Capability is defined as the physical and mental abilities that affect the use of TCM by cancer patients and HCPs (28, 29). A total of 10 patients’ perspective themes based on the capability component were generated in this study, with six facilitating and four impeding themes, four HCPs’ perspective themes, one facilitating and three impeding themes.

For patients, the ability to understand and process information related to TCM and the self-management of health plays a critical role in facilitating behavioral choices. Specifically, patients can obtain information about TCM through multiple channels, including its benefits in enhancing the efficacy of conventional treatments (30, 31), reducing side effects (30–42), improving mental health (32, 33, 35, 39, 40, 42–45), enhancing well-being and coping (30, 32, 33, 35, 41–48). Through the evaluation and assessment of the above information, patients may be more likely to choose TCM as a supportive therapy in tumor treatment (30–34, 42, 49–51). Additionally, by practicing TCM self-management skills in daily life, such as acupressure (46, 51), auricular pressure (52), and dietary therapy (35), patients can more effectively manage health issues and improve treatment adherence, ultimately increasing the likelihood of choosing TCM therapies.

Moreover, TCM therapy, rooted in traditional Chinese culture, adopts a holistic perspective that views health as an interconnected whole and emphasizes balance in body, mind, and spirit (40, 41). While addressing physical discomfort, it also focuses on the regulation and management of emotions and stress (33, 50). Additionally, by fostering an understanding of healthy behaviors and lifestyle changes, TCM enhances patients’ health awareness and their sense of self-efficacy in pursuing a healthier lifestyle (41). This process strengthens their psychological capability and indirectly promotes the adoption of TCM treatments.

The barriers influencing patients’ decision to adopt TCM therapies can be mapped to two domains: knowledge and skills. In the knowledge domain, barriers include a lack of understanding of existing efficacy evidence, as well as doubts regarding the mechanism of action (53), effectiveness (30, 33, 38, 49, 50), duration of therapeutic benefits, and safety of the therapies (42). Furthermore, information asymmetry between patients and healthcare providers is another potential barrier, primarily reflected in insufficient patient education by doctors regarding treatment frequency and precautions (36, 38, 48, 51, 54). In the domain of skills, patients found it challenging to locate TCM physicians with oncology expertise, which hinders their choices (55).

From HCP’s perspective, the potential factors associated with capability can be mapped to the knowledge and behavioral modification domains. In terms of knowledge, recognizing the benefits of TCM as a supportive therapy in clinical practice can encourage behavioral choices (32, 53, 55–59). Conversely insufficient evidence on efficacy, a lack of evidence-based data, and limited access to reliable information significantly hinder behavioral choices (32, 55). Behavioral regulation-related impediments involve a lack of interdisciplinary communication (32), which greatly hampers the likelihood that oncologists and physicians will be able to understand the mechanisms, and effectiveness of TCM.

Opportunity refers to external factors influencing the use of TCM in cancer care by patients and HCPs, categorized into social and physical opportunities (28). A total of 10 patients’ perspective themes based on the opportunity component were generated in this study, including seven facilitating themes, three hindering themes, and five themes from the HCPs’ perspective, all hindering factors.

From the patients’ perspective, key facilitators within the social influence cluster include positive influences from significant others, such as family members, colleagues, and doctors (30, 32, 35, 41, 42, 44, 49, 51, 52, 56, 62–65), the media (32, 49, 63, 64), and ward-mates (40, 43, 47, 50, 56, 67). Studies indicate that patients immersed in positive doctor-patient relationships, such as through listening (30, 32, 40, 41, 43, 45, 50, 51, 62, 64, 66), encouragement (39), and support (32, 34, 39, 44, 50, 51, 62, 67), play an important role in decision-making behaviors. Facilitating factors related to environmental context and resources include a comfortable treatment environment (40, 45), the authority of the clinic environment (65), economic feasibility and policy support (31, 34, 36, 41, 55, 56) (e.g., health insurance, health care policy, etc.). Three potential barriers include oncologists’ negative attitudes toward TCM (36, 41, 42, 44, 56, 62), false advertising (30), and inadequate medical resources (e.g., high treatment and transportation costs, long treatment duration, and excessive waiting times) (30, 32, 33, 36, 40–42, 44, 49, 52, 54–56, 59, 61, 63, 66).

From the perspective of healthcare professionals (HCPs), similar to patients’ views, the main barriers include oncologists’ negative attitudes toward TCM (32, 56) and the limited healthcare budgets (55, 56). Furthermore, TCM experts emphasized that the absence of cross-disciplinary communication with oncologists impedes their comprehension of the efficacy and safety of TCM (32), thereby indirectly influencing the adoption of TCM treatments.

This subgroup analysis of eight TCM therapies shows that the overall results remain robust despite minor variations due to intervention characteristics, with three facilitating factors and six barriers varying across interventions (Supplementary Table 6).

Among facilitating factors, HCPs and patients recognize TCM’s role in supportive cancer care and its position as an adjunct therapy. Some doctors also use anticancer herbs to enhance supportive effects, such as inhibiting tumor growth and metastasis (68). In contrast, some patients may view herbal therapy as an alternative to conventional treatment (34, 63). TCM interventions with self-care characteristics exhibit distinct advantages: acupressure is simple to learn and easy to apply (46); non-prescribed functional herbal products are available in various forms (e.g., tablets, teas, foods) and are easily accessible (35); dynamic therapies in mind-body practices (e.g., Qigong, Tai Chi) enhance physical function at appropriate intensity levels (35).

Regarding barriers, different TCM models present unique challenges. Regarding the perception of TCM efficacy and safety, some patients consider acupuncture may stimulate tumor growth (56) and are uncertain about its long-term efficacy (37, 38). In herbal therapy, both doctors and patients express concerns about the potential risks of herb-drug interactions (48, 68). In terms of economic burden, acupuncture increases costs due to its treatment frequency and duration (40, 61). In comparison, the high prices of standard herbal products, such as Lingzhi (Ganoderma lucidum) powder, add to the financial strain (44, 56). Negative experiences with TCM include needle phobia (32, 33, 36), and body exposure (39, 58) in acupuncture, pain and discomfort in acupressure (46, 51), unpleasant taste in herbal medicine and supplements (35, 63), and noise perception in Five Elements music therapy within mind-body therapies (31). Furthermore, unique barriers to non-prescribed functional herbal products include deceptive advertising (30), concerns about product transparency (35, 48), and lack of usage guidance (35, 48, 51).

Limited research on herbal footbath and moxibustion identified no distinct facilitating or barrier factors for these modalities. Therefore, this subgroup analysis highlights the diverse characteristics of TCM interventions in supportive cancer care, emphasizing their potential benefits and challenges in clinical application.

From the included studies, Western countries focus more on non-pharmacological TCM therapies such as acupuncture, Qigong, and massage. In contrast, research in Asian countries, particularly China, is more diverse, significantly emphasizing herbal treatment. This disparity is closely linked to the cultural and healthcare system differences between East and West. For example, acupuncture has been integrated into the healthcare systems of some Western countries (69). However, due to strict Good Manufacturing Practice (GMP) regulations in Western countries (70), issues related to the quality, purity, and standardization of herbal medicine remain unresolved. Consequently, research in the West often centers on single herbs and their active components, resulting in lower clinical use and research frequency compared to Asian countries. Unfortunately, our studies include participants from diverse age groups and disease backgrounds, challenging traditional stereotypes of TCM users and indicating broader cultural acceptance (71).

Our study indicates that the lack of evidence-based data and the cognitive gap between HCPs and patients are significant barriers to integrating TCM into cancer care. This aligns with challenges commonly observed in implementing other complementary and alternative therapies (72).

Evidence gaps are primarily reflected in the following areas: (1) Lack of research and standardized assessment of symptom clusters: Cancer patients often experience interrelated symptoms, collectively referred to as “symptom clusters,” sharing common mechanisms or pathways (44). Multiple studies included in this research suggest that TCM offers effective interventions for managing symptom clusters (53). However, standardized methods for measuring these clusters remain lacking. Future studies should focus on developing precise and consistent outcome measures to better evaluate the dynamic changes and treatment effects of symptom clusters (73); (2) Incomplete research on herbal toxicity and safety: There are notable differences in how healthcare professionals perceive the safety of herbal medicines. Oncologists, in particular, express caution regarding potential herb-drug interactions (HDIs) when herbal treatments are combined with chemotherapy or other conventional therapies (74). As such, they often cite concerns about compromised efficacy or increased toxicity. Moreover, the hepatic and renal toxicity of herbal medicines requires further investigation (75); (3) Insufficient clinical evidence for direct anti-tumor effects of herbal medicines: Although some TCM practitioners use specific herbal medicines for their purported anticancer effects (68), laboratory and preclinical studies have demonstrated anti-tumor activity in certain herbs (e.g., Astragalus) (13). However, high-quality RCTs are lacking to validate their clinical efficacy and identify appropriate patient populations; (4) Limited evidence on the long-term effectiveness of interventions: Subgroup analyses reveal that some patients remain skeptical about the long-term efficacy of acupuncture (38). Consequently, current evidence on the sustained benefits of acupuncture in cancer management is inconsistent (4). Future research should prioritize well-designed, long-term RCTs to provide robust evidence for their long-term efficacy.

The cognitive gap is primarily reflected in limited knowledge of key areas, including cancer biology, the scope and efficacy of TCM treatments, mechanisms of action, safety, and the optimal timing for integration into conventional cancer care. From the perspective of HCPs, concerns include doubts about the quality of evidence, a disconnect between research findings and clinical practice, and cross-cultural differences in understanding. Additionally, TCM practitioners may lack expertise in oncology and herbal pharmacology. For instance, some rely on traditional knowledge and clinical experience to prescribe herbs, such as using phytoestrogen-containing Yin-tonifying herbs for estrogen-positive breast cancer patients, as reported in certain studies (68).

Despite systematic reviews supporting the efficacy and safety of TCM in IO, the translating this evidence into practice faces several barriers. These include: (1) Trial design based on syndrome differentiation: TCM emphasizes individualized treatment based on syndrome differentiation, which introduces subjectivity in defining inclusion criteria, intervention, and outcome measures in RCTs (76). While this approach highlights TCM’s unique ability to address patients’ symptoms and conditions dynamically, it also demands higher standards of training and quality control, potentially compromising the reliability and clinical applicability of results; (2) Limited representativeness of populations: Most TCM research is conducted in East Asia, with culturally homogeneous populations, limiting the generalizability of findings to diverse settings and populations; and (3) Lack of effective evidence network collaboration: Evidence networks play an important role in connecting researchers, policymakers, and practitioners to facilitate the generation, dissemination, and application of evidence to inform decisions (77). However, the absence of a structured evidence network in the TCM field hinders the global dissemination and application of TCM research findings.

In Integrative Cancer Care (ICC), combining biomedical treatments with TCM demonstrates notable complementary strengths. Biomedical treatments are disease-centered care, focusing on tumor control and clinical outcomes. In contrast, TCM adopts patient-centered care, prioritizing holistic health, psychological support, and quality of life. Thus, this synergistic model provides a valuable framework for optimizing cancer care and improving patient outcomes, quality of life, and overall care experiences (78).

In patient-centered care models, Shared Decision Making (SDM) has garnered increasing attention. SDM emphasizes providing evidence-based, comprehensive recommendations while respecting patients’ preferences, beliefs, and priorities, enabling healthcare professionals and patients to collaboratively develop personalized treatment plans (79). This approach not only reduces decision-making conflicts but also enhances patients’ engagement and trust in their treatment. Our study found that the application of SDM demonstrates significant advantages in real-world TCM clinical practice. The “patient-centered” philosophy of TCM aligns closely with the core objectives of SDM, fostering a sense of involvement in decision-making (80). For instance, prioritizing patients’ most pressing symptoms and incorporating their preferences in selecting herbal formulations further underscores TCM’s personalized approach, improving the overall care experience.

Moreover, our research indicated that in this patient-centered model, patients often report that a supportive environment, active listening by doctors, and therapeutic alliance play an important role in psychological well-being. This relationship improves mental health and promotes holistic recovery, enhancing the quality of care (32, 51). Interestingly, from the physicians’ perspective, trust-based patient-provider relationships and patient-centered communication are tools to encourage patients to express their needs and disclose health issues (58). Like other chronic disease management settings, both doctors and patients emphasize the importance of building long-term trust to improve clinical outcomes and ensure adequate care (81).

However, despite these benefits, integrating TCM into integrative cancer care poses challenges, mainly due to differences in treatment models and the lack of interdisciplinary communication. Notably, some patients in our included studies reported withholding information about their use of TCM due to perceived negative attitudes from physicians. Studies indicate that approximately 29.3% of patients in the United States do not disclose their use of complementary and alternative medicine (CAM) to their doctors (12). This lack of communication hinders the proper integration of TCM with conventional therapies and negatively impacts optimal medical decision-making.

Through the “education” intervention function, evidence-based knowledge, guidelines, and research on TCM can be disseminated via various media channels, including online learning platforms, patient guidelines, educational brochures, and courses (83). Importantly users should critically evaluate online information, as research shows most online discussions about CAM are commercially and potentially misleading (84).

To overcome the challenge of limited evidence and low utilization of TCM guidelines, we propose systematic improvements through the intervention functions of “Enablement” and “Environmental restructuring.” First, conducting more high-quality TCM clinical trials is essential to supplement existing evidence for clinical practice. Second, standardized TCM utilization and risk management tools should be developed, drawing on examples such as the questionnaire tool by Shalgouny et al. (72). Finally, existing guideline implementation frameworks [e.g., Knowledge-to-Action framework (85), Guideline Implementability Decision Excellence Model (86)] can be utilized to systematically analyze barriers in diverse implementation contexts and design tailored solutions.

Establishing a multidisciplinary environment is crucial for integrating TCM into oncology care. This includes adopting the Collaborative Care Management (CoCM) model, organizing regular case discussions, and incorporating CAM education into medical training to enhance understanding and acceptance of TCM.

Utilizing patient-directed knowledge tools to address information gaps in doctor-patient interactions. For example, using a structured checklist (87) to address key patient concerns for more efficient doctor-patient communication, and creating informational leaflets (88) to provide guidance on treatment timelines, efficacy, and dietary therapies.

To address the shortage of TCM specialists, interventions should incorporate Environmental Restructuring, Training, and Enablement. Environmental Restructuring can be achieved by developing structured referral pathways that integrate TCM services into existing oncology care workflows. For example, oncology clinics could implement a standardized checklist or decision-support tool embedded within electronic health records (EHR) to streamline referrals to TCM practitioners. Additionally, creating formal partnerships between oncology centers and TCM clinics would facilitate coordinated care (89). Training involves training TCM practitioners in specialized oncology knowledge, such as cancer biology, pharmacology, and the management of treatment-related side effects. Enablement focuses on fostering patient-centered initiatives, such as establishing community-based Tai Chi classes and training patients in auricular acupuncture self-care, to empower individuals in managing their symptoms and improving quality of life.

To reduce safety risks, regional and cultural differences will be considered to formulate strict laws and regulations to restrict misleading advertisements of herbal dietary supplements and improve the transparency of production.

As the cost of TCM-related products and services is high, financial barriers may impact TCM implementation more (90). To address financial barriers impacting TCM implementation, it is necessary to assess healthcare needs and adjust financial support while considering variations in healthcare policies and payment models across countries.

As we identified impediments mostly at the systemic level, some of the structural changes proposed are complicated. Future research should focus on developing targeted interventions and implementation strategies. Furthermore, the research could be refined through interviews with relevant stakeholders to adapt to the specific contexts of different countries.