How can moxibustion help you? What the research says

During moxibustion, a trained therapist burns an herb to apply heat close to the skin at specific points, which can lead to improvements in several common side effects of cancer treatments.

How can moxibustion help you? What the research says

We summarize the clinical evidence for each medical benefit here. We begin with our assessment of the strength of evidence within each category, followed by a brief summary of individual studies or reviews of several studies. In assessing the strength of evidence, we consider the study design, number of participants, and the size of the treatment effect (how much outcomes changed with treatment).

To see more details, click the plus sign to the right of any section.

Our assessments of evidence for each medical benefit fall into one of these categories:

Strong evidence: consistent, significant effects in several large (or at least one very large) well designed clinical studies or at least two meta-analysesa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of clinical studies of moderate or better quality (or one large meta-analysis) finding similar results
Good evidence: significant effects in one large or several mid-sized and well-designed clinical studies ( randomized controlled trialsa study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects with an appropriate placebo or other strong comparison control or observational studies that control for confounds)
Modest evidence: significant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods studies), or several small studies aggregated into a meta-analysis
Preliminary evidence: significant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect
Weak evidence: one or more case studies, supported by animal evidence OR small treatment effects of limited clinical significance OR studies with no controls OR weak trends of effects
Insufficient evidence: preclinical evidence only OR clinical studies with such poor or unclear methodology that no conclusion can be drawn OR conflicting findings across clinical studies with no preponderance of evidence in one direction; conflicting evidence occurs when studies find conflicting effects (positive effect vs no effect or negative effect) with the same treatment and the same general study population (same cancer type, for example)

Learn more about how we research and rate therapies and practices in How We Rate Therapies ›

Preclinical evidence is summarized in Are you a health professional? ›

Optimizing your body terrain

Does moxibustion promote an environment within your body that is less supportive of cancer development, growth, or spread? We present the evidence.

See Optimizing Your Body Terrain ›

Find medical professionals who specialize in managing body terrain factors: Finding Integrative Oncologists and Other Practitioners ›

We also recommend that you share with your doctor the information here about how moxibustion might affect these terrain factors if you have any imbalances.

Immune function

Increased immune system activation is not always beneficial, so your oncology team needs to determine whether immune activation would be favorable in your situation.

Modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently) of higher markers of immune activation among people with cancer and people with other health conditions treated with moxibustion

Higher markers of immune activation after radical resection of colorectal cancer among people treated with conventional medication plus warm-needle moxibustion stimulation compared to conventional medication alone in a small RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects¹Sun H, Zhang B, Qian HH, Chen ZC. [Effect of warm-needle moxibustion intervention on immune function and intestinal flora in patients after colorectal cancer radical operation]. Zhen Ci Yan Jiu. 2021 Jul 25;46(7):592-7. Chinese.
Higher markers of immune activation during cancer treatment among people treated with acupoint stimulation compared to controls in a meta-analysisa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of 31 controlled trialsa study design in which people are assigned to either an experimental group or a control group to compare the outcomes from different treatment; assignment is not random, and so this is not as strong a study design as a randomized controlled trial, but still stronger than an uncontrolled trial²Chen HY, Li SG, Cho WC, Zhang ZJ. The role of acupoint stimulation as an adjunct therapy for lung cancer: a systematic review and meta-analysis. BMC Complementary and Alternative Medicine. 2013 Dec 17;13:362.
Higher markers of immune activation (CD3+T, CD4+T, CD8+T cells and B cells) among people with non-small cell lung cancer with fatigue treated with acupuncture and moxibustion compared to conventional Chinese and Western medicine in a small RCT³Li WT, Liu YH, Pet al. [Effects of “Tiaoyi Sanjiao” acupuncture and moxibustion on cancer-induced fatigue and immune function in patients with advanced non-small cell lung cancer]. Zhen Ci Yan Jiu. 2020 Dec 25;45(12):1000-5.
Higher markers of immune activation (increased white blood cell counts and T-lymphocyte subsets) among people with COVID-19 treated with Western medicine and moxibustion once daily for 14 days compared to Western medicine alone in a small RCT⁴Liu L, Xing XY, et al. [Effect of moxibustion on clinical symptoms, peripheral inflammatory indexes and T lymphocyte subsets in COVID-19 patients]. Zhongguo Zhen Jiu. 2020 Dec 12;40(12):1271-5.
Higher markers of immune activation among people treated with HIV receiving antiretroviral therapy (HAART) and moxibustion compared to HAART alone in a mid-sized RCT⁵Liu Z, Deng X, et al. [Moxibustion combined with highly active antiretroviral therapy for CD4+ and γ chain cytokines of HIV infected patients]. Zhongguo Zhen Jiu. 2018 Jan 12;38(1):3-6.
Greater regulatory effect of markers of immune function among people with ankylosing spondylitis treated with pharmaceutical treatment and moxibustion once daily for 7 consecutive days per round and a 3 day break, for 4 rounds compared to pharmaceutical treatment alone in a small RCT⁶Zuo Z, Liu Z, Yuan K, Wang Y, Dong K. [Effects and mechanism of the long-snake moxibustion on ankylosing spondylitis based on Th17/Treg/Th1 immune imbalance]. Zhongguo Zhen Jiu. 2018 Oct 12;38(10):1053-7.
A weak trendan apparent change due to a therapy, close to but not achieving full statistical significance (this is the CancerChoices definition; other researchers and studies may define this differently towards higher markers of immune activation (IgM, IgG, and SOD) among people with suboptimal health status treated with moxibustion once every other day for 2 months compared to medication in a small RCT⁷He L, Wang C, et al. [Impacts of mild moxibustion on immune indices and nailfold microcirculation in the subhealthy group]. Zhongguo Zhen Jiu. 2017 Feb 12;37(2):115-119.

Inflammation

Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) of lower inflammation among people with colorectal cancer or COVID-19 treated with moxibustion

Your microbiome

Preliminary evidence of better intestinal bacteria after colorectal resection surgery among people treated with warm-needle moxibustion stimulation

Managing side effects and promoting wellness

Is moxibustion linked to fewer or less severe side effects or symptoms? Is it linked to less toxicity from cancer treatment? Does it support your quality of life or promote general well-being? We present the evidence.

Anxiety

Preliminary evidencesignificant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect (this is the CancerChoices definition; other researchers and studies may define this differently) of less anxiety among people with cancer pain treated with acupuncture and heat-sensitive moxibustion

Blood-related side effects

Modest evidencesignificant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observational studies), or several small studies aggregated into a meta-analysis (this is the CancerChoices definition; other researchers and studies may define this differently) of better white blood cell counts during or after conventional cancer treatment among people treated with moxibustion

Modest evidence of higher serum hemoglobin during or after chemo/radiotherapy among people treated with moxibustion

Preliminary evidence of higher platelets during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to no treatment, but no further benefit when added to conventional treatments for platelets

White blood cell counts: modest evidence of better white blood cell counts during or after conventional cancer treatment among people treated with moxibustion

Higher white blood cell counts during or after chemo/radiotherapy among people with cancer treated with moxibustion and conventional treatment compared to conventional treatment alone in 2 small RCTsrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects with low-certainty evidence¹²Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Lower incidence and severity of low white blood cell counts (leukopenia) during chemo/radiotherapy among people with cancer treated with conventional treatment and moxibustion compared to conventional treatment alone in a small RCT with low-certainty evidence¹³Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Lower leukopenia after radical resection of colorectal cancer among people treated with warm-needle moxibustion stimulation and conventional medication compared to conventional medication alone in a small RCT¹⁴Sun H, Zhang B, Qian HH, Chen ZC. [Effect of warm-needle moxibustion intervention on immune function and intestinal flora in patients after colorectal cancer radical operation]. Zhen Ci Yan Jiu. 2021 Jul 25;46(7):592-7. Chinese.
Higher lymphocyte (type of white blood cell or leukocyte counts) (CD3+T, CD4+T, CD8+T cells and B cells) among people with non-small cell lung cancer with fatigue treated with acupuncture and moxibustion compared to conventional Chinese and Western medicine in a small RCT¹⁵Li WT, Liu YH, et al. [Effects of “Tiaoyi Sanjiao” acupuncture and moxibustion on cancer-induced fatigue and immune function in patients with advanced non-small cell lung cancer]. Zhen Ci Yan Jiu. 2020 Dec 25;45(12):1000-5.
Higher white blood cell counts 8 days after chemo/radiotherapy treatment ended among people with cancer treated with moxibustion compared to conventional medicines in a small RCT with low-certainty evidence¹⁶Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Higher white blood cell counts during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to sham treatment in a small RCT with low-certainty evidence¹⁷Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Higher white blood cell counts during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to no treatment in 2 small RCTs with low-certainty evidence, but no evidence of an effectoverall, one or more studies did not demonstrate that a treatment or intervention led to an expected outcome; this does not always mean that there is no effect in clinical practice, but that the studies may have been underpowered (too few participants) or poorly designed. Larger, well-designed studies provide more confidence in making assessments. on low white blood cell counts (leukopenia) in a separate small RCT¹⁸Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Maintained lymphocyte counts during chemotherapy among people with mid- to late-stage malignant tumors treated with moxibustion with or without a Chinese herbal compound, while counts dropped with the herbal preparation alone or no intervention, but comparisons among groups is not reported in a small RCT¹⁹Liu J, Yu RC, Tang WJ. [Influence of combined therapy of guben yiliu III, moxibustion and chemotherapy on immune function and blood coagulation mechanism in patients with mid-late stage malignant tumor]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2002 Feb;22(2):104-6. Chinese.

Hemoglobin counts: modest evidence of higher serum hemoglobin during or after chemo/radiotherapy among people treated with moxibustion

Higher serum hemoglobin during or after chemo/radiotherapy among people with cancer treated with conventional treatment and moxibustion compared to conventional treatment alone in 2 small RCTs with low-certainty evidence²⁰Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Higher serum hemoglobin concentrations during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to conventional treatment in a meta-analysis of 2 RCTs with low-certainty evidence²¹Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Higher serum hemoglobin concentrations during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to sham treatment in a small RCT with low-certainty evidence²²Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Higher serum hemoglobin concentrations during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to no treatment in 2 small RCTs with low-certainty evidence, but no evidence of an effect on low white blood cell counts (leukopenia) in a separate small RCT²³Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
No change in hemoglobin among people with advanced cancer treated with moxibustion compared to usual care in a small RCT²⁴Zhou T, Li WT, Yu JC, Jia YJ. [Impacts of moxibustion at Zusanli (ST 36) on the improvements in the quality of life in patients with advanced malignant tumor]. Zhongguo Zhen Jiu. 2019 Feb 12;39(2):133-6. Chinese.

Platelet counts: preliminary evidence of higher platelets during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to no treatment, but no further benefit when added to conventional treatment

No difference in platelets, during or after chemo/radiotherapy among people with cancer treated with moxibustion and conventional treatment compared to conventional treatment alone in 2 small RCTs with low-certainty evidence²⁵Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Higher platelets during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to sham treatment in a small RCT with low-certainty evidence²⁶Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.

Breathlessness

Preliminary evidence of less breathlessness (dyspnea) among people with advanced cancer treated with moxibustion

Changes in appetite

Preliminary evidence of better appetite among people with advanced cancer treated with moxibustion

Fatigue

Modest evidence of less cancer-related fatigue among people treated with moxibustion

Gastrointestinal symptoms

Modest evidence of less nausea, vomiting, and diarrhea during or after conventional cancer treatments among people with cancer treated with moxibustion

Less nausea and vomiting during or after chemo/radiotherapy among people with cancer treated with conventional treatment and moxibustion compared to conventional treatment alone in a meta-analysis of 7 RCTsrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects with low-certainty evidence³²Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Less nausea, vomiting, abdominal distention, and diarrhea after colon cancer surgery and during hyperthermic intraperitoneal chemotherapy among people with spleen and stomach deficiency syndrome treated with ondansetron and acupuncture with moxibustion compared to ondansetron alone in a mid-sized RCT³³Gu XY, Gao ZQ, Zhang ZJ, Huang ZM, Xie XH. [Influence of warming needling technique on gastrointestinal reaction after hyperthermic intrape-ritoneal chemotherapy in patients with postoperation of colon cancer] [Article in Chinese]. Zhen Ci Yan Jiu. 2020;45(4):315-319.
Less nausea, vomiting, and diarrhea during or after chemo/radiotherapy among people with cancer treated with moxibustion compared to sham in a small RCT with low-certainty evidence³⁴Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
Less nausea and vomiting after radical resection of colorectal cancer among people treated with conventional medication and warm-needle moxibustion stimulation compared to conventional medication alone in a small RCT³⁵Sun H, Zhang B, Qian HH, Chen ZC. [Effect of warm-needle moxibustion intervention on immune function and intestinal flora in patients after colorectal cancer radical operation]. Zhen Ci Yan Jiu. 2021 Jul 25;46(7):592-7. Chinese.

Pain

Preliminary evidence of less pain and soreness among people with cancer treated with moxibustion

Quality of life and physical function

Modest evidence of better quality of life among people with cancer as a whole treated with moxibustion

Preliminary evidence of less weakness among people with advanced cancer treated with moxibustion

Other side effects and symptoms

Preliminary evidence of shorter hospital stays after surgery for colorectal cancer among people treated with acupuncture and moxibustion

Keep reading about moxibustion

See all our reviews of complementary therapies

Authors

Nancy Hepp, MS

Lead Researcher

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Laura Pole, MSN, RN, OCNS

Senior Clinical Consultant

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Reviewer

Emily Ryan, ND, MSOM, LAc

Research Associate

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Last update: December 18, 2023

Last full literature review: September 2021

CancerChoices provides information about integrative in cancer care, a patient-centered approach combining the best of conventional care, self care and evidence-informed complementary care in an integrated plan cancer care. We review complementaryin cancer care, complementary care involves the use of therapies intended to enhance or add to standard conventional treatments; examples include supplements, mind-body approaches such as yoga or psychosocial therapy, and acupuncture therapies and self-care lifestyle actions and behaviors that may impact cancer outcomes; examples include eating health-promoting foods, limiting alcohol, increasing physical activity, and managing stress practices to help patients and professionals explore and integrate the best combination of conventionalthe cancer care offered by conventionally trained physicians and most hospitals; examples are chemotherapy, surgery, and radiotherapy and complementary therapies and practices for each person.

Our staff have no financial conflicts of interest to declare. We receive no funds from any manufacturers or retailers gaining financial profit by promoting or discouraging therapies mentioned on this site.

Moxibustion

How can moxibustion help you? What the research says

Optimizing your body terrain

Managing side effects and promoting wellness

Keep reading about moxibustion

Authors

Nancy Hepp, MS

Laura Pole, MSN, RN, OCNS

Reviewer

Emily Ryan, ND, MSOM, LAc

Learn more

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How to Integrate Your Choices

References
1, 8, 10, 14, 35	Sun H, Zhang B, Qian HH, Chen ZC. [Effect of warm-needle moxibustion intervention on immune function and intestinal flora in patients after colorectal cancer radical operation]. Zhen Ci Yan Jiu. 2021 Jul 25;46(7):592-7. Chinese.
2	Chen HY, Li SG, Cho WC, Zhang ZJ. The role of acupoint stimulation as an adjunct therapy for lung cancer: a systematic review and meta-analysis. BMC Complementary and Alternative Medicine. 2013 Dec 17;13:362.
3	Li WT, Liu YH, Pet al. [Effects of “Tiaoyi Sanjiao” acupuncture and moxibustion on cancer-induced fatigue and immune function in patients with advanced non-small cell lung cancer]. Zhen Ci Yan Jiu. 2020 Dec 25;45(12):1000-5.
4	Liu L, Xing XY, et al. [Effect of moxibustion on clinical symptoms, peripheral inflammatory indexes and T lymphocyte subsets in COVID-19 patients]. Zhongguo Zhen Jiu. 2020 Dec 12;40(12):1271-5.
5	Liu Z, Deng X, et al. [Moxibustion combined with highly active antiretroviral therapy for CD4+ and γ chain cytokines of HIV infected patients]. Zhongguo Zhen Jiu. 2018 Jan 12;38(1):3-6.
6	Zuo Z, Liu Z, Yuan K, Wang Y, Dong K. [Effects and mechanism of the long-snake moxibustion on ankylosing spondylitis based on Th17/Treg/Th1 immune imbalance]. Zhongguo Zhen Jiu. 2018 Oct 12;38(10):1053-7.
7	He L, Wang C, et al. [Impacts of mild moxibustion on immune indices and nailfold microcirculation in the subhealthy group]. Zhongguo Zhen Jiu. 2017 Feb 12;37(2):115-119.
9	Liu L, Xing XY et al. [Effect of moxibustion on clinical symptoms, peripheral inflammatory indexes and T lymphocyte subsets in COVID-19 patients]. Zhongguo Zhen Jiu. 2020 Dec 12;40(12):1271-5.
11, 36, 39	Ji JF, Ge XX et al. [Intradermal needling combined with heat-sensitive moxibustion for moderate to severe cancer pain]. Zhongguo Zhen Jiu. 2021 Jul 12;41(7):725-9. Chinese.
12, 13, 16, 17, 18, 20, 21, 22, 23, 25, 26, 32, 34, 38	Zhang HW, Lin ZX, Cheung F, Cho WC, Tang JL. Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer. Cochrane Database of Systematic Reviews. 2018 Nov 13;11(11):CD010559.
15	Li WT, Liu YH, et al. [Effects of “Tiaoyi Sanjiao” acupuncture and moxibustion on cancer-induced fatigue and immune function in patients with advanced non-small cell lung cancer]. Zhen Ci Yan Jiu. 2020 Dec 25;45(12):1000-5.
19	Liu J, Yu RC, Tang WJ. [Influence of combined therapy of guben yiliu III, moxibustion and chemotherapy on immune function and blood coagulation mechanism in patients with mid-late stage malignant tumor]. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2002 Feb;22(2):104-6. Chinese.
24, 27, 28, 31, 37, 40	Zhou T, Li WT, Yu JC, Jia YJ. [Impacts of moxibustion at Zusanli (ST 36) on the improvements in the quality of life in patients with advanced malignant tumor]. Zhongguo Zhen Jiu. 2019 Feb 12;39(2):133-6. Chinese.
29	He XR, Wang Q, Li PP. Acupuncture and moxibustion for cancer-related fatigue: a systematic review and meta-analysis. Asian Pacific Journal of Cancer Prevention. 2013;14(5):3067-74.
30	Lee S, Jerng UM et al. The effectiveness and safety of moxibustion for treating cancer-related fatigue: a systematic review and meta-analyses. Supportive Care in Cancer. 2014 May;22(5):1429-40.
33, 41	Gu XY, Gao ZQ, Zhang ZJ, Huang ZM, Xie XH. [Influence of warming needling technique on gastrointestinal reaction after hyperthermic intrape-ritoneal chemotherapy in patients with postoperation of colon cancer] [Article in Chinese]. Zhen Ci Yan Jiu. 2020;45(4):315-319.