The effectiveness of traditional Chinese medicine external therapies for cancer-related fatigue: a systematic review and network meta-analysis

Cancer-related fatigue is one of the most common and troublesome symptoms among cancer patients. Its pathogenesis involves multiple system interactions such as neuroendocrine disorders, immune inflammatory activation, and mitochondrial dysfunction, which not only reduces the quality of life of patients but also decreases chemotherapy compliance and tolerance. Although non-pharmacological interventions have been recommended as the preferred management strategy by guidelines, the existing therapeutic forms are diverse, lacking direct comparative evidence, and some interventions have limited applicability for frail patients. Traditional Chinese medicine external therapies demonstrate unique advantages in alleviating cancer-related fatigue through meridian acupoint stimulation and transdermal absorption of Chinese medicines. However, it is not clear which therapy is the optimal choice. Our study aims to systematically compare the efficacy of traditional Chinese medicine external therapies in treating cancer-related fatigue among cancer patients through a network meta-analysis, thereby providing clinical guidance. We systematically searched Chinese and English databases including PubMed, Embase, Cochrane Library, CNKI, Wanfang, and VIP database for randomized controlled trials evaluating traditional Chinese medicine external therapies for cancer-related fatigue.The search covered the period from database inception to December 2025. Two researchers independently conducted literature screening, data extraction, and bias risk assessment. A network meta-analysis was performed using Stata 18.0 software. The cumulative sorted probability curve area (SUCRA) was used to rank the efficacy probabilities of each intervention, and inconsistency tests and publication bias assessment were conducted. A total of 49 randomized controlled trials involving 1766 patients were included. The results of the network meta-analysis revealed that 14 types of traditional Chinese medicine external therapies demonstrated superior efficacy to conventional care in alleviating cancer-related fatigue. The ranked efficacy showed acupuncture combined with acupoint application had the highest probability of being the optimal intervention (SUCRA = 79.6%), followed by auricular acupuncture combined with acupoint massage (SUCRA = 74.9%) and herbal foot bath therapy (SUCRA = 70.8%). The overall performance of combined therapies was better than that of single therapies. The node splitting method did not detect significant inconsistency, and the publication bias analysis indicated no obvious bias. Acupuncture combined with acupoint application is the most effective in improving cancer-related fatigue. Auricular acupuncture combined with acupoint massage and herbal foot bath therapy are also effective preferred options. In clinical practice, combined interventions with synergistic effects should be prioritized based on the specific conditions of the patients. In the future, high-quality long-term follow-up studies are needed to verify their sustained efficacy and safety.