Effects of Chinese Medicine as Adjunct Medication for Adjuvant Chemotherapy Treatments of Non-Small Cell Lung Cancer Patients

The aim was to evaluate the effects of traditional Chinese medicine (TCM) as a combination medication with adjuvant chemotherapy on postoperative early stage non-small cell lung cancer (NSCLC) patients. The 314 patients with completely resected stage IB, II or IIIA cancers were assigned into vinorelbine plus cisplatin/carboplatin (NP/NC) (control, n = 158) and NP/NC with additional TCM (intervention, n = 156) groups. The primary endpoint was QOL scores; secondary endpoints were the toxicity and safety of the regimens. The NP/NC regimen caused mild (grade 1 or 2) non-hematologic toxic effects in the patients comprising vomiting (43.6%), fatigue (36.9%), pain (23%), dry mouth (27.6%) and diarrhea (7.9%). The incidence of adverse events was significantly lower in the intervention group than in the control group (0.57% vs 4.02%, P = 0.037). Transient severe (grade 3 or 4) hematological toxic effects occurred less often (hemoglobin reduction (11.9 vs 22.5 percent) and total bilirubin increased (to 42.1 vs 46.2%) in the intervention compared to the control group during the 2nd chemotherapy cycle. When combined with adjuvant chemotherapy, TCM led to partial relief of symptoms in addition to a reduction of side-effects and adverse events caused by the NP/NC regimens.

(TCM) includes mainly herbal medications and in its holistic approach TCM believes that a tumor is caused by shortness of the healthy qi, leading to organ dysfunction and the stagnation of qi and blood 5 . Then, pathological products such as dirty sputum and bruises emerge and accumulate into tumor masses. Diarrhea, hair loss, insomnia and pain symptoms arise as the tumor develops or when chemotherapeutic drugs are administered, which further reduces the healthy qi. Therefore, the key point of TCM cancer treatment is to strengthen a healthy qi and eliminate pathogenic factors. However, after analysis of TCM herb compounds used for cancer therapy, the effects of TCM medication were mainly attributed to the inhibition of cell proliferation and the induction of apoptosis via various mechanisms, as well as inhibition of angiogenesis and regulation of the immune system 5,6 . Since western medicine chemotherapy regimens have been adopted in China, TCM is mainly applied in clinical practice in combination with adjuvant chemotherapy and the formulas have been extended to cope with chemotherapy-related side effects in addition to prevention of cancer recurrence and metastasis as well as prolonging the survival time of postoperative cancer patients 7-12 . In the present study, a perspective randomized, double-blinded clinical trial was designed and conducted to evaluate the effects of four TCM formulations covering three different syndromes as adjunct medications, with a NP/NC regimen on clinical symptoms and QOL of postoperative NSCLC patients in comparison to a NP/NC regimen alone. The findings should help to improve adjuvant regimens for NSCLC patients after radical excision of their tumors.

Methods
Study design and patients. A randomized, controlled and double-blinded clinical study procedure was performed on 314 Ib-IIIa NSCLC patients enrolled in 7 centers in China. The trial was registered at ClinicalTrials. gov (Number: NCT01441752; Date: July 14, 2011) and enrolment has been completed; patients are still in follow-up. Eligibility criteria included the following: completely resected stage Ib-IIIa NSCLC, ages 18-75 years, An Eastern Cooperative Oncology Group performance status (ECOG PS) scale of 0-2 and adequate hematological, biochemical and organ functions. Chemotherapy was started within 6 weeks after surgery and consisted of 4 cycles of cisplatin/carboplatin and vinorelbine. All data collection and analyses was carried out in Longhua hospital. The primary aim of the study was to evaluate the effectiveness of TCM on QOL for postoperative NSCLC patients treated with adjuvant chemotherapy, and the secondary aim was to evaluate any beneficial effects of TCM on side effects caused by chemotherapy.
Our study was performed in accordance with the Declaration of Helsinki regarding the ethical principles for medical research involving human subjects. The protocol was approved by the ethics boards of Longhua Hospital. All participants signed informed consent forms. , combined with years of clinical observation and experience in our department, 3 basic syndromes were summarized for lung cancer, and they were determined by two senior physician/deputy chief physicians. Patients with at least 2 main symptoms and 1 secondary symptom could be diagnosed thus:

Qi syndrome deficiency
Main symptoms: cough, large amount of sputum, loss of appetite, fatigue and weakness, pale and bulgy tongue. Secondary symptoms: spontaneous sweat, unshaped stool, thin superficial and smooth pulse.

Yin syndrome deficiency
Main symptoms: cough, small amount of sputum, dried mouth, red tongue. Secondary symptoms: night sweats, insomnia, low fever, thready pulse, rapid pulse.

Qi and yin syndrome deficiency
Main symptoms: cough, small amount of sputum, fatigue and weakness, dried mouth without polydipsia. Secondary symptoms: spontaneous sweat, night sweat, reddish tongue or tongue with teeth imprints, thready and weak pulse. All medicines used were sourced from the same producing area and the same batch (Jiangyin Tian Jiang Pharmaceutical Co., Ltd produced the Chinese medicine granules and placebos) and were purchased as ready to use granules.
Chinese medicine applications were started on the first day after chemotherapy, but not the day chemotherapy drugs were applied. The medicine was dissolved into 160 mL of warm water for drinking at 9:30 a.m. and 15:00 p.m. every day until the end of the chemotherapy. All procedures were supervised by clinical research pharmacists. According to the 4 formulas of the TCM, we fabricated 4 kinds of oral placebos of matched weight, color, smell, taste and packaging as the TCM medicine.
1. Formula I (including qi and warming yang granules) The ingredients were Radix astragalus, which ameliorates exercise-induced fatigue and chronic fatigue syndrome 13,14 , Codonopsis pilosula with immune modulatory 15 anti-tumor 16 and anti-gut damage 17 effects, Atractylodes macrocephala, which has been reported to inhibit allergic diarrhea stimulation of the Th1type immune responses 18 , Poria cocos, an antioxidant 19 , Trigonella foenum-graecum, an antioxidant 20 , which also enhances endurance by facilitating increased utilization of fatty acids as an energy source 21 and ameliorates various impairments associated with physical fatigue 22 as well as Psoralea corylifolia, which is used as an antidepressant by inhibiting monoamine oxidase A and B (MAO-A and MAO-B) activity 23 (see supplementary Table 1).

Formula II (nourishing yin and promoting the secretion of body fluid granules):
The ingredients were Radix asparagus, Radix adenophorae, which suppress the development of inflammation and decreases airway damage by suppressing T cell activity, eosinophilia and bronchial hyper-responsiveness 24 , Glehnia literalis with anti-cancer effects 25 , Ophiopogon japonicus with antioxidant, immunomodulatory and salivary secretion stimulatory effects 26,27 as well as Lilium brownii with antitumor 28 anti-fatigue effects 29 and Ligustrum lucidum, which has been reported to inhibit proliferation and induce apoptosis of cancer cells [30][31][32][33] (see supplementary Table 2).

Formula III (yin-nourishing and qi-tonifying granules)
Formula III was a combination of formula I and formula II.
The 4 formulas were applied according to the following regimens: 1. Formula I + Formula IV: Indications for patients with qi deficiency syndrome. 2. Formula II + Formula IV: Indications for patients with yin deficiency syndrome. 3. Formula III + Formula IV: Indications for patients with qi and yin deficiency syndrome.

Assessments. A modified version of the European Organization for Research and Treatment of Cancer
(EORTC) quality of life questionnaire (QLQ-C30) was used to evaluate QOL changes (EORTC QLQ-LC43), which comprised 15 questions derived from the EORTC QLQ-C30 and 10 questions derived from the EORTC QLQ-LC13 questionnaires 53 . The data from every week during each cycle of chemotherapy until disease progression were collected. A high functional area score and a low symptom domain score indicated an improved quality of life. A change in score of 10 points from baseline was defined as significant in functional domain and symptom QOL determinations on the basis of previous studies [54][55][56] and published guidelines from the National Cancer Institute of Canada clinical trial group 57 .
All adverse and serious adverse events were recorded. Adverse events were defined by grade according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3 (NCI CTC AE 3.0), with an adverse event being defined as unanticipated symptoms, physical signs, disease or other body injuries, which might be linked to the administered medicine, yet not necessarily caused by them. All adverse events were coded by the Medical Dictionary for Regulatory Activities 14.0 (MedDRA14.0) and analyzed for each experimental patient group.
Statistical analysis. SAS software (version 9.2) was used for statistical analysis. Attributes data (QOL scale): a paired t-test was used for comparing the average score before and after treatment, and an independent-sample t-test to compare the score between groups. According to the homogeneity of variance test, data with a P-value Scientific RepoRts | 7:46524 | DOI: 10.1038/srep46524 not fitting a normal distribution was analyzed using a rank sum test between groups. For variable data (baseline, medicine for adjuvant chemotherapy), a chi-square test was used.
Ordered hierarchical data (NCI-CTC graded adverse events) were analyzed using a rank sum test. Analysis of demography and baseline characteristics was based on the full analysis set. According to the types and characteristics of the different variables, a t-test/Wilcoxon rank sum test was used for baseline comparison of the quantitative index and a chi-square/Fisher exact test for the baseline comparison of the qualitative index.
We used a full analysis set (FAS) to analyze the adverse events, which was comprised of all enrolled patients who met the inclusion criteria including lost but not excluded patients. The pre-protocol set (PPS) was composed of enrolled patients who completed the trial according to the protocol for QOL analyses.
According to a previous study, after three-month adjuvant chemotherapy of early lung cancer patients the QOL score assessed by the QLQ-C30 scale decreased by 27% compared with baseline 56 . With an estimated 15% of adjuvant plus TCM therapy patients with no deterioration of QOL and a significance level of α = 0.05, 1-β = 0.90 and a QOL score decline of 12% in the treatment and 27% in the control group after three-months, 198 cases was the necessary sample size in each group after power analysis. Considering a 20% drop-off rate, the research team was expected to observed 480 cases (n = 240 cases in each group) for 2 years to compare QOLs of postoperative NSCLC patients treated with chemotherapy with or without adjunctive TCM medication.

Results
Patient characteristics and the primary outcome. The study period was from December 14, 2012 until August 1st 2015. As shown in Table 1, 44.23% of the patients had pathological stage IB disease, 23.08% had stage II, and 32.69% had stage III disease and all had an Eastern Cooperative Oncology Group performance status score of 0 to 2; the median age was 59 years; 60.90% were men and 71.79% had adenocarcinomas. There was no statistically significant differences between the groups regarding demographic and baseline characteristics (Table 1).
Compliance to QOL Assessment. In our study, the compliance with the QOL assessment is summarized in Fig. 1. In the intervention arm, 134 patients completed the baseline QOL assessment, which represented 85% of all patients from this group. Similar compliance (132 patients; 85% of expected) was noted in the control arm.
In the entire study, 49 Baseline QOL Results. The two arms had similar baseline QOL scores in all domains and items (Fig. 2).
QOL after completed chemotherapies. After completed treatment, in the intervention group, the overall functioning scores beside social functioning (Fig. 4A) were improved, and overall symptom scores such as fatigue, pain, insomnia anorexia (Fig. 4B) as well as cough and chest pain (Fig. 4C) were also decreased, though all without statistical significance. These changes are illustrated in the bars, which depicts the difference scores before and after the 4 th cycle of chemotherapy. In Fig. 4B,C, data below zero indicates that the post-therapy scores were lower than the baseline scores which meant an improvement in related symptoms. Positive scores in Fig. 4B,C indicate that the symptoms became worse after the treatment.
Safety and adverse events. The NP/NC regimens caused mild (grade 1 or 2) non-hematologic toxic effects in patients comprising vomiting (43.6%), fatigue (36.9%), pain (23%), dry mouth (27.6%), anorexia (20%) as well as diarrhea (7.9%), and chemotherapy plus TCM was associated with a significantly lower incidence of adverse events than was chemotherapy alone (0.57% vs 4.02%, P = 0.037) ( Table 2). Tables 3 and 4 summarize the main reported hematological and non-hematological adverse events. After 7 days and 14 days of each chemotherapy cycle, TCM significantly reduced the incidence of non-hematological adverse events of pain (P = 0.01), dry mouth (P = 0.007, 0.04, 0.037), vomiting (P = 0.004), diarrhea (P = 0.02, 0.011) and fatigue (P = 0.03). We observed the changes in values measured by routine blood, liver and kidney function tests, and found that adverse events regarding leucocytes, blood platelets and γ -glutamyl transpetidase (Fig. 5), NEUT, Hb, Tbil and AST (data not shown) were associated with the application cycle of the chemotherapy medicine. While these index levels increased during chemotherapy, they returned to normal values after cessation of treatment. During the 2 nd cycle of chemotherapy, compared to the control, TCM decreased the incidence of Hb reduction (11.9 vs 22.5%, P = 0.019) and the total bilirubin increase (42.1% vs 46.2%, P = 0.026) as well as blood platelet and γ -glutamyl transpetidase induced by chemotherapy. We have not seen the hematological toxicity for the long-term in subsequent chemotherapy cycles. To some extent, TCM caused the loss of appetite with more grade 1 or 2 toxic effects than found in the control group (P = 0.04).

Discussion
Adjuvant chemotherapy is considered to be the gold standard after surgery for early stage patients with NSCLC, at least for stage II, resected IIIA, and selected IB NSCLCs 58 . Alternatively, platinum-based double adjuvant chemotherapy after surgery may be used to lower the risk of the recurrence of cancer. As shown in a LACE (Lung Adjuvant Cisplatin Evaluation) meta-analysis 59 , a cisplatin/vinorelbine combination was associated with a substantially superior survival benefit compared with other cisplatin-based regimens. However, toxicity has been a critical issue in platinum-based adjuvant protocols with neutropenia reported in up to 85% of patients and febrile  neutropenia in up to 9% of treatments. About 50% of patients did not complete the entire adjuvant treatment due to toxicity 3 . Although the JRB.10 study indicated that the negative effects of adjuvant chemotherapy on QOL appeared to be temporary 56 , 75% of patients experienced grade 3 or 4 toxicity and 77% had at least one dose reduction or omission in a previous study 60 . Symptoms such as loss of appetite, fatigue, pain and dyspnea reduce the QOL the most 61 . Furthermore, other studies have shown that the more symptoms of a disease, the lower the QOL is [62][63][64] . Increasing fatigue, dyspnea, cough and pain reduce the emotional dimension of QOL, while problems with night rest inevitably impair cognitive functioning 65 .
TCM has been successfully applied to postoperative lung cancer patients, with the special advantages of a reduction in tumor recurrence and metastasis 66,67 , and an enhanced QOL 68 , by alleviating symptoms such as shortness of breath, talk fatigue, coughing, loss of appetite and dried stools 69 . In addition, it has been reported that TCM combined with chemotherapy lessened the moderate to severe myelosuppression caused by conventional chemotherapeutic drugs 66,70 . According to previous meta-analysis of TCM when used as an adjunct therapy for NSCLC patients, including 24 studies of 2,109 patients, the frequently used herbs were Radix astragalus, Radix adenophorae, Radix ophiopogonis, Poria, Radix asparagi, Radix glycyrrhizae, Herba oldenlandia diffusa, Semen persicae and Radix notoginseng, from which the first 5 were also part of our formulations; Radix astragalus as well as Radix ophiopogonis are commonly used in the treatment of NSCLC in China 71 .
There are no published prospective, double-blinded trials of a TCM plus NP (vinorelbine plus platinum-based) regimen following surgical resection of NSCLC. By comparing the adjuvant chemotherapy (AC) with the placebo, the results of our study conclusively showed that the addition of TCM to AC provides better QOL scores for completely resected early stage NSCLC patients compared to chemotherapy agents alone.
In our study, role functioning impairment is usual for individuals after surgery and cognitive functioning is the main impairment after AC. TCM not only improved the scores of role functioning but also improved the cognitive function of patients after the 4 cycles of AC. Worry about future and symptom scores, such as fatigue, pain and dyspnea were high at baseline in both groups, but TCM released patients from pain, coughing blood, and pain in the chest. The combined treatment was significantly better compared with those patients who received 4 cycles of solely chemotherapy. TCM combined with chemotherapy was also effective in alleviating adverse events such as fatigue, diarrhea, dry mouth and vomiting. In our study, the incidence rate of adverse events was 0.57% in the intervention group, which was lower than in the control group (4.02%), a finding that was statistically significant (P = 0.037). A total of 8 patients terminated their treatment due to severe side effects, among which 7 were in the control group and only 1 patient in the intervention group.
It can be concluded that TCM combined with chemotherapy is safe. During the 2 nd cycle of chemotherapy, TCM plus chemotherapy increased the incidence of hematological hemoglobin reduction and the total bilirubin increase compared to chemotherapy alone. We have not yet seen the long-term hematological toxicity data for subsequent chemotherapy cycles.
Our clinical trial began enrollment from December 14, 2012, with the last patient being enrolled on March 26, 2015, and the last follow-up performed on August 1, 2015. By now, the longest follow-up time is 39.6 months, but further follow-ups will be required to confirm the survival benefit of TCM plus AC for resected lung cancer.
In summary, this study has shown that TCM can improve the temporary negative effects of AC on QOL and alleviate the symptoms with good safety. The results of this study provide additional practice guidelines and justification for the administration of TCM as an adjuvant chemotherapy in resected early stage NSCLC patients [72][73][74][75][76][77][78][79][80] .