Effect of Annona muricata (Soursop) on Patients with Cancer: A Systematic Review

ABSTRACT

Introduction: Annona muricata is among the most commonly used herbal remedies by cancer patients. Most previous systematic reviews on Annona muricata have reported studies performed in-vitro and in-vivo. However, no systematic review has been conducted solely to compile studies on humans with cancer. Objective: We aimed to summarise the effects of Annona muricata and explore its potential mechanisms of action and safety for cancer patients. Method: A systematic search was performed in the following electronic databases from inception until February 2022: MEDLINE, Cochrane library, EMBASE, ClinicalTrials.gov, WHO Trials Portal, Google scholar, and grey literature reports. The papers were then reviewed and assessed for eligibility based on the inclusion and exclusion criteria. Results: From the 475 abstracts, 11 were extracted for a full review, with five included in the final analysis. All studies included had a high or critical risk of bias, along with varying outcome measures; thus, caution is required when interpreting the results. Annona muricata has shown to inhibit cancer cell growth, enhance caspase activity, and provide anti-inflammatory effects. It was found to be safe, with minimal side effects in cancer patients. Annona muricata does not interfere with bone marrow, liver, and kidney function and may even improve nutritional status. Conclusion:Annona muricata could offer potential anticancer benefits while being safe for cancer patients. However, the absence of high-quality studies and incomplete evidence pose challenges in drawing a conclusive statement. More research is required to validate the efficacy and safety of Annona muricata, enabling more definitive evidence-based recommendations.

INTRODUCTION

The growth of cancer has become a significant health problem globally. The number of new cases reported in patients with cancer has been increasing recently, and it is expected to rise even more over time [1][2]. The increase in new cases will eventually elevate the burden on patients due to heightened health and social costs, especially in low- and middle-income countries. A data-based study in Pakistan found substantial and noticeable differences in price among different anti-cancer brands sold in the country, with variations ranging from 4.01% to 19,912.25% observed across 115 different formulations of anticancer drugs [3]. As a result, the self-usage of alternative medicines such as herbal medicines, may increase among cancer patients in these countries due to their lower cost and availability.   

Herbal medicine, as an adjuvant to the standard therapy, has been practised in some Asian countries to enhance therapeutic benefits and quality of life while reducing the side effects of the conventional treatments [4]. A cross-sectional study on the use of herbal medicines among multiethnic secondary care patients in Malaysia (n= 250) found that 42.4% of participants used herbal medicines, with over a third using herbs and conventional treatments concurrently (67.9%). In addition, those with higher education were more inclined to use herbal medicines (OR: 4.06, 95% CI 1.47 – 11.23, p=0.007) [5]. Although current standard cancer therapies are effective, growing evidence highlights substantial side effects, which restrict their use [4]. There is a lay belief that herbal medicine is likely to be safer and associated with fewer side effects.

Annona muricata, also referred to as soursop or graviola, is a tropical plant species belonging to the Annonaceae family[7].It is a small and slender tree with glossy evergreen leaves that produce spiny heart-shaped fruit, the largest group in the genus [7][8]. Annona muricata most likely originates from Central America and can be found in tropical areas of Central and South America, as well as lowlands of Africa and South-East Asia [7].

Annona muricata is among the most commonly used herbal remedies by cancer patients. A cross-sectional study on herbal medicines used by cancer patients in Trinidad (n= 150) reported that 80.7% of participants use Annona muricata, especially in prostate, breast and colorectal cancer (CRC) patients [9]. In addition, another similar cross-sectional study in Jamaica reported that nearly 60% (n = 100) of participants used Annona muricata as a complement to standard therapy mainly in breast and prostate cancer, as well as other types of cancer [10].

Annona muricata has shown promising potential in the treatment of cancer. Its leaves are also known as “cancer killers” due to their possible anticancer effects [11]. Annonaceous acetogenins, which are derivatives of long-chain fatty acids, are the major bioactive components in Annona muricata that exhibit selective toxicity to cancer cells, including those that are multidrug-resistant [12]. Acetogenins are natural compounds that exert anticancer effects by inducing tumour cell death via various mechanisms such as controlling the cell cycles (causing cell arrest in the G1 phase), and promoting apoptosis by inhibiting multiple proteins while also inducing autophagy [13].

Most previous systematic reviews on Annona muricata havereported studies performed in-vitro and in-vivo. These systematic reviews have addressed the anticancer, antibacterial, anti-inflammatory, and hypoglycaemic properties of Annona muricata. Although studies have been done on the effects of Anonna muricata on cancer patients, no systematic review has been solely dedicated to compiling studies on humans with cancer. Thus, the goal of this review is to summarise the effects of Annona muricata and explore its potential mechanisms of action and safety for cancer patients.

MATERIALS AND METHODS

The protocol for this systematic review has been registered on PROSPERO with the registration number CRD42022315081. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [14]. The Population, Intervention, Control, and Outcomes (PICO) framework was utilised to provide a structured framework for the review [15]. The population of interest is all adult patients with cancer, and the intervention of interest is the administration of Annona muricata. Studies must report a control arm receiving usual therapy or placebo and any reported outcomes are of interest.

Literature search

A systematic search was performed in the following electronic databases from inception until February 2022: 1) Medical Literature Analysis and Retrieval System Online (MEDLINE), 2) Cochrane library, 3) Excerpta Medica Database (EMBASE), 4) ClinicalTrials.gov, and 5) World Health Organisation (WHO) Trials Portal. Searches were also done in Google scholar, OpenGrey (www.opengrey.eu) and grey literature reports (www.greylit.org). The keywords applied were (“Annona muricata” OR Soursop OR Graviola OR Guyabano OR Guanabana OR Sirsak OR “Durian Belanda”) AND (Cancer OR Tumor OR Tumour OR Malignancy OR Malignant OR Neoplasm). One reviewer (MTA) conducted the systematic search, and two reviewers (MTA and KA) reviewed the included articles. Study authors were not contacted for additional non-published data.

Study eligibility

Studies were included if they met the following inclusion criteria: 1) Human intervention studies (including clinical trials and observational studies), 2) Participants over 18 years old with any type of cancer, 3) Intervention using Annona muricata in any form, at any dose, and in a single formulation or combination, 4) Published in English, and 5) Published from inception until the current date (February 2022).

Data extraction

Two reviewers (MTA and KA) independently reviewed the titles and abstracts of the potentially eligible studies to assess if they fulfilled the selection criteria. During each stage of reviewing and assessing eligibility, papers that met any of the following criteria were excluded: 1) Non-clinical trials, 2) Review papers, conference abstracts, book chapters, and duplicate studies, and 3) Studies examining the effect of Annona muricata not related to cancer. Any disagreements were resolved through discussion with a third reviewer (NJ). Relevant data from the included studies were extracted by two reviewers (MT and KA), including the following details: 1) Study details (first author, year of publication, country), 2) Study design, 3) Population, 4) Intervention group details (form, dosage), 5) Control group details, and 6) Outcome measures.

Risk of bias

Each study’s quality was assessed using the revised Cochrane Risk of Bias (RoB-2) Tools [16] for randomised controlled trial, with bias assessed as high, low, or some concern. For non-randomised studies of intervention, the ROBINS-I tool was used, with bias assessed as low, moderate, serious, critical, or no information [17].

Data analysis

Sufficient data could not be obtained to permit a meta-analysis, as no similar outcome was reported twice. Thus, only a narrative synthesis was conducted for the systematic review. Reported study outcomes were extracted and discussed according to similar subthemes: 1) Effect of Annona muricata in different types of cancer, 2) Possible mechanisms of action of Annona muricata on cancer, 3) Safety of Annona muricata for patient with cancer, and 4) Limitations of the included studies.

RESULTS AND DISCUSSION

Result of search

The electronic databases searches resulted in 516 relevant papers under consideration. Forty-one were duplicates, and were excluded from further review. The titles and abstracts of 475 papers were screened for potential relevance, excluding 464 for being irrelevant to the review. Eleven full-text papers were obtained and evaluated, resulting in exclusion of six papers (two case reports [12][38], two non-human trials [39][40], one not involving cancer patients [41], and one ongoing trial [42]. Five studies fulfilled all eligibility criteria and were included in the review. Meta-analyses could be conducted due to the differences in the outcome measures.

Characteristics of Included Studies

The five trials were included a total of 273 participants [18][19][20][21][22]. Table Ⅰ provides additional details on the characteristics of the studies included.

All four randomised controlled trials were conducted in Indonesia, whereas one observational study was conducted in Italy. Participants in all trials were enrolled from outpatient clinics and included both sexes. Baseline demographic characteristics were balanced between the intervention and comparison groups in three randomised controlled trials [19][20][21] and one observational study [22], whereas one randomised controlled trial [18] did not report demographic characteristics.

Four of the studies included were randomised double-blind controlled trials [18][19][20][21], which involved patients with colorectal cancer. In contrast, one study was a prospective observational, non-randomised study which included patients with invasive bladder cancer [22].

For all five studies, the intervention was Annona muricata extract given orally. In one trial with 162 participants [22], the intervention group received a combination of Annona muricata and ellagic acid with a dose of 100 mg per day, whereas 111 participants in other four trials received an ethanol-soluble fraction of Annona muricata (ESFAM) leaves in the form of capsules at a dose of 300 mg per day [18][19][20][21]. Among the five trials, one was conducted over a period of six months [22] and four trials lasted for eight weeks [18][19][20][21]. Four of the five trials used a placebo in the capsule form containing maltose [18][19][20][21], whereas one trial did not have a placebo in the control group [22].

Risk of Bias in Included Studies

The risk of bias assessment for randomised controlled trials is shown in Figure Ⅱ(a) and Ⅱ(b). Figure Ⅱ(a) presents studies assessed as having low, some concern or high risk of bias for each indicator. Figure Ⅱ(b) shows the risk of bias indicators for individual studies. The assessment of the risk of bias for the observational study is shown in Table II which is assessed as low, moderate, serious, critical or no information.

Four trials were assessed using RoB-2 tools, and the overall risk of bias for all four trials was high, as there were domains judged as high risk of bias [18][19][20][21].

Table Ⅰ. Characteristics of included studies

Authors	Country	Study Design	Population	Annona muricata form/ route/ dose	Control	Outcome Measure
Indrawati et al., (2016a) [18]	Indonesia	Randomised Double-Blind Placebo-Controlled Trial	30 patients with colorectal cancers; 15 in treated group, 15 in control group	Form: Capsule Route: Oral Dose: 300mg ethanol-soluble fraction of Annona muricata Leaves (ESFAM) after breakfast daily Duration: 8 weeks	Maltose in the form of capsule	1. Cytotoxicity 2.Caspase activity
Indrawati et al., (2016b) [19]	Indonesia	Randomised Double-Blind Placebo-Controlled Trial	30 patients with colorectal cancers; 15 in treated group, 15 in control group	Form: Capsule Route: Oral Dose: 300mg ethanol-soluble fraction of Annona muricata Leaves (ESFAM) after breakfast daily Duration: 8 weeks	Maltose in the form of capsule	Organ function by measuring metabolic profile and blood count test
Indrawati et al., (2017) [20]	Indonesia	Randomised Double-Blind Placebo-Controlled Trial	30 patients with colorectal cancers; 15 in treated group, 15 in control group	Form: Capsule Route: Oral Dose: 300mg ethanol-soluble fraction of Annona muricata Leaves (ESFAM) after breakfast daily Duration: 8 weeks	Maltose in the form of capsule	1. Cytotoxicity 2. Nutritional status
Surono et al., (2017) [21]	Indonesia	Randomised Double-Blind Placebo-Controlled Trial	30 patients with colorectal cancers; 15 in treated group, 15 in control group	Form: Capsule Route: Oral Dose: 300mg ethanol-soluble fraction of Annona muricata Leaves (ESFAM) after breakfast daily Duration: 8 weeks	Maltose in the form of capsule	1. Concentration of TNF-a, IFN-y, and interleukin-IO (IL-10). 2. Concentration of Cyclooxygenase-2 (COX-2) level serum concentration
Serretta et al., (2022) [22]	Italy	Prospective observational non-randomised study	162 patients with non-invasive muscle bladder; 90 in treated group, 72 in control group	Form: Not mentioned Route: Oral Dose: Ellagic Acid 100mg and Annona muricata 100mg Duration: 6 months	No placebo	1. Recurrence-Free Rate 2. Recurrence-Free Survival

All four trials were judged as high risk of bias for the randomisation process due to inadequate concealment of the allocation sequence, as there were no details provided on the randomisation process. Additionally, three of the trials exhibited an unusually high degree of similarity in baseline characteristics that is unlikely to occur by chance [19-21]. One of the trials did not mention the baseline characteristics [18]. Three trials were judged as having high risk of bias for deviation from intervention and missing outcome data, as two trials provided data that did not match with the total data [18][19][20], and one trial had discrepancies in the number of dropouts [21]. All four trials [18][19][20][21] were assessed as having some concerns of bias in the selection of reported results, as there were no details provided on whether the reported results were chosen from several eligible outcome measures within the outcome domain or from various eligible analyses of data.

One study [22] was assessed using ROBIN-I tools, and the overall risk of bias was assessed as critical, as one domain being judged as critical.

Cytotoxicity effect: Inhibitory effects on cancer cells

Possible mechanism of action

Annona muricata is capable of inhibiting cancer cell growth possibly through several pathways, such as inhibiting the signaling pathways of the eGFR receptor and disrupting  the regulation of the cell cycle, which leads to cell cycle arrest and inhibits cell proliferation [22]. Active component of Annona muricata, including ethyl acetate and n-butanol fractions, exhibit activity that inhibits pancreatic lipase, α-amylase, and α-glucosidase. In addition, acetogenins can inhibit mitochondrial ATP formation and suppress cancer cell growth by facilitating the nuclear translocation of apoptosis-inducing factor (AIF) and promoting AIF-dependent cell death [44].

Table Ⅱ. Assessment of study quality for the observational study (N= 11 Patients)

Details	Impact
Author	Serretta et al., (2022) [22]
Confounding	Serious
Selection of participants	Serious
Classification of intervention	Moderate
Deviation from intended interventions	Low
Missing data	Serious
Measurement of outcomes	Critical
Selection of reported results	Low
Overall	Critical

Findings from included studies

Two randomised controlled trials [18][20] demonstrated cytotoxicity effect, as the ethanol-soluble fraction of Annona

muricata (ESFAM) leaves extract had a lower IC₅₀ than fluorouracil (5-FU) and placebo [18]. In addition, ESFAM demonstrated significant reduction in the growth of the DLD-1 colorectal cancer cell line (p=0.013) after ESFAM administration, compared to before the treatment, whereas no significant changes in growth inhibition were observed in the placebo group before and after administration (p= 0.86). 97% of serum from the ESFAM group inhibited one or more of the colorectal cell lines, in contrast to 58.3% in the placebo group [20].

Findings from previous studies

These results are similar to several previous in-vitro and in-vivo studies showing significant inhibition of growth in other cancer cell lines, such as HT-29 cells [24] and A549 cells [25].

Cytotoxicity effect: Apoptosis of cancer cells

Possible mechanism of action

Caspases are regulatory factors responsible for the cell’s apoptosis and are classified based on their function. Caspases -2, -8, -9, and -10 play a central role in regulating the initiation of apoptosis, while caspases -3, -6, and -7 function as executioners in the apoptosis process [25]. Caspase-9 plays a crucial role in the intrinsic pathway, namely the mitochondrial-mediated pathway, whereas caspase -8 and -10 work through the extrinsic pathway, namely the death receptor-mediated pathway. These caspase trigger caspases -3, -6, and -7, leading to apoptosis [26].

The active component Annomuricin E in Annona muricata has been reported to induce apoptosis through a cascade of caspases. Annomuricin E causes a reduction in mitochondrial membrane potential (MMP), which results in the opening of mitochondrial permeability transition pores and the subsequently release of pro-apoptotic proteins like cytochrome C. This process results in the formation of the apoptosome and the activation of caspase -9 and caspase -3 or -7, which are implicated in the mitochondrial death pathway [45].

Findings from included studied

One trial measured the caspase activity of Annona muricata on cancer cell [18] and reported that caspase activity in the DLD-1 cell line was higher when treated with ESFAM extracts compared to 5-FU. Their ex vivo experiment showed ESFAM extract significantly enhanced caspase-9 activity (p= 0.001) of DLD-1 cell line.

Findings from previous studies

A similar in-vitro study found that Annona muricata elevated caspase-3 activity compared to leucovorin and placebo [27].

Cytotoxicity effect: Selective cytotoxicity against cancer cells

Possible mechanism of action

Annona muricata exhibits selective cytotoxicity against cancer cells by blocking ATP production in mitochondria. Cancer cells generate more ATP than normal cells;, therefore Annona muricata limits the ability of cancer cells to grow without affecting healthy cells [28]. 

Acetogenin activity in the mitochondrial complex I electron transport chain inhibits ATP production, thereby inhibiting the growth of cancer cells. This molecular mechanism effectively targets cancer cells, which produce more ATP than normal cells, therefore inhibiting cancer cell growth [44][46].

Findings from included studies

One of the trials [20] reported that the ESFAM group showed a significant increase in HEK cells (p=0.006) compared to the placebo group, exhibiting significant selective cytotoxic activity against HEK cells compared to baseline (p=0.04). Serum from the ESFAM group resulted in a 72% increase in normal HEK cells, compared to just 14.3% in the placebo group.

Findings from previous studies

These findings correspond with previous systematic reviews of in-vitro and in-vivo studies, which also found that Annona muricata selectively inhibits growth against various cancer cells, leaving normal host cells unaffected [29]. One mouse study reported that Annona muricata significantly inhibited the growth of MDA-MB-468 cell lines, with an IC₅₀ of 4.8 μg/ml, while showing no effect on MCF-10 cell lines [30].

Anti-inflammatory effect

Possible mechanism of action

Annona muricata also exhibit potent anti-inflammatory effects by activating the anti-inflammatory pathway through the prostaglandin synthesis pathway [31]. Chronic exposure to inflammatory markers can have pleiotropic effects on cancer development, facilitating carcinogenesis, tumour growth, and metastatic spread [32].

Inflammation is triggered through cyclooxygenase (COX) and lipoxygenase (LOX) pathways when a cell responds to mechanical trauma, cytokines, or other stimuli. Ethanolic and hydroalcoholic extracts of Annona muricata have been shown to produce an antinociceptive effect in both neurogenic and inflammatory phases, likely through inhibition of COX and LOX. Other than that, the seeds of Annona muricata contain amide N-p-coumaroyl tyramine and cyclopeptides, which have anti-inflammatory properties [45].

Findings from included studies

Annona muricata shows anti-inflammatory response, as Tumour Necrosis Factor-a (TNF-a) and Interleukin-10 (IL-10) showed a significant moderate linear correlation in the Annona muricata group after administration of the extract (R 0.64, p= 0.01) but not in the placebo group (p= 0.12). Furthermore, IFN-y and IL-10 showed a significant low linear correlation in Annona muricata group (R 0.47, p= 0.05) but not in placebo group (p= 0.07) [21].

Findings from previous studies

Similarly, in-vitro studies on RAW264.7 cell lines reported that the Annona muricata group had lower levels of TNF-a, IL-1B, IL-6, and nitric oxide levels than untreated cells [32],showing Annona muricata can inhibit inflammatory mediators.

Effect on cancer recurrence

Findings from included studies

One of the studies [22] examined the effect of Annona muricata on recurrence-free rate and recurrence-free survival. The recurrence-free rate (RFR) was better in participants consuming a combination of ellagic acid and Annona muricata (EA+AM) at 3 and 6 months: 96.5% versus 84.6% (p=0.003) and 85.4% versus 64.8% (p=0.005), respectively. In contrast, the recurrence-free survival (RFS) was better at 12 months in patients consuming EA+AM. (63.0% versus 34.5%，p<0.0001).

Finding from previous studies

These results are similar to a mouse study [34] that reported Annona muricata’sability to significantly reduce croton oil-induced mice skin papillomagenesis in a dose-dependent manner (p< 0.05), suggesting that Annona muricata can suppress cancer cells initiation and promotion.

Safety and adverse effect of Annona muricata on patients with cancer

Effect on bone marrow function

Finding from included studies

Baseline and end-line haematological parameters, such as platelets, erythrocytes, leukocytes, and haemoglobin, showed no significant differences between the Annona muricata group and the placebo group before and after administration, with all parameters remaining within the normal range (p>0.05 for all parameters) [19][21]. Haemoglobin concentrations before and after consuming Annona muricata were within a normal range, with no statistical difference between them (p= 0.582). There were also no statistically difference in haemoglobin concentration when comparing the Annona muricata group with the placebo group from baseline to endpoint (p= 0.88) [20]. Thus, Anonna muricata did not reduce bone marrow function.

Findings from previous studies

These findings were similar to an in-vivo study on mice, which showed no significant difference in haematological parameters between the Annona muricata group (with dose up to 2500mg/kg) and the placebo group [35].

Effect on liver and kidney function

Findings from included studies

Baseline and end-line biochemical parameters, such as ALT, AST, albumin, and C-reactive protein, were within the normal range, with no significant differences between the Annona muricata group and the placebo group before and after administration (p> 0.05 in all parameters) [19][21], showing that Annona muricata did not induce hepatotoxicity and nephrotoxicity.

Findings from previous studies

The findings were consistent with a previous systematic review involving in-vitro and in-vivo studies, where most studies investigating the effects on liver and kidney function reported the hepatoprotective and nephroprotective effects of Annona muricata [36].

Effect on nutritional status

Supplementation with Annona muricata showed no body weight loss or decrease in nutritional intake, indirectly suggesting an absence of detrimental effects. Energy intake in the Annona muricata group showed a significant increase at week 8 (1787.55±620.2 kcal) compared to week 4 (1544.31±560.43 kcal, p= 0.04) and week 6 (1596.6±531.11 kcal, p= 0.02). The placebo group showed no statistical difference in energy intake throughout the eight weeks [20].

Adverse effect

The 300mg ESFAM dose was found to be safe and highly tolerable, with only 6.7% participants experiencing severe adverse effects [19]. In addition, one study [22] reported that no grade 3 – 4 toxicity associated with Annona muricata. However, two patients (2.2%) suffered from grade 2 gastrointestinal disorders, and three patients (3.3%) complained of grade 2 headache.

Limitation of included studies

While all the studies show promising potential effects of Annona muricata, many were  at high or critical risk of bias, warranting caution in interpreting the result. Thus, the evidence is neither complete nor universally applicable, making it challenging to draw definitive conclusions.

All controlled trials recruited small study population (range, N= 25-162), which may not be sufficient for solid conclusions. The studies included [18][19][20][21] did not report on the sample size required. increasing the risk of bias and potentially affecting the precision and power of the results. Thus, more extensive studies are required to confirm the findings, with sample sizes reflecting the broader population.

In addition, the randomisation processes were not adequately explained in all four randomised controlled trials [18][19][20][21] One trial [18] did not declare baseline characteristics, raising doubt about the asequacy of the blinding process. In one observational study [22], the selection criteria for the intervention group posed a serious risk of bias, as  participants were selected solely based on their acceptance, with no maintenance of the control group, which might affect the overall results.

Other than that, most studies did not report matched data from the recruited samples, raising concerns about the risk of bias in the reported results [18][19][20][21]. There were also no explanations provided for participants who did not complete the studies.

All four randomised controlled trials [18][19][20][21] used ex-vivo studies to extract serum from the samples and measure the effects using a cell lines, which might not accurately reflect the actual effects on the human body. Information on the phytochemical bioavailability and pharmacodynamics of the compounds in the human body is also limited. Further pharmacodynamics studies are needed to understand better how Annona muricata act on the body.

There are no studies on the optimal dose of Annona muricata in humans. The doses used were extrapolated from traditional consumption amount. In addition, one study [22] used a much lower dose than the others. Even though all included studies reported that the doses given were safe with minimal side effects and demonstrated positive effects, the dosage might not be sufficient to achieve maximal therapeutic effects. One randomised clinical trial [18] reported that the serum concentration might have been too low to significantly increase caspase-8 activity, accounting for only 10% in the cell culture media, which may have contributed to the reported results, indicating that the provided dose might be insufficient. A systematic review on the safety and tolerability of Annona muricata leaf extract found that chemopreventive effects of Annona muricata were observed in four in-vivo studies using ethanolic and methanolic leaf extracts administered at doses ranging from 30–400 mg/kg [36]. In addition, in-vivo studies showed that the LD₅₀ of ethanolic extract of Annona muricata ranged from 1000mg/kg to 1670mg/kg [36]. Considering the tolerable dosesused in in-vivo studies, future studies should explore the optimal dose of Annona muricata in humans to ensure maximal therapeutic effect with minimal side effects. 

Besides, all studies were conducted over a short period. The safety effects of Annona muricata should be evaluated across various types of cancers over a duration longer than the lifespan of human cells, such as red blood cells, which survive in circulation for approximately 115 days [37]. Thus, more accurate results regarding the safety of Annona muricata can be obtained if studies were done over a period extending beyond the lifespan of human cells. 

Limitation of this review

Regarding this systematic review, the major strength is its adherence to systematic review guidelines and a thorough quality assessment of the selected studies.  However, the limitations of our systematic review include the inclusion of only studies published in English with full-text availability. Expanding the search to non‐English literature might have yielded additional relevant studies.

In addition, even though the search was thorough, involving 516 initial abstracts from 6 primary databases, it is a possiblr that articles published in foreign languages or less accessible journals were missed.

The high or critical risk of bias in all included studies, along with the inability to perform a meta-analysis due to differences in outcome measures, makes it challenging to draw conclusions from the current evidence.

CONCLUSION

Annona muricata, known traditionally as an anticancer agent, has only recently been the subject of appropriate scientific research regarding its effects.

This systematic review has identified that Annona muricata extracts exhibits beneficial effect on cancer, demonstrating cytotoxicity effect through inhibitory effect, apoptosis, and selective killing of cancer cells without affecting normal cells. Additionally, it has anti-inflammatory effects by activating the anti-inflammatory pathway through the prostaglandin synthesis pathway. Annona muricata extracts are considered safe for cancer patient, as they do not interfere with bone marrow, liver or kidney function, and may even improve nutritional status, with few adverse effects, none exceeding than grade 2 toxicities. However, the absence of high-quality studies, and incomplete evidence pose challenges in drawing conclusive statements. More research is required to validate the efficacy and safety of Annona muricata, enabling more definitive evidence-based recommendations. 

ACKNOWLEDGEMENT

No funding was received, and no further acknowledgments are declared.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

REFERENCE

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. Epub 2018 Sep 12; Erratum in: CA Cancer J Clin. 2020 Jul;70(4):313. https://doi.org/10.3322/caac.21492
2. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May; 71(3): 209-249. https://doi.org/10.3322/caac.21660
3. Mohd Baidi Bahari and Saw June Tze. Predictors of Herbal Utilization by Multiethnic Secondary Care Patients in Malaysia: a Cross Sectional Survey. Mal J Pharm 2011; 325-335. http://dx.doi.org/10.52494/LEML5968
4. Yin SY, Wei WC, Jian FY, Yang NS. Therapeutic applications of herbal medicines for cancer patients. Evid Based Complement Alternat Med. 2013;302426. Epub 2013 Jul 11. https://doi.org/10.1155/2013/302426
5. Sulaiman. Amal, Ayub. Fiza, Rabbani. Imtiaz, Lee. Kah, Goh. Khang Wen, Nadeem. Muhammad Faisal et al. Price variation among registered brands of anti-cancer medicines available in Pakistan. Mal J Pharm. 2022; 8:42-56. http://dx.doi.org/10.52494/EXVW6975
6. Liu W, Yang B, Yang L, Kaur J, Jessop C, Fadhil R, et al. Therapeutic Effects of Ten Commonly Used Chinese Herbs and Their Bioactive Compounds on Cancers. Evid Based Complement Alternat Med. 2019. https://doi.org/10.1155/2019/6057837
7. Badrie, N., & Schauss, A. G. Chapter 39 – Soursop (Annona muricata L.): Composition, Nutritional Value, Medicinal Uses, and Toxicology. Bioactive Foods in Promoting Health. Academic Press. 2010; 621-643 http://dx.doi.org/10.1016/B978-0-12-374628-3.00039-6
8. Pinto AC de Q (ed.). Annona species. International Centre for Underutilised Crops, University of Southampton, 2005; ISBN: 0854327851.
9. Clement YN, Mahase V, Jagroop A, Kissoon K, Maharaj A, Mathura P, et al. Herbal remedies and functional foods used by cancer patients attending specialty oncology clinics in Trinidad. BMC Complement Altern Med. 2016 Oct 21;16(1):399. https://doi.org/10.1186/s12906-016-1380-x
10. Foster K, Younger N, Aiken W, Brady-West D, Delgoda R. Reliance on medicinal plant therapy among cancer patients in Jamaica. Cancer Causes Control. 2017 Nov;28(11):1349-1356. https://doi.org/10.1007/s10552-017-0924-9
11. Yajid AI, Ab Rahman HS, Wong MPK, Wan Zain WZ. Potential Benefits of Annona muricata in Combating Cancer: A Review. Malays J Med Sci. 2018 Feb;25(1):5-15. https://doi.org/10.21315/mjms2018.25.1.2
12. Hansra, D., Silva, O., Mehta, A., & Ahn, E. Patient with Metastatic Breast Cancer Achieves Stable Disease for 5 Years on Graviola and Xeloda after Progressing on Multiple Lines of Therapy. Adv. Cancer Res, 2014; 03, 84-87. http://dx.doi.org/10.4236/abcr.2014.33012
13. Jacobo-Herrera N, Pérez-Plasencia C, Castro-Torres VA, Martínez-Vázquez M, González-Esquinca AR, Zentella-Dehesa A. Selective Acetogenins and Their Potential as Anticancer Agents. Front Pharmacol. 2019 Jul 18;10:783. https://doi.org/10.3389/fphar.2019.00783
14. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. https://doi.org/10.1136/bmj.n71
15. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007 Jun 15;7:16. https://doi.org/10.1186/1472-6947-7-16
16. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019. https://doi.org/10.1136/bmj.l4898
17. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, er al: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016. https://doi.org/10.1136/bmj.i4919
18. Indrawati, L., Purwantyastuti, A., Budiman, B., Abdullah, M., Surono, I. S., & Suwijiyo, P. Antiproliferative activity and caspase enhancement properties of Annona muricata leaves extract against colorectal cancer cells [Academic Journal]. Med. J. Indones, 2016; 25(3), 136‐142. https://doi.org/10.13181/mji.v25i3.1449
19. Indrawati, L., Purwantyastuti, P., Abdullah, M., Surono, I. S., & Basir, I. Safety of Annona muricata extract supplementation for colorectal cancer patients. The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy, 2016; 17(3), 170-175. http://dx.doi.org/10.24871/1732016170-175
20. Indrawati, L., Ascobat, P., Bela, B., Abdullah, M., & Surono, I. S. The effect of an Annona muricata leaf extract on nutritional status and cytotoxicity in colorectal cancer: a randomized controlled trial [Journal Article; Randomized Controlled Trial]. Asia Pac J Clin Nutr, 2017; 26(4), 606‐612. https://doi.org/10.6133/apjcn.062016.02
21. Surono, I. S., Lienggonegoro, L. A., Indrawati, L., & Wibowo, H. Inflammatory response of Annona muricata Linn leaves extract in colorectal cancer patients. J Global Pharma Technol, 2017; 9(7 Suppl), 150-157.
22. Serretta V, Berardinis E, Simonato A, Guarneri A, Dispensa N, Pavone C, et al. A prospective observational study on oral administration of Ellagic Acid and Annona muricata in patients affected by non-muscle invasive bladder cancer not undergoing maintenance after 6-week intravesical prophylaxis. Urologia. 2022 Feb;89(1):49-52. https://doi.org/10.1177/03915603211022285
23. Rady I, Bloch MB, Chamcheu RN, Banang Mbeumi S, Anwar MR, Mohamed H, et al. Anticancer Properties of Graviola (Annona muricata): A Comprehensive Mechanistic Review. Oxid Med Cell Longev. 2018 Jul 30; 2018:1826170. https://doi.org/10.1155/2018/1826170
24. Zorofchian Moghadamtousi S, Rouhollahi E, Karimian H, Fadaeinasab M, Firoozinia M, Ameen Abdulla M, Abdul Kadir H. The chemopotential effect of Annona muricata leaves against azoxymethane-induced colonic aberrant crypt foci in rats and the apoptotic effect of Acetogenin Annomuricin E in HT-29 cells: a bioassay-guided approach. PLoS One. 2015 Apr 10;10(4). https://doi.org/10.1371/journal.pone.0122288
25. Moghadamtousi SZ, Kadir HA, Paydar M, Rouhollahi E, Karimian H. Annona muricata leaves induced apoptosis in A549 cells through mitochondrial-mediated pathway and involvement of NF-κB. BMC Complement Altern Med. 2014 Aug 15;14:299. https://doi.org/10.1186/1472-6882-14-299
26. Olsson M, Zhivotovsky B. Caspases and cancer. Cell Death Differ. 2011 Sep;18(9):1441-9. https://doi.org/10.1038/cdd.2011.30
27. Pistritto G, Trisciuoglio D, Ceci C, Garufi A, D’Orazi G. Apoptosis as anticancer mechanism: function and dysfunction of its modulators and targeted therapeutic strategies. Aging (Albany NY). 2016 Apr;8(4):603-19. https://doi.org/10.18632/aging.100934
28. Abdullah M, Syam AF, Meilany S, Laksono B, Prabu OG, Bekti HS, et al. The Value of Caspase-3 after the Application of Annona muricata Leaf Extract in COLO-205 Colorectal Cancer Cell Line. Gastroenterol Res Pract. 2017;2017:4357165.
29. Waechter, A.-I., Hocquemiller, R., Laurens, A., & Cavé, A. Glaucafilin, an acetogenin from Annona glauca. Phytochemistry, 1997, 44(8), 1537-1540. https://doi.org/10.1155/2017/4357165
30. Ioannis, P., Anastasis, S., & Andreas, Y. Graviola: A Systematic Review on Its Anticancer Properties. Am. J. Cancer Prev, 2015, 3(6), 128-131. https://pubs.sciepub.com/ajcp/3/6/5
31. Dai Y, Hogan S, Schmelz EM, Ju YH, Canning C, Zhou K. Selective growth inhibition of human breast cancer cells by graviola fruit extract in vitro and in vivo involving downregulation of EGFR expression. Nutr Cancer.2011;63(5):795-801. https://doi.org/10.1080/01635581.2011.563027
32. Abdul Wahab SM, Jantan I, Haque MA, Arshad L. Exploring the Leaves of Annona muricata L. as a Source of Potential Anti-inflammatory and Anticancer Agents. Front Pharmacol. 2018 Jun 20;9:661. https://doi.org/10.3389/fphar.2018.00661
33. Multhoff G, Molls M, Radons J. Chronic inflammation in cancer development. Front Immunol. 2012 Jan 12;2:98. https://doi.org/10.3389/fimmu.2011.00098
34. Laksmitawati, D., Prima, A., Larasinta, N., Syauta, G., Hilda, R., Ramadaniati, H., et al. Anti-Inflammatory Potential of Gandarusa (Gendarussa vulgaris Nees) and Soursoup (Annona muricata L) Extracts in LPS Stimulated-Macrophage Cell (RAW264.7). J. Nat. Remedies, 2016; 16: 73-81. http://dx.doi.org/10.18311/jnr/2016/5367
35. Hamizah S, Roslida AH, Fezah O, Tan KL, Tor YS, Tan CI. Chemopreventive potential of Annona muricata L leaves on chemically-induced skin papillomagenesis in mice. Asian Pac J Cancer Prev. 2012;13(6):2533-9. https://doi.org/10.7314/apjcp.2012.13.6.2533
36. Arthur, F., Terlabi, B., Larbie, C., & Woode, E. Evaluation of acute and subchronic toxicity of Annona muricata (Linn.) aqueous extract in animals. European Journal of Experimental Biology, 1, 115. 2015
37. Chan WJ, McLachlan AJ, Hanrahan JR, Harnett JE. The safety and tolerability of Annona muricata leaf extract: a systematic review. J Pharm Pharmacol. 2020 Jan;72(1):1-16. https://doi.org/10.1111/jphp.13182
38. Franco RS. Measurement of red cell lifespan and aging. Transfus Med Hemother. 2012 Oct;39(5):302-7. https://doi.org/10.1159/000342232
39. Gunasekaran SS, Emmadi R, Landers LA, Gaba RC. Regression of Hepatocellular Carcinoma Lung Metastases after Guyabano Fruit Extract Consumption. J Diet Suppl. 2016;13(3):237-44. https://doi.org/10.3109/19390211.2015.1008613
40. Lee M-S. Evaluation of Antioxidant and Anticancer Activity of Guarana and Graviola in Human Colon Cancer. Journal of KOEN. 2019;13(1):217-23. http://doi.org/10.21184/jkeia.2019.1.13.1.217
41. Yuniarti, L., Sastramihardja, H. S., Purbaningsih, W., Tejasari, M., Respati, T., Hestu, E., et al, A. Soursop effect in cervical cancer apoptosys mechanism. Glob. Health Commun. 2014;2(1):6-14. https://doi.org/10.29313/gmhc.v2i1.1524
42. Morosetti G, Criscuolo AA, Santi F, Perno CF, Piccione E, Ciotti M. Ellagic acid and Annona muricata in the chemoprevention of HPV-related pre-neoplastic lesions of the cervix. Oncol Lett. 2017 Mar;13(3):1880-1884. https://doi.org/10.3892/ol.2017.5634
43. Study of Guanábana Leaves for The Treatment of Patients With Gastric, Gastroesophageal Junction, Pancreatic and Colorectal Adenocarcinomas; Hepatocellular Carcinoma, and Low Grade Lymphomas. Clinical Study ID: NCT04773769, CCAM 18-01
44. Ilango S, Sahoo DK, Paital B, Kathirvel K, Gabriel JI, Subramaniam K, et al. A Review on Annona muricata and Its Anticancer Activity. Cancers (Basel). 2022 Sep 19;14(18):4539. https://doi.org/10.3390/cancers14184539
45. Gavamukulya Y, Wamunyokoli F, El-Shemy HA. Annona muricata: Is the natural therapy to most disease conditions including cancer growing in our backyard? A systematic review of its research history and future prospects. Asian Pac J Trop Med. 2017 Sep;10(9):835-848. https://doi.org/10.1016/j.apjtm.2017.08.009
46. Mutakin M, Fauziati R, Fadhilah FN, Zuhrotun A, Amalia R, Hadisaputri YE. Pharmacological Activities of Soursop (Annona muricata Lin.). Molecules. 2022 Feb 10;27(4):1201. https://doi.org/10.3390/molecules27041201