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Qigong for cancer treatment: a systematic review of controlled clinical trials
Qigong for cancer treatment: A systematic review of controlledclinical trials
MYEONG SOO LEE1, KEVIN W CHEN2, KENNETH M SANCIER3 & EDZARD ERNST1
1Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Exeter, UK, 2Center for IntegrativeMedicine, University of Maryland School of Medicine, Baltimore, USA, 3Qigong Institute, Menlo Park, USA
AbstractQigong is a mind-body integrative exercise or intervention from traditional Chinese medicine used to prevent and cureailments, to improve health and energy levels through regular practice. The aim of this systematic review is to summarize andcritically evaluate the effectiveness of qigong used as a stand-alone or additional therapy in cancer care. We have searched theliterature using the following databases from their respective inceptions through November 2006: MEDLINE, AMED,British Nursing Index, CINAHL, EMBASE, PsycInfo, The Cochrane Library 2006, Issue 4, four Korean MedicalDatabases, Qigong and Energy Medicine Database from Qigong Institute and four Chinese Databases. Randomised andnon-randomised clinical trials including patients with cancer or past experience of cancer receiving single or combinedqigong interventions were included. All clinical endpoints were considered. The methodological quality of the trials wasassessed using the Jadad score. Nine studies met our inclusion criteria (four were randomised trials and five were non-randomised studies). Eight of these trials tested internal qigong and one trial did not reported details. The methodologicalquality of these studies varies greatly and was generally poor. All trials related to palliative/supportive cancer care and none toqigong as a curative treatment. Two trials suggested effectiveness in prolonging life of cancer patients and one failed to do so. We conclude that the effectiveness of qigong in cancer care is not yet supported by the evidence from rigorous clinical trials.
Cancer is a leading cause of death globally [1]. The
practiced daily to promote health maintenance and
World Health Organization estimates that 84 million
disease prevention. In external qigong a practitioner
people will die in the next 10 years if action is not
is involved in the treatment. Although neither qigong
taken [1]. Most cancer patients experience multiple
itself nor the mechanism of its effects is explicable
symptoms related to either the cancer itself or late
within the paradigm of medical science, there is
treatment effects.[2] Cancer patients therefore often
increased report of its effects on the human health.
turn towards complementary or alternative thera-
Several reviews claim that qigong offers therapeutic
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pies. The results of the 2002 National Health Inter-
benefits for cancer patients [7 Á9]. However, these
view Survey showed that rates of CAM used are
reviews are non-systematic and therefore open to
especially high among USA patients with serious
bias. The aim of this systematic review is to
illness such as cancer [3]. Several surveys reported a
summarize and critically evaluate the clinical trial
prevalence range of CAM in cancer from 53 to 88%
evidence regarding the effectiveness of any type of
[4 Á6] and showed that CAM is usually combined
Qigong is a mind-body integrative exercise or
intervention from traditional Chinese medicine
used to prevent and cure ailments, to improve health
and energy levels through regular practice [7]. Internal and external qigong can be distinguished.
Electronic databases were searched from their re-
Internal qigong is self-directed and actively engages
spective inceptions through November 2006 using
people in their own health and well-being. It is best
following databases: MEDLINE, AMED, British
Correspondence: Myeong Soo Lee, Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter,EX2 4NT, UK. Tel: '44 1392 439035. Fax: '44 1392 424989. E-mail: myeong.lee@pms.ac.uk or drmslee@gmail.com
(Received 11 January 2007; accepted 31 January 2007)
ISSN 0284-186X print/ISSN 1651-226X online # 2007 Taylor & FrancisDOI: 10.1080/02841860701261584
Nursing Index, CINAHL, EMBASE, PsycInfo, The
patients. Patients were divided non-randomly into
Cochrane Library 2006, Issue 4, Korean Medical
two parallel groups: qigong (2 hours daily for 3
Databases (Korean Studies Information, DBPIA,
months) combined with drugs (n 097, types of drug
Korea Institute of Science, Technology Information,
were not specified) and drug therapy only (n 030).
Research Information Center for Health Database
The outcome measures included physical strength,
and Korean Medline), Qigong and Energy Medicine
appetite, diarrhea, defecation, and body weight. At
Database (Qigong Institute, Menlo Park, version
the end of the period, 82% of patients from the
7.4) and Chinese Databases (China Academic
experimental group had improved physical strength,
Journal, Century Journal Project, China Doctor/
63% improved appetite, and 33% were free of
Master Dissertation Full text DB, China Proceed-
diarrhea or irregular defecation. The corresponding
ings Conference Full text DB). The search terms
rates for the control group were 10%, 10%, and 6%.
used were: qigong or chi adj gong or chi adj kung or
All these parameters yielded significant inter-group
qi adj kung or jih adj gong or qi adj gong or Korean
or Chinese letter for qigong and cancer. Several
Zheng [19] tested the effects of qigong on survival
experts were contacted and asked to contribute any
rates of various late-stage cancer patients. One
unpublished trials. In addition, the references of all
hundred patients were compared with patients in
located articles and our departmental files were
the same hospital who had other therapies but no
hand-searched for further relevant articles.
qigong. This study did not mention the type of
Randomised clinical trials (RCTs) and non-ran-
qigong (regimen) and neither were the interventions
domised controlled clinical trials (CCTs) were
administrated in the control group. The main out-
included if they investigated patients with cancer
come was survival rate and median survival time.
or past experience of cancer who received single or
One and 5 year survival rates were 83% and 17% for
combined qigong interventions as sole treatment or
lung cancer patients (in the control group, they were
as adjuvant to conventional treatments. Outcomes
7% in 5 years) and 83% and 23% for stomach cancer
had to be compared to other interventions or no
patients (controls: 12% in 5 years). The median
treatment at all. No language restrictions were
survival time favored the experimental group (20.7
All clinical endpoints were considered but the
Wang and co-workers [17] conducted an RCT to
main outcome measures were effectiveness of qigong
evaluate the effect of qigong in late stage cancer
for treating symptoms in cancer patients and cancer
patients. Sixty one patients were divided randomly to
survivors. Secondary outcome measures included
receive chemotherapy only (n 029) or chemotherapy
survival rate and quality of life. Trials were excluded
plus qigong (n 032). The main outcome measures
from this review if the outcomes were related only to
were improvement in health and white blood cell
immunological or other surrogate endpoints. All
(WBC) count. The experimental group experienced
articles were read by two independent reviewers
improved health and a stable WBC counts, whereas
and data from the articles were validated and
12 of 30 patients in the control group reported worse
extracted according to pre-defined criteria listed in
health with more symptoms related to cancer, and all
Table I. The methodological quality of all studies
controls showed a decline in WBC count.
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was independently assessed by the two reviewers
Fu and Wang [12] conducted an RCT to evaluate
using the Jadad score [10]. Taking into account that
the short-term effects of a Chinese herbal mixture
qigong practitioners cannot be blinded to the treat-
versus qigong therapy plus the herbal mixture among
ment, we used a modification of this scale. Dis-
elderly patients with late-stage stomach cancer.
crepancies between reviewers were resolved by a
Forty patients in whom the cancer was confirmed
third independent reviewer. Statistically significant
(x-ray, CT scan, biopsy, and/or ultra-sound) were
results of each trial were documented (Table I).
recruited. Most of the patients (80%) were too oldor too ill to have surgery. The patients wererandomly assigned to the two treatment groups.
After 3 months of treatment the majority of the
The searches identified 162 potentially relevant
patients reported improvement and 22 Á23% had
articles, of which nine met our inclusion criteria
measurable tumor reduction. However, there was no
(Figure 1). Eight of these trials tested internal qigong
significant difference between the two treatment
[11 Á18] and one trial did not report specifically on
groups. Patients receiving qigong plus herbal group
qigong form [19]. Four were RCTs and five others
reported significantly less symptoms (p B0.05) and
were CCTs. Key data are summarised in Table I.
more increase in the immune functioning (p B0.01).
Sun and Zhao [16] conducted a CCT to assess the
Fu [11] carried out an RCT to assess the effec-
effectiveness of qigong on symptoms of cancer
tiveness of combined qigong with herbal treatment
Table I. Summary of clinical studies of qigong for cancer treatment.
management of cancer has advantageof raising curative rate, extending thetumour-free of survival and betterquality of their survival.’
be related to the psychological factors.’
2) P B0.01 at week 4 and 8 difficulty of daily activities and some of
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quality of life was not significant either.’
Potentially relevant articles identified and
Trials included in the systematic review
Figure 1. Flowchart of trial selection process. RCT: randomized
clinical trial; CCT: controlled clinical trial.
for survival rate in 186 post-surgery patients of
cardiac adenocarcinoma (155 men and 31 women;
mean age 059.898.8 years). Patients were rando-
mised to four groups: surgery only (control; n
chemotherapy only (etoposide, doxorubicin and
cisplatin: EAP, n 042), herbal therapy only (not
specified, n 046), and qigong combined with herbal
treatment (n 050). The main outcomes were survival
rate and median survival period. The survival rate
were 80.1%, 36.5%, and 20.8% for the control group
at 1, 3, and 5 years respectively; 85.7%, 45.2%, and
25.1% for chemotherapy group; 84.5%, 43.5%, and
26.1% for herbal group; 86.0%, 64.0%, and 36.0%
for qigong combined with herbal treatment. There
were significant differences between the qigong
combined with herbal treatment and the control
group (p B0.01). The median survival period was
30 months for the control group, 36 and 36.5 months
for chemotherapy and herbal groups, and 48 months
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for qigong combined with herb group.
Wang and Ye [18] investigated the therapeutic
effects of qigong on psychological symptoms during
rehabilitation of cancer patients. They recruited 104
cancer patients from a qigong rehabilitation unit as
the experimental group, and 107 cancer patients
from a regular cancer clinic with similar demo-
graphic distribution and types of cancer. They
evaluated all patients with the Eysenck Personality
Questionnaire, Zung’s Self-evaluate Anxiety Scale
and Depression Scale, before and 3 months after the
treatment. Patients who chose going to qigong
rehabilitation were more likely to be extrovert, and
have lower anxiety and depression levels at baseline
than controls. Compared to the controls more
patients in the qigong group reported relief of
Hong [13] evaluated the efficacy of qigong on
there was no large-scale RCT study in the literature.
adverse events of chemotherapy in advanced sto-
The methodological quality of the existing studies is
mach cancer patients. Twenty four patients were
often poor. Of course, it is a methodologically
non-randomly divided into two groups receiving
challenging to design rigorous trials of qigong.
qigong with chemotherapy (5-FU plus Sunpla or
Uncontrolled studies are open to bias with high
Epirubicin) or chemotherapy only. The main out-
risk of false-positive results. In CCTs, the nature of
come was the level of fatigue as measured by Piper
the control intervention deserves consideration. A
fatigue scale. The difficulty of daily activities was
‘‘placebo’’ for qigong does probably not exist. In the
assessed according to the Physical functioning sub-
present set of studies absence of adequate statistical,
scale of Medical Outcome Study-36. The frequen-
variability of therapeutic protocols and poor quality
cies of nausea, vomiting for the last 12 hours were
of reporting are frequent methodological problems.
evaluated with an index ranging from 0 (none) to 5
Among the nine studies we included, only four
(for more than 7 times). Fatigue was lower in qigong
were randomized [11,12,14,17]. The rest of the
group compare to controls. There were also signifi-
studies [13,15,16,18,19] were therefore open to
cant differences between the two groups in the level
selection bias and false positive findings. Four
of difficulty for daily activities, nausea, vomiting and
studies were proceeding papers without adequate
reporting of essential details.[11,16,17,19] Two were
Lam [14] investigated the effect of qigong com-
unpublished thesis [13,14] and one was published in
bined with transcatheter arterial chemoembilisation
a book [12], which had not gone through formal
(TOCE) on survival rate and quality of life in
peer review. One RCT failed to show an effect of
patients with hepatocellular carcinoma. Patients
qigong on survival rate and quality of life in
were randomised into two groups receiving qigong
hepatocellular carcinoma patients when compared
with TOCE [14]. This trial lacked detail in reporting
exercise lasted 2 hours per session, and were
of methodological features such as carcinoma sta-
performed twice weekly for 6 weeks in class and
ging and co-interventions. Another RCT suggested
3.5 Á5 hours daily for 24 weeks at home. The main
some survival advantages in cardiac adenocarcinoma
outcome measured were survival rates and quality of
patients receiving qigong [11]. Its methodology was,
life, measured with SF-36. The survival rate was
however, not clearly described. The third RCT
52.6% for qigong group and 29.0% for controls. The
showed significant symptom reductions and an
median survival time was not provided for the
increase in immune function [12]. It was published
qigong group (overall survival rate was higher than
in a book, which had not gone through the process of
50%) and 242 days for the control group. The
formal peer review. The forth RCT reported that
differences between the intervention and the control
qigong had favorable effects on health status and
group are not statistically significant for either
WBC count [17]. Unfortunately, it was also pub-
lished only as an abstract, lacking essential details.
Lee and co-workers [15] conducted a CCT to
Assuming that qigong is potentially beneficial
evaluate the effect of qigong on symptoms and
option for cancer patients, possible mechanism
psychological distress of 67 breast cancer patients
may be of interest. These may include improvement
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receiving chemotherapy. Patients were divided into
of immune function, which may enhance the im-
one group having qigong with chemotherapy and
mune deficiency experienced by most of cancer
one having chemotherapy only. Primary outcome
patients [8]. Others have postulated that qigong
measures were symptom distress (measured with
McCorkle and Young’s symptom distress scale) and
changes in blood viscosity, elasticity as well as
psychological distress (measured with symptom
platelet function [8]. A third proposed mechanisms
is an increment of pain threshold combined with a
showed significant differences between the groups
relaxation effects [8]. If these theories were con-
for the symptoms distress after 21 days but not in 5,
firmed, they might explain how qigong leads to
8, 15 days. No significant differences between the
intervention and control groups were noted for
Limitations of our systematic review and indeed
systematic review in general, pertain to the potentialincompleteness of the evidence reviewed. We aimedto identify all RCTs and CCTs on the topic. The
distorting effects on systematic reviews and meta-
Perhaps the most important finding of this systema-
analyses arising from publication bias and location
tic review is that the value of qigong for cancer
bias are well documented [20 Á23]. In this review
patients has not been adequately investigated as
there were no restrictions in terms of publication
language and a large number of different databases
[9] Sancier KM. Therapeutic benefits of qigong exercises in
were searched. We are therefore confident that our
combination with drugs. J Altern Complement Med 1999;5:
search strategy has located all relevant data. How-
[10] Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ,
ever, a degree of uncertainty remains. Further
Gavaghan DJ, et al. Assessing the quality of reports of
limitations of our systematic review are the often
randomized clinical trials: Is blinding necessary? Control
poor quality of the primary data and poor reporting
of results were highly heterogeneous in virtually
[11] Fu JZ, Fu SL, Qin JT. Effect of qigong and anticancer body-
building herbs on the prognosis of postoperative patients
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with cardiac adenocarcinoma. In: Third World Conference
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on Medical Qigong; 1996. Beijing, China: 1996.
[12] Fu JZ, Wang SM. Qigong plus herbal medicine in treating
In conclusion, the notion that internal qigong is an
late-stage stomach cancer in the elderly. In: Lin ZP, editor.
effective therapy for cancer treatment is not based on
Understanding of true qi cultivation and sublimation.
data from rigorous clinical trials. Further research
Beijing, China: Chinese Publisher of Constructive Materials;1995. p. 155 Á7.
should attempt to answer the many open questions
[13] Hong EY. The effect of Yudongkong exercise in fatigue,
difficulty of daily activities and symptoms of side effect inadvanced gastric cancer patients receiving chemotherapy. PhD dissertion. Seoul, Korea: Yonsei University; 2003.
[14] Lam SWY. A randomixed, controlled trial of Guolin qigong
in patients receiving tanscatheter arterial chemoembolisation
for unresectable hepatocellular carcinoma Master’s thesis. Hong Kong: University of Hong Kong; 2004.
[15] Lee TI, Chen HH, Yeh ML. Effects of chan-chuang qigong
on improving symptom and psychological distress in che-
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