Table of Contents
- Key Points
- Why This Research Matters
- Understanding Cancer-Related Fatigue
- How the Study Was Conducted
- The 13 Therapies Compared
- Study Selection and Participants
- Quality and Risk of Bias
- Key Findings: Which Therapies Worked
- Ranking the Treatments: From Best to Least Promising
- Sensitivity and Subgroup Analyses: Do Results Hold Up?
- Clinical Implications: What This Means for Patients
- Study Limitations
- Recommendations for Patients
- Frequently Asked Questions
- Source Information
Key Points
- An analysis of 87 randomized controlled trials involving 7,028 cancer patients found that several TCM external therapies significantly eased cancer-related fatigue compared with usual care.
- Warming needle ranked as the most effective therapy (96.3% probability), followed by Chinese medicine foot bath (83.4%) and TCM emotional care (75.1%).
- Six therapies—moxibustion, foot bath, emotional care, acupoint injection, acupoint application, and warming needle—were also significantly more effective than sham controls.
- The overall certainty of the evidence was rated low, meaning the true effect may be substantially different from what the analysis suggests.
- These therapies are complementary and should not replace conventional cancer care; discuss any option with your oncology team first.
Why This Research Matters
Cancer is a major global health problem. The International Agency for Research on Cancer (IARC) reported about 20 million new cancer cases in 2022. Projections suggest this number will rise to 35 million by 2050.
Medical advances have steadily increased the number of cancer survivors. With more survivors comes a growing interest in improving their quality of life. Cancer and its treatment can cause many distressing symptoms. Among the most common and persistent is cancer-related fatigue (CRF).
Treating CRF is difficult. Commonly used drugs, such as psychiatric stimulants and hormones, have not shown significant benefits in randomized trials. Medication adherence is also poor. About half of patients with chronic conditions struggle to follow prescribed regimens, and many resist taking unnecessary medications.
This poor adherence has driven interest in complementary therapies. Traditional Chinese medicine (TCM) external therapies have gained attention as well-tolerated alternatives. They offer a holistic approach, lower side-effect profiles, and are non-invasive.
Understanding Cancer-Related Fatigue
CRF is a persistent, subjective feeling of physical, emotional, or cognitive exhaustion related to cancer or its treatment. It is far more intense than ordinary tiredness. Unlike normal fatigue, CRF is not relieved by rest. It disrupts daily living, work, social relationships, and mood, and it diminishes quality of life.
Crucially, CRF is very common:
- It affects about 40% of patients at diagnosis — about 4 in 10.
- During treatment, incidence reaches 62–85% — about 6 to 9 in 10 patients.
- Of those cases, 30–60% are moderate to severe — about 3 to 6 in 10.
- Long-term follow-up shows severe CRF affects approximately 30% of survivors — about 3 in 10.
CRF can also reduce a patient's tolerance to chemotherapy. It complicates treatment adherence and may lead patients to stop therapy entirely. All of these factors can negatively affect survival rates.
How the Study Was Conducted
This study is a systematic review and network meta-analysis (NMA). A network meta-analysis combines direct and indirect evidence. That means researchers can compare multiple treatments against each other even when no single study compared them head-to-head.
Researchers followed the PRISMA guidelines for reporting systematic reviews. The protocol was registered on PROSPERO, the international registry for systematic reviews (Registration No. CRD42023479194).
Two deviations from the registered protocol occurred:
- The protocol specified 13 external therapies, but the search included additional therapies that were not restricted to this list.
- The protocol specified only conventional controls, but trials with sham (fake) controls were also included.
These deviations added valuable insights into a broader range of therapies and into the placebo effect. However, they also increased heterogeneity (variability) in the findings, potentially affecting the precision of the effect estimates.
The search strategy
Researchers conducted a comprehensive search of eight databases: the Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Data, Chinese Biomedical Literature Database (CBM), and the VIP Chinese Science and Technology Journal Database.
The search covered literature published up to April 2025. Search terms were developed in both English and Chinese, using MeSH terms and free-text keywords. Reference lists of related studies were also manually checked.
Who was included
The review included randomized controlled trials (RCTs) that met strict criteria:
- Population: Adults aged 18 and older with a cancer diagnosis confirmed by tissue biopsy or cytology.
- Interventions: TCM external therapies such as acupuncture, acupressure, Chinese exercises (Tai Chi, Baduanjin, Qi Gong), transcutaneous acupoint electrical stimulation, moxibustion, auricular acupressure, foot bath, TCM emotional care, acupoint injection, acupoint application, auricular press needle, warming needle, and acupoint hot ironing.
- Comparisons: Usual care (standard medical care), waitlist, sham interventions, or different TCM external therapies.
- Outcomes: CRF scores measured by validated scales, such as the Brief Fatigue Inventory (BFI), Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F), and the Multidimensional Fatigue Symptom Inventory (MFSI).
Trials were excluded if they combined multiple TCM interventions (for example, acupuncture plus acupoint application). Studies with incomplete data, duplicates, insufficient intervention descriptions, or that were not published in English or Chinese were also excluded.
Two researchers independently screened studies and extracted data. Their agreement was excellent, with a kappa coefficient of 0.82. Disagreements were resolved by a third researcher.
Statistical methods
The analysis was performed with StataMP 17.0 software. Effect sizes were calculated using the standardized mean difference (SMD) and 95% confidence intervals (95% CI). For multi-arm trials, all relevant arms were integrated into the network. "Sham therapies" and "usual care" were treated as separate, independent comparison groups. This separation allowed researchers to evaluate placebo effects separately from standard care.
Researchers used the Confidence in Network Meta-Analysis (CINeMA) tool, which is based on the GRADE framework, to assess the certainty of evidence. CINeMA evaluates six domains: within-study bias, reporting bias, indirectness, imprecision, heterogeneity, and incoherence.
The 13 Therapies Compared
The review compared 13 distinct TCM external therapies. The list below shows the name and a plain-language description of how each one works:
- Acupuncture: Thin needles inserted into specific points on the body.
- Acupressure: Finger pressure applied to the same points, without needles.
- Traditional Chinese exercises: Mind-body movement practices, including Tai Chi, Baduanjin, and Qi Gong.
- Transcutaneous acupoint electrical stimulation (TEAS): Small electrical impulses delivered through electrodes on the skin at acupoints.
- Moxibustion: Burning dried mugwort (moxa) near the skin to warm acupoints.
- Auricular acupressure: Pressure applied to specific points on the ear.
- Chinese medicine foot bath: Soaking the feet in water containing Chinese herbal medicines.
- TCM emotional care: Psychological and emotional support based on TCM principles.
- Acupoint injection: Injecting a small amount of medication or herbal extract into an acupoint.
- Acupoint application: Applying herbal preparations to acupoints on the skin.
- Auricular press needle: Small needles or seeds taped to ear acupoints for ongoing stimulation.
- Warming needle: A technique combining acupuncture and moxibustion — a needle is inserted and moxa is burned on the handle to warm it.
- Acupoint hot ironing: Applying heat or heated herbal packs to acupoints.
All these approaches share a core TCM principle: regulating the flow of Qi and Blood, balancing Yin and Yang, and unblocking meridians. In TCM theory, fatigue results from disruptions in these systems.
Study Selection and Participants
The initial search produced 6,590 records. After removing 1,067 duplicates, 5,523 records were screened by title and abstract. Of those, 5,402 were excluded.
The full text of the remaining 121 articles was assessed. Thirty-four studies were excluded because they were not RCTs, their outcome measures did not meet requirements, or their intervention descriptions were insufficient.
Ultimately, 87 randomized controlled trials were included in the review. Together they involved 7,028 participants across ten countries. Most of the studies were conducted in China.
The included studies covered a diverse range of cancers:
- Mixed cancer types: 27 studies
- Lung cancer: 16 studies
- Breast cancer: 14 studies
- Gastrointestinal and colorectal cancers: 14 studies
- Gynecological cancers: 5 studies
- Lymphomas and leukemias: 3 studies
- Specific localized cancers (such as prostate, thyroid, and oral cancers): remaining studies
The number of trials for each therapy varied considerably. Moxibustion was the most studied, with 26 trials. Acupuncture had 13 trials, TEAS had 8, and acupressure had 6. Tai Chi (4), Baduanjin (5), and Qi Gong (7) were grouped as traditional Chinese exercises. Auricular acupressure and acupoint application each had 5 trials, while Chinese medicine foot bath had 3. TCM emotional care had 2 trials. Acupoint hot ironing, acupoint injection, and auricular press needle each had only 1 trial.
Common measurement tools included the Brief Fatigue Inventory (BFI), the Revised Piper Fatigue Scale (RPFS), the Piper Fatigue Scale (PFS), the fatigue subscale of the EORTC QLQ-C30 quality-of-life questionnaire, and the Multidimensional Fatigue Inventory (MFI).
Quality and Risk of Bias
Each study's risk of bias was assessed using the revised Cochrane Risk of Bias tool for randomized trials (ROB 2.0). This tool evaluates five domains: the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result.
The results were concerning. More than half of the studies (55.2%) raised "some concerns." The biggest issue was blinding — 74.7% of trials did not describe blinding of participants and personnel. Blinding is genuinely difficult in TCM trials. Patients cannot easily be blinded to whether they are receiving acupuncture, moxibustion, or a foot bath.
Just over a quarter (28.7%) of studies were rated "low risk" overall. Meanwhile, 16.1% were rated "high risk," mainly due to selective reporting or measurement bias. These methodological shortcomings directly affect the internal validity of the trials. They also contribute significantly to the overall low certainty of the synthesis evidence.
Key Findings: Which Therapies Worked
Researchers first ran standard pairwise meta-analyses of all direct comparisons. These confirmed that most TCM external therapies were significantly more effective than usual care for reducing CRF.
In direct comparisons between treatments, warming needle was significantly superior to acupuncture, acupressure, traditional Chinese exercises, TEAS, and auricular acupressure. Moxibustion was also significantly superior to acupuncture, traditional Chinese exercises, and TEAS. Other comparisons did not reach statistical significance.
The network meta-analysis then compared all therapies simultaneously. The analysis showed that ten therapies significantly relieved CRF compared with usual care (P < 0.05). The numbers below represent the standardized mean difference (SMD). A negative SMD means lower (better) fatigue scores. A larger negative number indicates a stronger effect:
- Warming needle: SMD = -4.18 (95% CI: -6.53 to -1.84)
- Chinese medicine foot bath: SMD = -2.62 (95% CI: -4.10 to -1.13)
- Acupoint injection: SMD = -2.41 (95% CI: -4.82 to -0.01)
- TCM emotional care: SMD = -2.19 (95% CI: -3.81 to -0.57)
- Moxibustion: SMD = -1.88 (95% CI: -2.33 to -1.43)
- Acupoint application: SMD = -1.56 (95% CI: -2.58 to -0.55)
- Traditional Chinese exercises: SMD = -1.11 (95% CI: -1.64 to -0.57)
- Acupressure: SMD = -1.06 (95% CI: -1.97 to -0.16)
- Acupuncture: SMD = -1.02 (95% CI: -1.72 to -0.31)
- Transcutaneous acupoint electrical stimulation (TEAS): SMD = -0.93 (95% CI: -1.73 to -0.13)
Notably, six therapies — moxibustion, Chinese medicine foot bath, TCM emotional care, acupoint injection, acupoint application, and warming needle — were also significantly more effective than the sham control group (P < 0.05). This is important. It suggests their benefits go beyond a placebo effect.
Is the difference big enough to matter clinically?
A statistically significant result is not always clinically meaningful. The authors therefore checked whether the observed changes exceeded the minimal clinically important difference (MCID) — the smallest change a patient would notice as a real improvement.
Established MCIDs vary by scale:
- BFI (scored 0–10): MCID of 1.0–2.0 points
- PFS (scored 0–10): MCID of 1.0 point
- FACIT-F (scored 0–52): MCID of 3.0–5.0 points
The authors converted SMDs to raw score changes using the formula: raw score change = |SMD| × pooled standard deviation. Most of the significant effects exceeded their corresponding MCIDs. For example, warming needle's SMD of -4.18 and Chinese medicine foot bath's SMD of -2.62 both corresponded to changes beyond the MCID thresholds. This indicates practical, meaningful benefit for patients, not just a statistical artifact.
Ranking the Treatments: From Best to Least Promising
Researchers used the surface under the cumulative ranking curve (SUCRA) to rank each therapy's probability of being the best option. Values near 100% indicate the highest probability of effectiveness. The full ranking was:
- Warming needle: 96.3%
- Chinese medicine foot bath: 83.4%
- TCM emotional care: 75.1%
- Acupoint injection: 75.1%
- Moxibustion: 73.2%
- Acupoint application: 60.9%
- Auricular acupressure: 48.3%
- Traditional Chinese exercises: 46.5%
- Acupressure: 39.5%
- Acupuncture: 35.0%
- TEAS: 34.6%
- Acupoint hot ironing: 32.4%
- Auricular press needle: 29.4%
- Usual care: 10.5%
- Sham interventions: 9.8%
Warming needle was identified as the intervention with the highest cumulative probability of effectively alleviating CRF. Usual care and sham interventions ranked at the bottom, which adds credibility to the model.
Sensitivity and Subgroup Analyses: Do Results Hold Up?
The authors ran several checks to test the stability of their findings.
Sensitivity analysis
Small studies (sample size of 30 or fewer) were excluded to see whether they skewed the results. The ranking trend stayed consistent with the full analysis. Warming needle remained the optimal intervention. Chinese medicine foot bath and TCM emotional care still ranked highly. Weaker interventions, such as auricular press needle and acupoint hot ironing, did not reverse their rankings.
Subgroup analysis by cancer type
Researchers also analyzed subgroups by cancer type: breast cancer, colorectal cancer, gastric cancer, lung cancer, and mixed cancers. Within each subgroup, there were slight variations in ranking. For example, in the breast cancer subgroup, acupressure ranked first (79.2%), followed by moxibustion (70.0%) and acupoint application (63.8%). However, the overall trend in each cancer subgroup remained consistent with the full-sample analysis.
This consistency suggests the main results are reasonably stable across different patient populations.
Clinical Implications: What This Means for Patients
This review provides the first comprehensive network comparison of 13 TCM external therapies for CRF. For clinicians and patients, it offers a clear, evidence-based ranking of options to consider.
The standout finding is warming needle therapy. It combines two traditional techniques — acupuncture and moxibustion — in one treatment. Its SUCRA value of 96.3% made it the top-ranked therapy in this analysis, although the authors say that effect sizes this unusually large (SMD = -4.18) likely reflect differences between fatigue scales and small-study effects rather than a realistic clinical size of benefit. Patients who wish to explore TCM external therapies may reasonably ask their health care team about warming needle first.
Chinese medicine foot bath (83.4%) and TCM emotional care (75.1%) also ranked highly. These may be particularly attractive options for patients who prefer gentle, non-invasive approaches without needles.
Importantly, several therapies beat sham controls. This matters because it reduces the chance that the benefits are purely a placebo response. Moxibustion, foot baths, emotional care, acupoint injection, acupoint application, and warming needle all outperformed sham treatment on fatigue scores.
The effects also appear to be clinically meaningful, not merely statistically significant. For most effective therapies, the improvement exceeded the minimal change patients can perceive. That translates into real-world improvements in energy, daily function, and quality of life.
Study Limitations
Readers should interpret these findings carefully. The CINeMA assessment rated the overall certainty of the evidence as low. A low-certainty rating means the true effect may be substantially different from what the analysis suggests.
Several specific limitations are worth noting:
- Blinding difficulties: Nearly 75% of trials lacked blinding of participants and personnel. This is hard to avoid in TCM studies but can inflate results.
- Risk of bias: Only 28.7% of studies were rated low risk. Over 16% were rated high risk due to selective reporting or measurement problems.
- Possible publication bias: The funnel plot analysis and Egger's test suggested publication bias (P < 0.05). Studies with negative results may not have been published, which could overestimate benefits.
- Protocol deviations: Including extra therapies and sham controls increased heterogeneity, potentially affecting the precision of effect estimates and complicating direct comparisons.
- Geographic concentration: Most studies were conducted in China, which may limit generalizability to other health care settings.
- Geographic concentration of small trials: Several therapies, such as warming needle, acupoint injection, and acupoint hot ironing, were supported by very few studies.
- Language restriction: Only English and Chinese publications were included, although these represent most research in this field.
Because confidence in the evidence is low, the authors stress that results should be interpreted with great caution. Further validation through additional, high-quality clinical trials is required.
Recommendations for Patients
If you are living with cancer-related fatigue, here are practical, evidence-based steps to consider:
- Talk to your oncology team first. Always discuss any complementary therapy with your doctor or nurse before starting. Some therapies may interact with cancer treatments or be unsafe in certain situations, such as low platelet counts or infections.
- Consider warming needle therapy. Based on this analysis, it ranked as the most effective TCM external therapy for CRF. Ask whether a qualified, licensed practitioner experienced in this technique is available near you.
- Explore foot baths and emotional care if needles are not for you. Chinese medicine foot bath and TCM emotional care ranked second and third, and both are gentle and non-invasive.
- Remember that moxibustion has the most research support. It was studied in 26 of the 87 trials, more than any other therapy, and ranked fifth overall.
- Do not replace conventional cancer care. These therapies are complementary — they work alongside standard treatment, not instead of it.
- Keep tracking your fatigue. Use simple tools like a 0–10 fatigue scale to record your energy levels before and during therapy. This helps you and your clinician judge whether a treatment is helping.
- Consider joining a clinical trial. Given the low certainty of current evidence, well-designed trials are needed. Participation can give you access to promising therapies while helping future patients.
Ultimately, the best approach to CRF is personalized. What works for one patient may not work for another. Use this research as a guide, weigh the options with your care team, and choose a therapy that fits your preferences, your cancer type, and your overall health.
Frequently Asked Questions
What is cancer-related fatigue (CRF)?
CRF is a persistent, subjective feeling of physical, emotional, or cognitive exhaustion related to cancer or its treatment. It is far more intense than ordinary tiredness and is not relieved by rest. It disrupts daily living, work, social relationships, and mood, and it diminishes quality of life. It affects about 40% of patients at diagnosis and 62–85% during treatment.
What is warming needle therapy and how does it work?
Warming needle is a technique combining acupuncture and moxibustion. A needle is inserted into an acupoint, and moxa (dried mugwort) is burned on the handle to warm it. In the analysis, it had the highest probability (96.3%) of effectively alleviating cancer-related fatigue, with a large effect size. The evidence certainty was low, so discuss it with your oncology team.
Are TCM external therapies safe for cancer patients?
The article does not provide specific safety data. It notes that TCM external therapies are generally well-tolerated, non-invasive, and have lower side-effect profiles. However, it advises talking to your oncology team first, as some therapies may interact with cancer treatments or be unsafe in certain situations, such as low platelet counts or infections.
What does a SUCRA value of 96.3% mean?
SUCRA stands for surface under the cumulative ranking curve. It estimates the probability that a treatment is the most effective option in the network. A value near 100% indicates the highest probability. Warming needle had a SUCRA of 96.3%, meaning it had the highest probability of being the most effective therapy for cancer-related fatigue in this analysis.
Can TCM external therapies replace conventional cancer treatment?
No. These therapies are complementary — they work alongside standard treatment, not instead of it. The article explicitly states: 'Do not replace conventional cancer care.' Always discuss any complementary therapy with your doctor or nurse before starting, as some may interact with cancer treatments or be unsafe in certain situations.
What should I do if I want to try a TCM external therapy for my fatigue?
First, talk to your oncology team. They can advise on safety and potential interactions. If appropriate, ask about warming needle, which ranked highest in this analysis, or gentler options like Chinese medicine foot bath or TCM emotional care. Keep tracking your fatigue with a 0–10 scale to see if the therapy helps. Consider joining a clinical trial.
When should a patient with cancer-related fatigue seek a second opinion about trying TCM external therapies like warming needle?
A second opinion is reasonable before starting any TCM external therapy for cancer-related fatigue, because the overall certainty of this evidence is low and most trials were conducted in China with few studies per therapy. Discuss options with your oncology team first, since some therapies may be unsafe with low platelet counts or infections. A second opinion can help weigh warming needle, foot bath, or emotional care against your cancer type, preferences, and current treatment. Diagnostic Detectives Network provides independent expert second opinions.
Source Information
This patient-friendly article is based on peer-reviewed research published in Frontiers in Oncology.
- Original article title: Efficacy of traditional Chinese medicine external therapy on cancer-related fatigue: a systematic review and network meta-analysis.
