Letter to the Editor: Response to “Advancing Integrative Oncology: Methodological Refinements in TCM-Informed Lifestyle Research for Chinese Patients With Cancer”

To the editor,

Thank you for sharing with us the letter to the editor titled “Advancing Integrative Oncology: Methodological Refinements in TCM-Informed Lifestyle Research for Chinese Patients with Cancer.” We appreciate that the authors reviewed our article, “Diet Habits, Smoking, and Alcohol Consumption among Chinese Patients with Cancer,” ¹ and acknowledged that our research provided new perspectives and valuable references for integrative oncology management. We also thank them for identifying several limitations of this research paper and would like to respond to some of their comments.

First, we acknowledge that using a single-item 0 to 3 scale to measure Traditional Chinese Medicine (TCM) belief (not at all, a little bit, somewhat, strongly) is a limitation, as was already noted in our original research article, “Belief in and Use of Traditional Chinese Medicine in Chinese Patients with Cancer Receiving Outpatient Care.” ² Many researchers have developed study-specific questionnaires tailored to Chinese cancer patients, incorporating cultural and clinical aspects of TCM. For example, Xin et al ³ assessed belief in TCM by asking, “In your opinion, is traditional Chinese medicine effective?” with possible responses of “Yes,” “No,” or “Not sure.” To the best of the author’s knowledge, no satisfactory TCM belief scale was available at the time our survey was conducted. In our original study, we developed our own questionnaire to assess not only belief, but also the use and perceived effectiveness of various TCM approaches, along with sociodemographic information. Our findings showed that belief in TCM was not associated with the actual use of TCM but did significantly shape lifestyle behaviors among Chinese patients after a cancer diagnosis. We support the idea of developing a specific, multidimensional TCM belief scale for future research, given that TCM belief is a potentially important factor influencing lifestyle behaviors in this population.

Regarding the second limitation, “merely recording frequency of yin-yang food intake,” we would like to clarify that the purpose of our secondary data analysis was to examine self-reported dietary habits, smoking, and alcohol consumption, and to explore influencing factors among patients with cancer. In China, the concept of yin and yang as complementary forces is widely understood, even among individuals who do not consult TCM practitioners when ill. As stated in our manuscript, “Increased consumption of balanced yin-yang food aligns with TCM principles emphasizing dietary balance to harmonize the body’s energies during cancer treatment. The shift reflects a cultural preference for TCM practices aimed at restoring equilibrium and enhancing well-being.” In the original survey, 84% of participants reported using Chinese herbs as adjunct therapy, with the majority of these herbs prescribed by oncologists practicing Western medicine. ² Many Chinese patients have their own understanding of balanced yin-yang food intake, shaped by cultural knowledge rather than professional consultation. ⁴ While TCM diet therapy prescribed by a TCM practitioner is highly personalized, taking into account constitution, health status, and symptoms, our study focused on the patients’ cultural perceptions and self-directed dietary behaviors. Given the strong influence of TCM beliefs on lifestyle behaviors identified in our study, we recommend collaboration between TCM practitioners and oncology physicians, nurses, and nutritionists to provide optimized, evidence-based dietary guidance.

We agree that many factors influence lifestyle behaviors after a cancer diagnosis. In this secondary data analysis, we were limited to the variables available in the original survey. While different studies have identified varying significant factors, a recent systematic review based on 71 quantitative and 52 qualitative studies summarized psychosocial determinants of lifestyle change after cancer diagnosis. ⁵ In this review, age, marital status, income, work-related factors, depression, anxiety, and others were identified as common influencing factors, many of which were included in our analysis. However, other common factors, such as environmental factors, social support, and self-efficacy, were not assessed in the original survey. We suggest that future research on lifestyle in cancer survivorship assess these psychosocial determinants above. Additionally, given the significant influence of Chinese cultural beliefs, such as TCM, identified in our study, we recommend including culture as a key factor in future research. Currently, there is no validated TCM-specific belief scale available. We therefore suggest developing such a scale. Alternatively, researchers may consider using existing Chinese cultural belief scales. For example, the Chinese Medical Belief Scale assesses 35 culturally rooted beliefs, including elements from TCM, Taoism, Confucianism, and Buddhism. ⁴

Once again, we thank Dr. Chen and Dr. Zhang for their thoughtful comments, which helped to further clarify both the limitations and significance of our paper. We also appreciate the opportunity provided by Integrative Cancer Therapy to respond to the methodological refinement suggestions.

Shan Liu, PhD, NP-C, RN, DipACLM
Adelphi University, Garden City, NY, USA