Effectiveness of comprehensive traditional Korean Medicine treatment on quality of life, anorexia and cachexia of cancer patients: Retrospective chart review

Wonju Han; Eunji Lee; Gajin Han; Sang-hoon Yoon; Gajin Han; Jungtae Leem; Han, Wonju; Lee, Eunji; Han, Gajin; Yoon, Sang-hoon; Han, Gajin; Leem, Jungtae

doi:10.13048/jkm.19022

JKM > Volume 40(2); 2019 > Article

Han, Lee, Han, Yoon, Han, and Leem: Effectiveness of comprehensive traditional Korean Medicine treatment on quality of life, anorexia and cachexia of cancer patients: Retrospective chart review

Review article

The Journal of Korean Medicine 2019; 40(2): 119-132.

Published online: June 30, 2019

DOI: https://doi.org/10.13048/jkm.19022

Effectiveness of comprehensive traditional Korean Medicine treatment on quality of life, anorexia and cachexia of cancer patients: Retrospective chart review

Wonju Han¹

, Eunji Lee²

, Gajin Han¹

, Sang-hoon Yoon²

, Gajin Han³

, Jungtae Leem²^{, 4}^{, *}

¹O-I Dang Korean Medicine Hospital

²Chung-Yeon Central Institute

³Department of Gastroenterology, College of Korean Medicine, Kyung Hee University

⁴Dongshin Korean Medicine Hospital

Correspondence to: 임정태, 서울시 양천구 오목로 351, 07999, 동신한방병원, Tel: +82-2-2640-2902, Fax: +82-2-2640-2727, E-mail: julcho@naver.com

Received May 15, 2019 Revised May 26, 2019 Accepted May 27, 2019

Abstract

Purpose

This study was conducted to collect and analyze real world data to evaluate the effectiveness and safety of comprehensive traditional Korean Medicine treatment on quality of life, anorexia and cachexia of cancer patients.

Methods

We analyzed medical records of 62 cancer patients admitted to O-I Dang Korean Medicine Hospital from February 2018 to February 2019. The primary outcome was a change score in the Anorexia/Cachexia Subscale of Functional Assessment of Anorexia/Cachexia Therapy (FAACT). The secondary outcomes were Functional Assessment of Cancer Therapy-General (FACT-G), Trial Outcome Index(TOI) of FAACT, 11 point Pain Intensity Numeric Rating Score (11 PI-NRS) and Patient Global Impression of Change (PGIC) and adverse event.

Results

Cachexia and quality of life in cancer patients assessed by FAACT, increased by 5.59±14.83 (p=0.004) after treatment. PI-NRS was reduced by 2.10±1.81 (p<0.001) and TOI and FACT-G total scores were increased by 5.17 ±11.70 (p=0.001) and 3.59±10.94 (p=0.012), respectively. These results were also clinically meaningful assessed via minimal clinically important difference (MCID). There was no severe adverse event.

Conclusion

These findings suggest that comprehensive traditional Korean Medicine treatment might be effective and safe strategy for improving quality of life, anorexia, cachexia and pain of cancer patients. Further advanced studies with controlled group and more participants with rigorous design are needed to ensure these findings.

Keywords: Anorexia, Cachexia, Neoplasm, Quality of life, Medicine, Korean Traditional, Retrospective studies

Fig. 1

Data Extraction Flow Sheet

Fig. 2

Distribution of each Clinical Outcome (N=62)

The value is ‘after treatment – before treatment’. PI-NRS was not normally distributed.

A, Trial Outcome Index (TOI); B, Functional Assessment of Cancer Therapy-General (FACT-G); C, Functional Assessment of Anorexia/Cachexia Therapy (FAACT); D, Pain Intensity Numeric Rating Scale

Table 1

General Characteristics of Included patients (N=62)

Variables	Frequency n(%) or Mean ± SD
Sex	Female, 42 (67.7%); male, 20 (32.3%)
Age	52.23 ± 10.09 <30, 2 (3.2%); 30~39, 2 (3.2%); 40~49, 15 (24.2%); 50~59, 29 (46.8%); 60~69, 13 (21.0%); ≧70, 1 (1.6%)
Height	163.47 ± 8.18
Weight	61.44 ± 9.11
Smoking status	Smoking, 1 (1.6%); Non-smoking, 48 (77.4%); Ex-smoking, 13 (30%)
Drinking status	Non-drinking, 10 (16.1%); Ex-drinking, 52 (83.9%)
Job	Office workers, 37 (59.7%); House wife, 18 (29.0%); Service, manufacturing workers, 4 (6.5%); None, 3 (4.8%).
Past History	Diabetes Mellitus, 4 (6.5%); Hypertension, 7 (11.3%) ; Hyperlipidemia, 3 (4.8%); Tuberculosis, 0 (0%); Hepatitis, 4 (6.5.%); Cardiovascular Disease, 2 (3.2%)
ECOG Performance status	Grade 0, 52 (83.9%); Grade 1, 8 (12.9%); NR, 2 (3.2%)
Chief complaint on admission (allow repetition)	[Gastrointestinal disorder, 29 (46.8%)] Anorexia, 9 (14.5%); Nausea and vomiting, 7 (11.3%); Abdominal pain, 6 (9.7%); Dyspepsia, 2 (3.2%) [Pain, 34 (54.8%)] Surgical site pain, 20 (32.3%); Neck, back, shoulder pain, 5 (8.1%); Lumbago, 3 (4.8%); Headache, 2 (3.2%); Other pain, 4 (6.5%) [Respiratory disorder, 4 (6.5%)] Cough, 2 (3.2%); Dyspnea, 2 (3.2%) [Other side effects of chemotherapy, 28 (45.2%)] Post-operative condition improvement, 8 (12.9%) Other side effects, 20 (32.6%)
Primary cancer	Breast, 15 (24.2%); Stomach, 9 (14.5%); Lung, 9 (14.5%); Thyroid, 9 (14.5%); Colon and rectum, 6 (9.7%); Liver, 3 (4.8%); Prostate, 2 (3.2%); Bile duct, 1 (1.6%); Uterus, 1 (1.6%); Brain, 1 (1.6%); Ureter, 1 (1.6%); Small Bowel, 1 (1.6%); Ovary, 1 (1.6%); Fallopian Tube Ovary, 1 (1.6%); Tongue, 1 (1.6%); Lymphoma, 1 (1.6%)
Metastasis (allow repetition)	Number of metastatic patients, 26 (41.9%) Metastatic site: Lymph node, 15 (24.2%); Lung, 6 (9.7%); Liver, 4 (6.5%); Peritoneum, 2 (3.2%); Brain, 1 (1.6%); Colon and rectum, 1 (1.6%); Chest wall, 1 (1.6%); Diaphragm, 1 (1.6%); Adrenal gland, 1 (1.6%)
Recurrence	Number of recurrent patients, 5 (8.0%)
Stage of cancer	0, 1 (1.6%); I, 19 (30.6%); II, 10 (16.1%); III, 2 (3.2%); IV, 12 (19.4%); NR, 18 (29.0%)
Chemotherapy	Number of patients treated with chemotherapy, 16 (25.8%) Session of chemotherapy: 1, 4 (6.5%); 3, 3 (4.8%); 4, 1 (1.6%); 6, 2 (3.2%); 7, 1 (1.6%); NR, 5 (8.1%)
Radiotherapy	Number of patients treated with radiotherapy, 6(9.7%) Number of radiotherapy: 27, 1 (1.6%); 30, 3 (4.8%); 32, 1 (1.6%); NR, 1 (1.6%)
Operation	Number of patients who had an operation, 57(91.9%) Number of operations: Once, 55 (88.7%); Twice, 1 (1.6%); Third times, 1 (1.6%)
Admission duration	1~5days, 3 (4.8%); 6~10days, 16 (25.8%); 11~15days, 36 (58.1%); 16~20days, 7 (11.3%)

NR, Not reported

Table 2

Detailed Information of Integrative Korean Medicine Treatment and Concomitant treatment (N=62)

Treatment	Frequency n(%) or Mean ± SD
Herbal Medicine	8 (12.9%) Banhasasim-tang(半夏瀉心湯) 2d/3d Cheonwangbosim-dan(天王補心丹) 1d, Sogeonjung-tang(小建中湯) 7d, Hyangsapyeongwi-san(香砂平胃散) 2d, Samulijin-tang(四物二陳湯) 15d, Uchashinki-hwan(牛車腎氣丸) 7d, Oryeong-san(五令散) 4d, Sipjeondaebo-tanggami(十全大補湯加味) 7d
Acupuncture (allow repetition)	62 (100%) In order of most used Sa-am acupuncture therapy SP(脾) jeonggyeok, 24 (38.7%); ST(胃) jeonggyeok, 11 (17.7%); ST(胃) seunggyeok, 9 (14.5%); KI(腎) jeonggyeok, 7 (11.3%); LR(肝) hangyeok, 7 (11.3%); LU(肺) jeonggyeok, 5 (8.1%); GB(膽) jeonggyeok, 5 (8.1%); LR(肝) jeonggyeok, 4 (6.5%); LI(大腸) seunggyeok, 4 (6.5%); TE(三焦) seunggyeok, 4 (6.5%); SI(小腸) jeonggyeok, 3 (4.8%); TE(三焦) jeonggyeok, 2 (3.2%); SP(脾) seunggyeok, 1 (1.6%); BL(膀胱) jeonggyeok, 1 (1.6%); HT(心) jeonggyeok, 1 (1.6%); LI(大腸) jeonggyeok, 1 (1.6%) In order of most used Sa-am acupuncture point(more than 5 times) SP 2(大都), 25 (40.3%); GB 41(足臨泣), 20 (32.3%); ST 43(陷谷), 19 (30.6%); ST 36(足三里), 15 (24.2%); LR 2(行間), 9 (14.5%); KI 3(太谿), 8 (12.9%); KI 7(復溜), 8 (12.9%); TE 2(液門), 6 (9.7%); LI 5(陽谿), 6 (9.7%); SI 5(陽谷), 6 (9.7%); SP 3(太白), 5 (8.1%); LU 9(太淵), 5 (8.1%); LR 8(曲泉), 5 (8.1%); SI 3(後谿), 5 (8.1%)
Infra-red	62 (100%)
Moxibustion	43 (69.4%)
Cupping therapy	43 (69.4%)
Concomitant treatment	Sodium selenite 500μg (Selenase®), 31(50%); Radiofrequency ablation, 9(14.5%); Mistletoe, 4(6.5%); Thymosin-α1 (Thy-1), 53(85.5%)

D, Days

Jeonggyeok(正格), taking the acupuncture point in the relevant meridian of the Deficient organ and tonifying the organ; Seunggyeok(勝格), taking the acupuncture point in the relevant meridian of the Excessive organ and sedating the organ; Hangyeok(寒格), taking the acupuncture point in the relevant meridian of the hot organ and cooling the organ.

SP, Spleen; ST, Stomach; KI, Kidney; LR, Liver; LU, Lung; GB, Gall Bladder; LI, Large Intestine; TE, Triple Energizer; SI, Small Intestine; BL, Bladder; HT, Heart

Table 3

Change value of cancer related clinical outcome (N=62)

Outcome	Before treatment Mean (SD)	After treatment Mean (SD)	Change value Mean (SD)	p-value
Physical Well-Being (PWB)	18.77 (6.08)	21.76 (4.72)	2.99 (5.11)	<0.001†
Social/Family Well-Being (SWB)	18.95 (5.38)	18.79 (5.60)	−0.16 (4.43)	0.771
Emotional Well-Being (EWB)	17.54 (3.95)	18.13 (4.09)	0.58 (3.65)	0.212
Functional Well-Being (FWB)	15.67 (5.80)	15.85 (5.93)	0.18 (4.63)	0.760
Anorexia Cachexia Subscale (ACS)	31.55 (6.88)	33.55 (6.42)	2.00 (6.63)	0.035†
FAACT Trial Outcome Index (TOI)	66.00 (15.02)	71.17 (13.21)	5.17 (11.70)	0.001*
FACT-G total score	70.95 (14.49)	74.54 (15.27)	3.59 (10.94)	0.012*
FAACT total score (primary outcome)	102.50 (18.52)	108.09 (18.82)	5.59 (14.83)	0.004*

PI-NRS	3.90 (2.38)	1.81 (1.71)	−2.10 (1.78)	<0.001†

FAACT, Functional Assessment of Anorexia/Cachexia Therapy; FACT, Functional Assessment of Cancer Therapy; PI-NRS, Pain intensity numeric rating score; SD, Standard Deviation

According to Normality test, Paired t-test or Wilcoxon signed rank test was conducted comparing before and after treatment value. Change value of PI-NRS, PWB and ACS was not normally distributed.

* or † p<0.05 was statistically significant (*, paired t-test; ^†, Wilcoxon signed rank test)

Except for PI-NRS, higher score means higher cancer related quality of life.

참고문헌

1. Lagman, RL, Davis, MP, LeGrand, SB, & Walsh, D. Common Symptoms in Advanced Cancer. Surg Clin North Am, (2005). Apr. 85(2), 237-55.

2. Mantovani, G, Macci?, A, Massa, E, & Madeddu, C. Managing Cancer-Related Anorexia/Cachexia. Drugs, (2001). 61(4), 499-514.

3. Wie, G-A, Cho, Y-A, Kim, S-Y, Kim, S-M, Bae, J-M, & Joung, H. Prevalence and risk factors of malnutrition among cancer patients according to tumor location and stage in the National Cancer Center in Korea. Nutr Burbank Los Angel Cty Calif, (2010). Mar. 26(3), 263-8.

4. Brierley, DI, Harman, JR, Giallourou, N, Leishman, E, Roashan, AE, & Mellows, BAD, et al. Chemotherapy-induced cachexia dysregulates hypothalamic and systemic lipoamines and is attenuated by cannabigerol. J Cachexia Sarcopenia Muscle, (2019). Apr. 29. jcsm.12426

5. Lis, CG, Gupta, D, & Grutsch, JF. Can anorexia predict patient satisfaction with quality of life in advanced cancer? Support Care Cancer Off J Multinatl Assoc Support Care Cancer, (2009). Feb. 17(2), 129-35.

6. Nelson, KA, Walsh, D, & Sheehan, FA. The cancer anorexia-cachexia syndrome. J Clin Oncol Off J Am Soc Clin Oncol, (1994). Jan. 12(1), 213-25.

7. Arends, J, Bachmann, P, Baracos, V, Barthelemy, N, Bertz, H, & Bozzetti, F, et al. ESPEN guidelines on nutrition in cancer patients. Clin Nutr Edinb Scotl, (2017). 36(1), 11-48.

8. Arends, J, Baracos, V, Bertz, H, Bozzetti, F, Calder, PC, & Deutz, NEP, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clin Nutr Edinb Scotl, (2017). 36(5), 1187-96.

9. White, JD. Complementary and alternative medicine research: a National Cancer Institute perspective. Semin Oncol, (2002). Dec. 29(6), 546-51.

10. Mao, JJ, Palmer, CS, Healy, KE, Desai, K, & Amsterdam, J. Complementary and alternative medicine use among cancer survivors: a population-based study. J Cancer Surviv, (2011). Mar. 5(1), 8-17.

11. Lau, CHY, Wu, X, Chung, VCH, Liu, X, Hui, EP, & Cramer, H, et al. Acupuncture and Related Therapies for Symptom Management in Palliative Cancer Care: Systematic Review and Meta-Analysis. Medicine (Baltimore), (2016). Mar. 95(9), e2901.

12. Huang, Z, Qin, Z, Yao, Q, Wang, Y, & Liu, Z. Moxibustion for Chemotherapy-Induced Nausea and Vomiting: A Systematic Review and Meta-Analysis. Evid-Based Complement Altern Med ECAM, (2017). 2017, 9854893.

13. Lee, J-H, Bae, K, & Yoo, H-S. The Effect of Traditional Oriental Herbal Medicine for Anorexia in Cancer Patients: A Systematic Review. J Korean Med, (2017). Mar. 31. 38(1), 8-20.

14. Han, S, Jang, B-H, Hwang, D-S, & Suh, HS. Experiences of Treatment-Related Side Effects and Supportive Care with Korean Medicine in Women with Breast Cancer - A Focus Group Study. J Orient Obstet & Gynecol, (2017). 30(1), 85-94.

15. Choi, Y-J, Lee, J-S, & Cho, S-H. Use of Korean Medicine among Cancer Patients. J Korean Orient Med, (2012). Sep. 33(3), 46-59.

16. Kroenke, K, Monahan, PO, & Kean, J. Pragmatic Characteristics of Patient-Reported Outcome Measures are Important for Use in Clinical Practice. J Clin Epidemiol, (2015). Sep. 68(9), 1085-92.

17. Shih, Y-L, Hsu, Y-C, Chiu, W-H, & Chao, C-SC. Estimating Life Expectancy From Chinese Medicine Could Improve End-of-Life Care in Terminally Ill Cancer Patients. Holist Nurs Pract, (2018). Oct. 32(5), 247-52.

18. Meropol, NJ, Egleston, BL, Buzaglo, JS, Benson, AB, Cegala, DJ, & Diefenbach, MA, et al. Cancer Patient Preferences for Quality and Length of Life. Cancer, (2008). Dec. 15. 113(12), 3459-66.

19. Cho, J-H, Son, C-G, Lee, Y-W, Yoo, H-S, Sung, J-H, & Kim, S-Y, et al. Current Status of Studies on Cancer-Related Quality of Life Instruments. J Korean Orient Intern Med, (2006). 27(1), 84-91.

20. Lee, J-A, Lee, S-H, Park, J-H, Park, J-H, Kim, S-G, & Seo, J-H. Analysis of the Factors Related to the Needs of Patients with Cancer. J Prev Med Pub Health, (2010). 43(3), 222.

21. Oken, MM, Creech, RH, Tormey, DC, Horton, J, Davis, TE, & McFadden, ET, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol, (1982). Dec. 5(6), 649-56.

22. Ribaudo, JM, Cella, D, Hahn, EA, Lloyd, SR, Tchekmedyian, NS, & Roenn, JV, et al. Re-validation and Shortening of the Functional Assessmentof Anorexia/Cachexia Therapy (FAACT) Questionnaire. Qual Life Res, (2001). 9(10), 1137-46.

23. Cella, DF, Tulsky, DS, Gray, G, Sarafian, B, Linn, E, & Bonomi, A, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol, (1993). Mar. 11(3), 570-9.

24. Cella, DF, Bonomi, AE, Lloyd, SR, Tulsky, DS, Kaplan, E, & Bonomi, P. Reliability and validity of the functional assessment of cancer therapy-lung (FACT-L) quality of life instrument. Lung Cancer, (1995). Jun. 12(3), 199-220.

25. Farrar, JT, Young, JP, LaMoreaux, L, Werth, JL, & Poole, MR. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain, (2001). Nov. 94(2), 149-58.

26. Guy W. ECDEU assessment manual for psychopharmacology. Rev. 1976. Rockville, Md. U.S. Dept. of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs;(1976). p. 603

27. Webster, K, Cella, D, & Yost, K. The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System: properties, applications, and interpretation. Health Qual Life Outcomes, (2003). 16(1), 7.

28. Tranmer, JE, Heyland, D, Dudgeon, D, Groll, D, Squires-Graham, M, & Coulson, K. Measuring the Symptom Experience of Seriously Ill Cancer and Noncancer Hospitalized Patients Near the End of Life with the Memorial Symptom Assessment Scale. J Pain Symptom Manage, (2003). May. 25(5), 420-9.

29. Tisdale, MJ. Mechanisms of Cancer Cachexia. Physiol Rev, (2009). Apr. 89(2), 381-410.

30. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Martí S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Pain, Palliative and Supportive Care Group, editor. Cochrane Database Syst Rev [Internet]. 2013. Mar. 28. [cited 2019 May 1]; Available from: http://doi.wiley.com/10.1002/14651858.CD004310.pub3

31. Mattox, TW. Cancer Cachexia: Cause, Diagnosis, and Treatment. Nutr Clin Pract, (2017). Oct. 32(5), 599-606.

32. Greenlee, H, Balneaves, LG, Carlson, LE, Cohen, M, Deng, G, & Hershman, D, et al. Clinical Practice Guidelines on the Use of Integrative Therapies as Supportive Care in Patients Treated for Breast Cancer. JNCI Monogr, (2014). Nov. 2014(50), 346-58.

33. Cheng, C-S, Chen, L-Y, Ning, Z-Y, Zhang, C-Y, Chen, H, & Chen, Z, et al. Acupuncture for cancer-related fatigue in lung cancer patients: a randomized, double blind, placebo-controlled pilot trial. Support Care Cancer Off J Multinatl Assoc Support Care Cancer, (2017). 25(12), 3807-14.

34. Tao, W, Luo, X, Cui, B, Liang, D, Wang, C, & Duan, Y, et al. Practice of traditional Chinese medicine for psycho-behavioral intervention improves quality of life in cancer patients: A systematic review and meta-analysis. Oncotarget, (2015). Nov. 24. 6(37), 39725-39.

35. Kim, T-H, & Kang, JW. Acupuncture for symptoms management in Korean breast cancer survivors: a prospective pilot study. Acupunct Med J Br Med Acupunct Soc, (2019). Mar. 21. 9645284198. 32610.

36. Lee, Y-W, Chen, T-L, Shih, Y-RV, Tsai, C-L, Chang, C-C, & Liang, H-H, et al. Adjunctive traditional Chinese medicine therapy improves survival in patients with advanced breast cancer: a population-based study. Cancer, (2014). May. 1. 120(9), 1338-44.

37. Zhang F, Shen A, Jin Y, Qiang W. The management strategies of cancer-associated anorexia: a critical appraisal of systematic reviews. BMC Complement Altern Med [Internet]. 2018. Dec. [cited 2019 May 8]. 18:1. Available from: https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/s12906-018-2304-8

38. Jeon, J-H, Yoon, J, Cho, C-K, Jung, I-C, Kim, S, & Lee, S-H, et al. Effect of acupuncture for radioactive-iodine-induced anorexia in thyroid cancer patients: a randomized, double-blinded, sham-controlled pilot study. Integr Cancer Ther, (2015). May. 14(3), 221-30.

39. Grundmann, O, Yoon, SL, Williams, JJ, Gordan, L, & George, TJ. Augmentation of Cancer Cachexia Components With Targeted Acupuncture in Patients With Gastrointestinal Cancers: A Randomized Controlled Pilot Study. Integr Cancer Ther, (2019). Dec. 18, 1534735418823269.

40. Jeon, J-H, Cho, C-K, Park, S-J, Kang, H-J, Kim, K, & Jung, I-C, et al. A Feasibility Study of Moxibustion for Treating Anorexia and Improving Quality of Life in Patients With Metastatic Cancer: A Randomized Sham-Controlled Trial. Integr Cancer Ther, (2017). Mar. 16(1), 118-25.

41. Cheon, C, Yoo, J-E, Yoo, H-S, Cho, C-K, Kang, S, & Kim, M, et al. Efficacy and Safety of Sipjeondaebo-Tang for Anorexia in Patients with Cancer: A Pilot, Randomized, Double-Blind, Placebo-Controlled Trial. Evid Based Complement Alternat Med, (2017). 2017, 1-9.

42. Inoue, T, Takagi, H, Owada, Y, Watanabe, Y, Yamaura, T, & Fukuhara, M, et al. The efficacy of the Kampo medicine rikkunshito for chemotherapy-induced anorexia (RICH trial): study protocol for a randomized controlled trial. Trials, (2017). Oct. 18. 18(1), 485.

43. Ohnishi, S, Watari, H, Kanno, M, Ohba, Y, Takeuchi, S, & Miyaji, T, et al. Additive effect of rikkunshito, an herbal medicine, on chemotherapy-induced nausea, vomiting, and anorexia in uterine cervical or corpus cancer patients treated with cisplatin and paclitaxel: results of a randomized phase II study (JORTC KMP-02). J Gynecol Oncol, (2017). Sep. 28(5), e44.

44. Kim, E, Kim, H, Jang, S, Kim, H, Han, Y, & Leem, J. A Cancer Patient Suffering from Chemotherapy-Induced Anorexia and Nausea Treated by Herbal Medicine (Dokhwaljihwang-tang-gamibang) Resulted in Improved Quality of Life: A Case Report. J Intern Korean Med, (2018). Oct. 30. 39(5), 1032-41.

45. Park M, Kim S. A Modern Clinical Approach of the Traditional Korean Saam Acupuncture. Evid-Based Complement Altern Med ECAM [Internet]. 2015 [cited 2019 May 9]. 2015. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4619944/

46. Ahn, C-B, Jang, K-J, Yoon, H-M, Kim, C-H, Min, Y-K, & Song, C-H, et al. A Study of the Sa-Ahm Five Element Acupuncture Theory. J Acupunct Meridian Stud, (2009). Dec. 2(4), 309-20.

47. Kim, D-J, Park, S-H, Seo, J-C, Kim, KS, Sohn, KC, & Shin, IH, et al. Efficacy of saam acupuncture treatment on improvement of immune cell numbers in cancer patients: a pilot study. J Tradit Chin Med Chung Tsa Chih Ying Wen Pan, (2014). Oct. 34(5), 550-4.

48. Mahajan, R. Real world data: Additional source for making clinical decisions. Int J Appl Basic Med Res, (2015). 5(2), 82.