action. Under such circumstances, experts organized by Classical Traditional Chinese Medicine Prescription for Cancer Treatment and Research Committee of World Federation of Chinese Medicine Societies, discussed and formed "Expert consensus on integrated traditional and western medicine prevention and rehabilitation during the epidemics of Corona Virus Disease 2019", according to national prevention and treatment experience of COVID-19, especially in Wuhan. This consensus aims to provide a model for TCM experts around the world to guide tumor patients to respond reasonably and safely through COVID-19. Giving full play to the advantages of integrated traditional and western medicine in diagnosis and treatment can minimize the adverse side effects of the epidemic on malignant tumor patients.
Key words: COVID-19; Oncology; Traditional Chinese Medicine
1. Daily protection.
1.1 Refrain from going outdoors and keep a regular schedule.
COVID-19 is generally susceptible to all population. If tumor patients, who have been attacked by cancer cells, get infected with COVID-19, it would be a double whammy. Therefore, tumor patients should reduce visits to relatives and friends, avoid going out to densely populated public places, especially with poor air mobility. Keep regular schedule and sleep no less than 7-8 hours a day.
1.2 Enhance awareness of protection.
Be sure to wear a mask when you go out and wash your hands frequently. Reduce exposure to staff in public places and consider wearing disposable plastic gloves. Wash hands with hand sanitizer or soap water no less than 15 seconds after returning from public places, coughing (covered by your own hands), before meals and after using toilet. Do not spray at others but using your own sleeves to cover when coughing or sneezing; and change your mask in time. If it is necessary to go to the hospital or to get medication, these protective measures should be strengthened.
1.3 Home quarantine and Moderate exercise.
Open windows frequently for ventilating. Do not spit anywhere. Oral and nasal secretions should be wrapped in paper towels and discarded in covered dustbins. Exercise moderately at home, avoid being bedridden for a long time and strenuous activity. You can practice tai chi, baduanjin, medical qigong, five-animal exercise, yoga and rehabilitation exercises and so forth for about 30 minutes every day. Sweating slightly is best.
1.4 Reasonable diet and Adequate nutrition.
Proper intake of protein food such as eggs, milk, fish, meat, beans, nuts, etc., and increasing intake of fresh vegetables and fruits in daily diet is suggested. Balance portions of vegetables and meat, avoid raw and cold food. Do not eat wild animals. It is recommend to increase the amount of drinking water to no less than 1500ml per day.
1.5 Self-regulation and Keep good spirits
Face up to the epidemic information rationally and objectively. Create a sense of security and stay relaxed through listening to relaxing music(called music therapy). If your psychological condition continues to deteriorate, such as severe insomnia, anxiety, depression, etc., and it cannot be relieved through self-adjustment, you can seek the help of relevant professional doctors.
1.6 Prevention prescription:
Prescription one: suitable for the prevention of commen tumor patients.
Fang Du Kang Ai Decoction:
Semen Coicis(Yi Yi Ren) 20g ,Radix Astragali(Huang Qi) 10g, Rhizoma Atractylodis(Bai Zhu) 12g, Fructus Amomi Villosi(Sha Ren) 6g,
Fructus Ammomi Rotundus(Bai Dou Kou) 10g, Rhizoma Phragmitis(Lu Gen) 10g, Radix Platycodonis(Jie Geng) 10g, Herba Rhodiolae(Hong Jing Tian) 10g, Rhizoma Dioscoreae(Shan Yao) 10g, Folium Perillae(Zi Su Ye) 10g, Half a pear.
One dose a day. Decocted with water or taken as tea. Take it continuously for 5-7 days.
Prescription two: suitable for the prevention of tumor patients with direct contact with suspected cases or close contacts.
Radix Astragali(Huang Qi) 9g, Radix Glehniae(Bei Sha Shen) 9g,
Rhizoma Anemarrhenae(Zhi Mu) 9g, Trollius chinensis bunge(Jin Lian Hua) 5g, Fructus Forsythiae(Lian Qiao) 9g, Rhizoma Atractylodis(Cang Zhu) 9g,
Radix Platycodonis(Jie Geng) 6g.
The above 7 herbs are decocted with water once a day and can be taken continuously for 5-7 days.
2. Suggestions on the treatment of tumor patients during the epidemics.
2.1 For patients with routine reviews:
Cancer patients may have some uncomfortable reactions or complications after discharge, which needs to be reexamined regularly. It is suggested that the reexamination should be delayed slightly under the premise of not affecting the prognosis of disease. Network consultation is recommended and outpatient reexamination when necessarily. Avoid hospitalization reexamination as far as possible and reduce the time spent in hospital. Avert cross-infection during the examination.
2.2 For patients undergoing elective surgery:
Moderate deferment of surgical treatment is recommended for patients with benign tumors that do not affect their health in the near future, or in the remission stage of malignant tumor after comprehensive treatment. For patients in the advanced or early and middle stage of malignant tumor who need to be operated as soon as possible, surgical treatment should be carried out under the condition of controllable risk after a comprehensive and detailed assessment of the patient's physical status and surgical risk, to ensure the safety of the patient during the perioperative period.
2.3 Patients during chemotherapy:
For patients treated by regular chemotherapy, contact the attending doctor in time. It is suggested that if the curative effect is not significantly affected, the chemotherapy cycle should be moderately reduced or prolonged, or oral chemotherapy should be given priority to. Chemotherapy is recommended in non-COVID-19 designated hospitals for patients with postoperative adjuvant chemotherapy. For the toxic and side effects caused by chemotherapy, pay attention to the characteristics of TCM treatment based on syndrome differentiation, give full play to the role of TCM reducing the toxicity, increasing the curative effect and relieving the symptoms.
2.4 Patients during radiotherapy:
For the patients undergoing radiotherapy, continuing to receive treatment in an orderly manner according to the overall arrangement of doctors is recommended. Moderate delay radiotherapy according to the attending doctors’ arrangement under the premise of not affecting tumor prognosis. Meanwhile, give full play to the role of TCM reducing the toxicity and increasing the curative effect, mitigating the toxic and side effects caused by radiotherapy.
The decision to postpone or change the plan of surgery, radiotherapy and chemotherapy should be made according to the epidemic intensity of COVID-19 and its impact on medical institutions. Under suitable condition, online multidisciplinary consultation can be considered. Limit surgery, radiotherapy and chemotherapy in extremely high-risk cases, and restrict personnel exposure, especially in treatment sites. The hospitals should have strict control, for example, tracking the travel history of the visitors before entering the hospital, and so forth.
2.5 Long-term follow-up patients:
For tumor patients in remission stage with relatively stable condition, the disease is mainly controlled by drugs at present. Meanwhile you should communicate with the attending physician in time to report your condition and current drug use, to decide whether or not continuing the original treatment. If drugs are used up, consult with the doctors to see if you can take a break to stop the medication. If you need more medication, take relevant materials and go to the designated drugstores or hospitals for registered prescription and maintenance treatment.
2.6 Patients with cancer pain:
According to the degree of pain, doctors prescribe drugs for specific days. After the medication is used up, bring all the data as many as possible, such as pathological report, imaging, previous discharge certificate and diagnosis certificate and so forth, to the nearest non-designated hospital of COVID-19.
Based on the characteristics of the malignant tumor patients, and the limitations during the special period of epidemic, conservative treatment and drug intervention should be given priority, followed by minimally invasive treatment among western medical treatments. While surgery and other treatments are limited to emergency conditions as far as possible, which needs strict protection. Although some specific plans should be adjusted in time, the comprehensive treatment strategy and principle of tumor patients will not be changed.
3. Differential diagnosis of covid-19 infection in cancer patients
Tumor patients may have complications of infection, such as cough, expectoration, fever and leucopenia caused by pulmonary infection, or cancerous fever caused by disease progress, after routine therapy of radiotherapy and chemotherapy. COVID-19 infection patients can also have the above conditions, resulting in confusion of the two easily, making the diagnosis more difficult. In treatment, COVID-19 infection should be excluded at first. Therefore, if tumor patients suffer from symptoms such as fever, dry cough, dyspnea, tiredness, runny nose, sore throat, vomiting, diarrhea, muscle pain, etc., they should go to the nearest fever outpatient department in time to make differential diagnosis and treatment. After excluding the COVID-19 infection, contact the oncology physician for related treatment.
In addition, tumor patients may have weaker ability to resist pathogens if they are treated with immune checkpoint inhibitors (mainly PD-1 and PD-L1 inhibitors). The combined application of immunosuppressant and other medicine result in more susceptibility of tumor patients, so the above daily protective measures need to be further strengthened. Meanwhile, some patients had serious adverse side effects after PD-1 treatment, including immune-related pneumonia, etc., and their clinical manifestations and imaging features were very similar to those of COVID-19. If such a situation occurs, especially without fever, strict differential diagnosis is required. Patients and their family members should provide a detailed history of antineoplastic application to the hospital (a 3A comprehensive hospital is recommended) and require the doctors to communicate closely with the oncology physicians, who can guide the related treatment[4].
4. TCM treatment strategy of malignant tumor during the epidemic of COVID-19
4.1 Advantages of TCM treatment of malignant tumor during the epidemic of COVID-19:
A large number of previous studies and clinical applications have proved that TCM treatment of malignant tumor has a significant curative effect and unique advantages. The TCM treatment, which has the advantages of not relying on large-scale equipment, infrastructure and relatively fewer hospitalization and side effects, can play a vital role during the epidemic and compensate for some losses, such as delayed treatment, poor constitution increasing susceptibility and so forth caused by various objective reasons.
4.2 For frail postoperative patients, during(or after) radiotherapy and chemotherapy, strengthening the vital qi is main focus while eliminating pathogen is auxiliary:
Most postoperative patients are in a state of qi and blood impairment, deficient with evil-lingering. Most of them have pallid or sallow complexion, fatigue and no intention to talk, spontaneous sweating, poor appetite, or operative incision recovering slowly and being susceptible to infection. The TCM treatment should take tonifying qi and blood and strengthening as the main focus while clearing residual pathogens, to help patients recover after operation, enhance constitution and immunity as soon as possible. Therefore, they can combat COVID-19 and prevent tumor recurrence and metastasis.
For patients during(or after) radiotherapy and chemotherapy with delayed treatment because of the epidemic, on the one hand, use TCM to regulate and strengthen the body to better respond to western medicine after the epidemic; on the other hand, to enhance the anti-tumor intensity of TCM to improve the curative effect when physical conditions allow.
4.3 For patients who have not been treated by western medicine at the first vist, eliminating pathogen is main focus while strengthening the vital qi is auxiliary:
TCM treatment should take eliminating pathogen as main focus and strengthening as auxiliary if patients’ vital qi not yet reduced. Meanwhile, we can consider enhancing the anti-tumor intensity of TCM or using oral Chinese patent medicine (CPM) to reduce the adverse effects caused by inability to be treated by western medicine timely.
4.4 For stable patients:
The tumor is in a stable state after systematic anti-tumor treatment. In addition to regular reexamination, Using TCM to regulate constitution, enhance immunity and prevent tumor recurrence and metastasis is still necessary. TCM treatment, which should be based on the specific conditions of patients, adopts the strategy of combining eliminating pathogen and strengthening.
4.5 Adjustment of TCM prescribing strategy during the epidemic of COVID-19:
The overall principle of TCM treatment strategy for tumor patients remains unchanged, with the combination of the characteristics of the epidemic. According to "notice on issuing COVID-19 's diagnosis and treatment plan(trial the 7th edition)", the incidence of COVID-19 mostly manifests as cold-damp [5]; therefore, we should prescribe herbal medicine in accordance with local conditions and the patient's individuality. For patients with cold tendency or(and) dampness tendency constitution, we should pay attention to the regulation of basic constitution and increase the TCM treatment of eliminating dampness and dispelling cold and so forth.
4.6 Pay attention to the integration of traditional and western Medicine:
The application of TCM does not conflict with Western Medicine during the epidemic of tumor patients. Integration of TCM and western Medicine is recommended to achieve maximum curative effects and minimum side effects. The TCM treatment plan should be adjusted accordingly with the physical condition of patients and the Western Medicine treatment stage.
4.7 Make full use of remote diagnosis and treatment platform:
We should make full use of the remote diagnosis and treatment platform such as We-chat due to the inconvenience of seeing doctor on site during the epidemic. Although the TCM diagnosis needs four ways-inspection, listening and smelling, inquiry, palpation, the inspection, listening and inquiry can still be realized through the platform under the limited conditions. The pulse-diagnosis-instrument can be used as a supplement to palpation if primary hospitals have such equipment.
Effective measures such as mailing service of traditional Chinese medicine or western medicine, using TCM granules and so forth, can reduce the patients going out and make it easy for them.
5. Recommendation of TCM recovery for tumor patients with COVID-19 in convalescence:
Basis: Beijing Administration of Traditional Chinese Medicine issued "Beijing COVID-19’s TCM prevention and treatment Plan (trial the 4th edition)"[6].
5.1 Qi and Yin deficiency Syndrome
Symptoms: fatigue and burnout, spontaneous sweating, palpitation, anorexia, dry mouth and throat, red tongue with less fluid or tender red tongue, yellow fur or few greasy fur.
Seen in convalescent cases.
Treatment principle: tonify qi and nourish yin. Prescription as reference:
Radix Adenophorae(Sha Shen) 15g, Radix ophiopogonis(Mai Dong) 15g,
Radix Astragali(Huang Qi) 15g, Medicated leaven(Liu Shen Qu) 20g, Radix Paeoniae Rubra(Chi Shao) 15g, Cortex Mori(Sang Bai Pi) 15g, Cortex Lycii(Di Gu Pi) 15g, Fructus Aurantii(Zhi Qiao) 10g,
Herba Artemisiae Annuae(Qing Hao) 10g,
Radix Rehmanniae Recens(Sheng Di Huang) 15g Addition and subtraction:
add Fructus Schisandrae Chinensis(Wu Wei Zi) 10g if shortness of and breathlessness occurs; add stir-frying Semen Ziziphi Spinosae(Suan Zao Ren) 15g if insomnia and irritability occurs; add Radix Codonopsis(Dang Shen) 15g, Rhizoma Dioscoreae(Shan Yao) 15g, Poria(Fu Ling) 15g, Rhizoma Pinelliae(Ban Xia) 9g, Pericarpium Citri Reticulatae(Chen Pi) 10g, Radix Glycyrrhizae(Gan Cao) 6g if anorexia and liquid stool occurs, which is spleen and lung qi-deficiency syndrome.
Chinese patent medicine(CPM): oral: Sheng Mai Yin, etc.
5.2 Remnant Lingering Pathogen Syndrome
Symptoms: shortness of breath, chest tightness, cough, less phlegm, red or tongue, a little greasy fur.
Seen in convalescent cases still with pulmonary inflammation.
Treatment principle: promoting blood circulation and eliminating dampness, dispersing the remaining pathogen.
Prescription as reference:
Radix Salviae Miltiorrhizae(Dan Shen) 15g, stir-frying Semen Coicis(Yi Yi Ren) 30g, Radix Codonopsis(Dang Shen) 15g, Radix Adenophorae(Sha Shen) 15g, Semen Persicae(Tao Ren) 6g, Fructus Trichosanthis(Gua Lou) 20g,
Cortex Magnoliae Officinalis(Hou Po) 10g, Rhizoma Phragmitis(Lu Gen) 30g, Herba Patriniae(Bai Jiang Cao) 30g, Fructus Hordei Germinatus(Mai Ya) 30g, Herba Rhodiolae(Hong Jing Tian) 10g.
5.3 Other treatments.
Treatments such as acupoint plastering, moxibustion, acupuncture, ba duanj in, tai chi, respiratory guidance exercise, qigong recovery, physical exercise, psychological counseling, music therapy, etc., can be chosen under the guidance of doctors.
A small number of COVID-19 patients have nucleic acid re-positive after they have been cured and discharged at present. There is no definite conclusion about whether the disease has relapsed or aggravated and the patients with re-positive nucleic acid have infectivity. Therefore we suggest that discharged patients continue to take oral traditional Chinese medicine for recovery treatment for 1-2 months to stimulate the continuous production of antibodies, striving to achieve complete negative nucleic acid.
6. Caveats for tumor patients with COVID-19 who was terminated quarantine and discharged from hospital.
According to caveats about COVID-19 patients who terminate quarantine and being discharged from hospital, as well as notice on recovered quarantine of cured and discharged COVID-19 patients in Wuhan, written in the “COVID-19 's diagnosis and treatment plan(trial the 7th edition)” issued by National Health Commission of the People’s Republic of China.
6.1 Terminate quarantine and discharge criteria.
Ⅰ. The temperature returns to normal over 3 days.
Ⅱ. Respiratory symptoms significantly improved.
Ⅲ. Pulmonary images show that acute exudative lesions significantly improved.
Ⅳ. The nucleic acid tests of respiratory sample are negative for two consecutive times (sampling time at least 1 day interval).
Those who fulfil the above conditions can be terminated quarantine and discharged, continuing to quarantine at home for 14 days.
6.2 Caveats after discharge.
Ⅰ. Designated hospitals should make good contact with primary medical institutions where patients go to, share case information, and timely send out the information of discharged patients to their jurisdiction or the neighborhood committee of their residence or primary medical institutions.
Ⅱ. The discharged patients have risky infection with other pathogens due to the low immune function during the convalescence. COVID-19 patients who were cured and discharged should go to the designated place for free recovery quarantine and medical observation for 14 days after completing their hospital treatment.
Ⅲ. It is recommended to go to the hospital for follow-up visit in the second and fourth week after discharge.
7. Summary and prospect.
The severe situation of COVID-19 epidemic and the various degrees of limitation of malignant tumor patients’ diagnosis and treatment requires us to adjust the diagnosis and treatment strategy in time, give full play to the advantages of TCM, minimize the impact of the epidemic on diagnosis and treatment, to achieve the best curative effect. The integration of traditional Chinese medicine and western medicine and the cooperation of doctors and patients will eventually win the battle of the epidemic and tumor diagnosis and treatment.
This consensus guidance is strongly supported by the Specialty Committee of Classical TCM Formula for Cancer Treatment and Research of World Federation of Chinese Medicine Societies and the Oncology Professional Committee of Hubei Association of Chinese Medicine, and solicits the opinions of some experts in disciplines related to epidemic prevention and control. Hereby, I would like to acknowledge you all.
The members of expert group:
Prof. Li Feng, chief physician, National Cancer Center/National Clinical Research Center for Cancer/Department of Traditional Chinese Medicine, Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College.
Prof. Yuguang Wang, chief physician, Department of Respiratory medicine, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University.
Prof. Zuowei Hu, chief physician, Department of Oncology, WuHan No.1 Hospital. Prof. Heng Fan, chief physician, Department of Traditional Chinese Medicine, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology. Prof. Yingwen Zhang, chief physician, Department of Chinese with Western Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.
Prof. Chenguang Yang, chief physician, Department of Oncology, Shanxi Traditional Chinese Medicine Hospital.
Prof. Dongxin Tang, chief physician, Department of Oncology, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine.
Prof. Weidong Lu, TCM physician, Center for Integrative Therapies, Dana-Farber Cancer Institute, Harvard Medical School.
Prof. Qingzhong Lin, Central Taiwan University of Science and Technology, director of Department of Traditional Chinese Medicine, Fengyuan Hospital of Health Promotion Administration of Taiwan, China.
Dr. Xiaohui Wang, associate professor, French federation of digestive cancer.
Advisory experts(given in strokes of surname order):
Prof. Junfeng Wang, chief physician, Department of Respiratory Medicine, Traditional Chinese Medicine Hospital Affiliated to Southwest Medical University.
Prof. Likun Liu, chief physician, Department of Oncology, Shanxi Provincial Hospital of TCM.
Prof. Xiaodong Wu, chief physician, Department of integrative Chinese and western medicine, Affiliated Cancer Hospital & Institute of Guangzhou Medical University.
Prof. Ge Li, chief physician, Department of Oncology, Dalian Hospital of Traditional Chinese Medicine.
Prof. Ping Li, chief physician, Department of Chinese and Western Integrative Medicine of Anhui Medical University, Department of Chinese and Western Integrative Medicine Oncology of First Affiliated Hospital of Anhui Medical University.
Prof. Qi Li, chief physician, Department of Medical Oncology, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine.
Prof. Wanyin Wu, chief physician, Department of Oncology, Guangdong Provincial Hospital of TCM, The Second Clinic School of Guangzhou University of Traditional Chinese Medicine.
Prof. Bing Yang, New England School of Acupuncture at Massachusetts College of Pharmacy and Health Science;Bing Yang Acupuncture and Herbal Care at Boston.
Prof. Qing Zhang, chief physician, Department of Oncology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University.
Prof. Huanfang Fan, chief physician, Department of Oncology, Hebei Traditional Chinese Medicine Hospital.
Prof. Yonghe He, chief physician, Department of Oncology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences.
Prof. Yingjie Jia, chief physician, Department of Oncology, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine.
Prof. Kai Xu, School of Chinese Medicine Hong Kong Baptist University.
Prof. Zhenzhen Chu, chief physician, Department of Oncology and Hematology, The First Affiliated Hospital of Beijing University of Chinese Medicine.
Prof. Yilan Jiang, chief physician, Department of Oncology, Affiliated Hospital of Hunan Institute of Traditional Chinese Medicine.
Prof. Niancai Jing, chief physician, Department of Chinese and Western Integrative Medicine, JiLin Cancer Hospital.
Prof. Qijin Shu, chief physician, Department of Oncology, Zhejiang Provincial Hospital of Traditional Chinese Medicine/The First Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine.
Write and English translation: Yukun Yin, Peijin Li, Hao Li and Lixing Liu. English version proofread: Prof. Bing Yang(United States).
Specialty Committee of Classical TCM Formula for Cancer Treatment and Research
of World Federation of Chinese Medicine Societies
Reference.
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