Abstract
Context
Traditional Chinese medicines (TCMs) have emerged as potential adjuvant therapies to treat non-small cell lung cancer. More direct comparative studies must be conducted among various oral TCMs.
Objective
This network meta-analysis evaluates the efficacy and safety of seven oral TCMs combined with chemotherapy in treating NSCLC.
Methods
The analysis included Zilongjin, Banmao, Hongdoushan, Huachansu, Kanglaite, Xihuang, and Pingxiao TCMs. Randomized-controlled trials (RCTs) were identified from the following databases: China National Infrastructure, Wanfang, PubMed, Embase, and the Cochrane Library up to April 2023. Two researchers independently extracted data.
Results
Sixty-eight RCTs (5,099 patients) were included. Compared to chemotherapy, Banmao capsules [odds ratio (OR) = 2.69, 95% confidence interval (CI) 1.96–3.69)] and Huachansu tablets [OR = 2.35, 95%CI (1.81, 3.05)] ranked in the top two in terms of increasing disease control rate. The two main TCMs to improve the objective response rate were Banmao capsules [OR = 3.49, 95%CI (2.17, 5.60)] and Zilongjin tablets [OR = 2.62, 95%CI (1.92, 3.57)]. Zilongjin tablets [OR = 3.47, 95%CI (2.14, 5.63)] and Huachansu tablets [OR = 3.30, 95%CI (1.65, 6.60)] were ranked as the top two in improving Karnofsky performance status. Hongdoushan capsules (SUCRA = 18.8%) and Banmao capsules (SUCRA = 19.8%) were the top two in reducing gastrointestinal toxicity. Zilongjin tablets (SUCRA = 18.9%) and Banmao capsules (SUCRA = 26.6%) were the top two to reduce liver and kidney toxicity. Hongdoushan capsules (SUCRA = 15.7%) and Huachansu tablets (SUCRA = 16.8%) ranked the top two in reducing thrombocytopenia. Banmao capsules (SUCRA = 14.3%) and Zilongjin tablets (SUCRA = 26.3%) were the top two decreasing leukopenia.
Conclusions
Combining oral TCMs with platinum-based chemotherapy has shown superior efficacy compared to platinum-based chemotherapy alone in treating NSCLC.
Introduction
Lung cancer, which accounts for 11.4% of all cancer diagnoses, is one of the most common cancers and the leading cause of cancer-related deaths at 18.0% (Mukherjee et al. Citation2020; Sung et al. Citation2021; Nie et al. Citation2021). Non-small cell lung cancer (NSCLC) represents up to 85% of lung cancer cases (Amatu et al. Citation2019; Duma et al. Citation2019). Many NSCLC patients are diagnosed at an advanced stage due to the subtle onset and rapid progression of the disease, often missing the opportunity for surgical intervention and facing a generally unfavorable prognosis. In China, the 5-year survival rate for lung cancer patients from 2012 to 2015 was approximately 19.7% (Zeng et al. Citation2018), compared to around 26.0% in the United States in 2022 (Miller et al. Citation2022). Standard treatment for NSCLC typically involves chemotherapy, which can lead to significant side effects such as gastrointestinal discomfort, blood toxicity, and neurotoxicity, adversely affecting the patients’ quality of life (Li et al. Citation2022). Therefore, it is urgent to explore and develop treatment strategies that improve efficacy, minimize adverse effects, and improve the overall well-being of NSCLC patients.
Traditional Chinese medicine (TCM) as adjuvant therapy in treating NSCLC has recently gained considerable attention. When combined with chemotherapy, TCM has shown promise in improving treatment efficacy and increasing the body’s immune response. Research suggests the potential of TCM to inhibit tumor recurrence and metastasis in NSCLC patients (Li et al. Citation2022). However, more direct comparative studies must be conducted among various oral TCMs. This study aims to systematically assess the efficacy and safety of seven commonly used oral TCMs in conjunction with chemotherapy drugs in treating NSCLC. The results will provide valuable information for clinicians in selecting appropriate oral TCMs for NSCLC patients undergoing chemotherapy.
Methods
Design
This systematic review adhered to the guidelines outlined in the Cochrane Handbook for Systematic Reviews (Cumpston et al. Citation2019) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Page et al. Citation2021). The protocol for this review was registered with the Open Science Framework (OSF, registration DOI 10.37766/inplasy2022.5.0129).
Search strategy
Randomized-controlled trials (RCTs) were identified through searches in the China National Knowledge Infrastructure Database (CNKI), the WanFang Database, PubMed, Embase, and the Cochrane Library. The most recent search was conducted in April 2023. The retrieval strategy involved using the following subject terms, which included a combination of Chinese and English search terms: ‘non-small cell lung cancer,’ ‘NSCLC,’ ‘lung cancer,’ ‘kanglaite,’ ‘zijinlong,’ ‘hongdoushan,’ ‘banmao,’ ‘xihuang,’ ‘huachansu,’ and ‘pingxiao.’ The searches were limited to articles published in English and Chinese.
Inclusion and exclusion criteria
The study included patients aged 18 years and older diagnosed with NSCLC and a Karnofsky Performance Status (KPS) ≥ 60. Patients who did not receive one of the seven oral TCMs were excluded. Reviews, meta-analyses, commentaries, case series, editorials, and letters were excluded. Studies for which the full text was not available were also excluded.
Interventions and control
The RCTs used the following design: the experimental group received a combination of Zilongjin tablets, Banmao capsules, Hongdoushan capsules, Huachansu tablets or capsules, Kanglaite capsules, Xihuang pills or capsules, or Pingxiao capsules, in addition to platinum-based chemotherapy for NSCLC. The control group received only platinum-based chemotherapy.
Outcomes
The following outcomes were assessed: complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD), objective response rate (ORR), disease control rate (DCR), KPS, gastrointestinal adverse effects, hepatotoxicity, nephrotoxicity, decreased red blood cell count (RBC), decreased platelet count (PLT), and decreased white blood cell count (WBC).
Data extraction
Two authors independently selected eligible studies based on prespecified selection criteria. The discrepancies were resolved by discussion with a third author. The data extracted included the first author’s name, publication year, participant characteristics (sex, age, tumor classification, tumor grading, and sample size), intervention characteristics (medication dose, medication time and frequency, and treatment course), outcomes, and adverse drug reactions.
Quality assessment
The risk of bias (ROB) in RCTs was assessed using the Cochrane Collaboration tool. This tool evaluates ROB in seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other sources of bias (Schakel et al. Citation2019). The ROB plot was created using Review Manager (RevMan, version 5.4, Cochrane, London, UK).
Statistical analyses
All statistical analyses were performed with Stata (version 15.1, Stata Corp LP, College Station, TX, USA). The weighted mean difference (WMD) was calculated for continuous variables to summarize their effects, while odds ratios (OR) were applied to dichotomous variables. Initially, a pairwise meta-analysis was performed using the DerSimonian and Laird method. This was followed by a network meta-analysis (NMA) conducted using the Stata mvmeta package (Chaimani et al. Citation2013). The REML Wald test was used to assess the presence of inconsistency (Veroniki et al. Citation2013). Treatment rankings were inferred using the surface under the cumulative ranking curve (SUCRA) method. Funnel plots were generated to assess the potential impact of small sample sizes. The results are reported with 95% confidence intervals (CIs), and statistical significance was established at p < 0.05.
Results
Study selection and characteristics
In the preliminary analysis, the search strategy identified 2,663 studies. After removing duplicates, 2,001 studies were screened based on titles and abstracts. During this phase, 1,895 irrelevant citations were excluded, resulting in 106 studies being selected for full-text review. Following the exclusion of reviews, meta-analyses, and studies that did not report outcome data, 68 studies were included ().
Figure 1. Flow chart of the literature review.
The 68 RCTs (Zhang et al. Citation2000; Li Citation2011; Wang Citation2019; Zhang Citation2015; Cao et al. Citation2016; Li et al. Citation2017; Ren et al. Citation2018; Wang and Cheng Citation2009; Guo et al. Citation2008; Du and Min Citation2018; Liu et al. Citation2018; Zhang and Niu Citation2019; Chen Citation2020; He et al. Citation2020; Long et al. Citation2013; Liang et al. Citation2016; Yan and Ye Citation2020; Wang Citation2018; Chi et al. Citation2021; Song et al. Citation2019; Fang Citation2022; Cai Citation2019; Duan Citation2016; Wu Citation2019; Wang and Wang Citation1999; Liu et al. Citation2000; Yang and Yi Citation2002; Shao et al. Citation2002; Tan and Li Citation2005; Zhao et al. Citation2007; Wan et al. Citation2007; Geng et al. Citation2009; Ming et al. Citation2010; Lan et al. Citation2011; Zhao et al. Citation2011; Wang and Li Citation2015; Wei and Xu Citation2017; Huang Citation2019; Wu et al. Citation2020; Li Citation2019; Chen et al. Citation2016; Pu et al. Citation2017; Guan and Li Citation2021; Miu et al. Citation2014; Li Citation2020; Shi Citation2017; Yu et al. Citation2018; Chen et al. Citation2018; Zhou et al. Citation2016; Liu Citation2014; Li et al. Citation2015; Li et al. Citation2015; Yi and Chen Citation2014; Chen et al. Citation2001; Guo et al. Citation2002; Wu and Zhang Citation2006; Shu et al. Citation2002; Yu and Jiang Citation2018; Zhang and Wei Citation2012; Yang et al. Citation2017; Shen et al. Citation2017; Li and Ma Citation2015; Chen et al. Citation2011; Shang Citation2016; Ma et al. Citation2017; Sun et al. Citation2015; Wang and Yan Citation2008; Wang Citation2009;) were published between 1999 and 2021. These studies had 5,099 patients, 2,588 in the experimental group and 2,511 in the control group. All participants were Chinese. Details of the included studies are presented in .
Table 1. Characteristics of the included studies.
Quality assessment
Among the 68 RCTs analyzed, 26 reported their randomization methods. However, 38 studies had unclear or inadequately reported methods of random sequence generation. Three studies categorized participants based on therapeutic schedules, while one group grouped them according to admission order. In particular, none of the studies reported allocation concealment or double-blinding. Despite this, all studies were assessed to have a low risk of incomplete outcome data and selective reporting. Fifteen studies were evaluated as having a low risk of other biases, but the remaining studies did not provide sufficient information. A detailed quality assessment can be found in .
Table 2. The result of quality assessment.
The results of the network meta-analysis of the disease control rate
DCR was reported in 61 studies, including eight different interventions and 4,550 patients. The network graph, as illustrated in , shows the relative amount of evidence available for these interventions, which include Zilongjin tablets, Banmao capsules, Hongdoushan capsules, Huachansu tablets, Kanglaite capsules, Xihuang pills, Pingxiao capsules, and chemotherapy. This graph highlights 61 direct comparisons among these treatments concerning their impact on DCR.
Figure 2. Network graph for disease control rate.
Relative effectiveness and uncertainty for all possible pairs of interventions can be presented using a league table. Compared to chemotherapy alone, the OR values of NMA for various treatments were as follows: Banmao capsules [OR = 2.69, 95% CI (1.96, 3.69)], Huachansu tablets [OR = 2.35, 95% CI (1.81, 3.05)], Kanglaite capsules [OR = 2.37, 95% CI (1.31, 4.28)], Hongdoushan capsules [OR = 2.33, 95% CI (1.39, 3.91)], Zilongjin tablets [OR = 1.95, 95% CI (1.45, 2.62)], Pingxiao capsules [OR = 1.80, 95% CI (1.38, 2.34)], and Xihuang pills [OR = 1.65, 95% CI (1.10, 2.49)]. According to the first column of the league table, all active interventions significantly increased DCR compared to chemotherapy alone (). It should be noted that a single league table can show results for up to two outcomes ().
Figure 3. Interval plot for the disease control rate in the network meta-analysis.
Table 3. Results of the network meta-analysis of disease control rate (DCR).
According to the NMA results, Banmao capsules were identified to have the highest probability of being the most effective intervention to increase DCR, with a SUCRA value of 84.5%. This was followed by Huachansu tablets, with a SUCRA value of 70.7% ().
Figure 4. Cumulative ranking probabilities for disease control rate in the network meta-analysis.
A comparison-adjusted funnel plot was generated to evaluate possible publication bias among included studies. The number of points of the same color in the plot represents pairwise comparisons of each original study. The symmetrical distribution of these points on both sides of the funnel plot suggests the absence of notable small-sample effects or publication bias. This symmetry in the funnel plot suggests the lack of significant sample size effects or publication bias ()).
Figure 5. Comparison-adjusted Funnel plot of intervention measures for disease control rate.
The results of the network meta-analysis of the objective response rate
ORR was reported in 60 studies that involved eight different interventions and 4,464 patients. The network graph, as shown in , illustrates the relative amount of evidence available for these eight interventions: Zilongjin tablets, Banmao capsules, Hongdoushan capsules, Huachansu tablets, Kanglaite capsules, Xihuang pills, Pingxiao capsules, and chemotherapy, about ORR. This graph includes 60 direct comparisons between these treatments.
Figure 6. Network graph for objective response rate.
Compared to chemotherapy alone, the OR values obtained from the NMA were as follows: Banmao capsules [OR = 3.49, 95% CI (2.17, 5.60)], Zilongjin tablets [OR = 2.62, 95% CI (1.92, 3.57)], Huachansu tablets [OR = 2.28, 95% CI (1.66, 3.14)], Hongdoushan capsules [OR = 2.27, 95% CI (1.10, 4.69)], Kanglaite capsules [OR = 1.91, 95% CI (1.05, 3.46)], Xihuang pills [OR = 1.74, 95% CI (1.00, 3.04)], and Pingxiao capsules [OR = 1.72, 95% CI (1.20, 2.47)]. The first column of the league table indicates that all active interventions significantly exceed chemotherapy to improve ORR (). presents a single league table that displays results for up to two outcomes.
Figure 7. Interval plot for the objective response rate in the network meta-analysis.
Table 4. Results of network meta-analysis for objective response rate.
Based on the NMA results, the treatments were ranked in the following order according to their effectiveness: Banmao capsules, Zilongjin tablets, Huachansu tablets, Hongdoushan capsules, Kanglaite capsules, Xihuang pills, Pingxiao capsules, and chemotherapy. Their SUCRA values were 92.9, 74.0, 60.7, 58.9, 43.6, 36.2, 32.8, and 0.9, respectively (). The funnel plot analysis for DCR revealed a largely symmetrical distribution, suggesting the absence of significant sample size effects or publication bias ().
Figure 8. Cumulative ranking probabilities for objective response rate in the network meta-analysis.
Figure 9. Comparison-adjusted Funnel plot of intervention measures for the objective response rate.
Results of the network meta-analysis of the Karnofsky performance status
KPS was reported in 29 studies involving 2,170 patients and investigated seven different interventions. A network graph was created to visually represent the relative amount of evidence available for each of the seven interventions: Zilongjin tablets, Banmao capsules, Huachansu tablets, Kanglaite capsules, Xihuang pills, Pingxiao capsules, and chemotherapy. Furthermore, this graph shows the 29 direct comparisons made about KPS ().
Figure 10. Network graph for karnofsky performance status.
Compared to chemotherapy alone, the OR values obtained from the NMA for various treatments were as follows: Zilongjin tablets [OR = 3.47, 95% CI (2.14, 5.63)], Huachansu tablets [OR = 3.30, 95% CI (1.65, 6.60)], Banmao capsules [OR = 3.10, 95% CI (1.36, 7.05)], Kanglaite capsules [OR = 2.78, 95% CI (1.22, 6.37)], Xihuang pills [OR = 2.58, 95% CI (1.33, 5.01)], and Pingxiao capsules [OR = 2.18, 95% CI (1.29, 3.69)] (). illustrates a single league table that can display results for up to two different outcomes.
Figure 11. Intervals plot for the Karnofsky performance status in the network meta-analysis.
Table 5. Results of network meta-anaysis for Karnofsky performance status.
Based on the NMA results, the interventions were ranked according to the SUCRA values as follows: Zilongjin tablets (74.1%), Huachansu tablets (69.3%), Banmao capsules (63.3%), Kanglaite capsules (56.5%), Xihuang pills (50.1%), Pingxiao capsules (36.5%), and chemotherapy (0.3%). Further details can be found in .
Figure 12. Cumulative ranking probabilities for Karnofsky performance status in the network meta-analysis.
The KPS analysis indicated that the funnel plot exhibited a predominantly symmetric pattern. Furthermore, no significant evidence of sample effect or publication bias was observed ().
Figure 13. Comparison-adjusted Funnel plot of intervention measures for Karnofsky performance status.
Subgroup analyses
Ranking probabilities of CR, PR, SD, and PD
For the complete response outcome, the efficacy of treatments was ranked as follows: Banmao capsules, Kanglaite capsules, Huachansu tablets, Pingxiao capsules, Hongdoushan capsules, Zilongjin tablets, Xihuang pills, and chemotherapy. Their SUCRA values were 81.9, 73.4, 61.2, 54.4, 48.3, 41.2, 35.1, and 4.5%, respectively ().
Figure 14. Cumulative ranking probabilities for CR, PR, SD, and PD in the network meta-analysis.
The efficacy ranking for the partial response outcome was as follows: Zilongjin tablets, Kanglaite capsules, Huachansu tablets, Hongdoushan capsules, Xihuang pills, Pingxiao capsules, Banmao capsules, and chemotherapy. The SUCRA values for these treatments were 76.3, 73.8, 69.2, 61.7, 46.4, 44.8, 25.6, and 2.2%, respectively ().
Regarding stable disease outcomes, the efficacy of treatments was ranked as follows: Zilongjin tablets, chemotherapy, Xihuang pills, Kanglaite capsules, Banmao capsules, Huachansu tablets, Pingxiao capsules, and Hongdoushan capsules. The SUCRA values were 92.6, 78.4, 55.4, 47.2, 45.3, 32.7, 26.3, and 22.0%, respectively ().
The efficacy ranking for the progressive disease outcome was: chemotherapy, Pingxiao capsules, Xihuang pills, Kanglaite capsules, Huachansu tablets, Hongdoushan capsules, Banmao capsules, and Zilongjin tablets. The SUCRA values were 99.2, 69.2, 68.3, 49.7, 46.2, 33.3, 20.6, and 13.6%, respectively ().
The funnel plot analysis for the CR, PR, SD, and PD outcomes suggests a largely symmetrical distribution, indicating no significant presence of sample size effect or publication bias ().
Figure 15. Comparison-adjusted Funnel plot of intervention measures for CR, PR, SD, and PD.
Adverse drug reactions
Chemotherapy-related adverse reactions primarily affected the blood system (thrombocytopenia, leukopenia, erythrocytopenia) and the gastrointestinal, liver, and kidney systems. According to the NMA results, the two interventions with the lowest incidence of leukopenia were Banmao capsules (SUCRA = 14.3%) and Zilongjin tablets (SUCRA = 26.3%) (). In terms of liver/renal toxicity, the interventions that showed the lowest incidence were Zilongjin tablets (SUCRA = 18.9%) and Banmao capsules (SUCRA = 26.6%) (). For erythrocytopenia, Banmao capsules (SUCRA = 0.6%) and Zilongjin tablets (SUCRA = 19.8%) had the lowest incidence rates (). Regarding gastrointestinal toxicity, Hongdoushan capsules (SUCRA = 18.8%) and Banmao capsules (SUCRA = 19.8%) were the least associated interventions (). Lastly, for thrombocytopenia, Hongdoushan capsules (SUCRA = 15.7%) and Huachansu tablets (SUCRA = 16.8%) exhibited the lowest incidence ().
Figure 16. Cumulative ranking probabilities for adverse reactions in the network meta-analysis.
The results of the adverse reaction analysis revealed that the funnel plot displayed a predominantly symmetric pattern. Furthermore, there was no significant evidence of a sample size effect or publication bias, as indicated by the funnel plot ().
Figure 17. Comparison-adjusted Funnel plot of intervention measures for adverse reaction.
Clustered ranking plot
Based on the efficacy index of DCR from SUCRA values and the safety index, the percentage of gastrointestinal adverse reactions, a network cluster ranking chart was generated for different interventions. The results indicated that the Banmao capsules exhibited the best efficacy and the least gastrointestinal adverse reactions, as illustrated in .
Figure 18. Clustered ranking plot of different intervention measures.
Heterogeneity
There was some heterogeneity in this study, particularly from a clinical perspective. We included patients diagnosed with various types of NSCLC, such as adenocarcinoma, squamous cell carcinoma, large cell carcinoma, and adenosquamous carcinoma. Furthermore, including disease stages ranging from I to IV and variations in patient age and disease duration contributed to this heterogeneity. However, the lack of detailed segmentation in the original literature limited our ability to conduct subgroup analyses.
Discussion
This study represents the first network meta-analysis to evaluate the efficacy of seven oral TCMs in conjunction with chemotherapy to treat NSCLC. The findings reveal that these seven oral TCMs can improve DCR and ORR. Furthermore, they alleviated clinical symptoms and improved the quality of life of NSCLC patients. These interventions show significant benefits in reducing liver and kidney toxicity, improving gastrointestinal toxicity, and reducing hematologic toxicity typically associated with chemotherapy.
Potential mechanisms
TCM has received significant recognition for its role in treating lung cancer. Its benefits go beyond merely reducing adverse reactions and enhancing the success rate of chemotherapy. TCM also has the potential to regulate immune function, induce apoptosis in tumor cells, reduce the risk of recurrence and metastasis, and ultimately prolong patient survival.
Kanglaite capsules, mainly made from Coix seed, contain active components such as Coix seed ester and alcohol extracts. These components are known for their anticancer effects, such as disrupting cancer cell DNA, inducing apoptosis, inhibiting cell proliferation, and impeding the formation of blood vessels that support tumors (Li Citation2011). Hongdoushan capsules, which contain active ingredients such as taxol and ginsenoside, effectively enhance the immune function of cancer patients, aiding in disease recovery. Furthermore, compounds such as glycyrrhizin in these capsules contribute to detoxification and liver protection, thus reducing the toxic side effects of drugs (Li et al. 2011). Xihuang capsules have been noted for their diverse therapeutic properties. These include inhibiting angiogenesis, reducing chemotherapy toxicity, preventing tumor metastasis, improving the hypercoagulable state associated with tumors, enhancing natural killer cell activity, and alleviating inflammation and pain (Du and Min Citation2018).
Banmao capsules show a specific affinity for lung cancer cells, inhibiting DNA and RNA synthesis. They are also known for increasing white blood cell counts and exhibiting antiviral and anti-inflammatory effects, all without myelosuppressive effects (Yan and Ye Citation2020). Pingxiao capsules enhance the body’s antibacterial capabilities, effectively inhibiting and eliminating the excessive proliferation of mutant cells. They strengthen white blood cells by enhancing phagocytosis and inhibiting tumor cell growth. Furthermore, they improve cellular and humoral immune functions, thus reducing the risk of recurrence and metastasis (Geng et al. Citation2009).
Huachansu capsules induce differentiation, proliferation, and apoptosis in tumor cells, exerting their anticancer effects by influencing tumor cell gene expression (Shi Citation2017). Zilongjin tablets block DNA synthesis and induce apoptosis in tumor cells, eliminating them. They also regulate cell dynamics to prevent tumor metastasis and modulate immune function by activating natural killer cells, T lymphocytes, and phagocytic cells (Zhang and Wei Citation2012).
Compared with other studies
In 2021, a network meta-analysis evaluated six commonly used oral Chinese patent medicines combined with platinum-based chemotherapy to treat NSCLC (Kong et al. Citation2021). Compared to their study, ours included a more comprehensive range of literature and more outcome indicators. Although there are similarities in our findings, particularly in the indicators of KPS and DCR, where Zilongjin tablets and cantharides showed the best effects, respectively, our study revealed inconsistencies in adverse reactions. For example, our analysis indicated that cantharides had the least gastrointestinal adverse reactions. Furthermore, we expanded our study to include additional efficacy indicators such as ORR, CR, PR, SD, and PD and the adverse effects on liver and renal toxicity.
Our study also differs from a previous meta-analysis published in 2020 (Yang et al. Citation2020). We included a wider variety of oral Chinese patent medicines, making our study more comprehensive and rich in content. Furthermore, as a network meta-analysis, our results offer more clinically relevant insights compared to that traditional meta-analysis.
Clinical implications and limitations
Adjuvant treatment of NSCLC includes a variety of TCM interventions. The insights gained from this study provide an evidence-based foundation for clinicians, helping them make informed decisions about selecting safe and appropriate TCM treatments. Furthermore, it is essential to acknowledge that patients may simultaneously present with multiple abnormal indicators in clinical practice. Therefore, choosing one drug to address one indicator and another to address a different indicator is insufficient. Instead, a comprehensive evaluation is necessary to devise an appropriate treatment plan that considers the multifaceted nature of the patient’s condition.
Our study has several limitations. First, the overall quality of the included studies was suboptimal. Many articles lacked detailed information on blinding and allocation concealment and don’t mention how patients were randomized, which could lead to implementation and measurement biases. Second, there was a disparity in the number of original studies available for each of the seven TCMs, which might introduce uncertainty in the ranking results. Third, the included patients varied in terms of disease progression (tumor classifications: adenocarcinoma, squamous cell carcinoma, large cell; tumor gradings: I-IV), treatment duration (ranging from 42 to 140 days), and medication regimens (differences in herb dosage and chemotherapy regimen). These variations could have influenced the outcomes and introduced potential biases. Fourth, our study was limited to articles in Chinese and English, raising the possibility of missing relevant studies in other languages, thus restricting the comprehensiveness of our findings. Future research should focus on conducting more high-quality studies to enhance our understanding of TCM in clinical practice. These studies should strive for rigorous design elements, such as large sample sizes, multi-center collaborations, randomized group assignments, allocation concealment, and blinding methods, to improve the robustness of the research.
Conclusions
Combining oral Chinese patent medicines with platinum-based chemotherapy has shown superior efficacy compared to platinum chemotherapy alone in treating NSCLC. The Zilongjin tablet has been particularly effective in improving patients’ quality of life. To improve DCR and ORR, the Banmao capsule and the Zilongjin tablet have shown better outcomes. The Zilongjin tablet has been effective in reducing gastrointestinal toxicity. Hongdoushan capsule and Banmao capsule have shown better results in mitigating liver and kidney toxicity. Zilongjin tablets and Banmao capsules have demonstrated significant advantages in reducing blood toxicity, highlighting their potential as effective adjunct treatments in NSCLC therapy.
Disclosure statement
Shusen Sun is an Associate Editor of this journal but was not involved in the peer review process, in line with journal protocol, COPE guidelines and current best practice. No other authors reported a conflict of interest.
Additional information
Funding
References
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