The Basis on Which I Select Formulas and Herbs for Cancer Patients—Reflections on TCM Cancer Research by Zhou Zhiyuan, Part 2

For a physician who treats disease with oral formulas and herbs, the basis on which he selects formulas and herbs is crucial.

According to traditional TCM theory, treating disease follows the sequence of "principle, method, formula, and herb" (li-fa-fang-yao).

After observing, listening-questioning, and palpating a patient, one analyzes the illness according to medical principle using the information gathered from the four examinations, selects a treatment method, picks the formula that matches the syndrome, and decides whether to add or remove herbs based on the patient's specific condition. This is the TCM process of diagnosis and of selecting formulas and herbs.

Most crucial among these is the principle of selecting formulas and herbs, which traditional TCM sums up as "treatment based on pattern differentiation" (bianzheng lunzhi) and "treatment based on disease differentiation" (bianbing lunzhi).

So then: what is a "pattern" (zheng)? What is a "disease" (bing)?

In the latest edition of the Basic Theory of Traditional Chinese Medicine, a planned textbook for the "13th Five-Year Plan" of national higher TCM education, the basic concepts of symptom, pattern and disease are defined as follows:

A symptom (zhengzhuang) is a symptom or sign—an abnormal manifestation that appears when the body falls ill, including the abnormal sensations reported by the patient and the various signs diagnosed by the doctor. For example, aversion to cold with fever, nausea and vomiting, irritability and irascibility, the tongue coating, and the pulse all belong to the concept of symptom.

A symptom is the main basis for judging disease and identifying the pattern. But it manifests the surface appearance, even the false appearance, of disease, and so it may not fully reflect the essence of the disease or pattern. The same symptom may be caused by different pathogenic factors, with different disease mechanisms, and may appear in different diseases and patterns. An isolated symptom or sign cannot reflect the essence of a disease or pattern, and thus cannot serve as a basis for treatment.

A pattern (zheng) is a summary of the essence of the disease mechanism at a certain stage of the disease process—the cause, location, nature, and tendency of the illness. For example, a spleen-stomach deficiency pattern has its disease location in the spleen and stomach and its nature as deficiency. A pattern is a summary of the disease mechanism; the disease mechanism is the inner essence of the pattern; the pattern reflects the essence of the disease.

A pattern manifestation (zhenghou), the outward sign of the pattern, refers to the organically connected reactive state of the disease location, cause, nature and tendency at a certain stage, expressed as clinically observable symptoms, generally constituted by a relatively fixed, internally connected set of symptoms and signs that reveal the essence of a lesion at a certain stage or of a certain type. For example, poor appetite and disinclination to eat, abdominal distension and loose stools, lassitude and fatigue, sallow complexion, a pale-red tongue with white coating, and a deep, moderate pulse are the pattern manifestations of spleen-stomach deficiency.

A pattern has the features of individual variation, phase, space, and dynamics.

A disease (bing), short for disease, refers to a complete abnormal life process with specific pathogenic factors, onset patterns, and disease-mechanism evolution, usually with relatively fixed clinical symptoms and signs, diagnostic criteria, and points of differentiation from similar diseases.

When pathogenic evil acts on the human body, the body's upright qi struggles against the evil, causing imbalance of yin and yang, damage to the form of the viscera, disorder of physiological function, or disturbance of mental activity, thereby expressing a complete life process. Throughout this process there constantly exists the contradictory struggle of injury, obstruction, repair, and regulation—the struggle between evil and upright qi.

A disease reflects the overall attributes, features, and laws that run through the whole course of a disease. For example, common cold, chest impediment, wasting-thirst, and accumulation/mass.

Symptom, pattern, and disease are both distinct and connected. Disease and pattern, though both understandings of the essence of disease, differ in focus: the disease reflects the basic contradiction running through the illness, while the pattern reflects the principal contradiction at the current stage. Symptoms and signs are the points from which we perceive disease and pattern, and the basic constituent elements of both.

Symptoms and signs with internal connection combine to form a pattern manifestation, reflecting the essence of a lesion at a certain stage or type. The patterns of the various stages, running through and overlapping one another, constitute the whole course of the disease. Thus a single disease may be composed of different patterns, and the same pattern may appear in different disease processes.

The several paragraphs above I have quoted verbatim from the standard textbook.

Treatment based on pattern differentiation and on disease differentiation, and even Zhang Zhongjing's "observe the pulse and signs, know what contrariety has occurred, and treat according to the pattern," are all guiding principles for the clinician in selecting formulas and herbs.

Traditional TCM lacked the sophisticated diagnostic equipment of modern medicine, so it could only "observe the exterior to know the interior"—through analysis of the series of symptoms, pulse, tongue, and other information the patient presents, decide what disease or pattern the patient has, and then decide which formula and which herbs to use.

Here is a big problem: what if the patient has no obvious symptoms? Many cancer patients feel nothing abnormal at all, and are only picked up by modern equipment during a physical. How do we select formulas and herbs for such patients?

Some fervent fans of TCM will say that one can rely on TCM pulse diagnosis to decide the medication. I can say responsibly: I have felt the pulses of so many cancer patients, and cancer has no typical pulse; among cancer patients every kind of pulse is seen.

I myself have no way to prescribe medication purely by pulse diagnosis. Not to mention that pulse-taking has always had the saying "the mind knows clearly, but beneath the fingers it is hard to make out"—that the pulse is hard to take accurately, or that the definitions of the various pulses are themselves vague, is a widespread phenomenon. Even if one could take the pulse accurately, prescribing purely on the basis of the pulse is an extremely difficult thing; I think it is very unreliable.

Pulse diagnosis can only serve as one reference in selecting formulas and herbs. Relying on pulse diagnosis alone works for some typical self-limiting diseases—for example, using Guizhi Tang for a floating, moderate pulse in a cold, or Mahuang Tang for a floating, tight pulse. Relying on pulse diagnosis alone to treat cancer would certainly be very dangerous.

There is another big problem: what if, after a period of Chinese and Western treatment, the patient's clinical symptoms have all disappeared, but the blood markers are abnormal and the imaging results abnormal? How do we select formulas and herbs then? And when the patient has recovered, the symptoms are gone, the blood picture is normal, and the tests are normal—how do we select formulas and herbs then?

In all these situations, following the TCM diagnostic principle of "observing the exterior to know the interior," it is very hard to determine what pattern or disease the patient has. If one cannot determine the pattern and disease, then neither treatment based on pattern differentiation nor treatment based on disease differentiation can get off the ground.

Nowadays many TCM doctors prescribe Chinese herbs directly according to modern medical test results, and according to the theories of modern pharmacology. As far as I know, the prescriptions written this way have an abysmal efficacy.

A key reason here is that, from ancient times to today, whether the drug effects recorded in the classics of Chinese medicine or those passed down among the folk, none are described in the terminology of modern medicine.

For example, fritillaria resolves phlegm and disperses nodules, tangerine peel moves qi, immature bitter orange breaks up accumulation and removes stagnation, licorice supplements qi and harmonizes the center. These effect terms have nothing to do with the corresponding actions described in modern pharmacology.

When we rely on modern pharmacology to say that a certain Chinese herb has anti-tumor or antioxidant effects, and use it to treat certain patients, ignoring what adverse reactions the patient will have after taking it, the result is that many patients are treated roughly: the Chinese-medicine prescription the doctor writes not only fails to solve their problem, but creates new ones.

For example, some patients believe that dandelion, Scutellaria barbata, and Oldenlandia fight cancer; the doctors in hospitals and many folk TCM doctors also believe these fight cancer, and nine out of ten anti-cancer formulas contain such herbs. As a result the patients take them and get diarrhea, or nausea, or rapidly weaken, and both doctor and patient are unclear about the side effects these drugs cause, blaming it on the illness itself.

With respect, treating cancer this way is worse than not treating it. Rather than receiving such chaotic treatment, the patient would be better off taking no medicine, eating and drinking well, and perhaps living a little longer.

I offer some views for readers' reference.

First, we must admit that TCM has major shortcomings in diagnostics. In the past, TCM, following the routines of pattern-differentiation and disease-differentiation treatment (though in fact the distinction between pattern and disease in traditional TCM is very vague), could mostly only treat acute and chronic diseases with obvious symptoms, or treat cancer patients in the symptomatic phase after the disease had entered the middle or late stage. When the patient has no obvious symptoms, it is hard to act.

Nowadays, with the times advancing, many diseases are diagnosed in the asymptomatic phase. Should we really wait until the patient develops symptoms before selecting formulas and herbs? Of course not. So should we select formulas and herbs according to the knowledge of modern pharmacology? No, not that either. Modern pharmacological knowledge can only serve as a reference. The key is still to find the basis for selecting formulas and herbs within the language system of Chinese medicine.

I believe we should select formulas and herbs according to the main symptom features of the same kind of disease, as compiled by big-data statistics; we may moderately refer to the knowledge of modern pharmacology, but we must absolutely be guided by the clinical effects of the Chinese formula and herb. Some patients have not yet developed symptoms only because the illness has not yet reached that stage; once it reaches that stage, the symptoms will all appear.

TCM's experience in solving certain problems of the human body was obtained through human experimentation on countless people's bodies; these human-trial data are extremely valuable. To abandon this experience and then expect the medicine to work is simply to climb a tree seeking fish.

And clinical TCM workers should not rigidly cling to the ancient traditions of pattern-differentiation and disease-differentiation treatment, marking time; nor should they randomly prescribe herbs according to vague pulses and metaphysical theories, or casually apply some "anti-cancer formula" to muddle through for the patient.

Tumor, as a special kind of disease, presents very typical symptoms; it is just that, when the tumor's location is atypical, or the tumor is still too small, these symptoms cannot yet manifest.

Traditional TCM mainly judges by results—it defines the nature and effect of a Chinese herb by the clinical symptoms it can relieve after use.

Only by taking this as the basis can we select the right formula and the right herb to solve the patient's problem.

I once treated a certain occupational-medicine expert. She was a well-known expert on detoxification and also a tumor patient. Although she had spent her whole life in Western clinical practice, after she herself developed lymphoma, she decisively chose pure TCM treatment. Because her main life's work was detoxification, she knew the toxic side effects of radiotherapy and chemotherapy too well and feared them too much.

During the time I treated her, she taught me a great deal of Western medical knowledge and her own clinical experience. Once she said to me that, in her early years, when she treated acute diseases such as meningitis in other departments, she diagnosed patients by experience, not by blood-test results. She said that when the blood test came back abnormal, those meningitis patients were already in a high-risk state, and many could not be saved.

So they did not look at blood-test results; relying on experience, as soon as they judged from the patient's symptoms that the patient was in the rapidly progressing state of meningitis, they acted at once. If they had waited another day or two, waiting for the blood test to confirm meningitis before treating, they would have missed the best chance to rescue the patient.

I have always remembered this experience of hers. When I face a patient with few symptoms, I predict, based on his condition, what symptoms he will develop next, and select formulas and herbs on that basis.

In TCM, the crux of selecting formulas and herbs is finding the "pattern." Disease has its disease-pattern, formula has its formula-pattern, and herb has its herb-pattern. As long as the effect of the formula and the effect of the herbs match the disease or pattern expressed by the patient's cluster of symptoms, the effect is extraordinary, and the disease is resolved very quickly.

It is of course good to find the medication indication and treat accordingly. When the "pattern" is not obvious, one relies on clinical experience to judge what pattern the patient will develop, and on that basis selects formulas and herbs; this allows one to anticipate the enemy and solve the patient's problem one step early.

I think this kind of approach is hard to describe by TCM's pattern differentiation or disease differentiation, but it can remedy the shortcomings of both.