My Experience in Composing Formulas and Selecting Herbs to Treat Cancer—Reflections on TCM Cancer Research by Zhou Zhiyuan, Part 1

1. The greatest way is the simplest

Truth is half a sheet of paper; idle talk fills ten thousand books.

I intend to use only one article, rather than a thick book, to set out my core philosophy of treating cancer—in truth, this philosophy is very simple.

Cancer patients may be called a complex of disease. Once diagnosed with cancer, not only the patient but the whole family sinks into great panic, growing suspicious and imagining all sorts of bodily problems. The slightest discomfort, they like to tie it to the cancer.

So I often meet patients or family members with a bellyful of words to pour out to me. They have read many shallow articles in the media (ashamedly, I too have written no few such shallow articles), then matched themselves to them, hoping the doctor will untangle their confusion.

When a person is ill, the doctor is their heaven. This hope, that the doctor will answer their doubts, is understandable.

In such a situation, it is not easy for a doctor to keep a clear head, neither led by the patient's pace nor misled by the literature.

Especially for less experienced physicians, who lack both experience and conviction, and who have read a literature of wildly divergent views, it is all too easy to suspect that the patient's cancer is related to this or that factor, and to try to solve the patient's problem through these connections—only to take the wrong path and drift farther and farther afield.

I myself once went through such a phase. I too once championed various ideas, until failure after failure left me utterly disillusioned with such sophistry.

In recent years I have walked out of this quagmire of sophistry, explicitly treating cancer as a disease of as-yet-unclear cause, talking little about etiology, and focusing instead on resolving the various symptoms that arise in cancer patients. Gradually I have worked out my own approach and knack for treating cancer.

My situation is very special: patients with mild conditions do not come to me. The patients who come to me have, in the great majority, first been treated by Western medicine, then by all sorts of TCM, and after every treatment has failed and their condition is quite dire, they find me.

So those I take on are basically the most intractable patients. These patients have severe pleural and ascitic fluid, or massive hemorrhage, or persistent high fever, or tumors that have ulcerated, pus and blood spilling everywhere. For a long stretch, I was an emergency doctor.

To put it bluntly, over these years most patients have treated me as their last straw. Especially in earlier years, many patients did not truly trust me; they came to me simply because there was no other way—fearing responsibility, or unwilling to face death, most doctors had already refused to take them.

So I needed to solve, very quickly, the problems threatening these patients' lives. This forced me to form my own distinctive medication style—it must work fast, or the patient dies at any moment.

Emergency treatment requires the physician to have both precise judgment and boldness, producing a plan that is safe and quick-acting.

Facing these emergency patients, the conventional logic of both TCM and Western medicine no longer works. Sometimes the formula I prescribe is small, sometimes very large, but every formula I write is the product of very careful thought.

In the first years, I treated some patients at death's door—patients the hospital doctors, following routine, had tagged as critically ill or sent to the ICU, talked over with the family, and made sign all the risk warnings and consent forms. These families mostly hoped I could raise the dead.

Being entrusted at a moment of crisis requires a cool head and strong judgment, as well as the courage to take responsibility and skillful communication. Without these qualities, such high-risk treatment can land one in thorny trouble.

I used to be invited frequently to make house calls out of town. Back then I did not have as many patients as now, and still had time to accept such invitations; now there are too many patients, and I no longer have the energy.

Such conditions do not allow me to hesitate, nor to show off my book-learning by trading metaphysical talk with the patient's family. When a patient has a persistent high fever, vomits blood filling a basin, or is already comatose, one can only decide on the spot, using medicine that is fast, forceful and precise.

Although I have also used single herb Baiji (Bletilla), or classic small formulas such as Maxing Shigan Tang and Xiao Chaihu Tang, to rescue patients, in most cases such ordinary approaches do not work for rescuing end-stage cancer patients.

Ever since I began practicing, I have carried two sets of keys when I go out; professional training has made my risk awareness this strong even in daily life. At a moment when life hangs by a thread, it is all the more necessary to minimize the risk of the patient's death.

So when I use medicine at the critical moment, I follow the principle of "Han Xin deploying troops—the more the better," combining several formulas that each solve a given problem and using them together. This way of stacking herbs, in staggering doses, draws the scorn of many of my TCM colleagues.

In my early years I did publish many of my emergency case records, which later drew criticism from all manner of armchair "TCM masters." To avoid trouble, I have since removed most of those cases.

But many patients have been snatched back to life in my hands.

A formula of sixty or seventy herbs may make a patient already paralyzed, within two or three days, leave his wheelchair and stand up.

A classical formula in a dose so large it takes one's breath away may make a patient, already bedridden and unconscious, get out of bed the next day and show me a goose-step march.

Using tens to over a hundred grams of Baiji a day, ground to powder and swallowed, may make a lung-cancer patient who vomits blood filling a basin every day stop the bleeding within a day or two.

Forcefully needling an emergency point and retaining the needle for a long time may bring a fainted patient back to consciousness.

This kind of immediate effect has made me deeply admire the efficacy of Chinese medicine, and has given me confidence in my own approach.

I have failed to rescue patients many times, but the number rescued is no small one. Moreover, every patient I rescue is, without exception, one whom other Chinese and Western doctors had already tried and failed to rescue.

I say this with complete certainty: for those patients I treated, had I not used this approach of mine—this way that looks like simply stacking herbs—they would have had no way out but death.

Many of the patients I snatched back from the gate of hell, and their families, have become my loyal readers and followers; other cancer patients around them have one after another become my patients.

I have passed the stage when few patients trusted me. Yesterday I counted: I have treated over ten thousand patients in total; more than three thousand are still in long-term follow-up; and every day there are twenty or thirty new patients, referred by patients I have treated, who express an intention to consult—whereas I only see three to five people a day in total, including follow-up patients.

And the patients have formed a clustering effect. In certain tumor-patient communities—such as neuroblastoma, gynecological tumors, sarcoma, lung cancer, and digestive-tract tumors—many patients or their families treat my clinic as a mandatory stop on their search for care.

This is very favorable for me in doing targeted research. Because I have a great deal of clinical experience with the same kind of disease, I can build on it and do deeper research, forming a more targeted and more effective treatment approach.

So, from two or three years ago, I have entered the stage where I can choose, from among the many patients, those I feel are fated to work with me, rather than letting patients choose me.

2. Between two points, the straight line is shortest

In medicine, perfect logic does not solve real problems. I do not think logic is worthless; on humanity's journey of medical exploration, logic has helped us greatly. But medicine differs from every other discipline in that it values practice more.

Truth one step forward is often error. The over-extension of medical theory does indeed make it look persuasive, but this false persuasiveness not only misleads patients and their families, it also leads the physician himself onto many detours.

TCM is too tightly bound up with traditional philosophy, so that many of its theories are purely the product of deductive reasoning, not distilled from practice. Such theories are very eloquent, yet their therapeutic effect is poor; guiding the clinic by them yields a low effective rate.

One basic principle I follow in treating disease is: between two points the straight line is shortest; less metaphysical talk, and directly and specifically solving the problem is what matters most.

The physician fears, first, not knowing the disease, and second, not knowing the drug. When disease-pattern and drug-pattern match well, the effect is immediate.

To treat disease one must first understand the disease. What features a given disease presents, the physician who specializes in it must know backward and forward.

For example, if a physician does not understand the features that most cancer patients tend to show—cachexia, cancerous wasting, the cancer pain caused by a tumor pressing on nerves as it grows, bleeding when a tumor ulcerates, or the cancer fever of late-stage cancer—then asking him to treat cancer patients is mere empty talk.

Second, one must be familiar with the properties and actions of drugs.

Li Dongyuan, of the Jin-Yuan period, after his mother fell ill sought doctors everywhere, yet by the time she died the doctors still could not say what she had; everyone was sunk in metaphysical talk about yin deficiency and yang deficiency, with divergent views and endless argument.

Li Dongyuan, stung to reflection, later, once he had mastered medicine, took on apprentices. The first thing he taught them was not the various isms of TCM schools, but the nature and effects of each individual herb.

Li Dongyuan required his disciples to learn the basic effects of each herb first, and only afterward study the basic theory of TCM, so as to avoid the preconception of falling into the bias of some TCM school and being unable to extricate themselves.

In that age of incessant warfare, plagues raged. Li Dongyuan himself witnessed many so-called famous doctors, during the plague, chattering on in theoretical disputes, while the prescriptions they wrote were almost all useless.

Li Dongyuan cast aside metaphysical talk and composed his own formulas to treat those infected in the plague, with outstanding effect. This formula became a classic famous formula in TCM history—Puji Xiaodu Yin (Universal Relief Decoction to Remove Toxin).

This formula, which Li Dongyuan created by casting aside traditional theory, saved many lives. At the time it was carved onto stones by the roadside and spread widely, making an important contribution to containing the "big-head plague" of the Jin-Yuan period. Li Dongyuan, too, because of his outstanding clinical efficacy and his many innovations in TCM history, became a great master of his generation.

Wu Youke, the famous Warm-Disease physician of the Qing dynasty, likewise firmly held that "each disease must have its own drug"; he studied the nature of herbs himself and created formulas, solving problems other doctors could not.

Cancer is a disease with very distinct features. The doctor researching cancer should not overvalue metaphysical talk, but should keep his feet on the ground in studying the features of cancer, and, based on the various symptoms of cancer patients, select herbs that can relieve the corresponding symptoms and inhibit tumor progression, combining them into formulas. Then, in practice, he should follow up the actual effect of the formulas he has composed, analyze the reasons for success and failure, accumulate clinical experience and data, and continuously refine his prescriptions.

Only thus can one develop formulas of outstanding clinical efficacy.

Formulas, from ancient times to today, have all been created by people. With the development of information technology, today's doctors have more ways to learn medicine than in the past, and learn more efficiently. So we are fully capable of creating formulas whose efficacy surpasses those created by the ancients.

To be frank, I have no secret recipe. I simply study hard the nature and effects of Chinese herbs, read widely the proven formulas and case records of TCM doctors ancient and modern, Chinese and foreign (including Japanese kampo physicians), learn from them the craft of composing formulas, think through the effects of combining various drugs, and on this basis build my own formulas.

Or I follow up the TCM doctors and their patients whom I can reach, learn from their medication experience, and try to incorporate that experience into my own commonly used formulas.

In recent years, in handling the various complications of cancer patients, my effective rate has risen sharply compared with before. The proportion of tumor patients I treat whose tumors shrink or even disappear has also clearly risen. And some of the medicines I have developed have achieved a broad-spectrum anti-cancer effect.

My formulas are still being refined. The herbs I commonly use number in the hundreds; many are folk medicines that cannot be bought even at the herb market, and must be procured from mountain dwellers.

I have many commonly used formulas, which I will organize and publish gradually in the future, introducing their uses and effects in detail.

Many people may think this way of composing formulas is too low-level. But I believe that the truly efficacious formulas of history were composed with this kind of low-level thinking, not with the seemingly lofty methods of philosophical speculation.

3. Multi-target medication

As I mentioned earlier, the greatest feature of my medication is "Han Xin deploying troops—the more the better."

I have been quietly following up the doctors and patients for whom TCM anti-cancer therapy works. I myself have also treated many tumor patients with the classic famous formulas of history. These doctors and formulas are not without effect, but the biggest problem is that the effective rate for treating cancer is too low.

Different patients must differ from one another, but patients with the same type of disease will also have a great deal in common.

Treating the different symptoms of each patient requires us to provide personalized treatment, and this personalized treatment requires a deep grounding in TCM formula studies and pharmacology.

But we cannot, through over-emphasizing TCM personalized treatment, ignore the basic fact that the same kind of disease has a large number of common symptoms. So the medication for treating the same kind of disease must have much in common.

It would of course be ideal if we could explain the scientific principle of every herb and every proven formula with modern science. But under present conditions, human medicine does not yet have that level.

Yet disease waits for no one. Before human medicine has developed enough to solve every problem with modern medicine, it is very necessary to study the experience of traditional medicine in treating disease; there is no need to wait until the scientific principle of these treatments is fully explained before using them to solve problems.

At present, a group of doctors trained in the modern natural sciences—some Western, some Chinese—oppose using TCM to treat disease. This is obviously overly extreme.

If modern medicine cannot solve a patient's problem, are we to let the patient sit and wait for death, or be treated to death by modern medicine, before that counts as ethical?

As for patients and families who wholly loathe and resist TCM, I will make no comment; people have the right and freedom to make their own choices.

The physician who studies traditional medicine has a responsibility to raise its effective rate. I believe every doctor has had some outstanding, successful experience of treating disease; I do not doubt at all the successful cases of certain doctors. But what I have seen is that everyone's success rate with this disease is not high.

I am trying an approach: combining various effective protocols to raise the clinical effective rate. And this attempt has indeed achieved a higher effective rate than before.

I have borrowed a fashionable medical term, and call this attempt "multi-target medication."

The few medicines I am now developing contain no fewer than forty herbs each, but I use them not as decoctions but in pill form. It is just that, when composing them, I refer to the basic logic of TCM formula composition; after all, much of that logic is mature clinical experience.

The best thing about pills is that I can control the dose according to the patient's constitution, starting from a small dose and gradually increasing to the maximum the patient can tolerate.

Another benefit of pills is that they lower the cost of treatment. I have a dream: to bring the monthly medication cost for child cancer patients down to around one thousand yuan at today's price levels, and the monthly cost for adults down to around two or three thousand. Apart from a few patients who are well-off, I do not use very expensive herbs for most patients.

Only, this wish of mine cannot yet be fully realized.

Pills, because they do not waste herbs the way decoctions do, cost much less to treat. Of course, going even lower to meet the needs of the very poorest would be even more ideal; but to be honest, this deliberate pursuit of low price is also irresponsible toward the patient's life.

Daring not to use medicine will likewise delay a patient's treatment.

My fondness for pills does not mean I have abandoned decoctions. For many problems that pills cannot solve, I still use decoctions to assist. And some patients poorly tolerate pills and can only take decoctions.

But when I use decoctions, I also follow the logic I developed in rescuing patients—combining multiple effective formulas and herbs to raise the clinical effective rate.

All my life I will walk forward in this direction, and will record my attempts for the reference of later generations.

It is not that I have no experience treating with small prescriptions. For many self-limiting diseases, and even for some tumor patients, I have used small formulas. But to be honest, treating self-limiting diseases is one thing; treating diseases like cancer, the effective rate of small formulas is simply too low.

By my own comparison, combining several effective formulas and drugs of the same kind gives a better outcome and a higher effective rate than using a single small formula or a single herb alone.

4. Deep accumulation, slow release, constant refinement

Large prescriptions are hard to manage, just as it is hard to command and coordinate when multiple arms fight together. A physician who wants to skillfully treat with large prescriptions needs a very solid grounding in pharmacology.

The medical books of China and abroad, ancient and modern, are as numerous as cattle's hair. Many people's medical practice is very valuable, but reading medical books requires the ability to pan for gold in the sand; otherwise it is hard to tell which content in the books is truly valuable.

This is just like Goethe's classic saying I quoted in the preface: in scholarship one must "be comprehensive" and "penetrate deeply"; in studying TCM one must "be able to enter" and "be able to exit."

To have the ability to pick out what is truly useful from a vast sea of records requires deep accumulation and slow release. One should read more and more books, but not grow more and more muddled as one reads.

To create formulas of outstanding efficacy, one must draw broadly on the records of predecessors and the practice of contemporaries, and then, standing on the shoulders of others, take one step forward, and then another.

Because my patient base is large, I have the chance to refine my various formulas once every half month. I can gather, from each patient, information on the actual effect and side effects after taking the medicine, and based on this feedback, assess the efficacy and side effects of my formulas for certain diseases.

Then, on the basis of this practical data, I refine my prescriptions step by step. I sincerely do not believe that proven formulas are created through some individual's "awakening"; proven formulas are all tested. The real reactions and effects after using a drug, one cannot possibly know without experimenting.

I limit the number of patients I see each day to three to five, and spend about an hour on each consultation (even if I charge them nothing), never taking on more.

I refuse to treat any patient carelessly, whether they can afford my fee or cannot, and whether they are patients whose fee I have waived. I need enough time to understand the patient's condition in detail; only so can I raise my efficacy.

I carefully collect each patient's clinical symptoms, and I also carefully collect and record each patient's reactions after taking the medicine. Based on the information I have gathered, I look up references, consult Chinese and Western colleagues, and seek a better medication plan.

Discover a problem, solve it; discover a new problem, solve it. When new problem after new problem is solved, and more and more patients achieve gratifying results, all the heart's blood and sweat we who study medicine have poured in receives its best reward.

Can these count as any secret? I think they count for nothing of the sort. So I have frankly named this my experience in composing formulas and selecting herbs.

It is not that I cannot engage in philosophical, speculative, metaphysical talk. I believe that, with my philosophical grounding and writing ability, I could write the kind of high-level metaphysical articles most TCM people cannot.

But I would rather write this book in simple, direct, plain language, introducing my experience and insights in treating disease.