Cautions in Treating Cancer Patients with Concomitant Pulmonary Tuberculosis

I have seen three cancer patients with concomitant pulmonary tuberculosis in clinic; two are patients I am currently treating, and the third was one I observed under the care of a well-known professor.

Pulmonary tuberculosis is called feilao (lung consumption) in TCM, one of the four most intractable diseases. It is generally differentiated as yin deficiency with blood dryness, or liver fire punishing metal; this pattern fits the great majority of TB patients. Thus TB patients must avoid warming, hot, acrid-drying and aromatic, dispersing herbs, which can cause hemoptysis and even more severe complications. On this point, the Japanese classic-formula master Dōmoto Kyūshin (汤本求真) explicitly stated that TB patients must be treated as yin deficiency with effulgent fire, and that misuse of warming formulas such as Guizhi Tang and Jianzhong Tang causes hemoptysis. He had learned this through bitter clinical experience of his own.

One gynecological tumor patient I treated had a history of TB and infertility (incidentally, TB itself can cause female infertility and amenorrhea). Before my in-person visit, she had not told me of the TB; I prescribed Yanghe Tang, and she developed discomfort after taking it. Fortunately she had taken little before coming to Beijing; when I took her pulse, both cun positions were floating, rapid, large and overflowing, though she had no exterior pattern. I suspected a prodromal cold; since she planned to stay in Beijing three days, I took her pulse again on the second and third mornings. All three pulses were floating, rapid, large and overflowing, yet she showed no signs of a cold over those three days.

Another esophageal cancer patient with lung metastasis whom I saw also had a long-standing TB history; her pulse, too, was floating, rapid, large and overflowing, looking unresolved exterior. As she had just had a cold, I gave acrid-cool, exterior-resolving herbs; the first three days worked well, but continuing made her weak. Before that, she had taken my yin-nourishing, blood-enriching, moistening, fluid-generating herbs for over a month with excellent results—regaining more than twenty jin in about a month to her pre-cancer weight, with greatly increased strength. Before the herbs she had been bedridden; she could not even sit up without fainting, and her family had begun arranging her funeral.

A third gynecological tumor patient with TB was treated in Beijing by a prominent professor inclined toward the "Fire God" school. I do not know what pulse he read, but he prescribed large doses of warming, hot herbs—ginger, cinnamon, aconite—along with blood-breaking herbs such as centipede and gecko. After taking them she vomited blood and sweated incessantly; in her last days she dripped sweat terribly, a horrifying sight, and finally collapsed from depletion of both yin and eleven days after starting the herbs, she died.

Talking with the family, I learned that neither patient nor family had told the professor about the TB; his inquiry was rushed—feeling the pulse and glancing at the chart took only a minute or two before he habitually wrote a prescription. This case gave me a real fright. The professor supervises many graduate students; these TCM graduates will eventually take key positions in hospitals and, riding their teacher's fame, be popular with patients. Such a level of diagnosis is no blessing for patients, nor for TCM.

When this patient and her family consulted me, I strongly urged her to stop the famous professor's herbs. But because they (1) lacked understanding of TCM theory, (2) over-relied on the professor's fame, and (3) found his herbs very expensive—over ten thousand yuan a month—she could not bear to waste the medicine, kept taking it, and ultimately declined rapidly to death. It is a lamentable case.

All three cases had their share of blunders. TB patients should not be given exterior-releasing formulas; in severe lung consumption with yin deficiency and fever, releasing the exterior does no good and one should strongly supplement the deficiency. Nor should warming hot herbs be used; Yanghe Tang—let alone ginger, cinnamon and aconite—is inappropriate. The Yanghe Tang patient I treated avoided serious harm for two reasons: her TB was not severe, and she took the herbs only two or three days; after my in-person visit I immediately told her, based on the pulse, that the prior prescription was wrong and must stop, and gave her a new one. The patient treated by the famous professor, by contrast, could not reach her doctor after starting the herbs, had already suffered severe side effects, yet out of faith in the "famous doctor effect" refused to change course—that is what is truly frightening.

After seeing these three cases, I reviewed the literature on lung consumption and summarized several points to note when treating cancer patients with TB in TCM.

First, do not misuse warming-hot or exterior-releasing herbs. Late-stage lung consumption presents with incessant sweating and insecure exterior; its mechanism is yin deficiency with blood dryness. The heat patients feel is a steaming heat, unlike the fever of an external contraction such as a cold. Exterior-releasing herbs—especially acrid-warm ones—damage the lungs seriously. Warming, acrid-drying herbs aggravate the steaming heat, bringing great fever, polydipsia and profuse sweating, ending in endless perspiration.

Second, in Western treatment, radiotherapy should be avoided as far as possible. Radiation pneumonitis is a complication these patients cannot bear; TB patients—especially those with fibrotic or cavitated lungs—die very quickly after radiotherapy.

Third, in TCM treatment, remember six characters: "nourish kidney, enrich liver, moisten lung." Especially for patients with long-standing, severe TB, the priority is the TB, with anti-cancer treatment as secondary. Even when the TB is not severe, it must still be taken seriously.

These three cases also show that, in treating tumor patients, understanding prior medical history is vital. Patients and families should proactively tell the doctor about past illnesses. Doctors should inquire carefully and patiently; a moment's carelessness can have grave consequences.