Zhang Huan-huan (章歡歡), Shen Lei (沈磊)

Department of Oncology, Changxing Hospital of Traditional Chinese Medicine, Zhejiang 313100, China

Abstract Objective: To observe the effect of moxa-stick moxibustion plus recombinant human granulocyte-colony stimulating factor(rhG-CSF) in preventing chemotherapy infection in gastric cancer and its effect on immune function.Methods: A total of 70 patients with gastric cancer treated by chemotherapy were randomly divided into an observation group and a control group, with 35 cases in each group. The control group was given rhG-CSF, and the observation group was given additional moxa-stick moxibustion on the basis of rhG-CSF. Both groups were treated for 2 chemotherapy cycles,totally 6 weeks. The number of patients with infection, the duration of infection and the duration of continuous use of antibiotics were observed. The leukocytes and granulocytes counts, the levels of tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ) were measured before and after treatment, and the levels of CD4, CD8 and natural killer (NK) cells were analyzed.Results: The infection rate of the observation group was significantly lower than that of the control group (P＜0.05), and the duration of infection and the duration of continuous use of antibiotics were also shorter (P＜0.05). After treatment, the leukocytes and granulocytes counts in the two groups were higher than those before treatment (all P＜0.05). After treatment, the levels of TNF-α and IFN-γ of the patients in the two groups were improved (all P＜0.05), and there were significant differences between the observation group and the control group (P＜0.05). After treatment, the numbers of CD4,CD8, and NK cells in the observation group increased significantly (all P＜0.05), but the changes in the control group were not significant (P＞0.05).Conclusion: Moxa-stick moxibustion plus rhG-CSF can significantly reduce the incidence and severity of chemotherapy infection in gastric cancer, increase the leukocytes and granulocytes counts, and regulate the levels of inflammatory factors,which may be related to the improvement of the immune function of the patients.

Keywords: Acupuncture-moxibustion Therapy; Moxibustion Therapy; Moxa Stick Moxibustion; Neoplasms; Stomach; Drug Therapy; Infections

Gastric cancer is a common malignant tumor of the digestive system. It is characterized by high incidence and mortality[1]. The early symptoms of gastric cancer are not obvious and the detection rate is low, which make most patients develop into the advanced stage when they are diagnosed, and lose the best period of radical operation. Chemotherapy is the most important way to treat advanced gastric cancer, as it can effectively alleviate clinical symptoms, prolong the survival time and improve the patients’ quality of life(QOL)[2]. However, when the chemotherapy drugs kill tumor cells, they inevitably kill normal cells, destroy immune function, and cause side effects such as myelosuppression, among which neutropenia and leucopenia occur more frequently. Patients with granulocytopenia and leucopenia are susceptible to infection during chemotherapy caused by pathogenic bacteria, which seriously affects the therapeutic effect and patients’ QOL, and even endangers their lives[3]. At present, recombinant human granulocyte-colony stimulating factor (rhG-CSF) is often used to promote the secretion and maturation of leukocytes, and to improve the condition of reduction of leukocytes and granulocytes, so as to achieve the effect of prevention and auxiliary treatment of infection in chemotherapy stage of malignant tumors[4]. However, the efficacy of rhG-CSF in the prevention of post-chemotherapy infection is not clear.

As an external therapy in traditional Chinese medicine (TCM), moxibustion has a long history in treating cancer-related diseases. Studies have shown that moxibustion can relieve cancer pain, boost immunity and alleviate gastrointestinal reaction caused by radiotherapy and chemotherapy[5]. There are also many studies on the mechanism of moxibustion in increasing leukocytes and granulocytes[6-7]. However, no one has set foot in the field of clinical observation and mechanism of moxibustion intervention of chemotherapy infection. Therefore, this study used moxa-stick moxibustion combined with rhG-CSF to intervene the patients undergoing gastric cancer chemotherapy to observe the infection- and immunityrelated indicators of the patients, in order to provide a reference for the prevention of infection in patients undergoing gastric cancer chemotherapy. The details of this study are as follows.

1 Clinical Materials

1.1 Diagnostic criteria

The diagnostic criteria of Western medicine referred to the Guidelines for Standardized Diagnosis and Treatment of Gastric Cancer (Trial)[8], and it was confirmed by pathology.

The syndrome differentiation of TCM conformed to the deficiency of spleen and stomach described in the

Guiding Principles for Clinical Study of New Chinese Meidicnes[9]. The main symptoms included epigastric pain that alleviated upon pressure or warmth and undigested food in stools. The minor symptoms included lassitude and curling up, loose stools, a pale tongue with tooth marks and white coating, and deep or weak pulse.

1.2 Inclusion criteria

People who met the diagnostic criteria of both Western medicine and syndrome differentiation of TCM;aged between 18 and 75 years old; estimated survival time ＞6 months; received chemotherapy in hospital for over 3 months; signed informed consent.

1.3 Exclusion criteria

Those with other malignant tumors; those who were delirious and unable to cooperate with the completion of the trial; those with incomplete clinical examination data.

1.4 Statistical methods

The SPSS 21.0 statistical software was used for data analysis. The rank-sum test was used for counting data;the measurement data were expressed as mean ±standard deviation ( x±s). Paired sample t-test was used for intra-group comparison and independent sample t-test was used for inter-group comparison.P＜0.05 indicated statistical significance.

1.5 General data

A total of 70 patients with chemotherapy-treated gastric cancer who visited the Oncology Department of Changxing Hospital of Traditional Chinese Medicine between January 2016 and January 2019 were recruited in the study. They were randomly divided into an observation group and a control group, with 35 cases in each group. There were no significant between-group differences in gender, age and the stage of gastric cancer (all P＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Comparison of general data between the two groups

2 Therapeutic Methods

Docetaxel combined with cisplatin for chemotherapy was taken in the two groups. Docetaxel (75 mg/m2) was dissolved in 250 mL of normal saline, intravenous drip for 1 h, day 1; cisplatin (75 mg/m2) was dissolved in 500 mL of normal saline, intravenous drip for 1-3 h, day 1; 21 d constituted a chemotherapy cycle. During docetaxel administration, dexamethasone was taken orally to prevent allergic reaction, and tropisetron was taken orally to stop nausea before cisplatin administration.

2.1 Control group

Blood routine test was performed every other day after chemotherapy. Whenthe leukocytes countin peripheralbloodwaslessthan 4.0×109/L,rhG-CSF injection (China Food and Drug Administration approval number: 20020051, Beijing Sihuan Biopharmaceutical Co., Ltd., China) was injected subcutaneously,150 μg/time, once a day, for 7 d, and two chemotherapy cycles in total.

2.2 Observation group

The same treatment of rhG-CSF injection was given in the observation group as that in the control group, and moxa-stick moxibustion was given at the same time.

Acupoints: Zhongwan (CV 12), bilateral Zusanli(ST 36), Sanyinjiao (SP 6), Pishu (BL 20) and Weishu(BL 21). The location of acupoints referred to the

Science of Meridians and Acupoints[10].

Method:Moxa-stick moxibustion wasbased onthe Tech niquesof Acupuncture andMoxibustion[11].The procedure was as follows. Asked the patient to lie down on the back first, then adjusted to a prone position to expose the local skin around the acupoint, and applied the ignited moxa sticks to the acupoint, 2-3 cm away from the skin, until the local skin became warm(without burning pain), 15-20 min for each point until the skin turned red. Repeated the aforementioned steps to all points. The treatment was done once every 2 d, for 2 chemotherapy cycles.

3 Observation of Therapeutic Effects

3.1 Observed items

3.1.1 Infection

The number of patients with infection, the duration of infection and the duration of continuous use of antibiotics were recorded.

3.1.2 Leukocytes and granulocytes counts

BC-1800 automatic hematology analyzer (Mindray Company, China) was used to detect the blood routine and analyze the changes of leukocytes and granulocytes counts in the two groups before and after treatment.The leukocytes and granulocytes counts reflected the patient's infection.

3.1.3 Levels of inflammatory factors

The levels of inflammatory factors including tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ) in the peripheral blood of the two groups were detected before and after treatment by enzyme-linked immunosorbent assay (ELISA). Inflammatory factors can induce, aggravate or alleviate infection by participating in inflammatory reaction.

3.1.4 Levels of CD4, CD8 and natural killer (NK) cells

The levels of CD4, CD8 and NK cells in the patients were analyzed before and after treatment by CytoFLEX flow cytometer (Beckman Coulter, Inc., USA).

3.2 Treatment results

3.2.1 Comparison of infection

During the chemotherapy, 30 patients in the control group and 12 cases in the observation group were infected, and the number of patients in the observation group was significantly lower than that in the control group (P＜0.05). The average infection days in the control group and the observation group were(9.13±2.63) d and (6.08±1.19) d respectively. The duration of infection in the observation group was significantly shorter than that in the control group(P＜0.05). The duration of continuous use of antibiotics was (12.80±3.13) d in the control group and(7.17±1.46) d in the observation group, and the duration was significantly shorter in the observation group than that in the control group (P＜0.05). Check Table 2 for details.

Table 2. Comparison of infection between the two groups

3.2.2 Comparison of leukocytes and granulocytes counts

The differences in the counts of leukocytes and granulocytes between the two groups before treatment were not statistically significant (both P＞0.05). After treatment, the leukocytes and granulocytes counts of the two groups were higher than those before treatment (all P＜0.05), and the leukocytes and granulocytes counts of the observation group were significantly higher than those of the control group(both P＜0.05). Check Table 3 for details.

3.2.3 Comparison of inflammatory factors

The differences in the levels of TNF-α and IFN-γ between the two groups before treatment were not statistically significant (both P＞0.05). After treatment,the levels of TNF-α and IFN-γ in the two groups were improved (all P＜0.05), and the differences in the levels of TNF-α and IFN-γ between the two groups were statistically significant (both P＜0.05). Check Table 4 for details.

3.2.4 Comparison of immune cell levels

Before treatment, there were no significant differences in the CD4, CD8 and NK cells levels between the two groups (all P＞0.05). After treatment, the levels of CD4 and NK cells in the observation group increased(both P＜0.05), and the level of CD8 decreased (P＜0.05);after treatment, the levels of CD4, CD8 and NK cells were significantly different between the two groups (all P＜0.05). Check Table 5 for details.

Table 3. Comparison of leukocytes and granulocytes counts between the two groups ( x±s, ×109/L)

Table 4. Comparison of inflammatory factors between the two groups ( x±s, pg/mL)

Table 5. Comparison of immune cell levels between the two groups ( x±s, %)

4 Discussion

The immune function of gastric cancer patients with chemotherapy is relatively low. T lymphocytes, NK cells and other immune cells can kill tumor cells, among which, T-lymphocyte mainly includes CD4 and CD8.Research shows that the CD4 value of peripheral blood in patients with digestive tract tumor is relatively low,and the CD8 value is relatively high[12]. This may be related to the inhibitive factor released by tumor cells in inhibiting the differentiation of T lymphocytes. Xu QX[13]compared the numbers of CD4, CD8 and NK cells in patients undergoing gastric cancer chemotherapy with healthy people, and found that the numbers of CD4, NK cells in patients undergoing gastric cancer chemotherapy decreased significantly, and CD8 increased significantly. There are some defects in the immune system of gastric cancer patients, and chemotherapy drugs can further damage the immune function of gastric cancer patients.

Infection is one of the most common complications of gastric cancer during chemotherapy, its occurrence and progress are related to the immune function of the patients. The immune function of gastric cancer patients undergoing chemotherapy is impaired, the secretion and maturation of neutrophils, platelets and leukocytes are decreased, and TNF-α and other endogenous thermogenic factors are induced[14]. TNF-α is an important proinflammatory factor, and produced by monocyte macrophage. High level TNF-α can promote the adhesion, migration and degranulation of neutrophils and macrophages by inducing neutrophil aggregation and regulating their proliferation,maturation and activation, and then stimulate monocytes and vascular endothelial cells to produce cytokines, leading to inflammatory damage[15].

IFN-γ is produced in activated T cells and NK cells. It mainly plays the role of anti-virus, inhibiting cell proliferation, activating macrophage sterilization activity,enhancing antigen-presenting ability, participating in inflammatory reaction, etc., and has non-specific inhibition function on invading virus[16]. The immune function of gastric cancer patients on chemotherapy is relatively low, the contents of CD4 and NK cells are reduced, and the level of IFN-γ is reduced, therefore, it is easy to induce infection. It can be seen that the deficiency of immune function in chemotherapy of gastric cancer can lead to the changes of TNF-α, IFN-γ and other inflammatory factors, and induce infection.

RhG-CSF can promote the production and maturation of leukocytes, and is the main drug for neutropenia after radiotherapy and chemotherapy. Reducing neutropenia is one of the main methods to prevent infection during chemotherapy. Although there is no consensus on whether rhG-CSF can prevent infection or not, most research results still support that rhG-CSF can reduce the incidence of granulocytopenia and infection after chemotherapy[17]. Therefore, rhG-CSF was selected as a positive control drug to prevent chemotherapy infection in this paper.

There is no relevant record of chemotherapy infection in gastric cancer in TCM literature. But according to its clinical manifestations, it can be classified as ‘consumption’ and ‘blood deficiency’[18].Chemotherapy patients are mostly at the advanced stage of gastric cancer, and often have deficiency of the spleen and stomach and deficiency of qi and blood.Chemotherapy drugs belong to the category of ‘poisons’in TCM, while chemotherapy is a process of ‘a(chǎn)ttacking poisons with poisons’. During this period, ‘poison’invades the body and further damages the spleen and stomach, causing spleen and stomach deficiency and insufficient generation of qi and blood[19]. If vital qi is severely damaged, the external pathogenic factors are more likely to invade the human body, and the clinical manifestations are mostly infection during the chemotherapy period. Therefore, weakness of the spleen and stomach and deficiency of qi and blood are the main pathogenesis. The treatment strategies are to fortify the spleen, harmonize the stomach, supplement qi and nourish blood.

Moxa-stick moxibustion is a moxibustion therapy. It acts on the surface of acupoints with mild and comfortable thermal stimulation. The characteristics of moxa-stick moxibustion are promoting circulation and supplementing by warming, mutually circulating and supplementing in order to support the vital qi and supplement the deficiency, warming and unblocking the meridians[20]. Zhongwan (CV 12) is the Front-Mu point of the stomach. It is often used in combination with the Back-Shu point of the stomach to treat stomach problems. Zusanli (ST 36) is the He-Sea point of the Stomach Meridian of Foot Yangming and the lower He-Sea point of the stomach. Moxibustion at this point can tonify the spleen and stomach, harmonize qi and blood and strengthen the body constitution. Sanyinjiao(SP 6) is a crossing point of the Spleen Meridian of Foot Taiyin, Liver Meridian of Foot Jueyin and Kidney Meridian of Foot Shaoyin. It acts to fortify the spleen,supplement qi, move qi, circulate blood and tonify the kidney. Pishu (BL 20) and Weishu (BL 21) are the Back-Shu points of the spleen and stomach. They are often used to treat spleen and stomach problems. The combination of the above five acupoints fortifies the spleen, tonify blood, harmonize the stomach, benefit qi,strengthen vital qi and remove pathogenic factors.

The results showed that the infection rate in the observation group was significantly lower than that in the control group (P＜0.05). The duration of infection and the duration of continuous use of antibiotics were also shorter in the observation group (both P＜0.05).After treatment, the leukocytes and granulocytes counts in the two groups increased significantly (all P＜0.05),especially in the observation group (both P＜0.05). After treatment, TNF-α and IFN-γ were improved in the two groups (all P＜0.05), and the levels of TNF-α and IFN-γ in the observation group were statistically different from those in the control group (both P＜0.05). After treatment, the numbers of CD4, CD8 and NK cells in the observation group improved significantly (all P＜0.05),but the changes in the control group were not significant (all P＞0.05). This suggests that moxa-stick moxibustion combined with rhG-CSF can significantly reduce the incidence and severity of chemotherapy infection in gastric cancer, increase the leukocytes and granulocytes counts, and regulate the levels of inflammatory factors, which may be related to the improvement of the patients’ immune function.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 1 July 2019/Accepted: 15 August 2019