Kangai Injection, a Traditional Chinese Medicine, Improves Efficacy and Reduces Toxicity of Chemotherapy in Advanced Colorectal Cancer Patients: A Systematic Review and Meta-Analysis

Objective To systematically review whether the Kangai injection (KAI), which is commonly used traditional Chinese medicine, can improve the clinical efficacy of chemotherapy and relieve adverse reactions of chemotherapy in advanced colorectal cancer (CRC) patients. Methods A comprehensive literature search was performed in three English and three Chinese electronic databases until March 2019. The literature was screened by EndNote X8 and data were analysed by RevMan5 and Stata12.0. Results This meta-analysis consisted of twenty-eight studies, of which 2310 cases were reported. Among the 2310 cases, 1207 cases were treated with KAI combined with chemotherapy and 1103 cases were treated with chemotherapy alone. The results showed that KAI combined with chemotherapy significantly improved tumor response (Risk Ratio (RR) =1.32; 95% confidence interval (CI): 1.22-1.43; p<0.00001); Karnofsky performance status (KPS score) (Risk Ratio (RR) =1.48; 95% CI: 1.36-1.60; p<0.00001); reduced adverse drug reactions (ADRs) such as nausea and vomiting (OR =0.31; 95% CI: 0.24-0.41; p <0.00001), diarrhea (OR =0.36; 95% CI: 0.25-0.52; p<0.00001), leukopenia (OR =2.97; 95% CI:2.27-3.88; p<0.00001), thrombocytopenia (OR =0.53; 95% CI: 0.38-0.74; p<0.0002), liver dysfunction (OR =0.29; 95% CI: 0.20-0.44; p<0.00001), neurotoxicity (OR =0.51; 95% CI: 0.36-0.71; p = 0.0004); increased immune function (CD3+: MD=6.34; 95% CI: 5.52-7.16; p < 0.00001, CD4+: MD=-5.99; 95% CI: 5.20-6.78; p < 0.00001; and CD4+/CD8+: MD=0.34; 95% CI: 0.14-0.54; p < 0.0009), and prolonged survival time (OR =1.77; 95% CI: 1.25-2.50; p = 0.001). Renal dysfunction caused by chemotherapy was not affected by KAI treatment (Odds Ratio (OR) =0.53; 95%IC: 0.25-1.12; p = 0.10). Conclusion KAI can increase clinical effectiveness, improve quality of life, alleviate ADRs, and prolong survival time in advanced colorectal (CRC) patients receiving chemotherapy.


Introduction
Colorectal cancer (CRC), including colon and rectal cancers, is the third most common diagnosed malignancy and the second most common cause of cancer-related deaths in the world [1]. Over 1.8 million new CRC cases and 881,000 deaths were estimated to occur in 2018 [1]. The incidence and mortality rates of CRC have been increasing in China and have become a major public health problem in the 2 Evidence-Based Complementary and Alternative Medicine metastatic CRC treatment, many factors, such as lack of selectivity for tumor cells, insufficient drug concentration in tumor tissues, drug resistance, and systemic toxicity, affect the efficacy of chemotherapy and quality of patients life [5,13]. Therefore, a more effective therapy is still necessary and urgent.
Traditional Chinese medicine (TCM), which is a promising alternative therapy for the treatment of CRC, has evolved over thousands of years in China and has been known to prevent tumorigenesis, minimize toxicity, reinforce the treatment effect, improve quality of life, and revert multidrug resistance [14][15][16][17]. Increasing evidence [18][19][20][21] has demonstrated that TCM combined with chemotherapy could significantly increase efficacy, improve quality of life, and alleviate the toxicity of chemotherapy. The Kangai injection (KAI), a TCM, consisting of Ginseng, Astragali radix and Kushen, has been widely applied as auxiliary treatment for multiple tumor in the clinic, and it has been demonstrated that it can enhance immunity, strengthen the effect of chemotherapy, improve quality of life, and alleviate adverse drug reactions (ADRs) [22,23]. However, KAI as an adjuvant drug to increase efficacy, improve quality of life, and alleviate the ADRs of CRC patients receiving chemotherapy has not been systemically reviewed thus far.
Therefore, a systematic review and meta-analysis were conducted to compare the clinical effective rate, quality of life, ADRs, and survival time of patients who were treated with KAI combined with chemotherapy versus those who were treated with chemotherapy alone.

Methods
. . Databases and Search Strategy. Various databases were searched from the database inception to March 2019, including English databases PubMed, the Cochrane Library, Web of Science and the Chinese databases China National Knowledge Infrastructure (CNKI), the VIP information resource integration service platform (VIP), and Wanfang Data knowledge service platform (Wanfang Data). The English terms used were ("colorectal cancer" OR "colorectal carcinoma" OR "carcinoma of large intestine" OR "colorectal neoplasm") AND ("kangai injection" OR "kang'ai injection" OR "traditional Chinese medicine" OR "Chinese medicine" OR "Chinese herbs") AND ("chemotherapy" OR "chemotherapeutic" OR "infusion chemotherapy" OR "chemical therapy" OR "chemotherapy combined"). The Chinese terms used were "kangai zhusheye", "kangai zhusheji", "zhongyao", "dachangai", "jiechangai", "jiezhichangai", "zhichangai" and "lianhehualiao". Two reviewers (Siqi Huang and Shaofan Zhang) independently retrieved articles from the databases using the same search terms. All identified literatures were screened after duplication checking with EndNote X8.1.
. . Inclusion Criteria. Included studies met the following criteria: (1) patients were diagnosed and confirmed as advanced CRC; (2) randomized controlled trial (RCT); (3) KAI was the only Chinese patent medicine used in RCTs; (4) KAI combined with chemotherapy treatment served as the experimental group, and chemotherapy treatment alone served as control group; (5) two or more of the following outcomes were measured: clinical effective rate, performance status (the Karnofsky performance scale, KPS), ADRs including nausea and vomiting, diarrhea, leukopenia, thrombocytopenia, liver dysfunction, renal dysfunction, peripheral neuropathy, and survival time.
. . Exclusion Criteria. Studies were excluded based on the following criteria: (1) reviews, meeting abstracts, and animal experiments; (2) the clinical stage of CRC was not advanced stage or was not clear; (3) patients had other tumors in addition to CRC; (4) treatment was combined with other traditional Chinese herbs; (5) incomplete or missing data; (6) the presence of less than two of the abovementioned outcomes.
. . Quality Assessment and Data Extraction. The quality of the included studies was evaluated according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions [24]. Selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome data), attrition bias (incomplete outcome data), reporting bias (selective reporting), and other bias were assessed according to the criteria of the Cochrane Handbook for Systematic Reviews of Interventions. The three biases of judgment were low risk, high risk, and unclear. Two reviewers (PengJi Yi and PanPan Xu) independently screened and extracted data from the texts. Any disagreements were ultimately resolved by two senior authors (Dan Mao and Weijun Peng). The following information was extracted: authors, year of publication, median age, sample size, gender, study design, KAI, details of intervention, and outcomes (tumor response, KPS, ADRs, and so on).
. . Statistical Analysis. (1) All the meta-analyses were performed using the Cochrane Collaboration software (RevMan 5.3). (2) The Odds Ratio (OR) or the Risk Ratio (RR) was used to analysis dichotomous variables such as clinical efficacy, KPS, and ADRs. If the 95% confidence interval (CI) did not include the value 1, the OR or RR point estimate was considered statistically significant at the p value less than 0.05. The weighted mean difference (WMD) was used to analysis continuous variables. If the 95% confidence interval (CI) did not include the value 0, the WMD point estimate was considered statistically significant at the p value less than 0.05. (3) The heterogeneity of the data assessed by the Chi 2 test and I 2 test. The combined data were considered as having heterogeneity if p < 0.1 or I 2 > 50% and a random-effects model was used; otherwise, a fixed-effects model was used. Sensitivity was used for the heterogeneity. (4) Begg's test and funnel plot analyses were used to determine the publication bias of articles by Stata12.0. A two-tailed p value less than 0.05 was considered significant.

Results
. . Search Results and Study Characteristics. A total of 739 publications were identified using the predefined search Evidence-Based Complementary and Alternative Medicine 3 strategy through several electronic databases. After excluding duplicates by EndNote X8, 670 studies were selected for analysis of the title and abstracts, and 43 studies were selected for through text reading. Fourteen studies did not meet the inclusion criteria or met the exclusion criteria: 5 articles included other tumors in addition to CRC; 3 articles included clinical stages of CRC that were not advanced stage; 1 article included other Chinese medicine; and 5 articles had no target outcomes. Finally, twenty-eight studies  were identified to meet the inclusion criteria. In this study, there were a total of 2310 cases, including 1207 cases for chemotherapy combined with KAI and 1103 cases for chemotherapy alone (Figure 1). The baseline characteristics for each study are shown in Table 1.
. . Risk of Bias. The quality of the included studies was generally low. Only eleven studies described the special randomization method, although all studies mentioned the random sequence generation. Four of the twenty-eight studies mentioned allocation concealment. One study provided information about the blinding of participants and personnel, blinding of outcome assessment, and selective reporting. The risk of bias is shown in Figures 2 and 3.
. . . Adverse Drug Reactions. Two stages of nausea and vomiting were reported in these studies. As for toxicity grades III-IV of nausea and vomiting, seven trails [32-35, 42, 43, 45] including 658 cases were assessed. No heterogeneity was found (Chi 2 =1.87, P = 0.87; I 2 = 0%), so fixed-effect model was applied to analyse the data. The results showed that KAI can alleviate III-IV nausea and vomiting caused by chemotherapy, despite the effect which was moderate (Odds Ratio (OR) =0.19; 95%CI: 0.08-0.41; p<0.00001) (Figure 6 The fixed-effect model was applied to analyse the data (Chi 2 =15.74, P = 0.40; I 2 = 5%). The results indicated that there was a statistically significant difference between the two groups and KAI combined with chemotherapy can significantly alleviate nausea and vomiting when compared with chemotherapy alone (Odds Ratio (OR) =0.31; 95%CI: 0.24-0.41; p<0.00001) (Figure 6(b)). No publication bias was detected by Begg's test (p = 0.594) (Figure 6(c)).
Nine studies [25-28, 30, 32, 34, 36, 40] that assessed 735 patients (368 patients in the experimental group and 367 patients in the control group) reported diarrhea. The fixed-effect model was applied to analysis because there was no heterogeneity (Chi 2 =9.14, p = 0.33; I 2 = 12%). The results indicated that there was a statistically significant difference between the two groups and KAI combined with chemotherapy notably improved diarrhea compared with chemotherapy alone (Odds Ratio (OR) =0.36; 95% CI: 0.25-0.52; p<0.00001) (Figure 7). No publication bias was detected by Begg's test (p = 0.864).
. . . Survival Rate. In this meta-analysis, five studies [29,37,45,47,52] involving 511 participants reported the one-year survival rate. A fixed-effects model was used to analyse the data due to no heterogeneity (Chi 2 =1.90, p = 0.75; I 2 = 0%). The results indicated that there was a statistically significant

Discussion
CRC is one of the most common malignancies in the world [3]. More than 50% patients already entered end-stage when diagnosed with CRC and lost the chance of surgery [10]. Despite advances in treatment modalities, the adverse reactions like bone marrow suppression, gastrointestinal reactions, and multidrug resistance are still widespread and seriously affect cancer patient's quality of life even end treatment [10,53]. TCM especially Chinese herbs medicines, as an important component of complementary and alternative medicine, has evolved over thousands of years in China with its own unique system of theories, diagnostic, and therapies [54]. KAI, a typical anticancer injection of TCM formula, mainly consists of ginseng, astragali radix, and matrine. (1) The major effective ingredients of Ginseng are Ginsenoside (Ginsenoside Rg , Ginsenoside Rb , Ginsenoside Rg , and Ginsenoside Rf ) and Ginseng Polysaccharides; these ingredients can improve immune functions and increase white blood cell (WBC) count after chemotherapy. (2) The major active ingredients of astragali radix is the root of the Leguminous Plant Astragalus, which has inhibitory effect on tumor cell proliferation and induces apoptosis. (3) Matrine and oxymatrine, two kinds of alkaloid form Kushen, have pharmacological activities to selectively kill tumor cells and inhibit tumor growth by changing the molecular sequence of the nucleic acids in cells [23,55].
Accumulating clinical evidence demonstrated that KAI has played an important role in cancer therapy which can enhance the effect, improve quality of life, strengthen immune function, and reduce adverse reactions. A metaanalysis systematically evaluated the efficacy and safety of KAI combined with chemotherapy for treatment of breast cancer in 2018, and the result showed that KAI combined with chemotherapy for treating Chinese breast cancer can improve quality of life and minimize the adverse reactions [23]. A meta-analysis [56] and a randomized controlled trial [22] evaluated the efficacy and safety of KAI combined with chemotherapy for non-small-cell lung cancer (NSCLC), and the result demonstrated that KAI can enhance the therapy effect, improve quality of life, and reduce reverse reactions when combined with chemotherapy.
To the best of our knowledge, this study was the first time to systematically evaluate the synergistic and detoxifying effects of KAI therapy on advanced CRC patients receiving chemotherapy. This meta-analysis of twenty-eight RCTS including 2310 cases comparing the efficacy and safety of KAI combined with chemotherapy and chemotherapy alone.
Our results suggested that KAI plays an important role in enhancing efficacy, improving quality of life, alleviating adverse drug reaction (ADRs), strengthening immune function, and prolonging survival time of CRC patients receiving chemotherapy.
The following limitations of this meta-analysis must be concerned. First, although we searched the PubMed, Web of Science, and the Cochrane Library databases, all of the included studies and all the subjects in the studies were   Chinese. Further research is needed to assess the efficacy of KAI in other populations. Second, the quality of the studies included in our meta-analysis was poor. Although most trials performed randomization, four studies referred to allocation concealment, and only one was a double-blinded study. Moreover, all trials were carried out at single a centre.
Third, publication bias was found in one of outcomes (KSP), so the results should be interpreted with caution. Fourth, the heterogeneity of the level of CD8 + and the ratio of CD4 + /CD8 + were observed to be high. Sensitivity analysis did not eliminate heterogeneity. The high heterogeneity might be due to differences in sample size, patient age, tumor Evidence-Based Complementary and Alternative Medicine 11 Figure 9: Forest plot and meta-analysis of thrombocytopenia.  stage and grade, difference doses of KAI, and other factors among the studies. Finally, although the doses of KAI in most studies were the same (40 ml/day), there were still differences (50 ml/day, 60 ml/day). Large doses may favour better results which may result in publication bias.

Conclusion
KAI combined with chemotherapy can improve the quality of life, enhance clinical effectiveness rate of chemotherapy, and reduce the chemo-induced toxicity of chemotherapy   14 Evidence-Based Complementary and Alternative Medicine treatment for advanced colorectal cancer patients. However, the outcomes were evaluated in a purely Chinese population, and the long-term, high-quality studies with a large sample size are needed to confirm the efficacy and tolerability of KAI in other populations.